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A SYSTEM OF PRACTICAL MEDICINE.

BY AMERICAN AUTHORS.




EDITED BY WILLIAM PEPPER, M.D., LL.D.,

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.


ASSISTED BY LOUIS STARR, M.D.,

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE
UNIVERSITY OF PENNSYLVANIA.




VOLUME IV.

DISEASES OF THE GENITO-URINARY AND CUTANEOUS SYSTEMS.--MEDICAL
OPHTHALMOLOGY, AND OTOLOGY.




PHILADELPHIA:
LEA BROTHERS & CO.
1886.




Entered according to Act of Congress, in the year 1886, by

LEA BROTHERS & CO.,

in the Office of the Librarian of Congress at Washington. All rights
reserved.




WESTCOTT & THOMSON,
_Stereotypers and Electrotypers, Philada._

WILLIAM J. DORNAN,
_Printer, Philada._




CONTENTS OF VOLUME IV.


DISEASES OF THE GENITO-URINARY SYSTEM.
                                                                   PAGE
DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS. By
  ROBERT T. EDES, M.D. . . . . . . . . . . . . . . . . . . . . . .   19

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS. By
  FRANCIS DELAFIELD, M.D.  . . . . . . . . . . . . . . . . . . . .   69

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA. By JAMES TYSON,
  A.M., M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . .  104

CHYLURIA. By JAMES TYSON, A.M., M.D. . . . . . . . . . . . . . . .  114

DISEASES OF THE MALE BLADDER. By EDWARD L. KEYES, A.M., M.D. . . .  123

SEMINAL INCONTINENCE. By SAMUEL W. GROSS, A.M., M.D. . . . . . . .  137

DISPLACEMENTS OF THE UTERUS. By EDWARD C. DUDLEY, A.B., M.D. . . .  147

DISORDERS OF THE UTERINE FUNCTIONS, INCLUDING AMENORRHOEA,
  DYSMENORRHOEA, AND MENORRHAGIA. By J. C. REEVE, M.D. . . . . . .  182

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.
  By B. F. BAER, M.D.  . . . . . . . . . . . . . . . . . . . . . .  208

PELVIC HÆMATOCELE. By T. GAILLARD THOMAS, M.D. . . . . . . . . . .  239

FIBROUS TUMORS OF THE UTERUS. By WILLIAM H. BYFORD, M.D. . . . . .  245

SARCOMA OF THE UTERUS. By WILLIAM H. BYFORD, M.D.  . . . . . . . .  271

CARCINOMA OR CANCER OF THE UTERUS. By WILLIAM H. BYFORD, M.D.  . .  274

DISEASES OF THE OVARIES AND OVIDUCTS. By WILLIAM GOODELL, M.D. . .  282

DISEASES OF THE URINARY ORGANS IN WOMEN. By ALEXANDER J. C.
  SKENE, M.D.  . . . . . . . . . . . . . . . . . . . . . . . . . .  339

DISEASES OF THE VAGINA AND VULVA. By EDWARD W. JENKS, M.D., LL.D.   367

DISORDERS OF PREGNANCY. By W. W. JAGGARD, A.M., M.D. . . . . . . .  405

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE. By W. W.
  JAGGARD, A.M., M.D.  . . . . . . . . . . . . . . . . . . . . . .  432

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND
  ENDOMETRITIS, INCLUDING LEUCORRHOEA. By W. W. JAGGARD, A.M.,
  M.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  447

ABORTION. By GEORGE J. ENGELMANN, M.D. (Berlin)  . . . . . . . . .  467


DISEASES OF THE MUSCULAR SYSTEM.[1]

[Footnote 1: Though properly belonging in Vol. V., with Diseases of the
Nervous System, this section has been placed here for convenience.]

MYALGIA. By JAMES C. WILSON, A.M., M.D.  . . . . . . . . . . . . .  529

PROGRESSIVE MUSCULAR ATROPHY. By JAMES TYSON, A.M., M.D. . . . . .  540

PSEUDO-HYPERTROPHIC PARALYSIS. By MARY PUTNAM JACOBI, M.D. . . . .  557


DISEASES OF THE SKIN.

DISEASES OF THE SKIN. By LOUIS A. DUHRING, M.D., and HENRY W.
  STELWAGON, M.D.  . . . . . . . . . . . . . . . . . . . . . . . .  583


MEDICAL OPHTHALMOLOGY.

MEDICAL OPHTHALMOLOGY. By WILLIAM F. NORRIS, A.M., M.D.  . . . . .  737


MEDICAL OTOLOGY.

MEDICAL OTOLOGY. By GEORGE STRAWBRIDGE, M.D. . . . . . . . . . . .  807


INDEX  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  843




CONTRIBUTORS TO VOLUME IV.


BAER, B. F., M.D.,
  Professor of Obstetrics and Gynæcology in the Philadelphia Polyclinic
  and College for Graduates in Medicine, and Dean of the Faculty;
  Obstetrician to Maternity Hospital; President of the Obstetrical
  Society of Philadelphia, etc.

BYFORD, WILLIAM H., M.D.,
  Professor of Gynæcology in the Rush Medical College, Chicago.

DELAFIELD, FRANCIS, M.D.,
  Professor of Pathology and Practical Medicine in the College of
  Physicians and Surgeons, New York.

DUDLEY, EDWARD C., A.B., M.D.,
  Professor of Gynæcology in the Chicago Medical College, Chicago.

DUHRING, LOUIS A., M.D.,
  Professor of Skin Diseases in the University of Pennsylvania,
  Philadelphia.

EDES, ROBERT T., M.D.,
  Jackson Professor of Clinical Medicine in Harvard University, Boston,
  Mass.

ENGELMANN, GEORGE J., M.D. (Berlin),
  Professor of Obstetrics and Gynæcology in the St. Louis Polyclinic
  and Post-Graduate School of Medicine.

GOODELL, WILLIAM, M.D.,
  Professor of Clinical Gynæcology in the University of Pennsylvania,
  Philadelphia.

GROSS, SAMUEL W., A.M., M.D.,
  Professor of the Principles of Surgery and of Clinical Surgery in the
  Jefferson Medical College of Philadelphia.

JACOBI, MARY PUTNAM, M.D.,
  Professor of Materia Medica and Therapeutics in the Women's Medical
  College, New York, and Professor of Diseases of Children at the New
  York Post-Graduate School.

JAGGARD, W. W., A.M., M.D.,
  Professor of Obstetrics in the Chicago Medical College, Medical
  Department Northwestern University; Obstetrician to Mercy Hospital,
  Chicago.

JENKS, EDWARD W., M.D., LL.D., Detroit, Michigan,
  Formerly Professor of Medical and Surgical Diseases of Women and
  Clinical Gynæcology in the Chicago Medical College, and in the
  Post-Graduate Medical School of New York.

KEYES, EDWARD L., A.M., M.D.,
  Professor of Genito-Urinary Surgery and Syphilis in the Bellevue
  Hospital Medical College, New York; Surgeon to Bellevue Hospital;
  Consulting Surgeon to the Charity Hospital.

NORRIS, WILLIAM F., A.M., M.D.,
  Clinical Professor of Ophthalmology in the University of
  Pennsylvania, Surgeon to Wills Ophthalmic Hospital, Philadelphia.

REEVE, J. C., M.D., Dayton, Ohio,
  Formerly Professor of Materia Medica and Therapeutics in the Medical
  College of Ohio.

SKENE, ALEXANDER J. C., M.D.,
  Professor of Gynæcology in the Long Island College Hospital,
  Brooklyn, and in the Post-Graduate Medical School of New York.

STELWAGON, HENRY W., M.D.,
  Physician to the Philadelphia Dispensary for Skin Diseases; Chief of
  the Skin Dispensary of the Hospital of the University of
  Pennsylvania, Philadelphia.

STRAWBRIDGE, GEORGE, M.D.,
  Clinical Professor of Otology in the University of Pennsylvania,
  Philadelphia.

THOMAS, T. GAILLARD, M.D.,
  Clinical Professor of Diseases of Women in the College of Physicians
  and Surgeons, New York; Surgeon to the New York State Woman's
  Hospital.

TYSON, JAMES, A.M., M.D.,
  Professor of General Pathology and Morbid Anatomy in the University
  of Pennsylvania; Physician to the Philadelphia Hospital,
  Philadelphia.

WILSON, JAMES C., A.M., M.D.,
  Physician to the Philadelphia Hospital, and to the Hospital of the
  Jefferson College; President of the Pathological Society of
  Philadelphia.




ILLUSTRATIONS.


FIGURE                                                             PAGE
 1. THE CLASSICAL REPRESENTATION OF THE PELVIC ORGANS  . . . . . .  148

 2. THE CORRECT REPRESENTATION OF THE PELVIC ORGANS  . . . . . . .  149

 3. FIRST DEGREE OF PROLAPSE OF THE POST-PARTUM UTERUS . . . . . .  155

 4. SHOWING EXTREME DESCENT OF THE UTERUS AND OF THE PELVIC FLOOR,
      AND THE HERNIAL CHARACTER OF THE LESION  . . . . . . . . . .  156

 5. DESCENT OF THE VIRGIN UTERUS INTO THE VAGINAL CANAL, SHOWING
      THE REDUPLICATED VAGINAL WALLS . . . . . . . . . . . . . . .  157

 6. DESCENT OF THE UTERUS, SHOWING EXCESSIVE CIRCULAR ENLARGEMENT
      OF THE LACERATED CERVIX, CONSEQUENT UPON REDUPLICATION OF
      THE VAGINAL WALLS AND OUT-ROLLING OF INTRACERVICAL TISSUES .  158

 7. THE EMMET CURVES (PESSARY) . . . . . . . . . . . . . . . . . .  160

 8. THE ALBERT SMITH CURVES (PESSARY)  . . . . . . . . . . . . . .  160

 9. THE FIRST SUTURE BEFORE TWISTING IN EMMET'S OPERATION IN
      PROCIDENTIA  . . . . . . . . . . . . . . . . . . . . . . . .  162

10. FOLDS ON THE ANTERIOR VAGINAL WALL FORMED AFTER TWISTING THE
      FIRST SUTURE . . . . . . . . . . . . . . . . . . . . . . . .  162

11. EMMET'S OPERATION FOR PROCIDENTIA AND URETHROCELE COMPLETED  .  163

12. DIAGRAM OF EMMET'S OPERATION . . . . . . . . . . . . . . . . .  164

13. THE SUTURES IN PLACE . . . . . . . . . . . . . . . . . . . . .  165

14. THE VAGINAL SUTURES TWISTED  . . . . . . . . . . . . . . . . .  165

15. EXTREME RETROFLEXION, WITH HYPERTROPHY OF THE CORPUS . . . . .  167

16. COMMENCING REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
      BY CONJOINED MANIPULATION  . . . . . . . . . . . . . . . . .  170

17. COMPLETED REPOSITION OF THE RETROVERTED OR RETROFLEXED UTERUS
      BY CONJOINED MANIPULATION  . . . . . . . . . . . . . . . . .  171

18. SHOWING THE PELVIC ORGANS SUSTAINED BY THE EMMET PESSARY AFTER
      REPOSITION OF THE PROLAPSED, RETROVERTED, OR RETROFLEXED
      UTERUS . . . . . . . . . . . . . . . . . . . . . . . . . . .  172

19. SCHULTZE'S SLEIGH PESSARY IN PLACE . . . . . . . . . . . . . .  173

20. FRONT VIEW OF SCHULTZE'S FIGURE-OF-EIGHT PESSARY . . . . . . .  174

21. THOMAS'S RETROFLEXION PESSARY  . . . . . . . . . . . . . . . .  174

22. PATHOLOGICAL ANTEVERSION . . . . . . . . . . . . . . . . . . .  175

23. CONGENITAL ANTEFLEXION . . . . . . . . . . . . . . . . . . . .  176

24. ANTEFLEXION WITH POST-UTERINE FIXATION . . . . . . . . . . . .  177

25. DIAGRAM SHOWING MUSCULAR STRATA OF UTERUS, AS DIVIDED FOR
      CLINICAL PURPOSES  . . . . . . . . . . . . . . . . . . . . .  249

26. IMPERFORATE HYMEN  . . . . . . . . . . . . . . . . . . . . . .  374

27. SIMS'S VAGINAL DILATOR . . . . . . . . . . . . . . . . . . . .  387

28. FOLLICULAR VULVITIS (HUGINER)  . . . . . . . . . . . . . . . .  390

29. ABSCESS OF GLANDS OF BARTHOLINI  . . . . . . . . . . . . . . .  397

30. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . .  400

31. ELEPHANTIASIS OF VULVA . . . . . . . . . . . . . . . . . . . .  400

32. DEFORMITY OF HAND IN PROGRESSIVE MUSCULAR ATROPHY  . . . . . .  548

33. SHOWING ATROPHY OF THE RIGHT DELTOID AND ARM, AND OF THE LEFT
      ARM  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  549

34. SHOWING ATROPHY OF THE DELTOID, POSTERIOR ASPECT, AND OF THE
      SCAPULAR MUSCLES . . . . . . . . . . . . . . . . . . . . . .  549




{17}

DISEASES OF THE GENITO-URINARY SYSTEM.


DISEASES OF THE KIDNEYS, INCLUDING | FIBROUS TUMORS OF THE UTERUS.
  THE PELVIS OF THE KIDNEYS.       |
                                   | SARCOMA OF THE UTERUS.
DISEASES OF THE PARENCHYMA OF THE  |
  KIDNEYS, AND PERINEPHRITIS.      | CARCINOMA OR CANCER OF THE UTERUS.
                                   |
HÆMATURIA AND HÆMOGLOBINURIA OR    | DISEASES OF THE OVARIES AND
  HÆMATINURIA.                     |   OVIDUCTS.
                                   |
CHYLURIA.                          | DISEASES OF THE URINARY ORGANS IN
                                   |   WOMEN.
DISEASES OF THE BLADDER.           |
                                   | DISEASES OF THE VAGINA AND VULVA.
SEMINAL INCONTINENCE.              |
                                   | DISORDERS OF PREGNANCY.
DISPLACEMENTS OF THE UTERUS.       |
                                   | FUNCTIONAL DISORDERS IN CONNECTION
DISORDERS OF THE UTERINE           |   WITH THE MENOPAUSE.
  FUNCTIONS.                       |
                                   | DISEASES OF THE PARENCHYMA OF THE
INFLAMMATION OF THE PELVIC         |   UTERUS; METRITIS AND
  CELLULAR TISSUE AND PELVIC       |   ENDOMETRITIS.
  PERITONEUM.                      |
                                   | ABORTION.
PELVIC HÆMATOCELE.                 |




{19}

DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS.

BY ROBERT T. EDES, M.D.


Anomalies of Shape, Size, Number, and Position.

The kidneys are two glandular organs, of a concavo-convex shape so
characteristic as to be frequently used as a term of comparison,
situated on each side of the vertebral column, with the longer
diameters nearly parallel thereto, but slightly convergent toward the
upper extremity, and extending from about the upper border of the
eleventh rib on the left side and the middle of the corresponding rib
on the right to the second or third lumbar vertebra. Hence they are
somewhat less than half covered by the last two ribs.

The upper extremity is a little the wider and the thinner, and by this
peculiarity and a recollection of the position of the vessels (from the
front, vein, artery, ureter) the two kidneys may be assigned to their
proper sides after removal from the body.

They are behind, and at their upper extremities nearly in contact with,
the peritoneum, resting, with their more or less voluminous envelope of
adipose tissue, upon the great muscles of the loins. The fat which in
the normal condition surrounds the kidneys varies, as might be
supposed, within wide limits, and is by no means devoid of importance,
since its deficiency is undoubtedly a predisposing cause for some of
the displacements hereafter to be described. In this fatty mass may
also be situated perinephritic abscesses, and into it spread with
considerable facility morbid growths originating in the kidney itself.

At the middle of the inner borders of the kidneys are situated the
hiluses into which enter veins, arteries, ureters, nerves, and
lymphatics, united by connective tissue and forming a sort of pedicle.

The normal weight of each kidney is to be expressed by a rough average
as from four and a quarter avoirdupois ounces, or one hundred and
twenty grammes, on the one hand, to seven ounces, or two hundred
grammes, on the other; but since a deficiency in the size of one is not
unfrequently compensated by an increase in the other, it would be safer
to give the weight of the pair as from two hundred and forty to four
hundred grammes, the lesser number representing those organs which are
not only small but anæmic, and the larger those which are either
distinctly hypertrophied or much congested: many diseased kidneys will
also be found within these limits.

The size of the kidney is in a general way proportioned to the size of
{20} the body: the proportion is stated as 1 to about 240. A
disproportionate change in the size of both kidneys without any change
in structure is a true hypertrophy, and may be met with in persons
whose habits as regards the ingestion of fluids (especially such as are
freely secreted by the kidneys--for instance, beer or other forms of
dilute alcohol) tend toward excess, or where a disease like diabetes
throws a large amount of diuretic material into the circulation.

The deep position of the kidneys makes them usually inaccessible to
physical exploration to any practical extent. In stout persons they are
so entirely covered by their own immediate envelope of fat, by the
adipose tissue of the mesentery, and by the thick abdominal walls as to
be completely indistinguishable. In thinner persons deep palpation with
both hands may enable us to say that there is a diminished resistance
to pressure, as in the case of movable kidney, or that there is or is
not any decided enlargement. Slighter changes in size cannot be
accurately determined, although Bartels[1] states that he was once
enabled to detect a considerable enlargement in a case of
parenchymatous nephritis by double palpation. In moderately thin
persons the lower end of the kidney can be more or less distinctly
felt.

[Footnote 1: _Ziemssen_, vol. xv.]

A position upon the hands and knees (not the gynecological semi-prone
position), allowing the whole abdomen to gravitate directly away from
the backbone, is said to afford, by the varying concavity of the lumbar
region on the two sides, information as to the absence of either kidney
from its usual place. When the kidney, however, is displaced, and when
it comes decidedly forward from increase in its own size or from the
pressure of a tumor behind it, it may very often become extremely
accessible.

Percussion gives even less information than palpation, since the
dulness of the lumbar muscles extends laterally beyond that of the
kidneys, and is of itself so complete as to offer no change from the
addition or subtraction of the resistance of the underlying organ.[2]

[Footnote 2: It is probable that Simon's method of thrusting the hand
into the rectum and large intestine might be made available by a person
with a small hand and arm for diagnosis in doubtful cases where the
value of the information to be obtained would be sufficient to
compensate for the risk of serious injury.

The removal of the kidneys may be accomplished through the rectum--and
has been effected many times by myself and assistants--in cases where a
complete autopsy is refused. The manoeuvre is not very difficult
through a large and especially a female pelvis, but under other
circumstances may be somewhat fatiguing. Considerable post-mortem
information in regard to other organs may be obtained in the same way.]

The most marked anomaly in the shape of the kidneys when both are
present, and the only one which possesses a clinical interest, is that
known as the horseshoe kidney, being a more or less complete fusion of
the organs of each side in front of the vertebral column and the great
vessels. This fusion is usually at the lower end, but may be in the
middle or at the upper end. Sometimes there is a portion lying directly
in front of the vertebral column so large and thick as to appear almost
like a middle lobe or a third kidney. In a few rare instances this
portion has formed a pulsating enlargement mistaken for an aortic
aneurism or other abdominal tumor. In others compression of the great
vessels has given rise to phlebitis, or the abnormal position of the
ureters has obstructed the passage of the urine, with the results, as
regards the secondary affection of the kidneys, to be described below.
{21} These instances are, however, among the curiosities of medicine,
and no rule for their diagnosis can be laid down. A horseshoe kidney is
usually discovered only after death, and with no special frequency in
cases of renal disease.

Variations in the number of the kidneys possess this point of practical
interest, that diseases affecting a single organ are more dangerous
than if another exists which can take upon itself extra duty. Apparent
absence of one kidney may be due to atrophy, attended with very small
size of the renal vessels; in which case a small mass of connective
tissue is found at the upper end of the ureter, which is usually illy
developed. The other kidney is usually hypertrophied.

The kidney may fail to be developed. In this case there are no vessels
corresponding to the renal artery and vein, and the ureter is stated to
be invariably absent, but the writer has seen a specimen where the left
ureter terminated superiorly in a rounded cul-de-sac, no kidney or
suprarenal capsule being present. The other kidney was of rather large
size in proportion to the size of the patient, but of the usual form.
This defect is apt to be associated with some anomaly of the genital
organs.

Another condition, apparently similar, but really due to a fusion of
the two embryonic kidneys, is sometimes found. In this the single
organ, situated upon one side, is irregular in form and in the number
and origin of its vessels. There are usually two ureters, arising one
above or beside the other, and directed to their proper positions in
the floor of the bladder. A single ureter arising from a single kidney
has been seen to empty upon the opposite side of the bladder.

Supernumerary kidneys have been noted. In one case an extra pair,
situated below the others, were intensely inflamed, while the normal
organs were not so.

A position of one kidney has been noticed considerably higher than
normal, so as to push the spleen from its place. A more common anomaly,
however, is the situation of one kidney at a point much below the
usual, most commonly at the brim of the pelvis. When this happens the
kidney itself is usually more or less distorted in form, and receives
its blood-supply from several small arteries which enter it at
irregular points, forming as it were several small hiluses. They may
originate from the aorta or from one or both iliacs. The ureter is
correspondingly short. This position is of some importance, since a
pelvic tumor is formed which has in one instance proved an obstacle in
childbirth, while in another the misplaced kidney itself underwent an
acute nephritis from the pressure of the foetal head. The kidney tumor
has in a few instances been felt in this position during life, but its
nature has not been diagnosticated.


Floating Kidney.

The most clinically important change in the position of the kidney is
not a permanent one, but varies from time to time with the posture of
the patient and the altered conditions of pressure--externally by dress
or apparatus, or internally by the other abdominal organs. It is known
as floating or wandering kidney. In this affection the kidney ceases to
{22} be firmly imbedded in the fat usually found in the lumbar region,
constituting a support and packing for these organs as well as for the
suprarenal capsules, and is allowed more or less liberty of movement,
which is restrained by a pedicle consisting of the ureter, vessels, and
nerves, with more or less connective tissue. As it passes downward and
forward it comes into more intimate relations with the peritoneum,
which usually covers only the anterior surface, often with an
intervening layer of fat, so that it may even gain a sort of special
investment or meso-nephron.

The extent of the excursions of which the tumor thus formed is capable
must naturally vary considerably. Sometimes the organ can be pushed or
make its own way forward so as to come into contact with the anterior
abdominal wall on the same side, and not much lower than the normal
position, or it may pass considerably downward, and thus be confounded
with tumors arising from the pelvis.

This affection is much more frequent among women than in men, and the
right kidney is more frequently movable than the left: both, however,
are sometimes dislocated. It is observed in a much larger proportion of
cases in the laboring classes than in those whose work is less severe
and carried on in less constrained attitudes. Judging from the relative
amount of the literature of the subject, it would appear to be much
less frequently observed in this country than among the lower classes
of Germany, where so large a proportion of the severest outdoor labor
is carried on by women.

Various causes are assigned for this displacement. It is stated to be
usually congenital, but is not described as found post-mortem in
children with at all the frequency that it occurs in adults; and it is
certainly possible in adults to fix in many cases the beginning of the
disease with a reasonable degree of certainty. That a certain amount of
predisposition, or peculiarly favorable position of the kidney, or an
unusual laxity of connective tissue, exists in a certain number of
cases is undoubtedly true.

The next most important factor is undoubtedly a laxity of the abdominal
walls, affording a less firm and unyielding support to the contained
viscera, and a deficiency, usually an acquired one, of the fat
surrounding the kidney, which enables it in the normal condition to be
supported by the layer of peritoneum passing across its front from the
spinal column to the flank. This is seen in a certain set of cases
where the trouble dates from an acute disease or a rapid emaciation.
The well-known influence of repeated pregnancies is undoubtedly exerted
in this way.

Another set, especially those exceptional cases which occur in
strongly-built and not thin persons, are referable to severe shocks
received in gymnastic exercises, hard riding, or falls from a horse.

One of the most frequent causes, and one which accounts for the fact of
the affection being most prevalent among the working classes, is the
use of a tight strap or cord to support the garments. Corsets, which
exercise a more even pressure over a larger surface, do not have this
effect. The right kidney, from the position of its superior extremity
in front of the liver and its slightly higher place in the abdomen,
appears to be more influenced by this pressure than the left. The
movements of respiration, especially when reinforced by the forced
inspiration and {23} compression of the abdominal viscera accompanying
violent exertion, appear to assist in the dislodgment already favored
by the pressure of the girdle.

According to Müller Warnek,[3] who has laid especial stress on this
method of causation, a slighter degree of displacement is possible in
this way without or preceding the full development of wandering kidney.
A pressure is exercised upon the descending duodenum with which the
right kidney is brought into intimate relations behind, and bound down
by, the peritoneum; which leads, as Bartels supposes, to a hindrance in
the passage of food from the stomach, and consequent dyspeptic
phenomena. In these cases, when the kidney has become a more freely
movable one and has dropped farther down in the abdominal cavity, the
pressure on the duodenum ceases, the consequent symptoms disappear, and
give place to the dragging sensations and severe colicky attacks which
are apt to characterize an older case.

[Footnote 3: _Berl. klin. Woch._, 1877, 38.]

SYMPTOMATOLOGY.--There is great variety in the kind and amount of
effect which the movable kidney exercises on the general organism and
the local effects it produces. Neither the local nor the general
symptoms are necessarily proportionate in severity to the amount of the
displacement.

It may be said in advance that, contrary to what might be expected, the
symptoms are not usually connected with any disturbance in the urinary
function, and, although exceptions are not unknown, the rule is for a
displaced kidney to be an otherwise healthy one. Cystitis and uterine
affections have been observed in this connection, but it is doubtful if
any relation other than coincidence or a mutual dependence upon
impaired general nutrition and overwork exists between them. The
partial stoppages which might be supposed to arise from the twisting of
the ureters are not frequently observed.

Hysteria and hypochondriasis have been frequently attributed to this
lesion, and might undoubtedly find their exciting cause in anxiety
about a tumor of unknown character and origin; but there seems no good
reason to connect them in any other relation of causation. It is
undoubtedly true that many pains and discomforts exist in these cases
which are neither satisfactorily explained nor gotten rid of by being
called hysterical. These abdominal pains, especially of a dragging
character, and also the sensation as of something falling or moving
about in the abdomen, particularly when the patient assumes the upright
posture or makes unusual exertions, are very naturally connected with
the existence of the actual condition which is likely to give rise to
them. Müller Warnek has recorded the frequent coincidence of flatulent
dyspepsia and dilatation of the stomach depending on retention, and its
consequent fermentation, in connection with the movable kidney and its
supposed pressure on the duodenum. It is not probable, however, that
all the symptoms are to be explained so simply, but it is quite as
likely that the dragging and tension of the pedicle may have a remoter
effect through the renal and sympathetic nerves.

Severer attacks occasionally occur with violent colic and inflammatory
symptoms, the tumor formed by the misplaced organ becoming exceedingly
sensitive to pressure. These have been attributed to some {24}
incarceration, but there is no evidence that this accident occurs, and
it has not been found after death. They are probably due to a localized
peritonitis of the investment of the kidney, or perhaps to simple
neuralgia. Icterus and hepatitis, consequent upon a circumscribed
peritonitis set up by the pressure of the movable kidney upon the
liver, have been observed.

Death is not one of the usual results of this affection, but a recent
surgical writer (Keppler[4]) has called attention to cases where
long-continued dyspeptic symptoms, with constant pain and the chagrin
and melancholy due to inability to work, have been followed by death
from exhaustion, and nothing except a movable kidney has been found at
the autopsy.

[Footnote 4: _Arch. für Klin. Chirurg._, 1879.]

There can be no doubt that in many cases the symptoms are more severe
than might be supposed from the ordinary descriptions, and are very
unfairly characterized as hysterical. On the other hand, many cases are
attended with but the mildest form of the symptoms just described, and
the patients, ignorant of any tumor either from its discomfort or from
having felt it, live in health and comfort for many years.

DIAGNOSIS.--The diagnosis of this condition, if the physician keeps in
mind the possibility of its occurrence, is usually not difficult. In
many cases a tumor has been felt by the patient which when called to
the attention of the physician is recognized by its shape. In some
cases in thin persons the form of the kidney, even to its hilus with
the strongly-beating artery, can be made out. It glides easily from
between the fingers, and can be moved more or less remotely from its
normal position, to which, however, it returns without difficulty,
especially when the patient assumes the recumbent position. The
excursions are of course limited to a certain length of radius, of
which the origin of the renal vessels is the centre, and seldom go much
beyond the median line toward the side opposite to that on which the
movable organ belongs.

The usual statement of text-books, that a depression or lessened
resistance is to be felt in the loins of the side from which the kidney
is absent, and a diminution of the normal dulness, which returns again
when the organ is replaced, rests, as regards the majority of cases,
rather upon theoretical considerations than on actual observation. The
thickness of the lumbar muscles, upon which the kidney rests, is such
that the dulness on percussion is not capable of much change. In most
persons the outer limit of dulness in this region is not that of the
outer edge of the kidney, but of the extensor dorsi communis. Palpation
and percussion therefore in the renal region are not likely to be of
much value in diagnosis, although an occasional case appears to justify
the ordinary statement. The hand-and-knee position described above
would be more likely than any other to show an existing depression.

Palpation for the purpose of finding the tumor, if it be not at once
evident, or for examining it after it is found, should be bimanual, one
hand being placed in the space between the ribs and the crest of the
ilium of the supine patient and pressed strongly upward, while the
surface rather than the points of the fingers of the other hand should
be carried and pressed with some firmness into the relaxed abdominal
parietes. In this way the kidney may be caught between the two hands
and examined more or less completely according to the thickness of the
abdominal walls. Sometimes the kidney can be partly grasped between the
{25} finger and thumb of one hand. In this way the size, shape, and
sensitiveness of the tumor can be determined, as well as its position
and movability.

A movable kidney may of course present some difficulties of diagnosis
from other abdominal tumors. The liver is sometimes, though very
rarely, movable, and never to the same extent as a wandering kidney,
and as it is pushed downward discloses its much greater bulk. The base
of the gall-bladder may occasionally be quite movable, but its
excursions are of a more limited radius, being of course executed only
by the base and not the whole organ.

The spleen, when it descends so as to be distinctly felt below the
ribs, is much less movable, and if it descends deeply without great
enlargement, its absence from its proper place is demonstrable by
percussion. The splenic tumor is also larger, firmer, and more closely
applied to the abdominal walls than the floating kidney. The left
kidney, it should be remembered, is less frequently movable than the
right.

A small ovarian tumor might be mistaken for a movable kidney low down
in the abdomen, or vice versâ. The latter error has actually been
committed, and has led to an attempted removal of the supposed cyst.
The more easy movability of the kidney upward and of the ovary downward
or laterally, as well as the shape, and in many cases the result of a
vaginal examination, should be sufficient to make the distinction,
which, if an exact diagnosis be absolutely necessary, may be confirmed
by aspiratory puncture.

A malignant omental tumor might at the first examination present points
of difficulty in diagnosis, but even if it were single and
counterfeited with considerable accuracy the shape of the kidney,
neither of these conditions would be likely to continue for any length
of time.

TREATMENT.--The treatment usually suggested for this affection is based
partly on the fact that many cases are hysterical, and also on that
other more important one, that very little can be done to restrain the
vagaries of the offending organ.

A correct diagnosis, it has been frequently remarked, is often
sufficient to relieve the patient's mind, and secondarily her body, and
may be all that is necessary in cases where the symptoms are all
psychical and have arisen from the discovery of a tumor of unknown
nature.

As a relief from the more serious annoyances the avoidance of certain
disturbing causes may be of value, and such will consist in a proper
regulation of the bowels and consequent avoidance of straining, and the
choice of an occupation as little laborious and involving as little
work in the upright posture as possible. No tight, narrow girdle should
be worn about the upper part of the abdomen.

On the other hand, the use of a tight bandage over the whole abdomen is
usually recommended, and seems to be useful in a small proportion of
cases. It can of course act only by rendering the whole abdomen a
little more tightly packed, and cannot exercise much restraint on any
special portion of its contents. Pads of various shapes worn under the
bandage may bring a little more local pressure to bear. One shaped like
a carpenter's square, with an ascending branch to check the lateral
movements, and a horizontal one to prevent the descent of the tumor,
has been proposed. A truss with pads adapted to the loins and a front
pad over the kidney has also been used.

{26} It is impossible to read the history of many cases of this
affection without becoming convinced that while the majority need but
the mental assurance of the harmlessness of the tumor to restore their
mental equilibrium, and others find their troubles bearable or capable
of relief by mechanical appliances, no inconsiderable number are
incapacitated from labor and the enjoyment of life by the necessity for
great care in their movements, or suffer from severe symptoms, as pain
and dyspepsia, which demand a more active treatment.

This has been afforded by operative surgery in two ways. Of these the
most obvious is removal of the offending organ. It has now been clearly
shown, by the number of nephrectomies that have been performed, that
one healthy kidney is sufficient to support the function of urinary
elimination; and if one kidney can be clearly shown to be healthy, the
other can be safely removed. Such an operation undoubtedly adds to a
patient's risks, since any subsequent renal affection is likely to
prove fatal; but it has been now done a considerable number of times
for the relief of the affection in question, and with good results. R.
P. Harris[5] has collected 16 cases with 10 recoveries, the organ
removed in 3 out of the 6 fatal cases being diseased. Only 2 of these
operations were by the lumbar incision, both being saved. They have
since been reported.

[Footnote 5: _Am. Journ. Med. Sci._, July, 1882.]

The operation has usually been done by the abdominal incision, which
offers the advantages of greater accessibility of the pedicle for the
purpose of ligating the arteries, and also greater ease in getting at
the kidney itself, since it has often formed a partly separate pouch in
the peritoneum, from which it would not be so easy to dislodge it by
the lumbar incision. The latter operation is, as just stated, by no
means impracticable nor specially dangerous. Of course it is desirable
to avoid for some time after the operation anything which, like the use
of diuretics or the excessive secretion of water, will throw any
increased work upon the remaining kidney until it has had time to
accommodate itself to them.

A singular case of attempted excision of a tumor supposed to be a
wandering kidney, which could not be found after the incision was made,
is recorded.[6] In this case the symptoms, which, as well as the
physical signs, had pointed distinctly to a movable kidney, disappeared
after the operation. The author compares this case to another, in which
great relief was experienced from a pretended operation for the removal
of normal ovaries.

[Footnote 6: _Hygeia_, 11, 12, 1880, Svensson.]

The other operation consists in the fixation of the movable organ. In
one case a curved needle bearing a strong tape ligature was passed into
the abdominal muscles, through the kidney, and out again. The ligature
remained for some time, giving a certain amount of relief from the
distressing symptoms, but maintaining a constant discharge until it
came away without having accomplished any permanent benefit. The kidney
was afterward removed by a lumbar incision, and a deep cicatrix found
running longitudinally along the otherwise healthy organ.[7]

[Footnote 7: A. W. Smyth, _New Orleans Med. and Surg. Journal_, Aug.,
1879.]

In other cases[8] a dissection has been made until the kidney was
reached, which was then, with its adipose capsule, stitched firmly into
{27} the wound. In one of these cases the kidney became somewhat
loosened again, but it is possible that the risk of this accident might
be avoided by some modification in the operative procedure. If this
operation can be made a successful one, and generally accepted, of
which as yet the paucity of cases hardly permits us to judge, it is
manifestly far preferable to removal, since it leaves in its place an
organ usually perfectly capable of performing its functions.

[Footnote 8: Hahn, "Fixation of Movable Kidney," _Am. Journ. of Med.
Sci._, April, 1882, from _Cbl. für Chirurgie_, 1881.]


Polyuria; Diabetes Insipidus.

Polyuria is the name of a symptom the presence of which may be easily
ascertained beyond a doubt, but which is notwithstanding occasionally
overlooked. Its existence is to be determined by measuring the urine.
In extreme cases this may be unnecessary, but slighter forms may easily
escape notice if this is not done. The quantity of urine normally
secreted varies considerably, owing to many causes, of which the
principal are--the quantity of fluid ingested, not necessarily in the
form of beverages, but of food more or less succulent; the activity of
the other secretions, especially those of the skin and the intestines,
and the presence of substances which increase the rapidity of its flow
through the kidney or stimulate the glandular cells; and, to a certain
extent also, individual peculiarities.

The quantity of water furnished by the kidneys depends largely upon the
excess of pressure in the vessels, and especially in the Malpighian
coils, over that in the interior of the tubes, and is consequently
influenced by the general blood-tension.

The second factor of importance is the calibre of the renal vessels,
especially the arterioles; and the third, the freedom of exit of the
formed secretion from the uriniferous tubes. A certain amount of back
pressure, so far from diminishing the amount of urine, seems to
increase it, as shown in some of the cases of surgical polyuria, where
the normal amount is considerably exceeded, while the renal parenchyma
is being gradually destroyed.

The arterioles of the kidney being, like all other arterioles in the
body, under the control of the nervous system through the vaso-motor
nerves, it is easy to see how the various affections of this
controlling element may act upon the secretion of urine; neither is it
possible to deny (although by far the most important factor in the
rapidity of the urinary secretion has been shown to be the
blood-pressure) that the nervous system may have a direct effect upon
the secreting renal parenchyma.

The normal quantity of urine for an adult of medium height and weight
and ordinary habits as regards the ingestion of liquids may be stated
as fifty fluidounces, or a liter and a half, which is of course to be
considered as only a very rough approximation. One liter on the one
hand, and two liters on the other, can hardly be considered
pathological limits, unless the increase or decrease takes place under
circumstances which ought to produce the opposite effect.

Frequency of micturition, especially if nocturnal, is often considered
almost a proof of polyuria, but can at most only justify a presumption
of it, which is to be confirmed or not by exact measurement. Any {28}
existing polyuria is likely to be greater during the night. Frequency
of micturition may mean polyuria, or, on the contrary, may coexist with
a considerably diminished total amount of urine; in which case it means
only increased irritability of the bladder, and is then a purely
nervous symptom; assuming, of course, the absence of inflammatory
trouble. The rapidity with which the secretion accumulates in the
bladder has a certain influence in determining the need for
micturition; that is, a bladder containing five ounces of urine which
has been gradually accumulating for some hours retains it with greater
ease than if the same amount had been rapidly secreted, as, for
instance, after a full meal with an abundant supply of fluids.

Polyuria is often, or always if persistent, an important symptom, and
the suggestions made by it can easily be added to and confirmed by a
more minute examination of the urine. Thus we may have the following
combinations indicating important diseases:

Polyuria, moderate, with diminished specific gravity, albumen usually
in small amount, and some casts; in chronic interstitial nephritis;

Polyuria, with pus and mucus and débris from the urinary passages,
usually turbid and often alkaline and offensive; in irritation of the
kidneys depending on lesions of the deeper urinary passages, prostate,
or bladder (surgical polyuria);

Polyuria, with increase of urea (azoturia);

Polyuria, with increase of phosphates (phosphaturia);

Polyuria, with increased specific gravity and sugar; in diabetes
mellitus;

Polyuria, with decreased specific gravity and diminished or normal
solids; in diabetes insipidus.

These conditions have many points of mutual contact and resemblance,
but the affection which is the subject of the present essay is diabetes
insipidus--_i.e._ that form of polyuria which is accompanied by no
abnormal constituents except occasionally inosite, a very little sugar,
or a very small amount of albumen. In the cases where these
constituents might lead to difficulties in the way of diagnosis the
absence of other symptoms of the disease likely to be mistaken will
suffice to mark off the affection as entirely distinct.

The normal elements may be decreased, normal, or increased. The disease
thus defined includes not only diabetes insipidus, but many cases of
so-called phosphaturia and azoturia, which, if not exactly coinciding,
have many points in common.

In some cases which, from the character of the urine as well as from
the other symptoms, should evidently be classed as diabetes insipidus,
the quantity of urine, although somewhat increased, is not very
excessive, reaching perhaps two liters, but in the great majority is
discharged in much larger quantity. In a case which came under the
observation of the writer by the kindness of H. E. Marion the amount of
urine gradually rose from two or three gallons to five or six and
seven, and on one occasion the patient, a girl of fifteen, after some
unusual excitement is supposed to have passed eight gallons in the
course of twenty-four hours. Of this eleven quarts was by actual
measurement, and passed in the presence of her mother in the course of
the afternoon.

The urine in these cases is, as would naturally be supposed, of a very
{29} pale color and of low specific gravity, which from 1005 to 1010,
representing the usual range, may in extreme cases fall to or even
below 1001 as measured by the ordinary urinometer. I have seen no case
recorded where the specific gravity of such a urine has been determined
by instruments of greater delicacy. Its odor is comparatively faint,
but it is somewhat prone to decomposition. The solid constituents are
often somewhat increased in the twenty-four hours, especially the urea,
which may be present in double the usual amount. This is probably the
result of an increased metamorphosis from the passage of so large an
amount of water through the tissues.

It is not always true, however, that the solids are increased, and the
difference in the amount of destructive metamorphosis taking place in
different cases is probably closely connected with the clinical
differences which may be observed in regard to the amount of wasting
and affection of the general health. The phosphates are frequently
increased, as found by Dickenson and Teissier; and such an increase has
probably about the same meaning as the increase in urea. In other
cases, however, they take part in the general diminution of solids, as
in the case of Marion just alluded to, where they were reported as
absent, which undoubtedly means simply present in so small amount as to
escape the usual clinical tests.

Among the concomitant symptoms the most necessarily and closely
connected with the increased discharge of fluid is its increased
ingestion, so that the disease has been called polydipsia instead of
polyuria, it being assumed that the thirst is the initial and important
symptom upon which the diuresis naturally depends. It has been observed
in many cases, however, that the quantity of water drunk is very much
below that which is passed. In the case last spoken of the water
ingested in the form of drink was but a small fraction of the quantity
of the urine, so that the patient drank but two or three pints while
passing many gallons. In cases where the beginning of the disease has
been carefully observed patients have distinctly stated that the
increased discharge began before they felt increased thirst. This of
course takes no account of the quantity of water contained in solid or
semi-solid food. Polyphagia is occasionally seen, as in the oft-quoted
case of Trousseau, the terror of restaurant-keepers. So intense is the
craving for water that in several instances where attempts have been
made to limit its amount the unfortunate patient has drained the
chamber-pot. Emaciation is probably connected with increased
metamorphosis, as indicated by the increased secretion of urea and
phosphates. Dryness of the skin has been frequently noted, and has been
said to mark the distinction between polyuria and polydipsia, in the
former the skin being dry, and in the latter moist. In one case,
however, where copious perspirations were noted, the patient stated
positively that the polyuria began a number of days before increased
thirst was experienced. In another very extreme case, attended,
however, with no wasting, night-sweats occurred. Pruritus has been
mentioned as affording another point in the resemblance which
undoubtedly exists between the severer cases of this disease and
diabetes mellitus. Dyspeptic symptoms have been noted in some cases,
and oedema may take place, as in many wasting diseases.

The nervous symptoms are perhaps the most important in the severer {30}
cases. In some which have been examined post-mortem distinct nervous
lesions have been found, such as the remains of tubercular meningitis,
tumors involving the cerebellum, and softening of the floor of the
fourth ventricle; in others the patients are known to have been
syphilitic.

Severe headache is a symptom of some importance, occurring in a
considerable number, but not the majority, of cases. Atrophy of the
optic nerve was present in two reported cases, to which the writer can
add a third, where failing vision, headache, and emaciation were the
principal and earliest phenomena, while at a later period the atrophy
was demonstrable by the ophthalmoscope. The polyuria in this case,
though marked, was not excessive, and the patient, a young man, after
remaining for some years in a condition of chronic invalidism, died.
Chronic interstitial nephritis had of course been suspected and sought
for, but no evidence of it found beyond the symptoms already stated;
neither were there any more definite cerebral symptoms.

Finally, it should be stated that a great many cases of this kind have
no marked symptoms at all except the essential one, and so long as they
are supplied with a sufficient amount of fluid live in comfort with
their single inconvenience.

The diabète phosphatique of Teissier[9] should be cited in this
connection. In only a small proportion of his cases where an excess of
phosphates was noted was the quantity of the urine also increased, and
in these the symptoms seem as appropriate to the polyuria as to the
phosphaturia. It is worthy of note, however, that one series of his
cases is connected with disease of the nervous system; another
alternates or coexists, as does also diabetes insipidus, with diabetes
mellitus; and his fourth class closely resembles, with the exception of
the increase of phosphates (if this can be looked upon, after what has
been said above of the increase of solid urinary constituents, as an
exception at all), the affection last named--_i.e._ diabetes mellitus.
In fact, many of these cases of Teissier read like what would have
evidently been called, without a quantitative analysis, simply polyuria
or diabetes insipidus.

[Footnote 9: _Du Diabète phosphatique_, par L. S. Teissier, Paris,
1877.]

According to Teissier, the presence of an excess of phosphates in the
blood is sufficient to determine a polyuria. It is possible that in
many cases where a polyuria accompanies phthisis, as noted in many of
his cases, the symptom may be really due to actual organic (perhaps
amyloid) disease of the kidney.

The COURSE AND TERMINATION naturally vary greatly with its etiology and
the diseases with which it is associated. In some cases where nutrition
is but little affected, and no attempt is made to check the natural
appetite for water, the disease may go on for years with no essential
change or impairment of the general health, as in the remarkable one
quoted by Dickenson, where a French infant had at the age of three
impoverished her family by her demand for water, which seems to have
been an expensive luxury, and at a later period kept her husband--to
whom, however, she bore eleven children--in a constant state of
impecuniosity by the same depraved appetite. At the age of forty she
drank in the presence of a scientific commission within ten hours
fourteen quarts of water, of which she returned through her kidneys ten
to their astonished gaze.

{31} When polyuria is merely a symptom of cerebral inflammation, of
central tumor, of syphilis, or of phthisis, the course and prognosis
will of course be that of the primary disease. It occasionally comes on
during pregnancy, and in one such case it is stated to have ceased two
days after delivery, and in another the secretion, uninfluenced by
parturition, resumed its normal quantity when lactation was fully
established.

It is very rare, if indeed it ever happens, for life to be terminated
by diabetes insipidus unaccompanied by any other disease, although from
its association with many and severe affections, both of the nervous
system and of the kidneys, it must of course not unfrequently happen
that a patient dies in, though not on account of, the polyuric state.
It is strange to observe, however, as has been often before remarked,
how thin a shell of renal structure will suffice to carry on not only
the usual, but an excessive, flow of water.

The ORIGIN of diabetes insipidus has been found in several conditions.
Greater disposition toward it exists in early life, although it is by
no means confined to youth. After middle life polyuria is likely to
awaken the suspicion either of chronic interstitial nephritis or of
prostatic disease, or other affection of the urinary passages setting
up a sympathetic irritation of the kidney. It has been found to
originate during convalescence from acute diseases, with perhaps
preference for meningitis. Syphilis has its share of cases, as in most
other organic nervous diseases. Shocks of various kinds, including
fright, sudden or prolonged immersion in cold water, the rapid
ingestion of large quantities either of water or of alcoholic fluids,
are undoubted potent factors. In this respect, again, we may see the
resemblance between diabetes without sugar and true or saccharine
diabetes. It is favored by the hysterical diathesis. A very interesting
case of severe hysteria with hemianæsthesia and hemiplegia and other
marked symptoms varied for a time between almost complete anuria and
the most profuse discharge of over two hundred ounces per diem.

A most interesting group of cases has been recorded by Weil,[10] where
out of a family of 91, 28 were polyuric. The head of the family, a
polyuric, lived to the age of eighty-three, while his descendants were
robust, many of them attaining a good old age. There were no anomalies
of the circulation, and the persons affected were not alcoholics. Their
only complaint was of a troublesome thirst, and they declined
treatment.

[Footnote 10: _Cbl. für die Med. Wiss._, 1884, p. 263, from _Virch.
Arch._, xcv.]

The PATHOLOGY of diabetes insipidus, so far as is positively known, may
be gathered from the previous account of its etiology and symptoms. It
is evidently of nervous origin in the great majority if not all cases.
It is often connected with distinct lesions of the nervous system, and
attended with other nervous symptoms. In some cases it occurs in
connection with a well-marked hysterical diathesis. The copious flow of
pale urine as a sequel to the hysterical paroxysm is well known, and
the same thing often attends a severe nervous headache in either sex.
It is probable that the polyuria attending lesions of the urinary
passages is a reflex nervous phenomenon, since it may be present when
there is no suspicion of organic renal disease.

Guyon[11] states that surgical polyuria occurs under three {32}
conditions--painful excitation of the sensibility of the deeper portion
of the urethra or the vesical mucous membrane; repeated attempts to
urinate during the night; retention of urine more or less complete, but
especially when there is distension of the bladder. Of the first cause
he gives an instance in the case of a young man who had a polyuria
whenever a bougie was passed beyond a urethral stricture.

[Footnote 11: _Leçons cliniques sur les Maladies des Voies urinaires_,
Paris, 1881.]

Where, however, polyuria, especially chronic, is due to habitual
over-distension, it is in the highest degree probable that it is at
least partly due to structural alteration of the kidney. The well-known
experiment of Bernard, by which an increased flow of urine was induced
by a puncture of the floor of the fourth ventricle, and those of
Eckhard on section of the splanchnic nerves, show how it is possible
for nervous affections to influence the secretion of urine, though the
path or paths of the influence are by no means completely made out.

One of the most noticeable points in the pathology of the more
excessive cases of polyuria is the disproportion which often exists
between the amount of fluid ingested and the amount discharged, the
latter often exceeding the former several times. The source of the
excess of water has not been satisfactorily determined, but it is
evident from a careful experiment of Watson, repeated by Dickenson,
that the body has under some circumstances the power of appropriating
water from the atmosphere instead of discharging aqueous vapor through
the lungs and skin as usual. In the experiments referred to persons
affected with extreme polyuria were weighed immediately after passing
water, and again after as long an interval as they were able to
restrain their thirst, of course being also without food and under
observation, when it was found that the weight had been increased by a
number of ounces. In Dickenson's case, weighing thirty pounds more or
less, where the amount of urine excreted daily was from seven to nine
liters, the gain in weight at several observations was as follows: in
three hours, 15½ oz.; in five hours twenty minutes, 19¾ oz.; in three
and a half hours, 3¾ oz.

The DIAGNOSIS of this affection rests, in the first place, upon the
determination of a permanent increase in the quantity of urine passed
considerably above the normal, and, as has been already remarked, may
require a measurement of the daily amount--a procedure which it is well
to make a matter of routine in any cases where urinary trouble may be
present. The increase being found, if it be very great it will only
remain to determine whether sugar be present, which will be indicated
by the specific gravity and the appropriate chemical tests. Traces of
sugar are sometimes found in cases of polyuria which do not present the
characteristics of saccharine diabetes, and can hardly be considered to
materially affect the character of the disease.

A specific gravity decidedly above normal, with an excessive quantity
of urine, is not likely to belong to anything but diabetes mellitus,
though the chemical tests should never be neglected. If, however, the
polyuria be only moderate, it becomes necessary to exclude surgical
affections of the urinary passages, especially an enlarged prostate,
often attended with retention and distended bladder. Pyelitis and
hydro-nephrosis may also give rise to the same condition of
over-activity of the kidneys. The appropriate surgical examinations
with the sound may be necessary, but the presence of pus, bacteria, and
the epithelium of the urinary passages {33} in the surgical urine, as
well as its frequent alkalinity, may direct a very strong suspicion
before the sound is used. The age of the patient also will be of
considerable weight in this connection.

A point of real difficulty of diagnosis, and great importance for
treatment and prognosis, is the distinction between simple polyuria not
excessive, but attended by constitutional symptoms, such as impaired
nutrition, dyspepsia, and severe headache, from chronic interstitial
nephritis, which often makes its appearance with similar symptoms.
Mistakes between these two affections have undoubtedly occurred, and
can in many cases hardly be avoided except by reserving the diagnosis
for a time.

The similarity is rendered still more deceptive by the undoubted
occurrence of a trace of albumen or a hyaline cast or two in cases of
nervous disturbance, without justifying a diagnosis of progressive
renal disease. High arterial tension also is likely to be found in both
conditions. Nothing but repeated and careful examinations of the urine
and of the circulation, especially at times when the nervous symptoms
are less marked, and often a considerable amount of time, can fix the
diagnosis.

Hypertrophy of the heart, and even slight dropsy, will undoubtedly be
extremely decisive symptoms, but are not likely to occur until after a
time when the doubt no longer exists. In other cases it may be highly
important to carefully exclude organic cerebral disease before making a
diagnosis of simple polyuria.

It is hardly appropriate to speak of a diagnosis from azoturia or
phosphaturia, since these conditions are extremely likely to exist
coincidently with typical polyuria and to make a part of the same
disease. It is of much importance, however, to ascertain their presence
with reference to the probable effect of the disease on the nutrition.

In regard to the TREATMENT, it may be remarked, to begin with, that
restriction of water, although naturally diminishing somewhat the
discharge of urine, does not cure the disease, but, on the contrary, in
many cases augments not only the discomfort of the patient, but tends
to the dryness of the skin, dyspeptic and nervous disturbances, and
emaciation. Patients may recover flesh, strength, and spirits on being
allowed to drink ad libitum, even although the inconvenience of
excessive urination be thereby somewhat increased. Sufficient food and
drink should therefore be allowed, although a patient may be ordered to
observe such moderation as will not put his powers of endurance to too
severe a test.

Of the drugs proposed, nearly all have offered some prospect of
success, and have been accordingly reckoned almost specifics. Opium has
in some cases been found as useful in these cases as in diabetes
mellitus, and probably, as in that disease, by diminishing the
sensitiveness of the nervous system. Valerian and valerianate of zinc,
recommended by Trousseau and apparently successful in his hands, have
reckoned both failures and successes in the hands of others. Nitric
acid, in the dose of from 1 to 5 drachms per diem of the dilute in a
large quantity of water, is said to have been highly efficacious in one
series of cases.[12] It is given until aching of the jaws and teeth,
with some gingivitis, denoting its constitutional action, is produced.
It was more successful than any other drug in Marion's case, although
the specific symptoms were not produced, the patient being now in good
health or free from {34} her trouble. Atropia from its general action
in diminishing secretion has been tried, and with occasional alleged
success, but with many more failures. Pilocarpine from its action on
the skin might be of value in those cases where the skin is very dry,
but has no very general applicability.

[Footnote 12: Kennedy, _Practitioner_, vol. xx. p. 95.]

The drug most frequently employed, and which can claim a larger
proportion of successes than any other, is ergot in full doses, half a
drachm or a drachm (2 to 4 cubic centimeters of the fluid extract)
several times per diem. Its method of action is undoubtedly in the
contracting effect which it exercises on the renal arterioles. In many
cases it has decidedly diminished the amount of urine, and in some a
permanent cure seems to have resulted.

In estimating the value of drugs in certain cases of this affection its
not infrequent neurotic origin should be borne in mind, as well as the
very capricious effect of supposed remedies in the hysterical
diathesis. Unfortunately, many cases remain rebellious to all drugs,
and can only be rendered as little uncomfortable as possible.

What has been said of treatment applies only to the well-marked cases
of diabetes insipidus. Polyuria, as a symptom of other diseases or of
surgical affections, is hardly likely to call for treatment other than
that of the disease upon which it depends.


Albuminuria.

Albuminuria signifies a condition in which albumen appears in the
urine, and has by some writers been made of equal significance with
nephritis or Bright's disease. It is hardly necessary to say that this
coincidence is far from being an exact one, and that the symptom may
exist without Bright's disease, and also Bright's disease without the
symptom. For our present purposes albuminuria will be taken to mean
those conditions in which albumen may be found in the urine without the
existence of decided diffuse nephritis. As a symptom, and a highly
important one, of Bright's disease it will be considered elsewhere.

Albumen is secreted in the kidneys chiefly in the Malpighian capsules,
where, if at all abundant, it may be easily demonstrated after death by
hardening the kidneys by boiling. This coagulates the albumen in situ,
where it may be shown by sections prepared in the usual method. It has
been supposed that albumen is normally secreted in the capsules of the
healthy kidney, and afterward absorbed by the epithelium lower down;
but this view can easily be shown to be erroneous by subjecting a
kidney which has not secreted albuminous urine to the process just
described, which shows no coagulated albumen in the place where it
ought to be most abundant.

The albumen found in the urine is chiefly that which forms the most
important portion of the blood-serum, although other albuminoid bodies
have from time to time made their appearance and have some diagnostic
importance. Semmola[13] states that the albumen appearing in the urine
in true Bright's disease differs from that found with the cardiac or
amyloid kidney. The distinction can, according to him, be shown in {35}
the appearance of the precipitate to a practised observer, and also by
a more rapid diffusibility through animal membranes. He admits,
however, that he has in vain sought for any distinct and clear chemical
test by which the difference can be recognized.

[Footnote 13: _Archives de Physiologie_, 2d Serie, tome ix., and 3d
Serie, tome iv.]

Fibrin may occur in inflammatory conditions in the form of coagulated
masses, and hence cannot affect the question of the presence of
albumen. Casein has not been detected with certainty. Various
albuminoid bodies, called albuminose, paralbumen, metalbumen, and
serum-globulin, are occasionally met with in renal disease, and may
give rise to some confusion during an analysis. They are at present,
however, more suitable for chemical than for clinical study.

A variety of albumen is said to occur in osteomalacia which is not
coagulated by heat alone nor by heat and nitric acid. This has been
called Bence Jones's albumen, but has been seen by others. Peptone has
been found in urine, but usually in such specimens as have been or
which afterward become albuminous. Its exact signification when alone
cannot be more exactly stated, as it has appeared in a variety of
diseases, though not in perfect health.

Finally, a protein body, a ferment called nephrozymase, may be thrown
down from every urine by an excess of alcohol.

Hæmoglobin gives a dark-red color to the urine, which on boiling forms
a brown coagulum floating on the surface.

Hæmoglobinuria may be produced in animals by the intravenous injection
of large quantities of water, causing a dissolution of the corpuscles,
but the degree of hydræmia necessary to produce this condition is much
in excess of any met with in diseases of the human being.

Human hæmoglobinuria may be the result of various pathological
conditions, among which may be mentioned some infectious diseases,
jaundice, burns, and the effects of many poisons, as well as the
transfusion of sheep's blood.

Intermittent hæmoglobinuria, which is attended with fever, is usually
the result of cold acting upon predisposed persons. The color of the
urine and of the coagulum, together with the absence of red corpuscles
under the microscope, will distinguish urine of this character from
others which are also coagulable by heat.

Several methods are in use for the detection of albumen. Of these,
boiling is perhaps the oldest and most generally employed, and if
conducted with due care is a very delicate and useful test. The urine
to be tested should be clear and slightly acid, when on boiling the
albumen, if present, will be precipitated in whitish flocculi, more or
less abundant according to the amount, or, if the quantity is very
small, as a turbidity. The flocculi soon settle to the bottom of the
tube when it cools, and the thickness of the deposit formed gives an
approximation to a quantitative estimate. It is to the proportionate
thickness of this deposit that the terms 30 or 50 per cent. of albumen
are commonly but incorrectly applied. If the quantity is very small, it
may not be distinctly perceptible until after cooling.

If alkaline or very slightly acid urine is boiled, a deposit of
phosphates will be thrown down which closely resembles that from
albumen, while, on the other hand, the albumen remains undissolved
unless in large amount. These deposits of phosphates differ a little in
appearance from {36} an albuminous one, but in order to be accurate
acetic or nitric acid should be added, drop by drop, to the hot urine,
when the phosphates will be redissolved and the albumen, if present,
precipitated. It is better, however, to add the acid cautiously to the
point of slight acidity before boiling. A recent work[14] gives the
following directions for this reaction, which is then "absolutely
conclusive and surpassed in delicacy by no other:" "The urine is first
made distinctly acid with some drops of acetic acid, and then about
one-sixth of its volume of a concentrated solution of chloride of
sodium or sulphate of sodium or magnesium added. If the urine contains
albumen, a precipitate of coarser or finer flakes appears on boiling."
This reaction may be used as a quantitative test by diluting and
acidifying, if necessary, a known quantity of urine, washing the
precipitate on a weighed filter, drying, and weighing the whole.

[Footnote 14: _Die Lehre vom Harn_, Salkowski und Leube.]

An exceedingly delicate and convenient test is that by nitric acid. The
acid is placed in the bottom of a conical wine-glass, and the urine,
filtered if necessary, allowed to flow on top of it from a pipette, so
as to disturb the plane of junction of the two fluids as little as
possible, and leave a distinct line of demarcation. At this plane of
union, if albumen be present, will be formed an opaque white line
varying in thickness according to the amount of albumen, so that after
some practice and with care an approximate estimate of the percentage
may be made. A deposit of urates may sometimes be formed a little above
the plane of union, but it may be distinguished by its position, by its
less distinct limitation on the upper surface, and also by its
disappearance on warming. In a very concentrated urine and in cold
weather this error may be conveniently avoided by previous warming of
the urine and of the reagent. The same remark applies to the brine
test.

A crystalline precipitate of nitrate of urea may give rise to error if
the urine be very concentrated or the experiment conducted in the cold.
This may be distinguished by its disappearance on warming or by the
microscope. The action of the nitric acid on the coloring matter of the
urine, forming a dark band at the point of junction, may obscure the
reaction, but with care will not give rise to mistakes.

Another test recently introduced, which presents some advantages over
the nitric acid, and is certainly quite as delicate, consists in a
saturated solution of common salt in water acidulated with about 5 per
cent. of the dilute hydrochloric acid of the _Pharmacopoeia_. This
solution should be used exactly in the manner described for nitric
acid. There is no change of color at the line of junction, and no
precipitate takes place there except albumen or peptone, or resins when
they have been administered. The opaque line of precipitate may, if the
amount of albumen present be small, require a short time to form, so
that in cases of doubt it is well to allow the test-glass to stand for
a few minutes. It will, however, show very distinctly in any cases in
which nitric acid shows any precipitate. The line does not, however,
increase in thickness and density in proportion to the amount of
albumen so exactly as that produced by nitric acid, so that the brine
test is not so useful for approximately quantitative use as the nitric
acid, although fully as delicate. If it be desired to distinguish
peptone from albumen, it may be done by a comparison of this test {37}
with the nitric acid, which does not throw down peptone. If a deposit
occur, which may consist of resin, the addition of more urine will
dissolve it if resin, while albumen will not be affected.

Picric acid is a delicate and often a convenient test. The dry acid may
be dissolved in the urine, or a saturated solution used into which the
urine may be slowly dropped, each drop making a slight whitish cloud as
it slowly falls through the yellow solution.

The iodo-hydrargyrate of potassium is perhaps the most delicate test of
all: Potassii iodidi, 3.32 gm.; Hydrarg. bichlor., 1.35 gm.; Acidi
acetici, 20 c.c.; Aq. destill. q. s. ut fiat 100 c.c.--Tauret's test.
It may be used in the same way as the nitric acid or brine, or simply
intermixed. Its only disadvantage is that it throws down alkaloids, but
as this will not happen unless the alkaloid be taken in large
quantity--as might happen, for instance, in the case of quinine--the
chances of error from this source are not very great if this
peculiarity be borne in mind.

Ferrocyanide of potassium in an acid solution has recently been
proposed as a convenient test. It may be made up into pellets with
citric acid or used in the same combination in the form of papers.

The phenic-acid test is prepared as follows:

  Ac. phenic. glacial. (95 per cent.), drachm ij;
  Ac. acet. puri.,                     drachm vij;
  M.  Add liq. potassæ,                ounce ij-drachm vj.
          Millard.

This is said to be very delicate, but the writer has no experience with
it.

Tungstate of sodium is another recent addition to the list, which it is
evident is already long enough for practical purposes.

Several of the tests mentioned have recently been prepared in the form
of papers saturated with known quantities of the reagent and dried.
They may be carried in the pocket-book and applied at the bedside, if
desired, in a test-tube small enough to be very conveniently carried in
the vest pocket. The iodo-hydrargyrate is perhaps the most useful. It
is the most delicate, and a plan has been proposed for making with it a
quantitative estimate of considerable accuracy by means of a standard
solution or piece of gray glass adjusted by such a solution, with which
the precipitate produced can be compared as to its opacity.

Exact quantitative examinations for albumen may be made by several
processes, but that by boiling, if carried out with the precautions
described in works on chemistry, is as accurate as any, and probably
the best adapted to the needs of the practitioner if he should wish for
such results.

For clinical purposes, however, it will rarely if ever be found useful
to determine the amount of albumen more accurately than can be done by
the various approximations mentioned above.

When even the smallest trace of albumen is discoverable by any of these
methods, the question of the integrity of the kidneys at once arises--a
question which a few years ago would have been considered as settled in
the unfavorable sense by the same occurrence.

It is necessary to distinguish, first of all, between an essential and
an accidental albuminuria, the first referring to that condition where
the albumen is secreted with the urine and forms an essential part of
it, and {38} the other to the accidental admixture from the presence of
pus or blood, which may have made its appearance at any point below the
secreting tubes. When hemorrhage takes place from the kidney, albumen
is of course present in the urine, but its signification under these
circumstances is entirely different from that which it bears when
unaccompanied by the corpuscular elements of the blood.

No means at present exist for determining whether a small amount of
albumen present in the urine is more than enough to be accounted for by
the pus or blood known to exist by the presence of its corpuscular
elements or of its coloring matter. An approximate estimate may be made
by one familiar with such examinations, but no rule can yet be laid
down. Such a rule might be approximately established by a succession of
counts with the hæmocytometer of the corpuscles found in albuminous
urine of known percentage, or estimates of hæmoglobin by color tests.

The exact conditions of the kidney or of the blood which may cause the
appearance in the urine of albumen without blood or pus--that is, of
true albuminuria--have been the subject of much experiment and
argument, which it would be impossible to reproduce, even in outline,
within the limits of this article; and this is the less to be regretted
since they have as yet led to no practical or generally accepted
conclusion. A few of the more important facts bearing on the question
may, however, be stated here.

Albumen other than serum-albumen, when introduced into the circulation
either by injection into the veins subcutaneously, or if in very large
quantity by the mouth, is rapidly excreted by the kidneys. This albumen
also, if collected from the urine of the first animal and injected into
the vein of a second, again comes through the kidneys. The albumen,
however, which is obtained from the urine of an ordinary case of
albuminuria--that is, serum-albumen--does not behave in this way, but
is not excreted through healthy kidneys. These facts seem to show that
the appearance of albumen in the urine in ordinary cases of renal
disease is not to be attributed to any change in its quality
approximating it to egg-albumen, for instance, but is due to the
condition of the kidneys.

Disturbances of the renal circulation, especially those giving rise to
venous stasis, are very likely to cause albuminuria; a temporary
ligature of the renal vein causes albumen to appear in the urine after
its removal, and ligature of the ureter has the same effect.

The albuminuria succeeding the collapse of Asiatic cholera or yellow
fever seems to have a somewhat similar origin, being the result of
re-establishment of the circulation after extreme anæmia of the kidney.
Clinical facts in general seem to point to simple disturbance of the
circulation and to alterations in the kidneys themselves as the usual
causes of albuminuria, though in many cases the lesion seems to be a
slight and temporary one.

Some other conditions under which such disturbances and alterations may
arise, exclusive of Bright's disease, are the following:

Munn[15] found albumen in small quantities in 11 per cent. of cases
presenting themselves for life insurance, supposing themselves healthy
and having no lesions of heart or lungs. It is not stated whether casts
were found in these cases or not, and their value as representing
healthy {39} persons cannot, it is obvious, be correctly estimated
until some time has elapsed. It is well known that renal lesions may be
exceedingly slow in their progress, and it is by no means improbable
that a part of these cases may have been really in the early stages of
a chronic form of Bright's disease. Albumen has been found in the urine
of boys and adolescents, as well as in that of healthy soldiers, tested
immediately after rising: in most of these cases the amount was
extremely small. Certain conditions, moreover, may greatly increase the
proportion of cases in these same classes in which albumen is present.
Thus, fatiguing exercise will bring it on in some persons, and the
urine of a body of soldiers if examined late in the day after severe
drill shows a much larger proportion of albuminurics than if examined
after rising. The urine of the pedestrian Weston is said to have
contained not only albumen, but casts. It is certainly not true that
fatiguing exercise will cause albuminuria in everybody, and it is not
claimed, even by those who report these and similar cases, that they
prove albumen to be a normal constituent. Some of the cases are
distinctly described as delicate without being actually ill. Cases have
been reported where cold bathing has been followed by temporary
albuminuria. Here it is in the highest degree probable that a
disturbance in the circulation is produced by contraction of the
cutaneous arterioles; and it is possible that we may find in this
increased sensitiveness of certain persons an explanation of the
occurrence of acute dropsy as a sequel to scarlatina or as the result
of exposure in only a small proportion of the cases where the exposure
takes place. It is hardly necessary to admit, on the basis of these
observations, that albumen is a constituent of healthy urine, although
this may be shown at some future day by still more delicate tests, but
simply that the renal circulation may in certain sensitive persons be
sufficiently influenced by slight and transient causes to permit
albumen to pass into the urine. It is the almost unanimous conclusion
of practical writers, taking fully into the account these
recently-ascertained facts of albuminuria in alleged health, that the
presence of albumen in the urine in sufficient quantity to be detected
by any of the ordinary tests is a decidedly serious symptom.

[Footnote 15: _New York Medical Record_, xv. 297.]

The influence of many well-recognized pathological states in bringing
about venous stasis, and that delay of the blood in the renal--and more
especially the Malpighian--vessels which seems the most essential
factor in the secretion of albumen, is well known, and its recognition
is of much importance in diagnosis and prognosis, since the unfavorable
signification of albuminuria in certain cases is liable to be
overrated, and a diagnosis of chronic renal disease made to depend upon
symptoms which really belong to some other affection. How far
alteration in the capillaries and epithelium is in each case concerned
in the production of albuminuria it is often impossible to say, since
any alteration in these elements which can be observed after death is
almost certain to be complicated with lesions which can disturb the
local circulation.

Cardiac obstructive disease is very likely to be accompanied by
albuminuria, and the state of the kidneys by which this condition is
brought about is undoubtedly venous congestion. The urine in a case of
this kind is usually scanty, of high specific gravity, high colored,
often with a deposit of urates, while the albumen appears in small
quantity. A few {40} hyaline casts are not infrequently seen, and do
not materially increase the gravity of the prognosis so far as renal
disease is concerned. The kidney which furnishes this urine is usually
a little harder and a little denser than normal, but with a nearly
normal microscopic structure, exhibiting but little more than
capillaries well filled with blood, and in the interior of some of the
tubes casts similar to those found in the urine during life.

Doubt may occasionally arise as to the diagnosis between a congested
kidney consequent upon valvular disease of the heart and an
interstitial nephritis with hypertrophy of the heart. In the latter
case, however, the urine, although containing albumen, is usually much
more copious and of low specific gravity. Diminished power of the heart
without valvular lesion may have as a consequence albuminuria which
disappears if the heart recovers its vigor.

In many of the cases in which albumen appears in the urine temporarily
it is not easy to say whether an actual nephritis may not be present,
though not sufficiently severe to give rise to other symptoms.

In almost any febrile disease of sufficient intensity albumen is often
found, and when such a case terminates fatally without renal symptoms,
the condition of the kidneys, consisting in more or less granular
degeneration of the epithelium, is often spoken of as parenchymatous
nephritis. If it is correctly called so, it is certainly very different
from the idiopathic form, whether acute or chronic, since it is very
rare for typhoid fever, for example, either to present the symptoms of
acute nephritis during life or to terminate in chronic Bright's
disease. In scarlatina, and rarely in other fevers, a distinct
nephritis is present, but a degeneration of structure sufficient to
produce albuminuria is in many instances a result merely of a high
temperature.

Many applications to the skin produce albuminuria, but in almost all,
if not all, of these an actual nephritis has been found to exist. The
same is true of poisoning with strong acids, phosphorus, and arsenic.

A very important form of albuminuria is that found during pregnancy,
more frequent with a first child or with twin pregnancy, and often
associated with other symptoms of nephritis. It is probable, however,
that in many instances it is a result of impeded abdominal circulation,
although it is very rarely that the gravid uterus can press directly on
the renal veins. In the severer cases a well-marked parenchymatous
nephritis exists; but it should be distinctly borne in mind that if
every instance of albuminuria in pregnancy is due to nephritis, it is
certainly a form of the disease which may lead neither to severe
symptoms nor to chronic disease. On the other hand, the appearance of
albumen in the urine of a pregnant woman, though not necessarily
calling for active interference of any kind, should always be a
danger-signal, and put the physician on the lookout for other
indications of actual renal disease.

In many nervous affections albumen may be found in the urine. It can be
produced, as was shown long ago by Bernard, by a puncture in the floor
of the fourth ventricle near to the point where a similar puncture
gives rise to diabetes. Lesion of the cerebral peduncles, section,
destruction, or irritation of the spinal cord, and irritation of the
renal nerves are also causes of this symptom. It is by no means
difficult to account for this phenomenon by the changes which take
place in the {41} renal circulation under influence of the vaso-motor
nerves which originate or pass through the peduncles, pons, and spinal
cord, although it is highly probable that similar results might follow
irritation transmitted from a distance. These facts are not without
practical importance, for they give rise to very considerable chances
of error in diagnosis; as, for instance, where a patient suffering from
severe headache, with possibly gastric symptoms, is found to have
albumen and casts in his urine, which is also copious and of low
specific gravity. It might not be easy to decide that such a case was
not one of interstitial nephritis with symptoms far from unusual, and
yet it might perfectly well be a cerebral tumor. The diagnosis would
demand a thorough search for other symptoms, such as double optic
neuritis on the one hand, as indicating cerebral disease and cardiac
hypertrophy, with high arterial tension on the other, as connected with
nephritis. A careful consideration of the order of their occurrence is
also desirable.

After an epileptic attack albumen may appear in the urine for a short
time, disappearing within a few hours. This occurrence might lead to an
erroneous diagnosis of uræmic convulsions if the examination happened
to be made shortly after a fit and not repeated at a later period.
Transitory mania may perhaps be placed in the same category.

Chronic mental disease, like general paralysis of the insane, is
frequently accompanied by albuminuria, and even temporary mental
disturbance in a sensitive person has been known to excite the symptom.

In narcotic poisoning both by alcohol and by opium a similar state of
things sometimes occurs. With alcohol, however, distinction is to be
made between chronic cases, where a suspicion of parenchymatous
nephritis may be fairly entertained, and acute alcoholism or delirium
tremens, where the albumen appears and disappears within a few days. In
a patient profoundly under the influence of opium the urine may contain
not only albumen, but casts, and the diagnosis of uræmic coma is very
likely to be made if nothing is known about the history--an error which
might be of great consequence, as tending to discourage the efficient
treatment necessary in opium-poisoning or causing the waste of time on
inefficient measures.

It is obvious from what has been said that the diagnosis of albuminuria
as a symptom is sufficiently simple with a little care in chemical
manipulation, but that its significance is not so easy to determine in
every case, since it is found in so many cases unconnected with chronic
or progressive renal disease, and on the other hand may be absent while
serious nephritis is going on.

Albuminuria, as defined at the beginning of this article--that is,
occurring in the absence of chronic and serious renal disease--is only
to be diagnosticated by the exclusion of such diseases, by careful
consideration of all the symptoms present, such as changes in the
quantity and specific gravity of the urine, in the force, rhythm, and
size of the heart, and of the arterial tension, as well as the relation
of the amount of albumen to the amount of urine and character of the
sediment as indicating one or the other form of nephritis. Thus a very
small amount of albumen with a highly concentrated urine is not likely
to be met with in the usual forms of nephritis, but is often found in
connection with valvular disease of the heart.

{42} Treatment is but rarely directed to this symptom, since, when
albumen is present in but small quantity, as usually happens, it is of
little or no consequence except as an important element in diagnosis,
while the few cases in which the amount is large enough to constitute a
serious drain upon the system are almost exclusively cases of actual
Bright's disease, and hence do not come under this head. The
administration of astringents, especially tannic and gallic acids, has
been found to diminish the quantity of albumen in the urine.

(A copious bibliography of this subject will be found in an article by
Ellis in the _Boston Medical and Surgical Journal_, vol. i., 1880.)


Renal Colic; Renal Calculus.

Renal colic is the appellation of a group of symptoms caused, in by far
the greater proportion of cases, by the passage of a renal calculus
through the ureter, or sometimes merely its engagement in the upper
extremity and impaction or subsequent falling back. Other foreign
bodies large enough to cause distension and obstruction, such as clots
of fibrin or portions of hydatid cysts, may give rise to the same
phenomena. Most physicians, however, have seen cases where the same set
of symptoms have not been followed either by the discharge of the stone
per urethram or by evidence of its continued sojourn anywhere in the
urinary organs. They may occur in persons of a neuralgic tendency in
connection with the uric or oxalic diathesis. The conclusiveness of
such cases, as proving the possibility of a purely neuralgic or
spasmodic attack, must of course depend upon the carefulness and
intelligence of the patient and the opportunities of the physician for
observation extending over years. As it is admitted, however, that
these symptoms may occur without the demonstrated presence of a
calculus, it would be perhaps better nomenclature to apply the term
renal colic to painful and spasmodic affections of the kidney and
ureter, however caused, and to describe the passage of a calculus or
other obstruction under its own name.

Calculi of various kinds, sizes, and shapes may be found in the pelvis
of the kidney. They are most frequently composed of uric acid, which
may exist alone or with layers of phosphates superimposed. They are
usually in concentric layers, more or less irregular in shape, and of a
reddish-brown color of various shades. Soft concretions of urates are
occasionally noted. Oxalate of lime is the material of many small
calculi, and may be the nucleus of a larger one or occur in alternate
layers with uric acid. These stones are of a dark grayish-brown and are
exceedingly rough and irritating. Among the most frequent constituents
of renal calculi are to be found phosphates, either of lime or the
triple salt of ammonia and magnesia. They may form layers with other
material, or constitute alone the largest and most curiously shaped of
all the renal calculi. Their surface may be smooth and almost polished,
or roughened, eroded, and almost crystalline in texture.

Cystine rarely forms a renal calculus, and xanthic oxide still more
rarely. Masses of fibrin resulting from renal hemorrhage are described.
They are said to be of the consistency of wax, tough and elastic.
Coagula of the ordinary form may also give rise to the same set of
symptoms. {43} On one occasion the writer saw the dilated pelvis of the
kidney filled with hundreds of spherical brownish soft masses from the
size of a mustard-seed to that of a pea, easily crushed in the fingers,
burning with the smell of albumen, and leaving but a small amount of
ash.

The size of renal calculi may vary from almost microscopic grains,
which then usually take the collective name of sand or gravel, and are
most commonly composed of uric acid, up to masses of some ounces in
weight, completely filling a dilated pelvis.

It is doubtful in what way renal calculi originate, their constituents
being always present in the urine, but rarely crystallizing out. The
uric-acid infarction of new-born children can hardly be considered as
accounting for any large number of cases, although it might be the
basis of calculi in young children. The uric and phosphatic deposits
sometimes found in the tubes of the more mature kidney may possibly,
when dislodged, be a point upon which additional quantities of the same
substances are deposited, but anything which delays in the pelvis or in
some of its calices a concentrated urine, especially if much mucus be
present, may be regarded as favoring the agglomeration of deposits. A
previous pyelitis is perhaps the usual cause of phosphatic deposits.
Small uric-acid calculi may sometimes be found in considerable numbers
in the sulcus surrounding some of the papillæ, and of a size which
could hardly afford any marked symptoms in passing down the ureter.
These, if any inflammation were to arise, would form a mass with pus or
mucus which might serve as a nucleus for a phosphatic calculus. These
suppositions are, however, rather theoretical and fragmentary, and do
not cover all the cases. Constitutional predisposition has been much
discussed, though not a great deal is known about it. A gouty tendency,
however, undoubtedly favors the production of uric-acid calculi.

A small renal calculus, when formed, may be the beginning of several
quite different sets of phenomena. Of these, the simplest and most
favorable event is its descent through the ureter into the bladder,
with its subsequent expulsion with the jet of urine from the urethra.
If the calculus be small and smooth, the passage through the ureter may
be attended with little or no uneasiness, but if it is large enough to
fill or distend the tube, and especially if the stone be irregular and
rough, its descent gives rise to excessively severe symptoms. These are
pain in the back at the level of the kidney, in the side and groin
corresponding to the ureter affected, sometimes shooting down the
thigh; with retraction of the testicle; usually no fever, but much
general depression; feeble pulse, coldness and paleness of the surface,
fainting, and vomiting. The beginning of the attack is usually sudden,
corresponding to the entrance of the calculus into the ureter, and the
pain continues without intermission, though with some remissions, until
its discharge into the bladder. The pain is usually of the severest,
and is described as cutting or tearing in character. It is probable
that an attack may sometimes end by the calculus, which has become
engaged in the ureter, falling back into the pelvis instead of
advancing through the ureter. In this case the pain ceases for the
time, to be perhaps subsequently renewed, or, if the stone grow larger,
so that it cannot re-enter the ureter, giving place to the symptoms due
to irritation of the pelvis.

The urine is usually diminished in amount until the arrival of the {44}
calculus at the bladder, when the fluid that has been retained is
suddenly discharged with the stone. Constant attempts to pass water
during the passage downward of the calculus are the consequence of
sympathetic irritation of the bladder, and not of accumulation of urine
therein. The urine is likely to be bloody, but is not necessarily so.
The smoothness or roughness of the surface of the stone is of much
importance as determining the presence of this symptom.

The DIAGNOSIS of renal colic is usually not difficult, but it may not
always be readily distinguished from hepatic or intestinal colic. The
suddenness of the attack and intensity of the pain, its location in the
side and downward to the groin, will in most cases make the condition
very characteristic.

From hepatic colic or the passage of a gall-stone the situation of the
pain, which is in the latter affection naturally somewhat farther
forward, the tenderness on pressure in the same region, and often the
whitish color of the stools or the presence of jaundice, as well as the
history of former attacks, will usually make the distinction a matter
of a high degree of probability.

Intestinal colic is usually referred to the middle of the abdomen, is
accompanied by constipation, while the movements of the intestines and
of flatus are often distinctly perceived by the sensation of the
patient or the ears of the bystanders, and on the whole the attack is
less severe and the pain less intense.

As has already been stated, it is probable that symptoms closely
resembling if not identical with those of the passage of a calculus may
occur when the substantial cause of them does not make its appearance;
and although many of these may perhaps be accounted for by the
ill-success of the search or by the calculus having ceased to pursue
its downward course and having become quiescent in the kidney, yet it
is well for the practitioner to be prepared for an occasional
disappointment in obtaining tangible proof of the nature of the attack.
Time may be required to decide whether an attack is due to calculus, or
is simply one of the spasmodic or neuralgic paroxysms mentioned above.

If after careful watching no stone makes its appearance, and on the
other hand the pain does not continue and no pus gives evidence of
pyelitis, it is highly probable that no stone is or has been present.

A true neuralgia of the kidney may undoubtedly exist. Lumbago and
lumbar neuralgia may simulate renal colic, but are almost always much
less severe, the pain less sharp and more dull and aching, aggravated
by movement, while the sympathetic phenomena, especially those
connected with the urinary apparatus, are wanting.

The diagnosis of the character of the calculus can sometimes be made
with a reasonable degree of probability. If crystals of uric acid or of
oxalate of lime have been or are present in considerable quantity, it
is highly probable that a possible stone may consist of those
substances. These crystals, however, are of little value in proving the
presence of a stone.

The important diagnosis of the occlusion of a ureter by a calculus, and
at the same time that of the soundness of the opposite kidney, may be
made with great certainty if the urine, which has previously been
purulent, bloody, or containing renal epithelium or casts, suddenly
becomes {45} clear coincidently with the occurrence of symptoms of the
impaction of a stone.

It is not of course necessary that in every case of impaction the flow
of urine from the affected side should be entirely stopped, since the
calculus may be of such a shape as to permit the passage of urine past
it.

The PROGNOSIS in this affection is extremely favorable, so far as the
recovery from the individual attack is concerned, since if the stone is
small enough to enter the ureter it will probably be successful in
forcing its way through sooner or later. It is of course possible that
this pain, like any other of excessive severity, might cause death, but
such an occurrence must be extremely rare.

Perforation of the ureter may occur, with consequent peritonitis. A
permanent plugging of the ureter from failure of the calculus to pass
will give rise to changes in the kidney to be subsequently described.

In cases where only a single kidney exists, and this becomes
obstructed, the symptoms of suppression of the urine may come on,
including death by coma if the obstruction is not relieved. Ten days is
the limit assigned by Ebstein beyond which recovery is not to be
expected, but he mentions a case in which it took place after thirteen
days of anuria. It must be remembered that a painful obstruction, or in
fact any severe shock to one kidney, may produce a very great
diminution in the amount of urine even when the other is sound. This is
undoubtedly the result of nervous sympathy.

One attack of renal colic renders another very probable, either
immediately or after months or years. Several hundred small calculi may
follow each other in rapid succession, or, on the other hand, a single
one may leave the patient in peace for a long time. Much depends on the
character of the calculus, the diathesis and habits of the patient, and
upon the treatment.

The subsequent history of the renal calculus belongs to surgery. After
it has reached the bladder and failed to be discharged, it increases in
size and is removed by lithotomy or lithotrity. The urethra, however,
will usually permit to pass any stone which has come through the
ureter. The patient who has just experienced relief from renal colic
should be instructed to pass his water into a vessel which can be
examined, and if the calculus do not soon make its appearance he should
void the urine when stooping forward or even lying on his face, so as
to bring the stone to the orifice of the urethra. It may catch in the
urethra and demand surgical interference.

The TREATMENT of the paroxysm consists chiefly in relieving the pain,
which may be partly done by the hot bath or hot applications. Opium, or
preferably morphine subcutaneously, is likely to be called for in large
doses. Attention has been called to the danger of morphine in
sufficient dose to relieve severe pain in cases where, as in renal
colic, the pain is likely to be suddenly terminated by the natural
progress of the affection, thus destroying the physiological antagonism
which exists between pain and morphine, and allowing the drug to
exercise its full power to an extent which may be over-narcotic. The
use of atropine with the morphine will mitigate to some extent its
danger, without interfering with its analgesic effects.

{46} In the milder cases ether and chloroform may be of value given by
the mouth, while in excessively severe ones anæsthetics by inhalation
may be called for, and their use continued for hours. This course also
is not without its inconveniences. The writer has seen a case where a
somewhat prolonged maniacal attack, with delusions lasting several
days, came on after the long-continued use of chloroform to relieve the
pain incident to the passage of a multitude of small uric-acid calculi.

The use of diluents has been suggested as hastening the passage, but
there is no reason to doubt that the pressure upon the calculus is
always sufficient to move it forward as rapidly as its shape and size
will permit. The relaxation of the spasmodically contracted ureter is
of much more importance than an excessive vis-a-tergo applied to the
calculus.

The treatment of the incipient calculus in the kidney or of the
condition which gives rise to it must naturally vary according to its
chemical constitution, which can only be certainly determined after its
discharge, but as to which an approximate opinion can be formed from a
knowledge of the tendencies and diseases of the patient and from an
examination of the urine.

The use of a largely-diluted solution of citrate of lithia or of
acetate, citrate, or tartrate of potassium will probably prevent the
deposition of uric-acid sand, and might even dissolve a small calculus,
although the proofs of this having actually been done are not
conclusive. If the urine be largely diluted the risk of the formation
of a calculus of another kind--_i.e._ phosphatic--is not great. Simple
water would be of great value in many cases, both as dissolving uric
acid and as promoting the metamorphosis of tissue, upon some
abnormality of which the accumulation of uric acid is supposed to
depend. The benzoate of lithia, by the destructive action which Garrod
has shown benzoic acid or its derivative hippuric acid to have upon
uric acid and the solvent action of the lithia, may be of value. The
phosphatic deposit, on the other hand, although beneficially influenced
by a sufficient supply of water, is not so amenable to chemical
influence as the other form, because it is much easier to render the
urine alkaline than acid when any irritation of the urinary passages is
present.

The vegetable acids, however, pass into the urine, and may render it
acid if in sufficient quantity. Benzoic acid becomes hippuric acid, and
can be used to make the urine more acid, as it causes very little
gastric irritation even in considerable doses. Boric acid also passes
into the urine, and acidifies as well as disinfects it, and might
perhaps be used to promote the solution of a phosphatic stone, though
the writer is unaware of any instance in which this has actually been
done. It does much toward diminishing suppuration in the urinary
passages, upon which phosphatic urine largely depends.

The conditions which lead to the deposit of oxalate of lime are not
sufficiently well known to make the prophylaxis of this calculus easy
by any chemical means, except by dilution of the urine and by a general
tonic regimen with abundant exercise.

Although it is not usual for a calculus to be arrested in the ureter
after having once fairly entered, this sometimes occurs, and the result
is stoppage of the flow of urine upon that side, dilatation of the
ureter, followed in turn by dilatation of the pelvis, and finally
atrophy of the {47} renal substance. This does not happen suddenly,
however. The urinary passages do not rapidly dilate to any considerable
extent, and their increase in calibre under pressure from within has
been considered a growth rather than a distension. This condition will
be treated under the head of Hydro-nephrosis.


Calculous Pyelitis.

When a calculus remains in the pelvis of the kidney without completely
obstructing the flow of urine, it usually increases in size, while the
resulting irritation may be the cause of fresh deposits either upon the
surface of the original calculus or in the form of new concretions. In
this way immense deposits of urinary salts may be formed. Thus, in a
case given in detail in the second series of _Boston City Hospital
Reports_ there was found upon the one side a calculus which when
perfectly clean and dry weighed 204 grammes, filling the whole dilated
pelvis and sending prolongations into the calices, so that its shape
was compared to that of a hippopotamus. The resemblance was made more
complete by the wrinkling and roughness of the exterior. In the other
kidney were several hundred calculi, from the size (and shape) of a
large almond down to that of white mustard-seed. The latter were
composed of two apparently distinct substances--one a reddish-brown,
looking like uric acid, and the other of the color and polish of white
marble; both, however, were phosphates.

The amount of local disturbance produced in the pelvis of the kidney by
the presence of a foreign body seems to depend somewhat upon the
character of its surface. Rough and uneven calculi, such as oxalate of
lime, are apt to produce inflammation much more rapidly than smooth and
polished ones, but it is seldom that any calculus remains without some
pyelitis. At first only a loss of polish of the mucous membrane, with a
little increase of mucus, may be observed, to which succeed roughening
and suppuration with occasional fibrinous deposit. The pelvis, more or
less dilated, may then contain a quantity of mucopurulent urine, with
perhaps some blood, in which are concealed the stones which have given
rise to this condition, and often phosphatic deposits not converted
into calculi.

Pyelitis is divided by some foreign writers into catarrhal and
diphtheritic--a distinction rather of degree than of kind. The mucous
membrane of the pelvis may, like other mucous membranes rarely, and
like serous membranes often, throw out a fibrinous exudation which
takes the form of false membrane. This indicates intensity of
inflammation, but has no necessary connection with diphtheria. A true
diphtheritic pyelitis, that is, connected with the general disease
known as diphtheria, is of course a conceivable lesion, but certainly
not a common one.

The renal symptoms--especially true albuminuria, so common and of such
grave import in this disease--are due to lesions of the secreting
substance, and not of the pelvis. It is important, but not always easy,
to decide whether there is more albumen present than is to be accounted
for by the pus. The pyelitis may be acute or chronic, being {48}
characterized by the intensity of the attack and the rapidity with
which the symptoms subside. The prospect of a given attack being acute
is decided largely by the supposed cause: a small calculus passing into
the ureter undoubtedly gives rise in most instances to a localized
pyelitis, which subsides after the cause of irritation has disappeared.
An inflammation from a larger one remaining is naturally of slower
development, but may be more acute while the calculus remains rough and
irritating, and partially subside when it becomes covered with a
smoother coating of phosphates. The mucous membrane, however, is not
likely to regain a completely healthy condition.

The mucous membrane in severe pyelitis may be deeply eroded, and even
perforated, so that the contents of the pelvis escape and give rise to
abscess in the perinephritic or prevertebral cellular tissue, which may
be discharged through the loins with resulting cure, or the
establishment of a fistula, from which issues pus and at times calculi.
Among the rarer results of perforation may be mentioned gastro-nephric
and duodeno-nephric fistulæ. These might be diagnosticated by the
presence of food and other intestinal contents in the urine, provided
that the ureter were still pervious. Vomiting of calculi and urine has
been reported by the older writers.

The writer is indebted to J. R. Chadwick for references to two modern
cases--one where such a fistula was diagnosticated during life;[16] and
another where a gastro-nephric fistula was found after death.[17] In
the latter case a diagnosis would have been impossible, as the kidney
was disorganized and the ureter occluded. The extent to which the renal
secreting substance suffers in calculous pyelitis varies considerably,
and is very probably connected with the amount of pressure exercised
either by the calculus itself when it attains a large size or by the
urine in cases of obstruction. It is rare for either pyelitis or
hydro-nephrosis to exist entirely independently.

[Footnote 16: _Giornale di Anat. e Fis. path._, iii. p. 370.]

[Footnote 17: Marquezy, _Thèse de Paris_, 1856.]

The changes which take place are those of atrophy. Interstitial
suppurative nephritis seems to follow this form of pyelitis much less
frequently than that which is due to extension upward of disease in the
lower urinary passages.

Corresponding to the pressure of solid or fluid, the papillæ are eroded
and the straight tubes shortened. In the cortical substance, which soon
becomes diminished in thickness, the interstitial tissue is
hypertrophied, dense, and hard, while the tubes become smaller or in
time disappear. The Malpighian bodies are changed to dense masses of
connective tissue, but are still plainly recognizable, irregularly
crowded together instead of being arranged as usual in more or less
symmetrical double rows. The cortex of the kidney may thus become but
little more than a mere skin stretched over a large stone, with perhaps
here and there a piece of renal structure recognizable and in a
comparatively normal condition.

The extremer grades of hydro-nephrosis do not seem to be met with in
this form of atrophy, but the pelvis is considerably dilated, while its
internal capacity is also added to by the atrophy of the renal
substance. The interior of the cyst thus formed usually retains
distinct traces of its original division into infundibula, and may be,
as already stated, almost filled by the calculus. Kidneys undergoing
this process of degeneration {49} often furnish up to a short time
before death a normal, or even more than normal, amount of urine, and
one is often astonished to find how little disturbance of elimination
has been caused in cases where the true kidney-structure seems to the
naked eye to have been almost entirely destroyed.

The DIAGNOSIS of a calculus remaining in the pelvis of the kidney
depends chiefly on the determination of hæmaturia and pyelitis for
which no other cause can be found, and upon the presence of pain in one
loin. It is naturally greatly assisted by the presence or history of
renal colic. An aching pain in the loins, more or less permanent, is a
frequent but not invariable symptom. It may be such as to prevent the
patient from standing upright, and cause him to assume an habitually
stooping posture in standing or walking. A careful examination of the
urine in conjunction with this symptom, especially if an unusually
abnormal condition has been preceded by an exacerbation of the pain,
may make the diagnosis almost certain. In the beginning of a case
occasional not severe hæmaturia, with some increase of mucus or a
little pus, may be all that can lead to the suspicion of calculus as
the cause of pain. At a later period an increase of these symptoms,
with a considerable quantity of the peculiar irregular epithelium
lining the pelvis, may be observed. The latter constituent, however,
can hardly be looked upon as entirely conclusive of pyelitis, since the
lower urinary passages may give rise to cells of about the same form
and size, and the irregularity is likely to be increased beyond
recognition by the presence of inflammation. They may also undergo
change of form in the urine. The presence of transparent or other casts
denotes the irritation of the renal parenchyma.

The point of chief difficulty in the diagnosis of pyelitis is the
determination of the origin of the pus, whether from the kidney or the
bladder. Cystitis may be only partly excluded by the absence of
dysuria. A point of considerable weight is the reaction of the urine,
that from the kidneys being usually acid, while that from the bladder,
when cystitis of much severity exists, is alkaline or rapidly becomes
so. The pus coming from the kidneys is more intimately mixed with the
often profuse urine than when formed in the bladder. The whole of it
does not in the former case completely subside, but remains in
sufficient quantity to form a turbid or opalescent mixture--the
polyuric trouble of Felix Guyon, according to whom this condition in an
acid urine is strongly indicative of renal as distinguished from
vesical lesion. In cystitis the pus subsides in more or less distinct
masses, but if the urine is alkaline, or when it becomes so, is altered
to a ropy consistency usually spoken of as muco-purulent.

The procedure recommended by Thompson may be resorted to in order to
determine whether the urine comes from the kidneys loaded with cellular
detritus, or whether the addition is made in the bladder. This consists
in washing out thoroughly the bladder with several successive
quantities of water through a single catheter, until the water comes
away clear and the bladder has contracted itself around the instrument,
when the urine from the kidneys will for a time come through direct and
comparatively uncontaminated.

In cases where the urine is alkaline in the kidney, which may happen,
distinctions founded on the reaction cannot be of value, and the same
{50} may be said of cases where cystitis is known to exist, but where
there is in addition a possibility of a renal calculus. In these some
such mechanical procedure as that just described must be resorted to.

The presence of a calculus as a cause of pyelitis cannot always be
demonstrated, but may be more or less strongly suspected according to
the conclusiveness with which any other cause can be excluded, by the
definiteness and character of the local pain, the history of renal
colic, the presence of uric-acid crystals in the urine, and perhaps in
some cases the results of palpation. The exploring-needle may be used,
and may of course, if reaching the calculus and giving a characteristic
grating feeling and sound, give absolutely positive results; but a
failure to strike a stone could hardly be regarded as proof positive of
its absence.

The diagnosis of renal calculus from lumbago or neuralgia should rest,
in case the pain is severe enough or long-continued enough to really
cause the question to arise, upon an examination of the urine.

A very important point in diagnosis, especially when the question of
operative procedure arises, is that of the soundness of the other
kidney. Accidental circumstances will sometimes permit this to be
determined; as, for instance, when one ureter is suddenly blocked by a
calculus, and at the same time the urine, which has previously been
found purulent, bloody, and containing renal cells and casts, becomes
clear and normal until the obstruction is removed and the abnormal
ingredients reappear. Cases of exstrophied bladder, where of course it
is possible easily to separate the urine of the two kidneys, may be,
from their rarity, practically left out of the account. Various
proposals for obtaining the separate urine of the two kidneys have been
made. A small catheter has been passed into the female ureter through
the dilated urethra. In the female also a finger in the vagina may
succeed in temporarily blocking one ureter, while the secretion of the
other alone is filling the bladder, a catheter with a bent portion at
the end being used for making counter-pressure from the inside. It
would probably remain doubtful in most cases how successful this
manoeuvre had been in completely stopping the flow of urine, although
experiments upon the dead body have been made by Polk,[18] who proposes
the method, with entire success. The male bladder offers greater
difficulties, which are at present insurmountable. A point opposite the
lower end of the ureter can, it is true, be reached with some
difficulty in the rectum, and it is possible that a catheter might be
so adjusted as to make counter-pressure to the finger in this position,
but there could be no certainty that the occlusion was complete.

[Footnote 18: _New York Med. Journ._, Feb. 17, 1883.]

The whole hand in the rectum, after Simon's method, would enable the
object to be accomplished with more certainty, but this procedure has
risks of its own. A staff with flattened extremity, as suggested by
Weir,[19] may more conveniently, though with somewhat less certainty,
be used for pressing from within the rectum on the ureter where it
passes over the brim of the pelvis. A compressorium consisting of an
empty and folded bag, to be introduced into the bladder and there
expanded by the introduction of metallic mercury, has been described
and used, with the result of partly checking the flow of urine.[20] The
proposition to pinch up the extremity of one ureter in the bladder by
means of the lithotrite is still {51} more open to the objection of
great uncertainty, and would, to say the least, demand very special
skill to obtain even a chance of success.

[Footnote 19: _Ibid._, Dec. 27, 1884.]

[Footnote 20: See Weir's article, just quoted.]

None of these procedures have as yet been put to practical use, and it
is doubtful whether any of them, unless we except perhaps the use of a
staff in the rectum, would be justified for purely diagnostic purposes,
considering the great risks involved. For the present, at least, the
possibility of separating the secretion of one kidney from that of the
other must be looked upon as depending chiefly upon accident, and in
case of contemplated operation it is not possible to assure one's self
of the integrity of the other kidney before the abdomen is opened. In
many cases after opening the abdomen both kidneys may be examined
before deciding upon further steps. Lawson Tait considers an
exploratory incision distinctly indicated whenever abdominal disease
not malignant threatens the life of the patient. The soundness of the
other kidney, however, may be considered highly probable if in spite of
demonstrated extensive disease of one kidney a sufficient quantity of
urine with a normal amount of urea and salts continues to be formed.

The SYMPTOMS arising from a large calculus producing destruction of the
renal substance, when both kidneys are affected or one is insufficient
to supplement the partial or total loss of the other, may closely
resemble those of diffuse nephritis, either interstitial or
parenchymatous, or perhaps it would be more correct to say that these
forms of nephritis are the symptoms of such a change. Thus we may have
polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. The
enormous calculus described above as resembling a hippopotamus had
given rise to no marked symptoms until palpitation, dyspnoea, and
oedema were complained of; the heart was hypertrophied.

The TREATMENT of calculi remaining in the kidney is, so far as medical
means are concerned, that which has been already described, and, to say
the least, is not a high degree of efficiency. Rest, diuretics, and
solvents of the kind already spoken of, and narcotics, may afford
relief, and in the case of quite small calculi, such as sometimes
remain in the kidney even when not too large to pass through the
ureter, solution is possible; but there is even less reason to suppose
that large calculi can be dissolved in the kidney than that the
tendency to their formation can be counteracted.

Surgery, however, offers in some cases complete relief. Two operations
have been undertaken for this purpose, of which the surgical details
are here inappropriate, but the indications for which may very properly
be discussed from a medical point of view. These are nephrotomy or
nephro-lithotomy, the removal of the stone through an incision in the
pelvis or secreting substance of the kidney; and nephrectomy, or the
removal of the whole gland with its contents. It is obvious that the
indications for these two operations are quite different, although
cases are likely to arise where it will be well to change the plan from
the former to the latter during the operation.

When a sinus exists from the inflamed and perforated pelvis, or an
abscess connected with the kidney has been recently opened, it may be
dilated or enlarged by incision sufficiently to allow the passage of an
exploring finger and forceps. The large arterial and venous branches
which surround the pelvis make it safer to trust rather to dilatation
or {52} tearing to get through to its interior than to incision, which
must, if necessary, be practised with great care. Experience has shown
that an incision can be made through the renal substance without great
danger, the hemorrhage being chiefly venous. This incision has been
made in several cases, and where the secreting portion is much
atrophied is obviously of still less consequence than in the healthy
kidney. After the removal of the calculus, drainage may be established
for a time until the pelvis has resumed its normal condition or the
purulent discharge has diminished.

If no sinus exists, but a diagnosis has been clearly made, or even if
symptoms of sufficient severity exist to justify a strong suspicion and
decisive treatment, an incision may be made along the edge of the
erector spinæ or the great mass of muscle attached to the spinal column
and passing through the quadratus lumborum. An incision outside of the
quadratus lumborum will come upon the kidney, but too far outside to
make a direct access to the pelvis practicable. If it be known,
however, that the cut must be made through the kidney itself, then the
primary incision through the skin may be made in the exterior line, and
will be less deep. Measuring along the last rib two inches from its
extremity, and then at right angles an inch and a half downward and
inward, will indicate a point at which a puncture will reach the renal
pelvis. This may be made the central point of an incision, though it is
often necessary to utilize the whole space from the last rib to the
crest of the ilium. After reaching and exploring the kidney with the
finger, the incision may be carried cautiously through the pelvis and
enlarged by dilatation or tearing.

In order to feel the calculus it may be necessary to have
counter-pressure made from the front of the abdomen in order to lift or
fix the kidney, and a case has been mentioned where the finger, having
failed to reach a calculus behind, was carried around and in front of
the kidney with success. If the calculus is too large or too irregular
to be removed whole, it may be broken and extracted piecemeal.

This lumbar method is undoubtedly to be preferred when it is known that
a simple nephrotomy will be sufficient or when the more or less
diseased kidney is to be treated as a cyst or abscess by drainage. It
is open to the objection that if it be found desirable to change the
operation into an nephrectomy, it is not quite so easy to remove a
large mass in this way as by laparotomy, and the pedicle is much less
accessible. The objection is not sufficient, however, to contraindicate
it in many cases, for additional room can be obtained by resection of
the last rib. So far as the writer is aware, laparotomy has never been
performed for the simple removal of a calculus.

Nephrectomy, or removal of the kidney, may be required for various
conditions, among which is to be reckoned a renal calculus with
pyelitis of sufficient severity to threaten life or give rise to
constant suffering; but as it is often indicated for other reasons, its
consideration will be deferred.

Pyelitis may be excited by the presence of other foreign bodies, among
which are coagula and parasites. An acute pyelitis may accompany an
acute nephritis. Occasionally also an idiopathic pyelitis is said to be
met with, but it must be difficult in such a case to exclude the
presence of some irritant which has escaped observation.


{53} Secondary Pyelitis.

Pyelitis is most frequently excited by the propagation of an
inflammatory process upward from the bladder, and hence it is, with its
resulting effects upon the renal structure, one of the most important
complications of chronic cystitis and of surgical affections in the
lower urinary passages. Anatomically, a pyelitis of this character
differs but little from that of local origin described above, except
that the contents of the inflamed cavity do not include deposits of
urinary salts unless such have been formed secondarily. It is, however,
more likely to be severe, and especially to affect the true renal
substance more rapidly and more seriously, and consequently to be
attended with constitutional symptoms in an acute form.

Two factors are of especial importance in determining the rate of
development and severity of pyelitis supervening on affections of the
urinary passages: First, the amount of obstruction which exists to the
exit of the urine; and, secondly, the character of the cystitis as
regards decomposition of the urine. It is obvious that whatever sends
urine back into the ureters, or, what is the same thing, prevents its
passage downward, will by keeping it longer in contact with the mucous
membrane intensify whatever morbid action such an irritant would have,
and of course a putrid or ammoniacal urine will induce inflammatory
action, while a normal secretion might remain for a long time
innocuous. Hence it is that we may have hydro-nephrosis and pyelitis
entirely distinct from each other, but are very likely to have both
combined in most cases.

It is especially in surgical affections of the urinary passages,
involving, as many of them do, considerable obstruction with a more or
less intense cystitis, that we meet with the combination of the two
conditions. Such are enlarged prostate with its usual obstruction and
frequent chronically-distended bladder, with ammoniacal, purulent, and
decomposing urine, or stricture with frequent over-contraction of the
bladder, forcing the urine backward as well as forward. In diseases of
the female generative organs we are more likely to have the
hydro-nephrosis and pyelitis as separate affections, since the
compression which so frequently arises in cases of cancer or of pelvic
inflammation is likely to be above the bladder, thus preventing the
regurgitation of urine as well as its passage downward.

Two conditions of the renal substance seem to result from pyelitis of
this kind: one, a chronic nephritis already described, with increased
formation of connective tissue, atrophy of the tubes and the Malpighian
bodies (the latter, however, remaining recognizable, although crowded
together), and a general, and at times extreme, shrinking of the whole
organ. The other is more acute, and consists in the formation of
abscesses of small size, which in the medullary portion are somewhat
elongated and arranged parallel to the tubes, and in the cortical
portion preserve a less degree of regularity, though still having some
reference to the columnar arrangement of the masses of convoluted
tubes. The intervening structure is usually in a marked condition of
parenchymatous degeneration. This is the so-called surgical kidney.

Whether the one or the other of these processes shall take place
probably depends chiefly on the infectiousness of the cystitis or of
the urine {54} contained in the bladder and backing up into the
kidneys, although it is not necessary that any degree of dilatation
should be present for this condition to arise. Sometimes also the
surgical kidney may be found when the original cystitis is not at all
severe.

The DIAGNOSIS of a pyelitis supervening on a cystitis is not always
easy, but may frequently be inferred, and it is possible that by
careful treatment of the cystitis it may be reduced to a very low grade
of severity, while the pyelitis still remains, which will permit the
diagnosis to be somewhat more conclusive.

If the urine comes acid, but pus-laden, from the kidney, it will soon
assume the contrary reaction in the bladder, and the pus will be
changed by the ammonia into so-called muco-pus; the cells supposed to
be characteristic of the pelvis of the kidney will, like the pus-cells,
be so altered by the same causes, and so intermixed with similar cells
from the bladder, that the distinction will be difficult or impossible.
The presence of a few hyaline casts is very likely to be noticed, and
indicates irritation, or perhaps a more decided implication, of the
renal substance. Nothing, however, can be inferred from failure to find
them. Hæmaturia is not so necessary an accompaniment of this form of
pyelitis as of that arising from a mechanical irritant in the kidney.
If, however, the urine does not become rapidly altered in the bladder,
or if by any of the processes mentioned above the kidney urine can be
obtained in a condition of comparative purity, the microscopic
indications become more precise.

A dull pain and tenderness in the loins and along the course of the
ureters is a symptom of value, though by no mean conclusive, and should
lead to a suspicion of pyelitis. A polyuria of short duration may be a
purely nervous symptom, but a persistent flow of pale urine, which
fails to settle clear, and of which the turbidity is caused by pus, is
due in great probability to renal disease, and if it could be shown to
come in this condition from the kidney would almost certainly denote
pyelitis.

The rational SYMPTOMS are of the greatest value as determining the
extent and severity of the disease, although it may be impossible to
distribute them with absolute exactness between the various organs
involved--that is, bladder, pelvis, and renal substance.

The occurrence of a single chill, or even of several, with rapid
subsidence of the fever, is not conclusive, since the ordinary urinary
fever supervening on surgical operations, even so slight as passing the
catheter, is not necessarily connected with renal disease.

A long-continued fever, not especially intense and of a more or less
distinctly intermittent type, especially if becoming at some definite
period decidedly more intense, is likely to mean the invasion of a new
tract of mucous membrane, such as that of the renal pelves or even of
the kidney-substance itself. Continued or remittent urinary fever is of
very grave import. With this fever will appear the dry red tongue and
the distressing anorexia, nausea, and vomiting, with either
constipation or diarrhoea.

The TREATMENT of this form of pyelitis, so far as it differs from that
of the calculous variety, depends largely upon that of the causative
cystitis, though not entirely, since if it has once assumed the chronic
condition it does not necessarily subside even if the cystitis be
cured. The essentials of treatment may be said to be drainage from
below and washing from below and from above. The measures for carrying
the first of {55} these indications are those which are also required
for the causative cystitis, and, being chiefly surgical, a minute
description of them does not come within the scope of this article.
They may be simply catheterization, dilatation, divulsion or section of
a stricture of the urethra, drainage of the bladder through the rectum
or through the perineum.

It is not out of place, however, even in a strictly medical essay, to
point out the extreme importance, not only in the way of treatment, but
of prophylaxis, of securing a free exit for the urine. Even that small
degree of obstruction or hindrance which leads a person to habitually
put a little extra strain upon the bladder in order to expel its
contents, especially if it be allowed occasionally to become dilated,
may gradually lead to dilatation of the ureters, and thus make an easy
passage upward for inflammatory and decomposed urine if such should
afterward be formed as a consequence of cystitis by retention. The
washing of the bladder from the urethra may be done with a great
variety of antiseptics and acids: nitric acid in the proportion of 1
per mille may be used to change the reaction of the urine. Carbolic
acid should be carefully used, from the danger of its absorption in
poisonous amounts. Boric acid is a safe and quite efficient antiseptic.

Washing from above, which is evidently that which alone can directly
affect the renal pelvis, must be done with such drugs as can be safely
given internally, so that carbolic acid cannot be of much use in this
way. Salicylic acid loses a part, but not all, of its antiseptic
properties in its passage through the blood and kidneys. Boric acid
passes readily into the urine, alters its reaction, and seems to have
some antiseptic action. It is unirritating in the stomach, and may be
given in doses of 30 centigrammes or 5 grains to the extent of 1 or 2
grammes per diem. Benzoic acid and the benzoate of sodium, ammonium, or
lithium have been found to be of value in cystitis, and as they can
only reach the bladder by previously passing over the pelvic mucous
membrane, they should also have a good effect here. It is obvious that
constitutional symptoms arising from cystitis and its consequent
nephritis may demand the most attention, and should evidently be of a
decidedly supporting character, the details of which have no special
reference to the disease, but to the general condition. Quinine may be
called for as an antipyretic.

The question of removal of a kidney for pyo-nephrosis is less likely to
arise in this form than the other, since from its causation it is much
more likely to be bilateral; but if under any peculiarity of anatomical
arrangement, such as greater dilatation of the one ureter, it should be
found that one kidney was nearly healthy while the other was in a state
of pyelitis, and purulent inflammation was giving rise to serious
constitutional disturbance, such an operation might be undertaken.

The operation of nephrectomy, or removal of the kidney, may be required
for various lesions, most of which include more or less pyelitis, and
it may be considered once for all in this place. It has now been
practised more than one hundred times. A table including 100 cases is
given by R. P. Harris in the _American Journal of the Medical Sciences_
for July, 1882, and many have been recorded since.[21] It can, of
course, hardly be expected that the removal of one of a pair of vital
organs, under circumstances where it is often the case that the other
is not {56} completely capable of carrying on the additional work,
should present the same favorable array of statistics as ovariotomy;
but it gives no small number of recoveries in cases which without it
would undoubtedly have proved fatal, and it must be considered as
having a legitimate and well-defined place among the major operations.

[Footnote 21: Weir, _New York Med. Journ._, Dec. 27, 1884.]

There are two distinct methods, besides, of course, all the minor
differences of detail called for in the individual case. The kidney may
be reached from the loin by an incision along the outer edge of the
erector spinæ, as already described for nephrotomy. It is to be
enucleated from its capsule of fat by the fingers, and a ligature or
ligatures passed around the pedicle consisting of the veins, arteries,
and ureter. The kidney is then cut off, possibly leaving a little renal
substance if the pedicle be short and accessible with difficulty. The
wound is left partly open for drainage. This method has the advantage
of avoiding the peritoneum and the handling of other abdominal organs.
Its disadvantages are, in some cases, the want of room, and when
undertaken for the relief of floating kidney the difficulty of finding
the organ, which is likely to be at the end of a pouch formed of
peritoneum. In cases of calculous pyelitis, where it may be at the
beginning of the operation uncertain whether merely an incision for the
removal of a stone or a total removal of a kidney of normal size may be
necessary, this line of approach presents decided advantages.

The other method is by abdominal incision or laparotomy, which is
usually made through the linea alba, though in a number of cases the
outer edge of the rectus abdominis on the side corresponding to the
organ to be removed has been taken as the guide. The steps of the
operation are similar to those of ovariotomy where the pedicle is tied
and returned to the abdominal cavity. This operation may be one of
choice, from the greater ease with which the pedicle can be reached and
the possibility of increasing the length of the incision in case of
necessity for the removal of a very large tumor. In one case a crucial
incision was made. When the kidney to be removed is a wandering one,
and especially when a kidney has become fixed in an anomalous position,
this is by far the easiest, and sometimes the only practicable, method.

Antiseptic precautions are of course to be used.


Hydro-nephrosis.

Obstruction to the discharge of urine from the body naturally produces
special disorders in the secreting and discharging organs. If the
obstruction exist below the neck of the bladder, as in stricture of the
urethra or enlarged prostate, then the bladder is the organ primarily
affected, and it may become distended, sacculated, its muscular coat
hypertrophied, its mucous membrane affected with catarrhal
inflammation, and its contents changed from the normal by the addition
of mucus, of pus, of bacteria, or a deposit of earthy phosphates from
the ammoniacal reaction produced by decomposition of the urea.

The effects of distension of the bladder will sooner or later make
themselves felt in the upper urinary passages, and will then give rise
to the same dilatation of the ureters and the renal pelvis as occurs
when the {57} obstruction is higher up. As regards the rapidity with
which such changes progress, much depends upon the degree of
obstruction as well as upon the amount of urine secreted. It probably,
however, never takes place suddenly.

In a case which came under the observation of the writer a partial
paralysis of the bladder, probably existing from infancy, had in the
course of three or four years, during which large quantities of light
urine were passed, given rise to dilatation of the ureters, slight
dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and
hypertrophy of the left ventricle.

Obstructions in the course of the ureters may exist at their opening
into the bladder, which may be contracted by chronic cystitis; at a
point immediately above this from compression by morbid growths,
especially of the uterus, one of the most common causes of
hydro-nephrosis, or even from retroflexion of the uterus when pregnant;
at any point in its course by a twisting or sharp angle, as in movable
kidney, although this is a much rarer accident than might be supposed;
or at the brim of the pelvis, where it may be bound down by old
peritoneal adhesions, and at its junction with the renal pelvis, which
may be formed in such a manner as to constitute a valve, so that the
urine escapes slowly or with great difficulty; or where it may be
blocked by a calculus or other deposit in the cavity of the pelvis.

Obstructions by a twist or angle or by a valvular opening may, it is
obvious, be temporary or intermittent in their action, and probably
some arrangement of this kind was present in the cases which have been
reported of relief of hydro-nephrosis by gentle massage of the abdomen.

Above the point of obstruction the ureter and pelvis are found dilated
and the walls somewhat thinned. The kidney and its pelvis form a more
or less irregular rounded pouch, with the tense cylindrical tube of the
ureter attached to it below. The kidney itself becomes in various
degrees atrophied. In some cases it retains nearly all its secreting
structure, and is merely spread out upon the surface of the sac; in
others, while the pelvis is but little dilated, the true kidney
substance atrophies almost completely, and becomes a mere shell
enclosing a cavity continuous with the pelvis and broken up by fibrous
septa into subordinate cavities representing the original calices. A
partial hydro-nephrosis is sometimes observed affecting only the
calices.

Whether the one or the other of these conditions shall result depends,
as has already been remarked, upon the completeness and suddenness of
the obstruction. If the ureter of a rabbit is ligatured, the second
condition--that is, atrophy of the kidney with but little
dilatation--is observed. The pressure of urine soon puts a stop to
further secretion, and there is no time for a slow and gradual
dilatation of the pelvis and ureter. When, as is much more frequently
the case in the human subject, the obstruction is more gradual or
incomplete, the back pressure is for a long time insufficient to
completely stop the passage of fluid through the renal capillaries, so
that the pelvis and ureter, though allowing their contents to pass out
only under a considerable vis-a-tergo, have time to accommodate
themselves to the change, and dilate gradually, attaining sometimes
enormous dimensions. The size of a hydro-nephrotic sac varies greatly:
60 liters of contents is certainly a very extreme case.

{58} The sac is usually white and glistening, thinner at some places
than at others, and lined with a smooth, pale, and atrophied mucous
membrane. The muscular layer has degenerated, and perhaps partly
disappeared. The liquid contained in the sac, supposing no inflammatory
products to have been mingled therewith, is at first nearly identical
with urine, and always contains urea. Afterward its character changes
from the absorption of the urinary salts and the secretion of mucus.
The contents may be dark-colored from hemorrhage or somewhat
gelatinous. At a later period again they become serous and may contain
cholesterin.

The description just given, as well as that of the symptoms, applies to
simple hydro-nephrosis. When the sac has become inflamed we have the
very common combination with pyelitis, and the affection is called
pyo-nephrosis. The progress of a case of hydro-nephrosis may be in rare
cases to recovery by spontaneous re-establishment of the permeability
of the ureter. In others it persists a long time without giving rise to
trouble. If inflammation supervene, it is obvious that fever, either
simply irritative or of pyæmic character, may be a severe or even a
fatal concomitant, or that in this condition a perforation may take
place. When the tumor is large it may from its bulk alone produce
disturbance of the circulation, dyspnoea, palpitation, and oedema of
the lower limbs.

As regards the influence of this lesion on the secretion of urine,
everything must depend on the amount of renal atrophy. A single kidney
may undoubtedly be completely atrophied by this as by any other lesion
without producing serious symptoms, since, as has been repeatedly
demonstrated, the other is sufficient to carry on the work under
ordinary circumstances; but if, as very frequently happens, both
kidneys are involved, there must come a time when the renal substance
no longer suffices, and the usual results of suppression of urine
follow. It is possible, however, for extensive changes to take place in
both kidneys before symptoms of insufficient secretion arise.

Hydro-nephrosis, in the entire absence of inflammatory symptoms and in
the presence of conditions likely to cause it known to exist in the
lower urinary passages, may be rather suspected than diagnosticated
until the appearance of a tumor. Some dull pain in the loins without
irradiations in any direction may exist, but so common a symptom can
have but little weight in diagnosis. For an early recognition of
swelling in suspected cases where nothing can be felt anteriorly, it
has been recommended that the patient be placed upon the hands and
knees, when the flank upon the affected side, instead of falling
slightly forward and leaving a shallow depression outside of the
erector spinæ, will remain full or protuberant. When an enlargement
evidently connected with the kidney makes its appearance after
obstruction to the passage of urine is known to exist, the diagnosis
may often be very simple; but if the tumor be the first phenomenon
observed, as may easily happen when the obstruction is situated high up
or even at the commencement of the ureter, it may require to be
distinguished from several other kinds of tumor occupying the lumbar
region, or, since hydro-nephrosis of a movable or misplaced kidney
sometimes takes place, from tumors of the abdomen in general. From
solid malignant tumors of the kidney the feeling of comparative
elasticity and fluctuation will in most cases distinguish it, though an
encephaloid kidney may be so soft as to render the second of these
points of {59} comparatively little value. Absence of hæmaturia and of
the cancerous cachexia, though not conclusive, would have much weight.

A hydatid cyst might counterfeit a hydro-nephrosis, but instances of
this affection having its primary seat in the kidney are of extreme
rarity. An ordinary cystic kidney is most likely to be connected with
chronic diffuse interstitial nephritis, which will have made itself
manifest by the usual symptoms, and is moreover unlikely to attain the
dimensions of a large or even moderate hydro-nephrosis. In a thin
person the ureter might, if felt dilated through the abdominal walls,
clear up the diagnosis. Extreme cases of cystic kidney with
comparatively little nephritis may, however, present great similarity
and cause difficulty in diagnosis.

From most other tumors of the abdominal cavity those of the kidney
present the important distinction that they are situated behind the
peritoneum, and consequently behind the intestines, so that the surface
of a renal tumor is likely to be crossed by a more or less extensive
area of percussion resonance, representing usually the large intestine.
This criterion is, however, not absolute, since a renal tumor may push
the colon completely to one side, or, on the other hand, tumors not
connected with the kidney may allow the intestine to come between
themselves and the abdominal wall.

An ovarian cyst is more manifestly attached to the pelvis, and its
history will disclose the fact of its having arisen from below. A
gravid uterus should also, when small, be manifestly connected with the
pelvis, and when larger be accompanied by the usual symptoms of
pregnancy. The same may be said of extra-uterine pregnancy, which may
be mentioned as among the conditions possibly giving rise to
difficulties in diagnosis.

The most efficient aid to diagnosis, when it is of importance that such
should be accurately made, is the aspirator-needle, which will procure
a fluid more or less characteristic of the tumor into which it is
thrust. In hydro-nephrosis the contents are a somewhat dilute urine,
with perhaps mucus; in a solid tumor, blood, with pieces of tissue
recognizable by the microscope; in a cystic tumor, fluid which is
perhaps somewhat urinous, but much more changed than in simple
hydro-nephrosis, and perhaps containing solid-looking bodies with
concentric and radiating striation; in hydatid cysts, hooks and
fragments of scolices; in ovarian cysts, the various contents, fluid
and semi-fluid, but not urinous, generally found therein.

With all these means, however, cases will occasionally arise in which
expert diagnosticians may be lead astray, and the difficulties become
considerably greater when the dilated pelvis is that of a displaced or
unusually-placed kidney. Such cases have been subjected to operation
under the impression that an ovarian cyst was present.

The medical TREATMENT of hydro-nephrosis is nil. In many cases nothing
is demanded by the immediate necessities of the case, and atrophy, if
it be probable that only one kidney is involved, may be allowed to take
place without interference. It is possible that in some instances
manipulation of the tumor might relieve the obstruction and allow the
tumor to subside when a slight twist or angle in the ureter is the
cause. The fact of an occasional spontaneous subsidence of such a tumor
shows that something of this kind has taken place.

{60} The surgical treatment of affections of the lower urinary
passages, as both a prophylactic and therapeutic measure, has already
been spoken of under the head of Pyelitis. It would, however, be only
in a minority of cases of pure hydro-nephrosis that the seat of
obstruction could be efficiently reached by surgery.

Puncture and aspiration of the sac may very properly be resorted to,
and may prove of value--in the first place, as a more or less temporary
relief; and secondly, as a means of re-establishing the flow through
the natural passages by the relief of pressure and consequent opening
of the valvular fold, which has occasionally been observed at the
junction of the ureter with the pelvis.

In a case where the obstruction is known to be irremediable, and where
the hydro-nephrosis, if existing only on one side, is likely to
increase, it is not desirable to make the puncture too early or to
repeat it too frequently, since by allowing the pressure to increase
the atrophy of the kidney will be more rapidly accomplished, and the
need of frequently emptying the sac will not arise so often in the
future. On the other hand, if there is a prospect of a restoration, if
both kidneys are affected, or if the kidney not involved in the
hydro-nephrosis is known to be seriously impaired in function, and it
is desirable to preserve the secreting structure as long as possible,
the punctures should be so arranged as to keep the pressure at its
minimum. This must, however, be regarded as a temporary expedient. The
puncture may be made either from the back or front, though in most
cases the latter position, if the puncture be made with a small clean
needle, would be the more convenient, and equally safe notwithstanding
its traversing the peritoneum.

A hydro-nephrosis may be treated either by removal or by drainage. Both
of these methods have been resorted to, and are to be employed
according to the circumstances of the individual case. A pyo-nephrosis
naturally demands interference more peremptorily and more promptly than
a simple hydro-nephrosis, because it exposes the patient to the dangers
not only of its pressure and of its tendency to destruction of the
renal substance, but to those more urgent ones of purulent infection or
of perforation and perinephritic abscess. Removal is to be undertaken
by the ordinary rules of laparotomy. Drainage has been arranged in
cases where removal was impossible or unadvisable by stitching the
edges of an opened sac to the external wound. It is possible that the
choice between the two operations can be made only after the primary
incisions and explorations have advanced sufficiently to enable the
extent of adhesions and the amount of healthy renal substance to be
approximately determined.

Staples of Dubuque states, on the basis of 71 cases collected by him,
that "63 per cent. of patients operated on are cured by lumbar
nephrectomy, 68 per cent. by open methods in general, and up to date
100 per cent. by either lumbar incision and drainage or the creation of
a fistula."


Malignant Growths.

As pathological rarities only, and having but little clinical interest,
may be mentioned, as occurring in the kidneys, fibroma, lipoma, {61}
myxoma, anginoma, and adenoma. Malignant growths originating in or
involving the kidneys, sarcoma or carcinoma, are, however, more
frequent and more important.

Sarcoma, primitive or secondary, of the kidney is a somewhat rare
occurrence, but most frequent in children. The whole kidney may be
transformed into a mass occupying its place and somewhat resembling it
in form, but many times exceeding it in bulk and weight. Such a tumor
may largely distend the abdominal cavity and compress its contents.
Upon section we often find a substance varying greatly in consistence,
from almost fibrous hardness to cavities filled with grumous material
broken down by fatty degeneration and often colored by hemorrhage. In
the interior may be found remains of the pyramids and cortical
substance occupying their usual relative positions, but as it were
distended, these portions being surrounded by a much thicker layer of
purely abnormal neoplasm, probably connected with the capsule and its
surrounding fat. In other cases all traces of normal form and structure
may have disappeared. The microscopic structure of such a growth
presents no peculiarity except so far as the arrangement of cells in
the normal gland may be followed to a certain extent in the
less-altered portions of the tumor. Besides this total destruction of
the kidney, it is not uncommon to find nodules involving a part of one
or both the organs, and more or less distinctly marked off from the
healthy portion.

The origin of sarcomata involving the kidneys may be the subperitoneal
cellular tissue or the neighboring organs. As a primary disease sarcoma
of the kidneys is very rare.

True cancer or carcinoma of the kidney is not a common disease, and is
said to have been found 12 times in 447 cases of cancer of various
organs. It may be primary or secondary, and a description of the gross
appearances would be essentially the same as that of the sarcoma. The
tumor does not, however, usually attain so large a size, and the amount
of degeneration of neighboring organs and of ulceration is greater.
Calculi are often found in cancerous kidneys.

The SYMPTOMS produced by either sarcoma or carcinoma may be none at all
for a time. Dull pains in the loins or referred to the
hypochondrium--which, however, from their indefiniteness can have but
little diagnostic importance--are among the early phenomena. Pains like
nephritic colic may appear. The urine usually shows little of
importance. There may be sympathetic disturbance of micturition, but
unless hemorrhage occurs there is not likely to be anything in the
urine discoverable by the microscope to fix the nature of the trouble.
Fragments of cancer-structure in the very rare cases in which they are
said to have been found would of course be conclusive, but evidence
based on the alleged discovery of cancer-cells in the urine must be
received with the utmost caution, recollecting the great variety of
shapes and sizes assumed by the epithelium of the urinary passages.
Hæmaturia is a symptom occurring in only a portion of the cases, its
appearance in a given case evidently depending on the way in which the
tumor invades the kidney and increases in size. If growing in such a
way as to compress the ureter at an early stage before any erosion of
the mucous membrane has taken place, blood, even if set free in the
pelvis, cannot reach the bladder. If hæmaturia is present before any
tumor can be felt, it has {62} only a subordinate value, but if
occurring after the discovery of such a tumor, the combination is of
the highest significance. At a later period all the symptoms of
compression of other abdominal viscera arise--anorexia, vomiting,
jaundice, oedema, ascites, emaciation, and death.

When a tumor has become evident, it is to be diagnosticated from cystic
disease and from hydro-nephrosis, with which it agrees in position and
possibly in form. From the former of these its hardness and rapid
growth, the invasion of other organs, and the cachexia will serve to
distinguish it. Hæmaturia is not present in cystic disease. From
hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated.
On the right side it might not in every case be easy to distinguish a
morbid growth of the kidney from one affecting the liver, and a similar
difficulty might arise on the other side with the spleen. The diagnosis
is to be made by a careful location of the tumor by palpation and
percussion and the absence of symptoms likely to occur in connection
with affections of the organs named. In children psoas abscess and
degeneration of the lumbar lymphatic glands should also be considered.

A sarcoma of the kidney has been mistaken and punctured for an empyema.
A sarcoma behind the kidney, pushing it forward, is very difficult to
distinguish from a similar growth affecting the organ itself,
especially as it is likely to give rise to signs of renal irritation
discoverable by the microscope. A slight pyelitis, distinguished by pus
and the absence of any cellular elements to indicate an origin at a
lower point, has been observed in such a case.

The results of exploratory puncture have been before alluded to. If a
piece can be brought away large enough to be examined microscopically,
it may settle the diagnosis, not only as to a malignant growth, but
also as to its kind.

The distinction between carcinoma and sarcoma cannot always be made
during life, nor indeed, without a microscopical examination, after
death. It is of importance chiefly with reference to prognosis after
operation for removal of the organ. A more rapid growth, a greater
tendency to invade other organs, and a more marked cachexia would speak
in favor of carcinoma, while a tumor gradually attaining a very large
size, and not spreading beyond the kidney and its immediate envelopes,
is more likely to be a sarcoma.

There is no TREATMENT known to be of value in cancer or sarcoma of the
kidney, except so far as it may diminish pain or regulate the
secretions. Surgically, removal of the diseased organ is the only
expedient to be thought of. Although nephrectomy has been shown to be a
perfectly practicable operation, and one that is usually well borne
when the other kidney is sound, it has not proved very successful with
malignant growths, even as a temporary expedient. This is partly at
least to be accounted for by the difficulties lying in the way of
diagnosis in the earlier stages, and the reluctance with which so
serious an operation would naturally be resorted to until hopes based
either on the uncertainties of diagnosis or mistaken reliance on
medical treatment have been given up. Cases, however, have been
reported where patients have recovered from the operation, and the
disease has not returned for some months. When an operation has been
resorted to, the tumor has usually become too large to be extracted
through the loin, and laparotomy has been the course {63} pursued.
According to Billroth,[22] out of 33 operations for tumors of the
kidney, 13 have been cured.

[Footnote 22: _Mittheil. der Aerzte in Nieder Oesterreich_, Bd. x. p.
161 _et seq._]


Cysts.

Three kinds of cysts are met with in the kidney besides those connected
with the growth of parasites.

Kidneys congenitally affected with cystic degeneration contain a large
number of sacs lined with a vascular membrane, among the partitions of
which are found the remains of secreting structure. Both kidneys are
equally affected, and are enlarged and more or less lobulated. They are
occasionally so large as to constitute an obstacle to labor, and
various operative procedures, even evisceration, have been required to
accomplish the delivery of the foetus affected. The cysts are filled
with fluid of various degrees of darkness of color from almost perfect
limpidity to almost black. The fluid in the smaller cysts, at least,
contains some of the urinary solids. The slighter degrees of this
affection do not render a child necessarily non-viable, but with the
larger some accident is likely to happen.

The formation of these cysts has been referred to an intra-uterine
chronic nephritis, but another theory accounts for them by a vice of
development. The fact that when the lesion is unilateral, as sometimes
happens, there is apt to be a deficiency of some other part of the
genito-urinary apparatus on the same side, and that several infants
with cystic degeneration have been born of the same mother, speaks
strongly in favor of the latter theory.

Serous cysts of later origin do not usually attain so large a size, or
rather the kidney does not, on account of their smaller number. They
are lined with a thinner membrane, and their contents are nearly clear,
but coagulable, comprising uric acid, carbonate of lime, and
cholesterin. Occasionally a single cyst attains considerable dimensions
and produces by its pressure atrophy of part of the kidney. These cysts
are supposed to arise in consequence of the blocking of a tube.

The third class of cysts closely resemble the first in appearance and
in form, and contain more or less serous or gelatinous fluid, with
albumen, blood-corpuscles, and pus, as well as the peculiar colloid
bodies previously mentioned. They undoubtedly arise from the distension
of tubes and of Malpighian bodies. These cysts are usually associated
with chronic interstitial nephritis, and in fact they are rarely absent
in cases of this kind, although the extreme degree--that is, where the
cysts assume the most prominent position while the contracting
nephritis falls into the background--are less common. In these latter
cases the organ may be almost transformed into a mass of rounded bodies
somewhat resembling a bunch of grapes.

The SYMPTOMS of the first two of these conditions--that is, of the
cysts which are not connected with an active nephritis and attract
attention simply as tumors--depend on the pressure they exert; and a
diagnosis is to be made by a knowledge of their history and by the
rules already given. The symptoms and diagnosis of the third variety
are involved in those of chronic interstitial nephritis.

{64} There is no reason to suppose that any drug has any therapeutic
action on such kidneys, so far as the cysts are concerned. It should
always be remembered that a kidney may contain a large number of cysts,
and yet scattered portions of secreting substance enough be left to
carry on the function indefinitely.

It might under some circumstances be justifiable to remove a cystic
kidney on account of the pressure exercised on other organs, but as the
cysts do not increase rapidly in size, punctures several times
repeated, so as to empty a number of them, would in most cases prove as
effectual an operation, and, what is of greater importance, would not
involve the loss of any portion, even if small, of secreting structure
which may be left.


Tuberculosis.

The tubercles which are found in the kidney in cases of general miliary
tuberculosis have usually no clinical interest, since the kidney is
not, even in children, one of the points where tubercular localization
is most intense, and renal tubercles are consequently but little
advanced when death takes place from the extension of the disease in
other organs. They present no symptoms which are perceptible among the
much graver ones attending the progress of the disease elsewhere.

In the disease known as tubercle of the kidney, caseous nephritis, or
nephro-phthisis, masses of caseous material are deposited in the renal
parenchyma which may soften, break down, and communicate with each
other and with the calices and pelvis. In some cases it is probable
that the disease originates in or immediately underneath the mucous
membrane of the urinary passages. This process of breaking down
continues much in the same way as that of a phthisical lung, until the
kidney becomes little more than a hardened, irregular, knobby shell
enclosing a ragged, ulcerated cavity with thickened, pus-secreting
walls and filled with pus, more or less blood, and débris of
kidney-structure and tubercle. In such portions of renal substance as
may remain it is not unusual to find miliary tubercle. If obstruction
of the ureter exists, a pyo-nephrosis may exist in addition. Rupture
into the peritoneal cavity or into the intestine has occurred.

It is probable that in this affection are included two processes,
differing in pathology and etiology and to some extent in clinical
history. It is probable that true tubercle may originate in the kidney
as a result of either tubercle or cheesy inflammation elsewhere, as in
the lungs, bodies of the vertebræ, or scrofulous glands. In this case
there are no marked symptoms until the process of softening and
breaking down has reached the mucous membrane of the pelvis. Besides
this, renal phthisis sometimes succeeds, as a more local invasion, to
tubercle or cheesy inflammation of the urinary passages, and in this
case the symptoms appear simply as aggravations of those already
present and depending upon ureteritis and pyelitis. Renal phthisis is
seldom if ever an independent disease. It is often associated, besides
the affections already named as standing in etiological relationship
with it, with cheesy inflammation of the testicle, vesiculæ seminales,
and much less frequently of the ovaries and Fallopian tubes.

{65} The DIAGNOSIS of tubercle in the kidney before it has reached the
pelvis is probably impossible. Pain in the back or slight albuminuria,
as has been already stated, is of no diagnostic value except as
pointing to some renal irritation, as to the cause of which it tells
nothing. In the presence of tubercle elsewhere it might be regarded as
suspicious.

After cavities have become connected with the pelvis or have extended
from it, the symptoms become more marked. In the urine are to be found
pus, some blood, epithelium of the urinary passages and often of the
kidneys, in many cases in the form of casts; and it is claimed that
masses of caseous matter as large perhaps as the head of a pin may be
found, which will of course make the diagnosis almost a matter of
certainty. If the urine containing such a deposit is acid, it is almost
certain that the lesion is mainly in the kidney and that the bladder is
but slightly if at all affected. It is also stated that the bacillus of
tubercle has been found. The presence of this parasite will not only
testify as to the presence of the clinical condition known as phthisis
of the kidney, but will also make it sure that the affection depends
upon tubercle in the strictest pathological sense, and will influence
the prognosis accordingly. Inoculation of purulent sediment from the
urine of a patient suffering from tuberculosis of the urinary passages
has produced tubercle in the iris of the rabbit. This procedure has
been suggested as a means of diagnosis as to the character of a chronic
catarrh of these passages before the appearance of tubercle
elsewhere.[23]

[Footnote 23: Ebstein, _Centralblatt für die Med. Wiss._, 1882, p. 918,
from _Deutsch. Arch. f. klin. Med._, xxxi. S. 63.]

If pyelitis have already been present, the change in the appearance of
the urine will be less characteristic, but there may be a marked
aggravation of symptoms when the contents of softened masses are added
to the secretions of the mucous surface. There is likely to be much
fluctuation in the quantity of débris present from day to day. Urinary
fever of the hectic or subcontinued type, with anorexia, nausea, dry
tongue, and diarrhoea, is present. In some cases the enlarged and
irregular kidney may be felt.

The PROGNOSIS of this condition is in the highest degree unfavorable,
although the finding of cicatrices in kidneys where symptoms of renal
phthisis have been present suggests that it is possible for caseous
masses in these organs, as well as in the lungs, to undergo absorption
and healing.

The TREATMENT must be, in the first place, constitutional by tonics and
reconstituents, and local by the use of such antiseptics as are
eliminated through the kidney, as boric or benzoic acid or the
benzoates. But little, however, is to be expected from it.


Parasites.

The most important parasite which is known to inhabit the kidney is the
immature tapeworm of the dog, or Tænia echinococcus. It is decidedly
rare in this country to meet with this affection in any part of the
body, and as the kidney is not one of the organs most likely to be
chosen as its habitat, the condition is not one which comes often under
the observation of physicians.

{66} It is hardly necessary to describe here the structure or contents
of the hydatid cyst which forms the home of the parasite, nor its
etiology, since these topics belong to general pathology, and the cyst
is the same in whatever organ it may be seated. When it affects the
kidney, it is usually the left--more frequently that of a man between
thirty and forty years of age.

A hydatid cyst may be situated upon any part of the kidney. If small,
it may never make its presence known. A larger one may give rise to
those vague pains in the back found with so many diseases of the kidney
and characteristic of none of them. A cyst may open in any direction,
but is more likely to empty into the pelvis of the kidney. When this
happens, the smaller cysts or pieces of the larger ones often enter the
ureter and give rise to renal colic, and possibly, later, to a
pyelitis. Other points of discharge are the intestines, the lungs, or
the abdominal walls.

After a hydatid cyst has reached a certain size its presence may be
recognized by palpation, but the diagnosis between it and other tumors
of the kidney must be very difficult unless characteristic fragments
make their appearance in the urine at the same time that the tumor
diminishes in size, or unless they can be obtained by puncture. The
hydatid thrill, if it can be obtained, will be an important factor in
diagnosis.

The TREATMENT of this affection in the kidney presents no special
points of difference from that of similar cysts in the liver; with this
important exception, that besides punctures with large and small
trocars, incisions, electrolysis, etc., the resource of complete
extirpation still remains. Cures have been obtained by repeated
punctures and subsequent suppuration, and by partial removal through
the abdominal walls and subsequent drainage.

Among the parasites of the kidney it is customary to mention the
Strongylus gigas, which is a worm somewhat resembling the ascaris and
inhabiting the pelvis. It is not very infrequent among the Carnivora,
but since only seven cases have been described in the human subject
since the seventeenth century, and only a part of these are admitted as
genuine by certain authors, its diagnosis, prognosis, and treatment
must depend more upon theory than upon experience. The diagnosis is to
be made, if at all, on the basis of a pyelitis and the discovery of the
eggs of the parasite in the urine.

The Distoma hæmatobium is a parasite found chiefly in the
blood-vessels, and especially those of the portal system. It is
occasionally, however, met with in the veins of the kidney and also in
the urinary passages. Its eggs pass into the pelvis and ureters, and
there begin their development, which, however, is soon arrested, as
they rapidly perish in the urine.

These parasites appear to produce either by a direct action or by the
occlusion of vessels, ulceration, and hemorrhages from the urinary
mucous membrane, including that of the bladder. These effects are
supposed to be due to the blocking of the smaller vessels by the worms
themselves. An adherent deposit consisting of masses of distoma eggs
and grains of uric acid sometimes forms in grayish-yellow patches
within the ureter, and gives rise to stricture, with dilatation and
hydro-nephrosis above. This parasite has been considered the cause of
the endemic hæmaturia of hot countries, but as cases of this affection
have been carefully examined {67} for the distoma with negative
results, it must be considered as only one among several causes.
Strongyli are said to have been found in some of the cases.

Nothing is known of an appropriate TREATMENT for the distoma. An
abundant flow of urine might perhaps carry off more rapidly such
individuals as have found their way into the urinary passages, and,
considering the character of the deposit described above as causing
stoppage of the ureter, treatment directed against the uric-acid
diathesis might diminish the risk of this particular form of trouble.


Diseases of the Ureters.

Absence of the ureter may take place when one kidney is congenitally
absent, though this is not an absolute rule, since the ureter may
terminate above in a rounded sac. When a single kidney exists,
consisting of the fusion of two, there are usually two ureters opening
in the usual position. In one instance, in which only one kidney and
one ureter were present, the ureter opened into the bladder on the side
opposite to that upon which the kidney was situated.

Not very infrequently two ureters exist in connection with a normal
kidney, remaining separate for the whole or a part of their course to
the bladder. This condition is merely a sort of exaggeration of the
separation between the two branches of the renal pelvis.

A few instances have been noted where a ureter or a fistula connected
therewith has opened outside of the bladder at a point near the
urethra. This malformation gave rise to symptoms of incontinence of
urine, and in one case was remedied by operation.

Abnormal openings of the ureter into the uterus and vagina as the
results of pelvic inflammations, and upon the external surface as the
result of wounds, have occurred. They are more or less amenable to
surgical treatment, and belong to the domain of surgery and gynecology
rather than to medicine.

Occlusion of the ureter has already been spoken of in connection with
the hydro-nephrosis and pyelitis to which it gives rise. This occlusion
results from pressure exerted either at the vesical orifice from
cystitis; a little higher up from malignant disease connected with the
uterus or a fibroma surrounding the ureter; from contracting adhesions
resulting from pelvic inflammation; or from sharp flexions of the tube
itself, perhaps also from valvular folds of the mucous membrane.
Sometimes its obliteration seems to be the result of old inflammation
of the mucous membrane of the ureter itself in connection with that of
the renal pelvis. In the latter case the occlusion may be complete at
several points, while at others a collection of dry, cheesy, or
putty-like material occupies the cavity of the ureter as well as the
pelvis of the atrophied kidney.

Cancer is not known primarily to invade the ureter.

Tubercle is not infrequently found in the form of small granulations in
cases of general tuberculosis, and it is possible that this deposit may
be among the earlier ones; hence a chronic catarrh of the urinary
passages without some known cause should be looked upon with suspicion,
{68} and the development of phthisis as far as possible guarded
against. The presence of these small tubercles in the ureter, if none
are present or no ulceration exists in the kidney, are of little or no
local importance.

Inflammation of the ureter often exists in connection with cystitis and
pyelitis, and in fact constitutes the means by which the higher urinary
passages become gradually involved in the diseases below.

The DIAGNOSIS of this condition as a distinct disease is hardly
possible, and is besides unnecessary, as the treatment to be directed
thereto would be included in that called for by the more extensive and
obvious inflammation of the kidney and bladder.




{69}

DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS.

BY FRANCIS DELAFIELD, M.D.


CHRONIC CONGESTION OF THE KIDNEY.

SYNONYMS.--Passive congestion; Cyanotic induration.

It is now generally recognized that we must separate from the other
forms of kidney disease the condition of chronic congestion. Since
Traube first called attention to the causation and characters of this
lesion, all authors have recognized its special character, although
there are still minor differences of opinion concerning it.

ETIOLOGY.--Chronic congestion of the kidney may be produced by any
mechanical cause which interferes with the escape of the blood from the
renal veins. Thrombi of the veins, tumors pressing on the veins,
emphysema of the lungs, hydro-pneumothorax, pericarditis,--all may
produce this lesion. As to how often it is produced by the pregnant
uterus is still a question. But the most common cause of all is organic
disease of the heart. Practically, the lesion comes under consideration
as a complication of heart disease, of aneurism of the arch of the
aorta, and of emphysema of the lungs.

LESIONS.--If the congestion has not existed for a long time, we find
the kidneys increased in size and their weight great in proportion to
their size. They are of an unnatural hardness--a hardness which can be
imitated by injecting the blood-vessels of a normal kidney with water.
The capsules are not adherent, the surfaces of the kidneys are smooth.
Both the cortical and pyramidal portions are congested, and this
congestion gives the entire organs a peculiar reddish, livid color. No
lesions are found in the Malpighian bodies, tubes, stroma, or
blood-vessels, except that the epithelium of the convoluted tubes may
be a little swollen.

If the congestion has lasted for a longer time, the kidneys may
continue to be large or they may be somewhat reduced in size; the
weight remains out of proportion to the size. There are the same
unnatural color and consistence. The capsules are now often slightly
adherent and the surfaces of the kidneys finely nodular. In the cortex
there may be patches of new connective tissue enclosing atrophied
tubules, or there may be a more diffuse growth of connective tissue
separating the tubes from each other. In the convoluted tubules the
epithelial cells may be swollen and finely granular, or very much
swollen and coarsely granular, so as to nearly fill the tubes, or
flattened so that the cavities of the tubes are {70} unnaturally large.
The tubes may also contain cast-matter and detached and broken
epithelial cells. The capsules of the Malpighian bodies may be a little
thickened and the capsular endothelium swollen. In the pyramids the
epithelium of the straight tubes may be granular and detached, and
there is often cast-matter in the looped tubes. It is difficult to tell
whether there is any real change in the veins of the kidney.

As a result of the same interference with the venous circulation,
similar changes are found in other parts of the body--in the lungs,
liver, spleen, stomach, small intestine, and pia mater. In all these
organs there is, first, simply a venous congestion, then after a time
structural changes are added. Formation of new connective tissue and of
new functional cells of the particular organ, degeneration of these
cells, dilatation and tortuousness of the small veins and capillaries,
are regularly present. The kidney lesion, therefore, is only one of a
number of lesions, all dependent on a common mechanical cause.

SYMPTOMS.--Of the persons who die with chronic congestion of the
kidney, a large number present marked symptoms during life, but it is
difficult to determine how largely these symptoms are due to the
congestion of the kidney.

A congestion of the kidney of only a few days' duration does not seem
usually to give rise to any symptoms. Even if such a congestion is
prolonged to two or three weeks, as we see in some cases of
hydro-pneumothorax from perforation of the lung, there may be no renal
symptoms and no changes in the urine. On the other hand, it is
extremely rare for organic heart disease or emphysema of the lungs to
prove fatal without some disease of the kidneys.

The question is still further complicated by the fact that both in
cardiac disease and emphysema there may be either chronic congestion of
the kidney or chronic diffuse nephritis with the same symptoms.

After excluding the cases of cardiac hypertrophy secondary to kidney
disease and the cardiac diseases with complications, I find in my
casebooks 137 cases in which the patients died simply from heart
disease, changes in the viscera due to the disturbance of the venous
circulation, and kidney disease. Of these cases, 84 presented the
lesions of chronic diffuse nephritis; 53 were in the state of chronic
congestion. Of the cases of chronic diffuse nephritis, 27 were large
white kidneys, 29 atrophied kidneys, 28 could not be classed as either
large white or atrophied. In these cases there existed during life
certain regular symptoms. There were changes in the urine, dropsy,
headache, delirium, convulsions, coma, dyspnoea, vomiting, cough,
hæmoptysis, loss of flesh and strength.

As regards the quantity of the urine, there was a very great variety
until shortly before the patient's death; then the urine was usually
diminished in amount, sometimes suppressed. A very marked decrease in
the amount of urine was more constant in the cases of chronic diffuse
nephritis than in those of chronic congestion. But in several cases
both of chronic diffuse nephritis and of chronic congestion the
patients passed from thirty to forty ounces of urine up to the time of
their deaths.

Albumen and casts were often present--nearly always with the large
white kidneys, not nearly as constantly with atrophied kidneys or with
{71} the cases of chronic congestion. In cases of chronic congestion
the albumen was usually in small amount and often not accompanied with
casts.

The specific gravity of the urine was apt to be low with chronic
diffuse nephritis and high with chronic congestion, but there were many
exceptions to this rule. With large white kidneys, atrophied kidneys,
simple diffuse nephritis, and chronic congestion the specific gravity
might be either normal, high, or low up to the time of death.

Transudation of the serum into the subcutaneous connective tissue and
the serous cavities was a very constant symptom. It was a little more
constant, and perhaps usually reached a greater degree, in the cases of
chronic diffuse nephritis than in those of chronic congestion.

Headache, delirium, convulsions, and coma occurred in a moderate number
of all the cases.

Dyspnoea was a very frequent symptom in all the cases.

Vomiting was also present in many cases.

Cough, with mucus or muco-purulent sputa, sometimes with hæmoptysis,
was a very common symptom.

Many of the patients lost flesh and strength and became anæmic.

COURSE OF THE DISEASE.--There is a great deal of similarity in the
histories of patients who suffer from the combination of cardiac and
renal disease. There is first the history of the heart disease. A
patient goes on for a number of years, sometimes apparently perfectly
well and unconscious that his heart is diseased, sometimes more or less
troubled with cough, cardiac dyspnoea, and palpitation. But after a
longer or shorter time there is a marked change for the worse. Either
gradually or rapidly the cough becomes worse, the dyspnoea greater, the
functions of the stomach are disturbed, the patient loses flesh and
strength, dropsy is developed, and finally cerebral symptoms. Some die
suddenly, some with exhaustion, some with dropsy, some with dyspnoea,
some comatose. It is always possible for the patient to recover from
the first attack of this kind, sometimes even from a second, but
eventually there comes an attack which proves fatal.

The most striking cases are those in which cardiac disease exists for
many years without giving any symptoms, and then the symptoms are
developed rapidly. Such persons, although they have organic disease of
the heart, may seem to enjoy perfect health. They may even be able to
take long walks, climb mountains, or perform laborious work. On some
day they suddenly become sick. Sometimes the exciting cause of the
attack is a pleurisy or a pericarditis, sometimes there is no apparent
cause. The first symptom is usually dyspnoea, and this is not an
ordinary cardiac dyspnoea. It is a very distressing and constant
dyspnoea, which does not allow the patients to lie down. They pass days
and nights sitting in a chair, fatigued, ready to sleep, but kept awake
by the constant dyspnoea. Some of these patients will die at the end of
a few days; others live longer and develop dropsy, anæmia, and cerebral
symptoms.

When the chronic congestion of the kidneys is secondary to emphysema of
the lungs, the course of affairs is much the same. The patient goes on
for a number of years with the ordinary symptoms of emphysema, and then
gradually or suddenly becomes worse. Dyspnoea, dropsy, {72} anæmia,
cerebral symptoms make their appearance, and the case terminates in the
same way as the cardiac cases.

DURATION.--How long congestion of the kidneys may exist without
producing symptoms it is hard to say. Certainly it may exist for a
number of days without any apparent disturbance of the functions of the
kidney. Whether it may exist for a time, give symptoms, and then
disappear, is uncertain; the rule seems to be that the lesion, when
once well established, persists up to the death of the patient.

TREATMENT.--It must be acknowledged that we can hardly hope for a cure
of the lesion of the kidneys, and that even alleviation of the symptoms
is not always possible. The mechanical cause of the obstruction to the
venous circulation cannot be removed, and it is not only the functions
of the kidneys that are disturbed, but those of the lungs, liver,
spleen, stomach, and small intestine. Still, we can do something. The
iodide of potassium, convallaria, caffeine, and digitalis may be of
service in equalizing and strengthening the heart's action, and at the
same time act as diuretics. Inhalations of the nitrite of amyl dilate
the arteries and capillaries, and so unload the veins. Opium is the
great remedy for the dyspnoea, although it must be given with caution.
Inhalations of ether may render the patient's last days more
comfortable.


BRIGHT'S DISEASE OF THE KIDNEYS.

After considering separately the condition of chronic congestion of the
kidney, we find that there are a group of kidney diseases characterized
by certain rational symptoms, changes in the urine, and alterations in
the structure of the kidneys which are popularly known by the name of
Bright's disease.

Various attempts have been made to classify these cases.

1. All the kidney lesions have been supposed to correspond to the
stages of an inflammatory process--a stage of congestion, a second
stage of exudation, and a third stage of contraction.

2. The disease has been divided, according to its clinical symptoms,
simply into acute and chronic Bright's disease.

3. The gross appearances have been taken as a standard, and the cases
are classed as examples of large white kidney, atrophied kidney, waxy
kidney, etc.

4. The kidneys have been compared to mucous membranes, and authors
speak of catarrhal and croupous nephritis.

5. The disease has been classified, according to the particular part of
the kidney affected, into parenchymatous, tubular, glomerular,
interstitial, and diffuse nephritis.

With our present knowledge of the subject it seems to me most
convenient to speak of acute and chronic parenchymatous nephritis and
acute and chronic diffuse nephritis. I include under the head of
parenchymatous nephritis all those kidneys in which the lesions are
strictly confined to the epithelial cells lining the tubules and the
capsules of the {73} glomeruli; under the head of diffuse nephritis,
those kidneys in which the lesions involve the tubes, stroma,
glomeruli, and arteries; under the head of interstitial nephritis,
those kidneys in which the essential morbid changes are in the stroma.

This classification seems to me to be theoretically correct, but yet I
must admit that from a clinical standpoint nearly all the cases may be
conveniently arranged into the two classes of acute and chronic
Bright's disease.

GENERAL SYMPTOMS OF BRIGHT'S DISEASE.--There are a certain number of
symptoms common to all the varieties of Bright's disease, and it is
convenient to consider them before going on to the special description
of each of these varieties. These symptoms are--

Changes in the Urine.--Healthy adults usually secrete during the
twenty-four hours from 40 to 50 ounces of urine of a light-yellow
color, of acid reaction, of a specific gravity of 1015 to 1025, and
holding in solution a number of excrementitious substances. Small
amounts of albumen and of sugar seem to be, in some persons,
physiological ingredients of the urine.

In most cases of Bright's disease the quantity of the urine at some
time in the course of the disease deviates from the normal standard.
Either the urine is increased in amount or diminished or suppressed,
and in the course of the same case the urine may be at one time
increased, at another diminished.

We find in healthy persons that the quantity of urine varies with the
amount of fluids that are imbibed and with the condition of the skin
and the bowels--that nervous influences and certain drugs will increase
or diminish the amount of urine. Physiologists teach us that the amount
of urine excreted varies with the degree of the blood-pressure in the
renal arteries or with the rapidity with which the blood circulates
through these arteries.

The urine may be very much increased or diminished in amount as the
result of various morbid conditions. Scanty urine or suppression of
urine is observed in the course of acute parenchymatous and acute
diffuse nephritis and in the early stages of the development of the
large white kidney. During the course of any case of chronic Bright's
disease there are usually periods during which the urine is scanty or
suppressed, especially toward the close of the disease. The kidney
lesions which complicate scarlet fever, yellow fever, and cholera are
often attended with suppression of urine. Any diseases accompanied by a
well-marked rise of temperature are apt to be associated with a
diminution in the amount of urine. Injuries to the urethra, even very
slight ones, may be followed by complete suppression of urine, without
any changes in the kidneys except congestion.

Marked diminution in the amount of urine occurring in the course of
acute and chronic Bright's disease is usually associated with the
development of cerebral symptoms--headache, restlessness, delirium,
muscular twitchings, convulsions, stupor, and coma. Such a change in
the amount of the urine usually lasts only a few days and may terminate
fatally, or the quantity of urine will increase and the patient get
better. There are, however, cases in which the suppression of urine
lasts for several days without the development of uræmic symptoms.
Whitelaw[1] relates a {74} case of suppression of urine lasting for
twenty-five days in a boy eight years old. The suppression began twelve
weeks after an attack of scarlatina. There were no uræmic symptoms, and
the child recovered completely.

[Footnote 1: _Lancet_, September, 1877.]

The suppression of urine due to injuries of the urethra gives rise to
symptoms of great prostration--rigors, vomiting, and collapse--rather
than to uræmic symptoms.

Suppression of urine is also produced by occlusion of the ureters by
calculi, new growths, etc. It is a curious fact that in these cases the
patients continue to live for a number of days (9 to 11, Roberts), and
no uræmic symptoms are developed until a few hours before death.

The most marked examples of persistent increase in the quantity of
urine are afforded by cases of diabetes mellitus and diabetes
insipidus. But a daily excretion of from 70 to 100 ounces is common
enough with atrophied kidneys, with large white kidneys, and with waxy
kidneys.

It is exceedingly difficult to form any rational idea of the causes of
the variations in the amount of urine in the course of the same case,
and in different cases with similar kidney lesions. Various
explanations have been attempted, ascribing these changes to the
hypertrophy of the left ventricle of the heart, to changes in
blood-pressure, to lesions of the arteries, to changes in the
composition of the blood, to lesions in particular portions of the
kidneys. But any one who tries to apply these explanations to any
number of actual cases will find many difficulties.

The most evident causes of diminution in the amount of urine seem to be
an abnormal condition of the circulation of the blood and either
congestion or structural changes of the kidneys.

The specific gravity of the urine varies from day to day and from hour
to hour in the same person, having a regular relation to the quantity
of urine passed. But a long-continued deviation from the normal
specific gravity is usually an evidence of disease. The highest
specific gravities obtain with saccharine diabetes. Abnormally high
specific gravities also often occur in the urine of patients with a
high temperature, with chronic congestion of the kidneys, and in some
cases of acute and chronic parenchymatous nephritis.

Low specific gravities are the rule in diabetes insipidus and with
acute and chronic diffuse nephritis. In chronic diffuse nephritis the
specific gravity remains low even if the quantity of urine passed is
very small. When there is almost suppression of urine from occlusion of
the ureters the urine that is passed is of low specific gravity.

These changes in specific gravity correspond of course to the amount of
solid matter in solution in the urine, and may depend upon a change in
the relative proportion of the fluid and solid constituents of the
urine, or upon an absolute increase or decrease of the solid portions.

Any change in the absolute amount of solid matter excreted in the urine
must depend upon changes in the composition of the blood, or in the
circulation of the blood through the kidneys, or in the structure of
the kidneys themselves. All these three conditions seem to exist in
Bright's disease, and either together or separately may diminish the
daily excretion of solid matter.

It is not necessary here to enumerate the different solid constituents
of {75} the urine. A change in the amount of many of them merely
indicates disorders of the digestive process. Urea seems to be the most
important of the excretory substances, and its quantity is regularly
diminished both in acute and chronic Bright's disease.

Blood is found in the urine in a considerable number of cases of
Bright's disease. If it is present in large quantities, the urine will
be of a reddish color; if in smaller quantities, of a smoky color; and
if in still smaller quantities, the color will not be changed. Blood is
found regularly with acute diffuse nephritis, with the more severe
cases of acute parenchymatous nephritis, with the exacerbations of
chronic diffuse nephritis, and with suppurative nephritis. The blood
seems to be derived from the tufts of vessels in the Malpighian bodies.

Albumen in the urine is a very common symptom of renal disease, but it
is not confined to such cases. It is also found without any structural
lesions of the kidneys.

1. There are some individuals whose urine, for many years, will contain
small quantities of albumen, and yet their general health is good and
they never develop any renal symptoms. In some of these cases the urine
is always somewhat diminished in quantity, and in some there is also a
little sugar in the urine.

2. In a large number of perfectly healthy persons small amounts of
albumen will appear as a temporary condition after muscular exercise,
sea-bathing, eating certain kinds of food, etc.

3. Albumen may be present in considerable amount for weeks or months in
the urine of young persons, and then disappear altogether. The general
health may continue good or be somewhat depreciated. After a time the
albumen disappears and the patients have no further trouble.

4. General convulsions, concussion of the brain, and transfusion of
blood often produce a temporary albuminuria.

Some observers believe that albumen is always present in the urine, but
in such small amounts as to elude the ordinary tests.

Both physiological and pathological albuminuria is most constant and
abundant after eating.

The albumen is not all of the same character. Most of it is
serum-albumen, but with it is a smaller amount of globulin and
sometimes of peptones. As yet the serum-albumen seems to be of the
principal practical importance.

Pathological albuminuria is most constant and the albumen is most
abundant with acute and chronic parenchymatous nephritis, with acute
diffuse nephritis, and with the large white variety of chronic diffuse
nephritis. It is least constant and least abundant with the atrophic
variety of chronic diffuse nephritis, with some waxy kidneys, with
interstitial nephritis, and with chronic congestion of the kidney. A
variety of explanations have been given to account for the production
of albumen by diseased kidneys, but none of them are very satisfactory.

The albuminuria has been ascribed to disease of the epithelium of the
Malpighian bodies; to increase of the blood-pressure within the renal
arteries, either with or without disease of the arterial walls; to
slowing of the blood-current in the arteries; to diminution of the
blood-pressure in the arteries; to congestion of the renal veins; to
changes in the {76} composition of the blood; to changes in the
epithelium of the renal tubules.

For practical purposes it is to be remembered that large amounts of
albumen regularly indicate structural changes in the kidneys; that
small amounts of albumen are found without any kidney lesions, with
chronic congestion of the kidney, and with chronic diffuse nephritis;
that chronic diffuse nephritis may exist without albuminuria for a long
time.

In many cases of kidney disease we find in the urine bodies of
cylindrical shape called casts. The same bodies are also found within
the tubules of diseased kidneys. Concerning the nature and origin of
these bodies we are still ignorant. We only know that they are formed
within the kidney tubules and are carried thence into the urine. With
the exception of the blood-casts, which are composed simply of a number
of blood-globules pressed together, all casts seem to be formed of a
peculiar homogeneous hyaline substance to which other elements may be
added. Hyaline casts are composed entirely of such material. Waxy casts
are formed of the same substance, which becomes denser. Epithelial
casts are made by the adhesion of epithelial cells to the surface of
hyaline casts. Nucleated, granular, and fatty casts are hyaline casts
with the fragments of degenerated epithelium incorporated in them.

Occasionally hyaline casts are found in the urine of healthy persons.
They also occur as a temporary condition after severe muscular
exertion, with typhlitis, with renal calculi, and with jaundice. Most
frequently, however, they are associated with structural disease of the
kidneys. Usually they are found in albuminous urine, and in proportion
to the amount of albumen, but we may find casts without albumen and
albumen without casts.

With chronic congestion of the kidney the casts are hyaline and few in
number. With acute parenchymatous nephritis there are hyaline,
granular, nucleated, and epithelial casts. With chronic parenchymatous
nephritis there are hyaline, granular, and nucleated casts. With acute
diffuse nephritis there are blood, epithelial, hyaline, granular,
nucleated, and fatty casts. With chronic diffuse nephritis there are
hyaline, waxy, granular, fatty, nucleated, and epithelial casts.

An accumulation of serum in the subcutaneous connective tissue, in the
serous cavities, and in the lungs is one of the regular symptoms of
Bright's disease. It usually appears first in the feet or in the face.
Such dropsy is said to be due to a low specific gravity of the
blood-serum; to the loss of albumen; to the scanty elimination of
urine; to hydræmia plethora; or to changes in the walls of the
blood-vessels.

The functions of the stomach are often disordered, either with or
without the existence of chronic gastritis. Loss of appetite, nausea
and vomiting, oppression after eating, etc. continue and grow worse
throughout the disease. Vomiting is also a frequent concomitant of the
so-called uræmic attacks.

Diarrhoea often occurs with dropsy and a scanty excretion of urine, and
may then be of service to the patient, but it sometimes becomes very
profuse, rebellious to treatment, and is of positive injury.

Dyspnoea associated with Bright's disease seems to occur in several
different ways. It may be of mechanical origin from oedema of the lungs
or from hydrothorax. It may be a purely nervous phenomenon, {77} or it
may depend upon a complicating heart lesion. The nervous dyspnoea seems
to be allied to the uræmic vomiting and cerebral symptoms; it is often
most distressing.

In the course of chronic Bright's disease disturbances of vision occur
dependent on three different conditions: (1) There may be a loss of
vision, usually temporary, without any discoverable lesion of the eye.
(2) There may be simple neuro-retinitis. (3) There may be the
characteristic nephritic retinitis with hemorrhages and fatty
degeneration of the retina. These two forms of retinitis are often the
first symptoms of renal disease.

Neuralgic pains, most frequently referred to some part of the head or
face, but also to other parts of the body, are prominent symptoms in
some cases.

The Blood.--Both in acute and chronic Bright's disease the patients
often become markedly anæmic and pale. This change in the color of the
patient corresponds to an alteration of the composition of the blood
with the details of which we are not as yet fully acquainted. The blood
seems to be thinner and more watery.

Cerebral Symptoms.--Headache, drowsiness, stupor, sleeplessness,
delirium, coma, muscular twitchings, and general convulsions are of
frequent occurrence. The headache and drowsiness may continue during
the course of the disease for many months. The stupor, sleeplessness,
delirium, coma, muscular twitchings, and general convulsions are apt to
occur in attacks which last for several days, and then pass away or
terminate in the death of the patient. With such cerebral symptoms are
often associated dyspnoea, vomiting, increased temperature, and
diminution in the excretion of urine. The entire group of symptoms is
commonly known by the name of uræmia.

It is a matter of great practical importance to determine the cause of
these cerebral symptoms, for otherwise there can be no rational
treatment of them. It is evident that such cerebral symptoms must
depend upon anatomical changes in the brain or its membranes, or upon a
change in the composition of the blood which circulates through the
brain, or upon the quantity of blood supplied to the brain.

It is to be remembered that such cerebral symptoms occur most
frequently with the atrophic form of chronic diffuse nephritis; that
they are often the first symptom of renal disease; that the same person
may have several such attacks, with no cerebral symptoms during the
interval; that the urine is usually, but not always, diminished during
the attack, and becomes more abundant when the attack ceases; that such
attacks also occur with the chronic congestion of the kidney due to
cardiac disease, in pregnant women without kidney disease, and with
diseased arteries and high arterial tension without kidney disease.

Anatomical changes in the brain or its membranes do exist in a
considerable number of cases of chronic Bright's disease. Chronic
meningitis with thickening of the pia mater and an increase of serum is
quite common; anæmia and oedema of the brain-tissue are often seen. But
there are a great many cases with cerebral symptoms without such
lesions, and with such lesions without cerebral symptoms.

The composition of the blood is undoubtedly changed in most of the
cases with cerebral symptoms. It is natural to look for such changes as
{78} are due to perversion of the excretory function of the kidneys,
and to ascribe the cerebral symptoms to the poisoning of the blood by
urea, by urea transformed into carbonate of ammonia, or by the other
excretory matters which should be eliminated by the urine. Moreover, it
has been demonstrated that there is a very marked increase in the
amount of urea contained in the blood in such cases. On the other hand,
we find that suppression of urine with accumulation of urea in the
blood may exist for a long time without cerebral symptoms if the
suppression is due to obstruction of the ureters; that with chronic
congestion of the kidney, puerperal convulsions, and diseased arteries
urea is excreted in fair amount, although cerebral symptoms exist; and
that even in cases of cerebral symptoms with chronic diffuse nephritis
there may be no increase of urea in the blood.

In most of the cases with cerebral symptoms, however, there are other
changes in the composition of the blood, concerning the exact nature of
which we are still ignorant. In most cases of chronic Bright's disease
the patients become pale and the blood is thin and watery; and this is
also often the case with chronic congestion of the kidney and with
diseased arteries. In pregnancy the quantity of blood is said to be
increased: in cholera a considerable part of the fluid portions of the
blood is lost.

Changes in the amount of blood in the brain may be due to lesions of
the cerebral arteries or to contraction of these arteries; to changes
in the arteries in other parts of the body; to organic disease or
functional disorder of the heart; or to a change in the whole amount of
blood contained in the body.

It seems to me probable that the so-called uræmic symptoms are most
frequently due to disturbances of the circulation of blood. Such
disturbances of the circulation produce in the brain cerebral symptoms;
in the lungs, dyspnoea; in the stomach, vomiting; in the kidneys,
suppression of urine.

With the atrophic form of chronic diffuse nephritis we have all the
conditions necessary for an irregular circulation--hypertrophy of the
left ventricle, diseased arteries, and hydræmic plethora. In the other
cases with cerebral symptoms there are also conditions present capable
of interfering with the circulation.


Acute Parenchymatous Nephritis.

PATHOLOGICAL ANATOMY.--The lesions of acute parenchymatous nephritis
vary with the intensity of the inflammatory process.

(1) Mild Cases.--The kidneys are of normal size and weight. The
capsules are not adherent, the surface of the kidney is smooth, the
cortex is of normal color or rather pale. The epithelial cells lining
the convoluted tubes are swollen and granular.

(2) More Severe Cases.--The kidneys are increased in size. The cortex
is thick and whitish, with white striæ extending in to the bases of the
pyramids. The epithelium of both the convoluted and straight tubes and
of the Malpighian bodies is swollen and granular. There is cast matter
in the tubes. {79}

(3) The Most Severe Cases.--The increase in the size of the kidneys is
still more marked. The epithelium of most of the tubes is not only
swollen and granular, but is also in many tubes detached from their
walls. A great deal of cast-matter, and sometimes blood, is found in
the tubes. There are no changes in the stroma or in the blood-vessels
of the kidneys.

ETIOLOGY.--Acute parenchymatous nephritis occurs both as a primary and
secondary lesion. The idiopathic cases occur without assignable cause
or after exposure to cold, and are not very common. The secondary cases
are seen very frequently. They complicate a variety of other diseases.
With pneumonia, typhus fever, and typhoid fever the nephritis is
usually of mild type. With yellow fever and acute atrophy of the liver
the nephritis is very severe. With scarlatina, diphtheria, pyæmia,
peritonitis, phosphorus- and arsenic-poisoning the severity of the
nephritis varies with the different cases.

SYMPTOMS.--(1) The Idiopathic Cases.--The urine is diminished in
quantity and may be suppressed; its specific gravity continues nearly
normal; it contains albumen, usually in large amounts, sometimes blood:
in some cases very few casts are seen, in others there are large
numbers of hyaline, granular, and nucleated casts.

As regards the other symptoms, it is convenient to divide the
idiopathic cases into three classes. In the first class dropsy and
anæmia are the most marked symptoms; with these there are loss of
appetite and a depreciation in the general condition of the patient. In
the second class cerebral symptoms are more prominent. There will be
delirium, convulsions, stupor, coma, and with these persistent
vomiting, dyspnoea, and great prostration, but no dropsy. The third
class suffer from the symptoms of both the other classes. Dropsy,
anæmia, loss of appetite, cerebral symptoms, vomiting, dyspnoea, and
prostration are all present.

(2) The Secondary Cases.--The condition of the urine varies with the
intensity of the nephritis. In the mild cases the urine is unchanged.
In the more severe cases we find the urine diminished in quantity,
containing albumen in varying amount, sometimes blood. Hyaline and
granular casts are often present, but are not very numerous. Dropsy
does not usually occur except with the parenchymatous nephritis of
scarlatina. Nausea and vomiting are not infrequent, but it is often
difficult to tell whether they are due to the primary disease or to the
nephritis. Cerebral symptoms--convulsions, delirium, stupor, and
coma--occur with the more severe cases.

DURATION.--(1) The Primary Cases.--The class of cases characterized by
cerebral symptoms are of short duration. The bad cases die at the end
of a few days, the milder cases recover within a few weeks. The class
of cases characterized by dropsy last longer, often for several months.

(2) The Secondary Cases.--The renal symptoms continue during the course
of the primary disease, and may disappear with the termination of this
disease. But if the nephritis is severe the renal symptoms may continue
for months after the primary disease has run its course. Albumen and
casts are especially apt to persist for a long time. Such a persistence
of the nephritis is especially apt to occur with scarlatina and
diphtheria.

{80} PROGNOSIS.--(1) The Primary Cases.--The cases characterized by
both dropsy and cerebral symptoms usually end fatally. The cases
characterized by cerebral symptoms alone are also very apt to die. The
cases characterized by dropsy and anæmia often get well, but the
albumen and casts may persist for a long time, and the patient may have
several attacks of such a nephritis.

(2) The Secondary Cases.--Here the prognosis varies with the intensity
of the nephritis. The more severe forms of the inflammation may add
very much to the danger of the primary disease or may persist for a
long time afterward.

TREATMENT.--(1) The Primary Cases.--In the cases characterized by
dropsy the first indication is to get rid of the dropsy, and this is to
be done by the methodical use of diuretics, cathartics, and
diaphoretics. It will be found, however, that there is a great
difference in the different cases as regards the precise time when
these remedies will take effect and the dropsy decrease. Usually it is
the best plan during the first few weeks of the disease to keep the
patient confined to bed or to the house, and on a milk diet. From time
to time efforts should be made to reduce the dropsy, but if these
efforts produce no effect they should be discontinued and then tried
again. In addition to the dropsy the condition of the stomach and the
anæmia require treatment. For the stomach the milk diet is perhaps the
most efficacious treatment. For the anæmia iron given by the mouth,
combined with daily inhalations of oxygen gas, is of very great
service. It is very important in these cases to guard against relapses.
If possible, the patients should not return to their ordinary pursuits
for a year after their apparent recovery, but should spend that time in
travelling and improving their health in every possible way.

In the cases characterized by cerebral symptoms it must be confessed
that treatment is not very efficacious. Diuretics have no effect,
cathartics seem to do no good. Systematic sweating, the use of
pilocarpine in small doses twice a day, inhalations of nitrite of amyl,
the administration of chloral hydrate, caffeine, digitalis, and
convallaria, and the use of fluid food in small doses, are indicated.

(2) The Secondary Cases.--While the primary disease, to which the
nephritis is secondary, is running its course there is little to be
done for renal symptoms. If, however, these symptoms persist after the
termination of the primary disease, then the main indication is to
improve the general health in every possible way.


Chronic Parenchymatous Nephritis.

A good deal of confusion is connected with this name, for the reason
that many authors include in this one class all the large white kidneys
except the waxy ones, and such kidneys present a variety of lesions.
There are, however, a moderate number of cases in which the morbid
changes are confined to the epithelium of the tubes and to the
Malpighian bodies. All the kidneys, no matter what their gross
appearance may be, which present changes in the stroma and
blood-vessels, as well as in the tubes, belong properly to the class of
chronic diffuse nephritis. I confine the name of chronic parenchymatous
nephritis, therefore, to {81} those kidneys in which the inflammatory
process runs a chronic course and is confined to the epithelium of the
tubes and the Malpighian bodies.

LESIONS.--The kidneys are regularly increased in size, often weighing
sixteen or twenty ounces. The capsules are not adherent, the surface of
the kidney is smooth. The cortex of the kidney is thick and white, with
white striæ running into the bases of the pyramids; the pyramids are
large and red. The epithelium of most of the tubes and of the
Malpighian capsules is swollen, granular, and detached. Cast-matter is
present in the tubes. There may be an increase in the number of the
small cells which cover the tufts of vessels in the Malpighian bodies.

ETIOLOGY.--This form of nephritis is not very common. It may follow
acute parenchymatous nephritis and chronic congestion of the kidney; it
is one of the complications of chronic pulmonary phthisis, and it
occurs as an idiopathic disease.

SYMPTOMS.--There is a good deal of variety in the different cases as to
the quantity and specific gravity of the urine. Usually the quantity is
somewhat diminished, and the specific gravity is between 1020 and 1030.

Albumen is regularly present in considerable quantity, but it may be
scanty, and may even disappear altogether for a time. Hyaline and
granular casts are usually present, but in small numbers.

Dropsy is a regular symptom, and often goes on to general anasarca,
although the degree of the oedema varies from week to week.
Occasionally a case will run its course without any dropsy.

The functions of the stomach are disturbed, and the patients suffer
from loss of appetite, nausea, and vomiting.

Muscular twitchings, convulsions, stupor, and coma only occur in the
very severe cases.

Dyspnoea is often produced by the dropsy, sometimes is simply a nervous
phenomenon.

Bronchitis with cough and expectoration may be a complication.

DURATION.--The course of the disease is slow; it lasts for months and
years. The cases vary a good deal in the number and severity of the
symptoms. Some cases run their course with nothing but the changes in
the urine, loss of appetite, and a moderate degree of anæmia. In other
cases the dropsy is the most prominent symptom, and in still others the
cerebral symptoms predominate. There may be intervals of weeks and
months during which all the symptoms, except the changes in the urine,
disappear and then come on again.

PROGNOSIS.--The prognosis of chronic parenchymatous nephritis is not
good, but still it is not so bad as that of chronic diffuse nephritis:
some of the cases recover and never have any further indications of
kidney disease.

TREATMENT.--The main indications for treatment are to improve the
digestion, remove the dropsy, and restore the blood to a natural
condition. It is usually necessary for the patient to give up his
ordinary business and if possible to pass the winter months in a warmer
climate.


{82} Acute Diffuse Nephritis.

This form of nephritis has been described under a variety of names. It
has been called acute Bright's disease, acute desquamative nephritis,
acute tubular nephritis, croupous nephritis, acute albuminuria, the
first stage of chronic Bright's disease, acute parenchymatous
nephritis, glomerulo-nephritis, and acute interstitial nephritis.

MORBID ANATOMY.--The kidneys are increased in size, the capsules are
not adherent, the surfaces are smooth. There may be an intense
congestion of the entire kidney, including its pelvis, or the cortex is
of an opaque white color mottled with red spots, and the pyramids are
red. The tissue of the kidney is usually moist and succulent. In the
tubes the epithelial cells are swollen, granular, and detached.
Cast-matter and blood are found in many of the tubes. In the Malpighian
bodies the cells which line the capsules are increased in size and
number, sometimes to such an extent as to compress the tuft of vessels.
The stroma of the kidney is infiltrated with serum, pus-cells, and
blood.

ETIOLOGY.--Most of the cases of acute diffuse nephritis occur after
exposure to cold or as a complication of scarlatina.

SYMPTOMS.--(1) The Idiopathic Cases.--Of these we may distinguish two
sets of cases. In the first set of cases the invasion of the disease is
acute. A person who has previously been usually in good health, after
exposure to cold and wet will be suddenly attacked with rigors, a
febrile movement, and pain in the back. There will be frequent and
painful micturition, the urine being only passed a few drops at a time,
or it is completely suppressed.

The urine is bloody or of a brownish smoky color. It is of low specific
gravity. It contains a very large amount of albumen, numerous hyaline,
granular, epithelial, and blood casts and renal epithelium, and
sometimes pus-cells. Later in the disease fatty casts are also present.

The patient soon develops dropsy, the extent of which varies in the
different cases. Sometimes it involves only the face, sometimes the
hands and feet, or there may be general subcutaneous oedema, serum in
the serous cavities, oedema of the lungs and of the glottis. The
patients lose their appetite; often there are nausea and vomiting. As a
rule, there are cerebral symptoms--headache, drowsiness, stupor,
delirium, muscular twitchings, convulsions, and coma. In the milder
cases there will be only headache and periods of drowsiness,
alternating with periods of irritability. In the severe cases there
will be dyspnoea, delirium, repeated convulsions, and coma.

These are the regular symptoms of the disease--symptoms varying in
their number and development with the intensity of the nephritis. In
the worst cases the cerebral symptoms are developed early and the
patients die at the end of a few days. In other cases the symptoms
continue for months, and at the end of that time terminate either in
the death or recovery of the patient. Albumen and casts in the urine
may persist long after all other symptoms have disappeared. In other
cases the disease runs a very mild course; the patients are not at any
time seriously ill, and they recover completely at the end of two or
three weeks. In still other cases the acute inflammation is succeeded
by {83} chronic diffuse nephritis. Relapses and repeated attacks of the
disease occur in some persons.

The course of the disease may be modified by complicating
inflammations. Pericarditis, pleurisy, peritonitis, pneumonia,
cystitis, and inflammations of the joints and muscles are not uncommon.

PROGNOSIS.--In the larger number of cases the prognosis is good. The
milder cases recover after two or three weeks; more severe cases last
for several months. The bad cases die at the end of a few days with
cerebral symptoms, or all the symptoms continue and the patient dies at
the end of several months, or they pass on to the lesions and symptoms
of chronic diffuse nephritis, or they die from some complicating
inflammation.

TREATMENT.--In the mild cases but little treatment is required. The
patients should be kept in bed, should have a fluid diet, the bowels
should be moved, and the restlessness should be quieted by the
bromides, chloral hydrate, or opium. If the dropsy is a marked feature,
more active purgatives are to be employed, hot-water or hot-air baths
are to be used, and jaborandi may be of service. When the urine is very
scanty, wet or dry cups over the region of the kidneys and hot
fomentation over the same region are of much service. For the more
marked cerebral symptoms treatment is not very satisfactory. As the
patients get better iron and tonics are usually indicated. Great care
must be used to prevent relapses. All exposure to cold must be avoided;
the patient is to be kept in the house or sent to a warm climate for
some time after he is apparently well. So long as albumen and casts
persist in the urine the patients must not be considered well, although
they may present no renal symptoms.

(2) In the second set of cases the invasion of the disease is not
acute, and the symptoms may at first be so slight that the patient will
hardly notice them. Usually the first symptoms are referable to the
stomach. The patients lose their appetite, are troubled with nausea,
and vomit occasionally. There may be a moderate amount of pain in the
back, general languor, and indisposition for mental or physical work.
Then they notice a change in the urine; they pass much less than
before. The urine remains of its ordinary color or is a little smoky;
its specific gravity is less; it contains a good deal of albumen,
sometimes a little blood, and large numbers of hyaline, granular, and
epithelial casts.

Dropsy makes its appearance at first in the face or feet; it may remain
confined to these regions or extend to the rest of the body and become
a general dropsy. The cerebral symptoms are slight--headache,
irritability, drowsiness. The blood becomes thin and watery and the
patients unnaturally pale. There may be dyspnoea either dropsical or
nervous. The symptoms continue for weeks or months.

PROGNOSIS.--These cases, as a rule, do well, and recover at the end of
a few weeks or months. But in some the symptoms continue and the
patients go on to have chronic diffuse nephritis.

TREATMENT.--In the mild cases it is only necessary to keep the patients
in the house, put them on a milk diet, keep the bowels open, and after
a time give them iron. If the dropsy is more marked, we must try to get
rid of it by cathartics, sweating, and diuretics. If the anæmia is
marked, inhalations of oxygen must be combined with the {84}
administration of iron. In these cases also it is important to guard
against relapses.


The Acute Diffuse Nephritis of Scarlatina.

Most cases of scarlatina are complicated either by acute parenchymatous
or diffuse nephritis. Some confusion has arisen from the attempt to
describe scarlatinal nephritis as if it was one disease, while really
there are two anatomical forms of nephritis which occur as
complications of scarlatina. When we try to fix the time during the
course of scarlatina when the kidney lesions are developed, we meet
with the same difficulty--that statistics have been compiled on the
supposition that there is only one form of scarlatinal nephritis. If we
take all the cases together, we find that kidney symptoms may be
developed from the very first day of scarlet fever to the end of the
ninth week--that the largest number of cases develop symptoms on the
fourteenth day, the next largest on the twenty-first day, and next to
this on the seventh day (Tripe). It seems probable that parenchymatous
nephritis belongs to the first weeks of the disease, diffuse nephritis
to the later weeks.

SYMPTOMS.--The urine is diminished in amount, and may be suppressed.
Its specific gravity is low, its color is bloody or smoky; it contains
blood, large amounts of albumen, and numerous hyaline, granular, and
epithelial casts.

The patients lose their appetites, and suffer from nausea and
occasional vomiting. There is a febrile movement, usually not very
severe, pain in the back and limbs. They become unnaturally peevish and
irritable and complain of headache, the irritability alternating with
drowsiness. In the more severe cases delirium, convulsions, and coma
are developed. The color of the patients is changed, the skin and
mucous membranes becoming pale. Dropsy is developed--sometimes only a
little puffiness of the face, hands, or feet, sometimes general
anasarca. Synovitis and muscular rheumatism are frequent complications,
while pericarditis, pleurisy, and pneumonia occur less often.

The disease runs its course within a moderate length of time, although
the changes in the urine often persist long after all the other
symptoms have disappeared. The ordinary cases recover after from one to
three weeks; the very bad cases die at the end of a few days. In a few
cases the symptoms continue and the patient develops chronic diffuse
nephritis.

PROGNOSIS.--The prognosis is quite good. The larger number of the cases
recover completely. In the more severe cases, however, the patients may
die with cerebral symptoms, or all the symptoms will continue and the
patient die after several weeks.

TREATMENT.--The indications for treatment are the same as in the
idiopathic form of acute diffuse nephritis.


Chronic Diffuse Nephritis.

This is the most common and the most important form of kidney disease.
It has been described under a variety of names--chronic Bright's {85}
disease, croupous, catarrhal, interstitial, tubal, and parenchymatous
nephritis; fatty, granular, atrophied, cirrhotic, and large white
kidney.

Although all patients with chronic diffuse nephritis suffer from
essentially the same symptoms, yet there is a good deal of difference
as to the way in which these symptoms are developed and as to the
predominance of some symptoms over others. Although the minute lesions
of the kidneys are essentially the same in all cases, yet the gross
appearance varies a good deal. There is, therefore, a practical
convenience in distinguishing certain varieties of chronic diffuse
nephritis. Of late years, however, the tendency to do this has been
carried very far, especially as regards the atrophic form of chronic
diffuse nephritis. Writers speak as if there were only two forms of
chronic diffuse nephritis--the large white kidneys and the atrophied
kidneys--and as if each of these had a distinct clinical history. More
than this, the changes in the blood-vessels and in the circulation
which so often complicate chronic Bright's disease have attracted so
much attention that the arterial changes have been regarded as the most
important part of the disease, so that we even hear of Bright's disease
without any lesion of the kidneys. It is also customary to describe
separately those kidneys of which the arteries have undergone waxy
infiltrations.

I do not think that either the lesions or the symptoms are such as to
justify such views. After separating the true cases of chronic
parenchymatous nephritis--cases in which only the epithelium of the
tubes and of the Malpighian capsules is changed--all the other kidneys
of chronic Bright's disease present essentially the same lesions and
give rise to the same symptoms.

We can indeed often tell during the life of the patient whether he has
large white or atrophied or waxy kidneys, but in many cases such a
diagnosis is impossible.

MORBID ANATOMY.--There is good deal of variety in the gross appearances
and size of the kidneys. Most numerous are the so-called atrophied
kidneys. These kidneys are usually diminished in weight, the kidneys
weighing together three or four ounces, but often they weigh up to ten
or twelve ounces. The capsules are adherent, and when they are stripped
off portions of the kidney-tissue adhere to them. After stripping off
the capsules the surface of the kidney is left finely or coarsely
nodular. The cortex is thinned and of a red or grayish mottled color;
the pyramids are small or of normal size, sometimes studded with small
white concretions of urate of soda. There are often small cysts both in
the cortex and pyramids.

Next in frequency come the so-called large white kidneys. Of these a
certain number are not examples of chronic diffuse nephritis at all,
but of acute or chronic parenchymatous nephritis. Of the large white
kidneys which belong to chronic diffuse nephritis we can distinguish
three varieties--the simple large white, the waxy large white, and the
large white of cardiac disease.

The gross appearance of the kidneys is very much the same whether they
are or are not the seat of waxy infiltrations. They are increased in
size, weighing together from sixteen to twenty ounces. The capsules are
not adherent; the surfaces of the kidneys are smooth and pale, often
mottled by large stellate veins. The cortex is thickened, of white or
{86} white mottled with red, or yellow or grayish color. In the very
waxy kidneys the gray or white color has a semi-translucent appearance.
The pyramids are large and red, contrasting with the cortex. We find
some kidneys of the same color and general appearance as large white
kidneys, but with atrophied cortex and adherent capsules.

The large white kidneys due to cardiac disease are increased in size
and weight. The capsules are not adherent, the surfaces are smooth. The
cortex is thickened and of a peculiar pinkish-white color; the cortical
striæ may still be visible. The pyramids are of a somewhat darker red
than the cortex. The whole coloring is entirely different from that of
chronic congestion of the kidneys, and the texture, although firm, is
not of the stony hardness of that lesion.

Besides the atrophied and the large white kidneys, there are a large
number of kidneys which are not diminished in weight and which do not
resemble either the large white or the atrophied kidneys. These kidneys
weigh together from nine to twenty ounces. The capsules are sometimes
adherent, sometimes not. The surface of the cortex may look like that
of a normal kidney or be finely or coarsely nodular. The cortex is of
normal thickness or thickened; it is of a variety of colors. Sometimes
it is not to be distinguished from a normal kidney, or it may be gray
or gray mottled with yellow or red or white, or of a diffuse red color.
The pyramids are of natural size or large, of red or pale color. I do
not know a good name for these kidneys, but their appearance differs
altogether from that of the large white or atrophied kidneys.

Still another class may be made of those kidneys which pass from the
condition of chronic congestion into that of chronic diffuse nephritis.
These kidneys retain the color and the hardness of chronic congestion,
but the capsules are adherent, the surfaces finely nodular, and the
cortex irregular.

Minute Lesions.--Nearly all the component parts of the kidneys undergo
morbid changes. In the tubes the epithelial cells undergo marked
changes, especially in the cortex. The epithelial cells are swollen,
finely or coarsely granular, or fatty or completely disintegrated, or
the seat of hyaline degeneration. They may be detached from the walls
of the tubes, or sometimes they are in place, but flattened. The tubes
may contain cast-matter, blood, pus-cells, small polygonal cells. The
calibre of the tubes is often changed. The tubes may be dilated either
in the form of cylindrical or sacculated dilatations; the latter often
form cysts of considerable size. Such dilatations regularly affect
groups of tubes, as if they were due to obstruction of the large tubes
in the pyramids. In other cases the tubes are denuded of epithelium,
become smaller, fall together, and look like connective tissue. The
membranous wall of the tubules may be thickened or it may undergo waxy
degeneration.

The Malpighian bodies are changed. Their capsules may be thickened,
contracted, or dilated. The flat cells which line the capsules are
increased in size, sometimes in number. The capillary tuft may be
dilated or its walls may be thickened; it may be completely obliterated
and changed into a ball of fibrous tissue, or it may be the seat of
waxy infiltration. Often the Malpighian bodies are much closer together
than they are in a normal kidney.

{87} In the stroma, especially in the cortex, there is a new growth of
connective tissue. This new connective tissue is in patches of varying
size, surrounds Malpighian bodies and blood-vessels, and may be
continuous with the capsule of the kidneys.

The arteries are frequently changed. There is a general thickening of
all their coats, usually a simple sclerotic thickening.

All these changes, when they have once begun in the kidneys, have a
natural tendency to go on and become more and more marked. There is
much difference in different kidneys in the predominance of one or more
of these changes over others. In one kidney the changes in the tubes
will be most marked, in another those in the Malpighian bodies, in
another those in the stroma. But there seems no good reason for
believing that these changes are developed successively--that there is
first a lesion of the stroma, then a lesion of the tubes, or first a
lesion of the tubes, and then of the stroma. The earliest examples of
chronic diffuse nephritis, obtained from persons dying accidentally of
other diseases, show that the lesions are diffuse at the very outset.

In the atrophied kidneys the new connective tissue is in patches. In
the earliest stages of the lesion these patches are confined to the
region close to the capsule; later in the disease the whole thickness
of the cortex is involved. The tubes embraced within these areas of new
connective tissue are atrophied and collapsed. The rest of the
cortex-tubes exhibit marked degenerative changes in the epithelium, and
often cast-matter. Dilatation of the tubes is very common. The
Malpighian bodies are usually much altered--the capsules thickened, the
tufts atrophied. Occasionally there is waxy degeneration of the
Malpighian tufts. There are some atrophied kidneys in which the changes
in the stroma are very slight.

In the large white kidneys there is much variety. In some of them one
is surprised to find how slight the minute lesions are. In others the
principal changes are in the epithelium of the tubes, so that it may be
difficult to tell whether they are examples of parenchymatous or of
diffuse nephritis. In many others there is a very marked production of
new connective tissue either in patches or diffuse. The large white
kidneys which are waxy differ from the others only in the addition of
the waxy degeneration of the Malpighian tufts and arteries to the other
lesions. I have no knowledge of any kidneys in which waxy degeneration
exists without the presence of the regular lesions of diffuse
nephritis.

In the large white kidneys of cardiac disease the large thickened
arteries are a prominent feature.

ETIOLOGY.--Chronic diffuse nephritis is more common in males than in
females. It is said to occur at nearly all ages; the maximum liability
is in persons between the ages of forty-five and fifty-five years. The
disease prevails principally in temperate climates; in New York it is
of very common occurrence. Persons who are habitually intemperate, who
have constitutional syphilis, who suffer from privation, are very
liable to the disease. There is a disposition in certain families to
the development of the disease. Not that it is, strictly speaking,
hereditary, but there will be a number of examples of it in the same
family. A number of brothers and sisters or of more distant relatives
in the same family will {88} at different times suffer from the
disease. There seems also to be some sort of relationship between
chronic diffuse nephritis and pulmonary phthisis. Not only does
nephritis complicate phthisis, but in the same family some members have
phthisis, others nephritis.

Acute diffuse nephritis and chronic congestion of the kidney may be
followed by chronic diffuse nephritis.

Heart disease, emphysema, phthisis, cirrhosis of the liver, chronic
inflammation of the bones and joints, gout, rheumatism, and chronic
arteritis, are often complicated by the disease.

SYMPTOMS.--It is sometimes impossible to tell which of the varieties of
chronic nephritis exists in a given patient, but in other cases the
diagnosis can be made. If, however, we correct our clinical diagnosis
by post-mortem observations, we find that we may be mistaken about even
the (apparently) most characteristic cases. There is more difference in
the earlier stages of these cases than in the later ones. In hospitals,
where the patients come to die, all the cases of chronic diffuse
nephritis are a good deal alike.

The atrophied kidneys present us with a very great variety of clinical
histories. It is impossible to describe all the different ways in which
the disease may begin and run its course, but we may enumerate some of
them:

1. Persons may have atrophied kidneys for a number of years without any
renal symptoms; they die from accident or from some other disease, and
at the autopsy the kidneys are found to be far advanced in disease.

2. The disease of the kidneys exists, but it gives no symptoms until
the patient suffers from some severe accident or is attacked by some
acute disease, and then the renal symptoms are suddenly developed.

3. The patient will very slowly lose flesh and strength, the appetite
will be capricious, either mental or bodily exertion is an effort, but
there are no positive symptoms, except that the urine is of rather low
specific gravity, and in the evening urine there will be occasionally a
trace of albumen. In this condition these patients may continue for
years. They may improve very much under treatment, and finally die from
some other disease without ever developing any renal symptoms. Other
cases, however, do after a time develop all the characteristic
symptoms.

4. For several months the patients do not feel well: the appetite is
lost, there is nausea and occasional vomiting, they become pale and
anæmic, do not sleep well at night, are irritable and easily worried,
are troubled with headache. The urine continues normal or is of low
specific gravity or contains a little albumen. Then they suddenly
become worse and the regular symptoms are developed.

5. In other cases headache or sleeplessness or dyspnoea or loss of
vision may precede all the other symptoms by several weeks.

6. Severe neuralgic pains in different parts of the body, coming on in
attacks and very rebellious to treatment, may precede the other
symptoms for months.

7. The very first symptoms may be an attack of convulsions. The patient
may have been apparently in good health, and while sitting quietly in a
room or lying in bed will be seized with a general convulsion. In some
of these cases the convulsions are repeated; between them the patient
remains partly or completely unconscious, and dies in {89} a few days.
In other cases one or two convulsions are followed by the development
of the other symptoms of the disease.

8. With valvular disease of the heart and atrophied kidneys we may get
the same combination of symptoms which I have described in the section
on chronic congestion of the kidneys.

9. The patient may first notice that he is passing too much urine. This
urine is of low specific gravity, and occasionally contains a little
albumen and hyaline casts. Then the health begins to fail: there are
dyspeptic symptoms, headache, occasional oedema of the legs. From time
to time the patient becomes worse; the urine is diminished in quantity,
the headache is more marked; he cannot sleep, he has dyspnoea, he
vomits, the muscles of the face twitch, or there may be general
convulsions or delirium or partial or complete coma. Such attacks may
last for days or weeks, and then either terminate fatally, or the
patient gets better and may be able to return to his ordinary business
for a time. In this way the same patient may suffer from a number of
such attacks.

10. In some cases dropsy is a prominent feature from the very first and
goes on to general anasarca.

The following history would answer for many of the cases of atrophied
kidneys: A woman, thirty-eight years old, was in good health, fat and
robust, until January, 1873. Then she caught cold; her feet became
oedematous; she had headache, pain in the back, vomiting; her eyesight
was impaired; her urine was increased in amount and passed more
frequently. She continued in this condition and losing flesh and
strength until June, 1873, when she came into the hospital. At that
time the urine was diminished to eighteen ounces in twenty-four hours;
it contained a considerable amount of albumen and hyaline and granular
casts. Her color was still good. There was moderate oedema of the feet.
After this the urine increased in amount to eighty ounces
daily--specific gravity 1002, albumen diminished. The dropsy
disappeared, and the patient left the hospital feeling very well on
September 29, 1873. In December, 1873, she returned to the hospital
with nausea and vomiting, dyspnoea, cough, no dropsy; urine 80 to 100
ounces daily. She had become feeble and anæmic, and there was
well-marked hypertrophy of the left ventricle of the heart. She again
improved, and was discharged after two weeks. In March, 1874, she
returned. The urine was now scanty, and she was troubled with vomiting,
dyspnoea, cough, sleeplessness, slight convulsive movements of the
voluntary muscles, no dropsy. By the end of April she was again feeling
well, and left the hospital. In June, 1874, she returned with all the
old symptoms and oedema of the legs. On July 20 she had two general
convulsions. After this she again improved for a time, but in September
all the symptoms returned, and she was delirious a good deal of the
time. Urine 40 to 50 ounces daily, specific gravity 1005, moderate
amount of albumen, no casts. By the end of September she again was
sleepless, had several slight convulsions, and died October 2. The
kidneys were a typical picture of the red atrophied kidneys with
thickened arteries.

We may say in general that with the atrophied kidneys the so-called
uræmic symptoms--headache, sleeplessness, delirium, convulsions, coma,
dyspnoea--are very apt to occur, and that early in the disease. The
urine is regularly increased in amount and of low specific gravity,
except {90} during the uræmic attacks, when it is diminished; but the
uræmic attacks may come on while the patient is passing 30 to 40 ounces
of urine of a specific gravity of 1020. Albumen is regularly present
only in small amounts, and not constantly, but exceptionally there will
be a good deal. Casts are hyaline, not constant, but exceptionally in
considerable numbers. Dropsy may be absent throughout the disease, or a
little oedema of the face and legs may come and go, or there may be
marked general anasarca. Not unfrequently during the uræmic attacks the
temperature runs up to 99° to 100°. Hypertrophy of the left ventricle
of the heart is a frequent complication, but I have not found it in as
large a proportion of cases in New York as it is described by English
and German writers.

The duration of the disease is very uncertain. In fact, we seldom know
what its real duration is, for the reason that there is no necessary
relation between the development of the kidney lesions and the
appearance of the symptoms. After the appearance of the kidney symptoms
some of the patients die in a few days; others go on for months and
years with either constant or intermittent symptoms.

The Large White Kidney.--These cases are more readily recognized than
the cases of atrophied kidneys, for the reason that dropsy is more
constant and occurs earlier in the disease, and that albumen is
regularly present in the urine.

In many of the cases oedema of the face or feet is the first symptom.
Often the patients will tell you that it is the only symptom, and that
they would feel perfectly well if they could only get rid of the
swelling. Closer questioning, however, will usually show that the
functions of the stomach are disturbed, that there is occasional
headache, that the eyesight is impaired, and that the patient has been
passing less urine.

In some cases impairment of vision is the first symptom that attracts
the attention of the patient. In some cases disturbances of digestion,
or neuralgic pains, or gradual loss of health and strength, or a
diminished amount of urine, will be the first symptoms, and may last
for weeks before other symptoms are developed. Or the patient may be
attacked suddenly as if with acute diffuse nephritis. The urine will
contain blood and numerous casts; the dropsy and the other symptoms are
rapidly developed. In some of the cases complicated with cardiac
disease the history will be that of heart disease rather than that of
kidney disease.

When the disease is fairly established the dropsy is always a prominent
symptom, often very distressing to the patient. In some patients when
once developed it continues to increase steadily up to the time of
their death; in others the dropsy comes and goes, sometimes
disappearing altogether for weeks and months.

The functions of the stomach are usually disturbed, the patients lose
appetite, have nausea and vomiting, oppression after eating, etc. But
some persons retain a good appetite for a long time, even though they
vomit occasionally. Diarrhoea is often developed; sometimes only enough
to carry off part of the dropsy, sometimes profuse, persistent, and
uncontrollable. The blood becomes thin and watery, and the skin, the
mucous membranes, and the sclerotic assume an unnatural white
appearance. The patients lose both mental and bodily vigor, and become
less and less fit to carry on their ordinary occupations.

Of the uræmic symptoms, headache and dyspnoea occur at any time in {91}
the course of the disease, but convulsions, delirium, and coma belong
to its later stages.

The urine is regularly first diminished and afterward increased, but
the quantity often varies very much from day to day. The specific
gravity is regularly low, albumen is constant and in large amount;
casts are usually present in considerable numbers, especially during
the exacerbations of the disease, when hyaline, granular, and
epithelial casts are found, but in other cases hardly any casts can be
found. Blood is sometimes present in the urine during the exacerbations
of the nephritis.

The disease varies much in its course and duration. Some cases progress
steadily, getting worse from day to day, and die at the end of a few
months from the time at which the first symptoms appeared. Other
persons go on living for years, the symptoms improving or disappearing
for weeks or months, and then coming again. Finally, the patients
die--some in an exacerbation of the disease with bloody urine and acute
symptoms; some with excessive dropsy; some with delirium, convulsions,
and coma; some suddenly; some with complicating disease.

The following histories may serve to illustrate the course of the
disease:

A male, thirty years old, of intemperate habits, for one year before
his death noticed that his urine was sometimes scanty and high-colored,
sometimes abundant and pale, and that his eyesight became impaired. For
four months there was occasional nausea and vomiting. For six weeks
there was occasional headache, dyspnoea, and oedema of the feet, the
urine more scanty. For nine days before death he passed from one to
four ounces of urine daily, specific gravity 1014, albumen 50 per
cent., numerous hyaline, granular, and epithelial casts. The man was
now feeble and anæmic, had headache, was drowsy, vomited occasionally,
had twitching of muscles of face; continued drowsy, but with his mental
faculties quite clear, so that he was able to transact some business an
hour before he died. Death was sudden while lying quietly in bed. The
kidneys weighed twenty ounces, surfaces smooth, cortex thick and white,
pyramids large and red. The Malpighian bodies showed a marked increase
in the size and number of the capsule cells; the cortex-tubes were
dilated; in some the epithelium was flattened, in others swollen,
granular, and detached; in the pyramid-tubes the epithelium was swollen
and detached; there was cast-matter in some of the tubes, both in the
cortex and pyramids; there was a very extensive new growth of new
connective tissue in the cortex, partly diffuse, partly in patches.

A male, forty-one years old, six years before his death caught cold
while bathing, and suffered with dropsy, a febrile movement,
prostration, scanty urine which contained albumen, blood, and numerous
casts. After a few weeks all the symptoms disappeared and he returned
to his business. He continued to enjoy good health for about eighteen
months; then in the winter the urine became scanty and contained blood,
albumen, and numerous casts. General anasarca was rapidly developed.
The dropsy lasted for six months, and then disappeared, but the urine
from that time always contained varying amounts of albumen and casts.
For nearly two years after this time the man continued to feel well,
was actively engaged in business, had no dropsy, but the urine still
contained {92} casts and albumen. Then the dropsy returned again, and
was very considerable. But the appetite and digestion continued good,
there was no headache, the patient was intelligent and cheerful. The
dropsy, a moderate diarrhoea, and the change in the urine were the only
symptoms. In two months the dropsy had again disappeared and the
patient returned to his work. After this time, however, the patient was
never as well: a little oedema of the legs was present much of the
time; he became gradually more and more anæmic and feeble, and finally
died with marked dropsy and anæmia about six years from the time of the
first appearance of kidney symptoms.

The Large White Kidneys with Waxy Infiltration.--It is well known that
in certain persons a peculiar morbid change takes place in the viscera.
The walls of the blood-vessels and some of the glandular cells become
infiltrated with a peculiar translucent substance. This morbid change
is commonly known by the name of waxy or amyloid infiltration. It is
known that such an infiltration occurs regularly in persons who have
chronic inflammations of the bones and joints, constitutional syphilis,
and pulmonary phthisis. It is also known that this new substance is
colored in a special way by iodine and some of the aniline colors.
Beyond this we have no real knowledge of what the substance is or how
it is produced.

In other parts of the body the waxy infiltration can hardly be said to
produce any local symptoms. If one has a waxy liver or spleen, these
organs may give the physical evidences of their enlargement, but that
is all. We look upon such patients as suffering from some general
changes concerning the nature of which we are ignorant, but not as
suffering simply from disease of the liver or spleen.

It seems at first sight natural to think of waxy kidneys in the same
way--not as examples of kidney disease, but as parts of a general
morbid condition. This view has been adopted by most authors. They
describe the waxy kidneys as something different from the other forms
of nephritis. But really this is an error. In the vast majority of
cases the waxy kidneys are simply a variety of chronic diffuse
nephritis. It is possible (Cohnheim) to have waxy infiltration of the
Malpighian bodies without other lesion of the kidney, but this is a
rare exception. The rule is that we find the ordinary lesions of
chronic diffuse nephritis; and, more than this, we often find the
nephritic lesions very much farther advanced than the waxy
infiltration. The association of the lesions is not at all such as to
give the idea that the waxy infiltration is produced first and the
other lesions afterward. It is also not uncommon to find waxy
infiltration of the Malpighian tufts without similar changes in any
other part of the body.

The type of the nephritis varies in different cases. Most of the
kidneys resemble the large white kidneys, some the atrophied, some
those which are neither large white nor atrophied. The clinical history
varies in the same way, and is that of a large white or atrophied
kidney, as the case may be. The only difference is that in some
patients (not in the majority) there is a very large amount of urine
passed of low specific gravity.

As a matter of fact, in most cases of waxy kidneys we simply make the
diagnosis of chronic diffuse nephritis, and if we add to this that of
{93} waxy infiltration it is because the patients have had syphilis or
bone or joint disease. Even in this way we are often enough deceived,
as in the following case:

A woman, twenty-six years old, came into the hospital on January 25,
1876. She had contracted syphilis five years before. For two years she
had suffered from dyspnoea and frontal headache. For seven months there
was occasional oedema of the face and feet. At the time of her
admission to the hospital she was very pale and anæmic; the urine was
of a specific gravity of 1008, abundant, and contained no albumen or
casts. The liver was very large and smooth. It was supposed that she
had waxy liver and kidneys. She grew steadily weaker, continued to have
a little oedema, vomited occasionally, developed the physical signs of
bronchitis, with a temperature of 104° Fahr., and died on April 3,
1876. At the autopsy the aortic valves were found thin and
insufficient. There was muco-pus in both the large and small bronchi,
with irregular spots of red hepatization in the lung. The liver and
spleen were large and waxy. The kidneys weighed together four ounces,
and presented the ordinary lesions of atrophied kidneys, with only
commencing waxy infiltrations of a few of the Malpighian tufts.

The Large White Kidney of Heart Disease.--This variety of chronic
diffuse nephritis seems to be secondary to organic disease of the
heart, and, less frequently, to emphysema of the lungs. The urine is
diminished in amount, sometimes suppressed; it is dark-colored, the
specific gravity varies between 1010 and 1030; albumen is absent
altogether or present in small amount; hyaline and granular casts may
be present, but are not constant. Dropsy may be absent or moderate or
excessive. Cerebral symptoms--vomiting, cough, dyspnoea, anæmia--are
usually present. Some of the patients die suddenly, some with dropsy,
some with urgent dyspnoea.

The examples of chronic diffuse nephritis which are neither atrophied
kidneys nor large white kidneys are numerous. Some of them give the
clinical history of the large white kidneys, some that of the atrophied
kidneys, some do not correspond to that of either; but they all exhibit
some of the characteristic symptoms of chronic nephritis--changes in
the urine, dyspnoea, vomiting, cerebral symptoms, dropsy, anæmia.

The following histories will show the course of the disease in some of
these cases:

Case 1.--A male, forty years old, came into hospital on October 9,
1881. The patient was a beer-drinker, but denied rheumatism and
syphilis. He said that he had been perfectly well until fourteen months
before; then he had an attack of lobar pneumonia which confined him to
the house for four weeks. Since that time he has never felt as well and
has had occasional dyspnoea. Nine months ago the dyspnoea became so
troublesome that he had to give up work, and he also began to suffer
from severe headaches. Three weeks ago the urine became scanty and
dropsy appeared in the legs and scrotum. When admitted to the hospital
the patient was large and fat. There was dropsy of the legs and of the
scrotum, marked dyspnoea, sibillant râles over both lungs; 10 ounces of
urine in twenty-four hours, specific gravity 1023, albumen 10 per
cent., hyaline and epithelial casts. The urine on Oct. 12 was 13
ounces; on Oct. 14, 42 ounces; on Oct. 18, 54 ounces. On this last day
he had {94} several convulsions, became comatose, and died October 19.
At the autopsy the pia mater was thickened and there was an increase of
serum beneath it. The heart weighed fourteen ounces, the aortic and
mitral valves were a little thickened, the walls of the ventricles were
unnaturally hard. In the lungs there were a few old hard miliary
tubercles. The kidneys weighed sixteen ounces, surfaces smooth,
capsules not adherent, cortex and pyramids of red color, urates in the
pyramids. The cortex-tubes showed marked changes in their epithelium,
but the Malpighian bodies, stroma, and arteries were nearly normal.

Case 2.--A female, forty-five years old, was admitted to the hospital
December 5, 1881. Denied rheumatism, syphilis, and intemperance. She
had considered herself strong and well until two months before. Then
she had a sudden attack of dyspnoea, dizziness, faintness, and cardiac
palpitation. After this she was never well, complained of pain about
the heart, headache, attacks of dyspnoea, dropsy of the face, hands,
and feet. The urine was scanty and dark-colored. She is now emaciated
and anæmic, has moderate oedema of the legs, complains of dyspnoea,
headache, and nausea. The heart's action is feeble and irregular, and
there is a presystolic murmur. On December 19 she vomited blood. On
January 2 she had a chill, followed by a temperature of 102°. On
January 5 she became drowsy, then had twitchings of the muscles of the
face; became semi-comatose, and died January 11. While she was in the
hospital the urine varied in amount from 1 to 6 ounces daily; it
contained a very large amount of albumen and a few hyaline casts. After
death the pia mater looked sodden and finely granular. The walls of its
arteries were a little thickened, and there were little clumps of
endothelial cells on its outer surface. The mitral valve of the heart
was thickened and stenosed. The kidneys were of medium size, their
capsules slightly adherent, their surfaces finely nodular, the cortex
of normal thickness, red mottled with yellow spots. There was an
extensive growth of diffuse connective tissue separating the tubes both
in the cortex and pyramids. The tubes were large and contained much
cast-matter. Most of the Malpighian bodies were normal.

COMPLICATIONS.--The most frequent complication of chronic diffuse
nephritis is disease of the heart. We find cardiac lesions and renal
lesions associated in three different ways:

1. Valvular lesions or dilatation of the ventricles produce chronic
congestion of the kidney, with its changes into parenchymatous or
diffuse nephritis or the large white kidney of cardiac disease.

2. Chronic diffuse nephritis is followed by the development of
hypertrophy of the left ventricle. This may occur with all the
varieties of chronic diffuse nephritis, but is most common with the
atrophied kidneys.

3. Valvular lesions and chronic nephritis occur in the same persons,
but neither can be said to depend upon the other.

The arteries are often diseased, the aorta and the arteries throughout
the body. There may be a simple sclerosis and thickening of the wall of
an artery, or endarteritis deformans, or obliterating arteritis.

Cerebral apoplexy may occur with all the varieties of chronic diffuse
nephritis, but much more frequently with atrophied kidneys.

Thickening of the pia mater, with increase of serum beneath it, is
often seen.

{95} Dilatation of the lateral ventricles of the brain sometimes
occurs, and may give rise to cerebral symptoms.

Pericarditis is seen more frequently with the atrophied kidneys.

Pneumonia is especially apt to be fatal when it occurs in persons
already suffering from chronic diffuse nephritis.

Emphysema and chronic bronchitis are often associated with the
atrophied kidneys.

Phthisis is found with all the varieties of chronic nephritis.

Peritonitis occurs in a few cases as a complicating inflammation.

Cirrhosis of the liver is found quite frequently.

PROGNOSIS.--In every case of chronic diffuse nephritis the natural
course of the morbid changes in the kidney tissue is to become more
marked and involve more and more of the kidney. The effect upon the
general health of the patient is not in any exact relation to the
degree of the kidney lesion. These two facts render the prognosis of
chronic diffuse nephritis very uncertain. The disease is always a very
serious one, and terminates regularly in destroying life, but the
length of time that will elapse before this fatal termination, and the
precise way in which death will take place, are difficult to determine
beforehand.

TREATMENT.--There seems no good reason for believing that we can
directly influence the development of the lesions in the kidneys. It is
possible that such a development may be indirectly delayed by improving
the general health of the patient.

There is good reason to believe that some of the symptoms which occur
regularly in patients who have chronic diffuse nephritis are dependent
not upon the nephritis, but upon other causes. We may therefore look
for indications for treatment in three different directions:

1. To delay the development of the disease by improving the general
health of the patient.

2. To treat those symptoms which are not produced by the kidney
disease.

3. To treat those symptoms which are produced by the kidney lesions.

To fulfil the first indication the most potent influences that we have
are the giving up of business and of vicious habits and causing the
patient to live year after year in the most suitable climates.
Generally speaking, warm climates are to be preferred, but the
individual disposition of each patient must always be consulted.

Of less efficacy, but still of importance, are the improvement of the
digestion by means of drugs and the feeding of the patient.

In every patient suffering from chronic diffuse nephritis there are a
number of symptoms which seem to depend directly upon other conditions,
and not upon the kidney lesions; for if these conditions are removed
the symptoms disappear, although the kidney lesions continue. To this
category of symptoms seem to belong the headache, delirium, stupor,
coma, and convulsions, the nervous dyspnoea, the vomiting in part, the
dropsy in part, the diminution of urine in part. All these symptoms are
due to disturbances of the circulation, and the disturbances of the
circulation are produced by a number of causes which may act separately
or together. Changes in the valves and walls of the heart, in the force
and regularity of the heart's contraction, in the walls and size of the
arteries and capillaries, and in the volume and composition of the {96}
blood, each, separately or associated, may interfere with the proper
circulation of the blood, and this interference usually takes the form
of too much blood in the veins and too little blood in the arteries.

Anatomical changes in the valves of the heart, in its walls, and in the
walls of the arteries and capillaries cannot be influenced by any means
at our command. The force and regularity of the contractions of the
heart can, however, be very decidedly modified by drugs. Opium in
moderate doses makes the heart's action slower and stronger; iodide of
potassium makes the heart's action more regular; convallaria makes the
heart's action slower and stronger; digitalis increases the force of
the heart's action, but at the same time contracts the arterioles;
aconite and veratrum viride make the heart's action slower and more
feeble.

The size of the arteries and capillaries can also be altered by drugs.
Nitrite of amyl and nitro-glycerin relax and dilate the whole arterial
and capillary system; chloral hydrate dilates the arterioles
(Fothergill).

The volume of the blood can be diminished by bloodletting and by
eliminating the plasma of the blood indirectly by sweating, purging, or
diuresis.

The symptoms which can be ascribed directly to the presence of the
kidney disease are--(1) The changes in the composition of the blood. We
have still very little exact knowledge of what these changes are, but
we may say generally that there is an increase in the relative quantity
of the watery constituents of the blood and of the excrementitious
products which should be eliminated by the kidneys. (2) The changes in
the quantity of urine probably depend partly on the changes in the
circulation, partly on the composition of the blood, and partly upon
the structural changes in the kidneys. The albumen and casts seem to be
directly due to the kidney lesion. (3) The changes in the nutrition of
the patient, the disturbances of digestion, and some of the headaches,
all seem to belong directly to the kidney disease.

Now let us try to apply these principles to the practical treatment of
the different symptoms.

The Urine.--As regards the presence of albumen and casts, it is
doubtful whether we are able to do anything, although it is customary
to give the tr. ferri chloridi and the bichloride of mercury in order
to diminish the excretion of albumen. As regards the quantity of urine,
we must distinguish whether the patient is in the ordinary course of
the disease, whether he is having an uræmic attack, or whether he is
having an acute exacerbation of the nephritis with congestion of the
kidney and blood in the urine. Under the circumstances last mentioned
the indications are to apply wet or dry cups over the lumbar region, to
use hot fomentations to the back or hot-air baths, to open the bowels
freely, to put the patient on a milk diet, and, if the heart's action
is too strong, to give aconite in small doses.

If during the ordinary course of the disease the urine is constantly
diminished, diuretics are often of good service, although the cases
differ as to the particular drugs which answer best. The preparations
of digitalis, the diuretic pill of digitalis, squills, and bichloride
of mercury, the iodide and acetate of potash, and jaborandi in small
doses, are the most reliable agents of this class. Sometimes the
frequent use of milk or of water in small quantities (half an ounce or
an ounce every half hour) will {97} answer the purpose. There can never
be any use in continuing the employment of diuretics in these cases if
after a fair trial they do not increase the flow of urine.

During the progress of uræmic attacks diuretics do not act, and the
same is often the case with cathartics and diaphoretics. The urine is
only to be increased by the same means which are indicated for the
relief of the whole uræmic condition, and of these we will speak later.

The dropsy in many cases will vary in amount, and even disappear at
times without any treatment. It is regularly most marked with the large
white kidneys and with those kidneys which are neither large white nor
atrophied, especially when there is complicating heart disease and the
patient is anæmic. Generally speaking, it is best to keep dropsical
patients in bed most of the day. We attempt to get rid of the oedema by
the skin, the bowels, and the kidneys, to regulate the heart's action,
and to improve the condition of the blood. Hot-air baths or hot-water
baths repeated every day, the milder hydragogue cathartics, and the
different diuretics may all be used with advantage. If the dropsy is
excessive, it may be necessary to tap the peritoneal or pleural
cavities or to puncture the skin of the legs and scrotum. Sometimes
bandaging the legs so as to exert moderate pressure seems to assist in
getting rid of dropsy. To regulate the heart's action we find that
digitalis, convallaria, and the iodide of potash are often of service.
To improve the condition of the blood the systematic use of iron and
oxygen is indicated. The most hopeless cases are those in which there
is complicating heart disease and those in which the dropsy steadily
increases, although the patient is passing from 60 to 100 ounces of
urine daily.

Disturbances of the stomach are of different kinds and dependent upon
different conditions. There may be simply loss of appetite or
discomfort after eating, or nausea, flatulence, and vomiting; and these
symptoms will be associated with chronic catarrhal gastritis or with a
stomach that is anatomically normal. Sometimes, although there is
occasional nausea and vomiting, the appetite continues good, or as part
of an uræmic attack there will be constant vomiting.

The habitual dyspeptic disturbances are to be treated like other cases
of gastric dyspepsia. A regulated diet, the vegetable bitters, the
mineral acids, or the alkalies are sometimes of service. The repeated
and persistent vomiting of uræmic attacks is a most distressing symptom
and one often very difficult to control. The patients must be fed with
small quantities of fluid food or of prepared meat. The most efficient
remedies are those addressed to the condition of the circulation.
Hypodermic injections of morphia, enemata of chloral hydrate,
inhalations of nitrite of amyl, convallaria in small doses by the
mouth, are all of service.

The anæmia from which the patients suffer is to be combated by the
systematic use of iron and oxygen. Any efficient preparation of iron
will answer, but it must often be given in considerable doses.
Sometimes the bichloride of mercury in small doses answers better than
iron. The oxygen should be inhaled for from five to thirty minutes
twice a day.

The so-called uræmic attacks, although they have a general similarity,
yet vary in their manifestations in different cases. In some cases the
{98} patient develops an unnatural restlessness and anxiety, an
inability to sleep, now and then a sudden twitch of one of the facial
muscles, and headache. Or a patient whose color is still good will only
complain of pain in the epigastrium and moderate dyspnoea, and yet will
be in bed and evidently seriously ill. Or a patient who has been
troubled with dyspeptic symptoms and gradual loss of strength suddenly
develops vomiting, intense headache, sleeplessness, a single convulsion
followed by facial paralysis. A man with a previous history of chronic
Bright's disease becomes persistently anæmic and dropsical; he has
constant dyspnoea, cannot lie down, cannot sleep, and yet looks drowsy
and stupid; is mildly delirious and has very little intelligence; then
gradually becomes unconscious, then comatose, and so dies. Or there are
first attacks of dyspnoea, either spasmodic or from exertion, but which
are temporary and can be relieved. Then the dyspnoea becomes more
constant and severe; the patient cannot lie down at all, all remedies
become less and less efficacious, and the dyspnoea only ends with the
life of the sufferer. In other cases a patient will suddenly become
unconscious, although not comatose; he will lie flat in bed, the skin
livid and bathed in perspiration, the respiration labored and rapid,
with coarse râles all over the lungs, the heart's action rapid and
feeble, the temperature perhaps a little elevated; or sudden and
profound coma or noisy delirium or repeated convulsions may be the
prominent features.

There is hardly a limit to the variety of the precise manner in which
all these symptoms--restlessness, sleeplessness, headache, vomiting,
delirium, convulsions, and coma--may present themselves. It is to be
remembered that although all these symptoms are always dangerous, and
often fatal, yet patients may pass through a number of such attacks
before the fatal one arrives.

To relieve these attacks the most effectual remedies are opium, chloral
hydrate, nitrite of amyl, convallaria, digitalis, caffeine,
bloodletting, purging, sweating, and cathartics.

Opium is a very valuable remedy, but great judgment is required in
selecting the preparation and the dose for each case. The old doctrine
that opium is a dangerous drug for patients suffering from Bright's
disease is perfectly true, but it is equally true that it is also a
valuable remedy. Generally speaking, the more marked the uræmic attack
the larger the dose of opium that will be borne. It is always well to
try to obtain a free movement from the bowels, although this is not
always possible.

In the milder cases the fluid extract of convallaria in ten-minim doses
will often diminish the frequency of the heart's action, increase the
production of urine, and improve the general condition of the patient.

In the earlier stages of dyspnoea five-grain doses of the iodide of
potash with a little opium will sometimes keep the patient comfortable
for months. For the severe attacks of dyspnoea dry cups over the chest
and inhalations of oxygen are of service. In the worst and most
uncontrollable dyspnoea it seems justifiable to keep the patient under
the influence of ether or chloroform.


{99} SUPPURATIVE NEPHRITIS AND PYELO-NEPHRITIS.

Suppurative inflammation of the tissue of the kidney and of its pelvis
and calices occurs under several different conditions: It is the result
of injuries; it is due to emboli; it occurs without discoverable
causes; it is secondary to cystitis, the cystitis being due to
strictures of the urethra, to stone in the bladder, to paraplegia, to
operations on the urethra, bladder, and uterus, to gonorrhoea, to
enlarged prostate.

Chronic suppurative pyelo-nephritis is often caused by the presence of
calculi in the pelvis of the kidney.

1. Suppurative Nephritis from Injury.--Gunshot wounds, incised or
punctured wounds, falls, blows, and kicks are the ordinary traumatic
causes. If the injury is a very severe one, it causes the death of the
patient in a short time; if it is less severe, suppurative inflammation
may be developed.

The inflammatory process may be diffuse, so that the whole of one or
both kidneys is converted into a soft mass composed of pus, blood, and
broken-down tissue, or it is circumscribed, and one or more abscesses
are found in the kidney which may communicate with the pelvis.

SYMPTOMS.--Rigors mark the beginning of the suppuration, and are often
repeated through its course. A febrile movement is developed which is
apt to assume the hectic character with sweatings. There is often
vomiting. There may be very severe pain, referred to the region of the
inflamed kidneys. The urine is diminished or suppressed; it contains
blood alone or blood and pus.

In the bad cases the patients pass into the typhoid condition, become
delirious, and die comatose or with a very rapid or febrile pulse. Or
the disease is protracted, the patients become more and more emaciated,
and finally die exhausted.

In other cases the symptoms abate, the urine returns to its natural
condition, and the patients recover.

TREATMENT.--The management of these cases is rather surgical than
medical. The external wound is to be treated antiseptically, and the
general condition of the patient to be looked after in the ordinary
way.

Such traumatic abscesses are of infrequent occurrence. I have no
personal knowledge of them.

2. Abscesses produced by Emboli.--In ordinary endocarditis with
vegetations on the valves it often happens that fragments of the
vegetations become fixed in the branches of the renal arteries. When
this is the case infarctions are produced, usually of the white
variety.

With malignant endocarditis, with surgical pyæmia, and with the curious
cases called idiopathic pyæmia, small emboli seem to find their way
into the smallest branches of the renal artery. They do not produce
infarctions, but small abscesses. In these cases the kidneys are
increased in size and dotted with little white points surrounded by a
red zone. These little white points are formed by an infiltration of
pus-cells between the tubes, and in the larger foci by a breaking down
of the kidney-tissue. Colonies of micrococci are sometimes, but not
always, found in the Malpighian tufts, the veins, and the abscesses.

{100} SYMPTOMS.--These embolic abscesses can hardly be said to have any
clinical history. Whatever symptoms may belong to them are lost in
those of the general disease from which the patient is suffering.

3. Idiopathic Abscesses.--Occasionally cases of abscesses of one of the
kidneys are met with. They last a long time, and when the patient dies
both the kidney tissue and the pelvis are involved to such an extent as
to render the anatomical diagnosis difficult. The greater part of the
kidney-tissue is destroyed and replaced by sacs full of pus; the pelvis
is dilated and its walls thickened. The surrounding connective tissue
is thickened; perforations and sinuses may extend into the surrounding
connective tissue, into the large intestine, and through the diaphragm
into the lung.

SYMPTOMS.--At first these cases are apt to be very obscure. An
irregular febrile movement accompanied with rigors comes and goes,
lasting for shorter or longer periods. The patients lose appetite,
vomit occasionally, and become emaciated and anæmic. With this there
may be pain over the region of one of the kidneys.

After a time a tumor may make its appearance in the position of one
kidney--a tumor which can be felt through the anterior abdominal wall.
If the abscess communicates with the pelvis of the kidney and the
ureter remains pervious, pus and fragments of kidney-tissue are
discharged with the urine. The pus is usually discharged at intervals,
and at such times the size of the tumor diminishes. In other cases the
pus burrows in other directions--into the retro-peritoneal connective
tissue, the peritoneal cavity, the colon, or through the diaphragm into
the lung. These cases are apt to run a protracted course and terminate
fatally.

TREATMENT.--The only plan of treatment likely to cure the patient is a
surgical one--either to extirpate the diseased kidney, or to cut down
on the abscess and treat it on the antiseptic plan like any deep
abscess.

4. Suppurative Pyelo-Nephritis with Cystitis.--LESIONS.--Usually both
kidneys are affected. They are increased in size, and both the kidneys
and their pelvis are congested. The mucous membrane of the pelvis is
thickened and coated with pus or patches of fibrin. Scattered through
the kidneys are abscesses and purulent foci of different sizes. The
smallest foci are not visible to the naked eye, but with the microscope
we find collections of pus-globules between the tubes, with swelling
and degeneration of the epithelium within the tubes. The larger
purulent foci look like white streaks or wedges running parallel to the
tubes and surrounded by zones of congestion. The larger abscesses
replace considerable portions of the kidney.

The ureters in some cases are inflamed, their walls thickened, their
inner surface coated with pus or fibrin. The bladder presents regularly
the lesions of acute or chronic cystitis.

ETIOLOGY.--For the production of this form of nephritis inflammation of
the bladder seems to be necessary. How the inflammatory process is
transmitted from the bladder to the kidneys is still uncertain, but it
seems probable that it is effected by bacteria. The cases of cystitis
in which a suppurative nephritis is likely to be developed are those
due to strictures of the urethra, stone in the bladder, operations on
the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged
prostate.

SYMPTOMS.--When the nephritis occurs with cystitis due to stone in the
bladder, strictures, or operations on the genito-urinary tract, the
{101} symptoms are much the same. The patient has first the symptoms
belonging to the cystitis, then he is attacked with rigors, followed by
a febrile movement. The rigors are often repeated; the febrile movement
is very irregular and often accompanied by profuse sweating. There is a
rapid change in the general condition of the patient. He becomes much
prostrated and emaciated from day to day. The face is drawn and
anxious, the tongue dry and brown, the pulse rapid and feeble, and
delirium is developed, and the patient finally dies in a condition
resembling that of typhoid fever or of pyæmia. The urine is diminished
in amount; it may be suppressed. It contains blood, pus, and mucus. The
pus and mucus belong to the cystitis; the blood seems to be derived
both from the kidneys and the bladder.

Cases of suppurative nephritis complicating gonorrhoea are fortunately
not common, but several of them have been observed. Murchison[2]
describes two cases, in both of which the cerebral symptoms were very
marked--delirium, convulsions, and coma. I have seen one such case. The
patient was a prostitute who came into the hospital with a specific
vaginitis. After a few days she developed symptoms of an acute
cystitis; then after a few more days she was attacked with rigors and a
febrile movement, passed rapidly into the typhoid condition, and died.
At the autopsy there were found acute cystitis, pyelitis, and numerous
small abscesses in both kidneys.

[Footnote 2: _Lancet_, 1875, p. 80.]

When suppurative nephritis complicates the cystitis due to enlarged
prostate, the clinical symptoms are somewhat different. The patients
are usually men over fifty. They have generally suffered from the
symptoms of enlarged prostate--retention of urine, either constant or
intermittent, and more or less cystitis, with pus and mucus in the
urine in varying amount. Sometimes, however, no such history is
obtained; the patients assert that they have had no previous bladder
trouble. The first symptom is diminution in the amount of urine passed
and the appearance of blood. The quantity of urine is only a few ounces
or it is completely suppressed. The blood is present in considerable
amount; often the patients seem to pass pure blood instead of urine.
The patients rapidly become prostrated and very anxious. There are
usually no rigors, and there may be no febrile movement. After this the
prostration becomes more marked, the pulse is rapid and feeble, the
skin cold and bathed in perspiration, and the patients die in collapse
at the end of a few days.

PROGNOSIS.--Suppurative nephritis secondary to cystitis is a very fatal
disease; so far as I know, all the cases die.

TREATMENT.--The treatment for these cases is altogether a preventive
one directed to the cystitis. In the cases of paraplegia, stone in the
bladder, stricture, and enlarged prostate constant care must be used to
prevent the accumulation of urine in the bladder and the development of
cystitis.

In all cases of operation on the genito-urinary tract the supervention
of cystitis is to be guarded against.


{102} PERINEPHRITIS.

The loose connective tissue which is situated around and beneath the
kidney may become the seat of suppurative inflammation, and in this way
abscesses of considerable size are formed.

LESIONS.--The connective tissue behind the kidney seems to be the usual
point of origin of the inflammatory process, and it is here that the
pus first collects. After the abscess has reached a certain size the
suppuration seems to have a natural tendency to spread and the pus
burrows in different directions--backward through the muscles; downward
along the iliac fossa, even as far as the perineum and scrotum or
vagina; forward into the peritoneal cavity, the colon, or the bladder;
upward through the diaphragm. The kidney is either compressed by the
abscess or its tissue also becomes involved in the suppurative process.
The soft parts around the abscess become thickened.

ETIOLOGY.--Perinephritis is either secondary or primary. The secondary
cases are due to extension of the inflammation from abscesses in the
vicinity, such as are formed with caries of the spine, pelvic
cellulitis, puerperal parametritis, perityphlitis, suppuration of the
kidneys, and pyelo-nephritis. The primary cases occur after exposure to
cold, after contusions over the lumbar region, great muscular exertion,
and without discoverable cause. The lesion is said to complicate typhus
and typhoid fever and smallpox. The disease occurs both in children and
adults, most of the cases reported having been between the ages of
twenty and forty years.

SYMPTOMS.--The disease begins regularly with pain and tenderness
referred to the lumbar region on one side between the lower border of
the ribs and the crest of the ilium, sometimes to a point above or
below this. At about the same time are developed repeated rigors, a
febrile movement with evening exacerbations, sweating, loss of
appetite, vomiting, and prostration. These are all the symptoms for
from one to two weeks. Then the skin over the lumbar region on one side
becomes red and oedematous; the corresponding thigh is kept flexed and
rigid, for any movement of it gives pain. Then the lumbar region
becomes more and more swollen until fluctuation can be made out, and
finally the abscess breaks through the skin. If such cases are left to
run their course the abscess may reach a very large size. If the pus
does not extend backward, but in some other direction, the symptoms are
more obscure, for the local symptoms of an abscess in the back are
absent.

If the abscess ruptures into the peritoneal cavity, the symptoms of
acute general peritonitis are suddenly developed. If it perforates into
the colon or bladder, the pus is discharged with the feces or the
urine. If the perforation is through the diaphragm, there will be
empyema, or the lung becomes adherent and pus is coughed up from the
bronchi. As soon as the abscess is opened and the pus escapes the acute
constitutional symptoms subside.

Trousseau believes that the inflammatory process sometimes stops short
of the production of pus. In such cases of course there are no
evidences of the formation of an abscess.

The disease may terminate in different ways: {103}

1. The inflammation may terminate in resolution (Trousseau).

2. The abscess is opened by operation or spontaneously and the patient
recovers.

3. Although the abscess is opened either by the surgeon or
spontaneously, the suppurative process continues and the patient dies
exhausted, usually with waxy viscera.

4. Perforation into the peritoneum, the pleura, or the lung causes
death.

TREATMENT.--The main point in treatment is to discover the abscess and
to open it. The longer the suppurative process goes on and the larger
the abscess, so much the worse is the prognosis. It is proper to
explore with the aspirator after the disease has lasted for a few days,
even if no fluctuation can be made out. The abscess is to be opened and
treated on antiseptic principles.




{104}

HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA.

BY JAMES TYSON, A.M., M.D.


The above terms are applied, the first to a condition of urine in
which, of the constituents of blood, red discs at least are present;
the second to that in which, while no corpuscles are found, blood
coloring matter is abundant. Each of these conditions has been
repeatedly observed as a distinct state at the moment when urine is
passed; but it is also to be remembered that a true hæmaturia may, in
the course of a few hours, become a hæmatinuria or hæmoglobinuria, by
solution or disintegration of the red blood-discs. So far as I know,
this subsequent solution and conversion can take place only in an
alkaline urine; but as any urine through decomposition may become
alkaline, it is evident that any hæmaturia may, in the course of time,
become a hæmoglobinuria--a fact sometimes overlooked. I have, for
example, known urine to be sent from Southern parts of the United
States which, when shipped, contained blood-corpuscles, but which, when
received in Philadelphia, contained no blood-discs, only large amounts
of blood coloring matter. Especially does this occur in warm weather,
when urine decomposes quickly. Such a hæmoglobinuria might be
characterized as secondary. Doubtless, too, a more rapid solution is
contributed to in some instances by the state of the blood-discs
themselves, which are at times disintegrated before or at the moment
they leave the blood-vessels, at others are intact, and at others,
still, may be just ready to fall to pieces. In the hæmoglobinuria,
where the blood-corpuscles have been secondarily dissolved and
disintegrated, their remnants may be found in the shape of dark-brown
or red granules, which form a sediment of varying bulk.

The immediate cause of this dissolved state of the blood-discs, where
not due to the solvent action of an alkaline urine, appears to be the
difference in degree of the cachexia which is at the bottom of the
renal hemorrhagic tendency.

The term hæmaturia is applied to blood in the urine from whatever part
of the urinary passages it may come, whether the bladder, ureters,
kidney, or even urethra; whereas the blood in primary hæmoglobinuria
always comes directly from the kidney.

In this paper I shall confine myself to the consideration of renal
hæmaturia and hæmoglobinuria in the strict sense of the term; nor will
I include such renal hæmaturia as constantly occurs in the first stage
of acute Bright's disease.

Emphasizing again that all primary hæmoglobinurias are renal, it is
{105} important to be able to say of a given hæmaturia whether it is
renal or not. Even coarse methods are often sufficient to settle the
question. Blood from the kidney, so far as my experience goes, is never
discharged in the shape of clots, at least large enough to be
recognized as such by the naked eye. More frequently coagula of blood
are passed when hemorrhage takes place into the pelvis of the kidney.
These coagula generally cause severe pain in their descent, and by this
symptom are distinguished from coagula from the lower part of the
ureter and bladder.

The smoky hue, which is characteristic of the presence of small
quantities of blood in an acid urine, affords presumptive evidence that
the blood is renal in its origin, because the conditions which are
associated with blood from other parts of the genito-urinary tract are
very apt to be associated with an alkaline urine, to which blood
imparts a bright-red hue. This is, however, not invariable, as
smoke-hued urine may be due to admixture of blood from the bladder and
parts of the genito-urinary tract other than the kidney.

The microscope affords valuable assistance in determining the source of
blood in the urine. In addition to blood-discs or their molecular
débris, tube-casts made up of cemented blood-discs or their débris are
very constantly, although not invariably, found in such urine. This
evidence is conclusive, and, although sometimes wanting, the invariable
absence of clots from blood descended from the kidney, together with
the absence of irritation of the bladder, makes it usually quite easy
to recognize a renal hæmaturia.

It is scarcely necessary to say that all urine containing blood or
hæmoglobin contains albumen, the quantity varying with that of these
substances present. Any further deviations from the normal composition
of the urine are, in the main, due to admixture of other constituents
of blood.


Causes which give rise to Hæmaturia and Hæmoglobinuria.

Hæmaturia is due to a variety of causes, which may be local or general.
Local hæmaturia is caused by wounds, blows upon the kidney, or falls in
which the kidney receives the force of the blow, as in striking the
edge of a fence in falling; from cancer of the kidney, impacted
calculus, parasites, embolism, acute Bright's disease; also poisoning
from carbolic acid, cantharides, and mustard. General causes of
hæmaturia are malaria, purpura, scurvy, blood-dyscrasias due to
continued and eruptive fevers, especially typhus fever and smallpox,
septicæmia and pyæmia, and cholera. Finally, it must be admitted that
there is a hemorrhagic diathesis manifested by hæmaturia and
hæmoglobinuria. Primary hæmoglobinuria may be produced by any of the
general causes just named, or by the prolonged inhalation of
arseniuretted hydrogen and carbonic acid, and the introduction of
numerous substances into the blood, as iodine, arsenic, etc.

While a rupture of the blood-vessels of the kidney may be supposed to
be at the bottom of a certain proportion of cases of hæmaturia, it is
by no means a necessary condition of their occurrence, as it is well
known that in inflammations there may be extravasations of blood
without rupture of {106} the blood-vessels. There is implied, however,
in all these conditions an alteration of the vessel-walls which permits
such transudation. Indeed, Ponfick[1] goes so far as to say that even
transudations of hæmoglobin through the blood-vessels of the kidney are
impossible without the presence of serious diffuse nephritis. There is
every reason to believe, however, that simple alterations of the blood
are of themselves sufficient to cause such transudations. Take, for
instance, the extravasations in purpura, which are not confined to the
vessels of the kidney. It is impossible to conceive inflammatory
conditions so general as would have to be presupposed in this disease.

[Footnote 1: "Ueber die Gemeingefährlichkeit der essbaren Morchel,"
_Virchow's Archiv_, Bd. lxxxviii. S. 47.]


Hæmaturia from Local Causes.

It is unnecessary to consider in detail the local causes of hæmaturia.
It is evident how injuries and blows upon the kidney, and impacted
calculus may produce hemorrhage. The history of nephritic colic or of
gravel in urine, along with blood, would suggest the latter cause. Nor
is it necessary to detail the phenomena of hemorrhagic infarction which
succeeds embolism and is the direct cause of hemorrhage into the
tubules of the kidney. Hæmaturia is by no means a constant symptom in
sarcoma and cancer of the kidney. A small amount of blood in the urine
is a constant symptom in acute nephritis, where it is due to a rupture
of the blood-vessels of the Malpighian tuft. It is accompanied by
blood-casts and other symptoms of acute Bright's disease. Carbolic
acid, cantharides, oil of mustard, and similar substances produce
hæmaturia by causing congestion and inflammation of the kidney.

The parasites which may cause hemorrhage in the substance of the kidney
are the Bilharzia hæmatobia, the Filaria sanguinis hominis, the
Strongylus gigas, and possibly common intestinal worms which may reach
the kidney through fistulous openings. The first is a thread-like worm
three or four lines in length, which was discovered by Bilharz, and
infests the small vessels of the mucous and submucous tissue of the
veins of the intestinal tract, the pelvis of the kidney, ureter,
bladder, and more rarely of the kidney itself. It is very frequent in
Egypt, where Griesinger found it 117 times in 363 autopsies; also in
South Africa (Cape of Good Hope), where it gives rise to an endemic
hæmaturia. It has been studied by Bilharz, John Harley, and William
Roberts.

The Filaria sanguinis hominis is a long, narrow microscopic worm, not
wider than a red blood-disc, and one seventy-fifth of an inch long,
which infests the blood. Hemorrhages result from its accumulation in
the vessels, causing rupture. The cases which have been studied
occurred mostly in India, China, and Australia.

The Strongylus gigas is a large worm, resembling the ordinary
lumbricoid, but larger, the male being from ten to twelve inches long
and one-fourth of an inch wide, while the female is sometimes more than
a yard in length. It infests the kidneys and urinary passages of
certain lower animals (the dog, wolf, horse, ox, etc.), but rarely
those of man.


{107} Malarial Hæmaturia and Hæmoglobinuria.

SYNONYMS.--Intermittent hæmaturia; Paroxysmal hæmaturia; Malarial
yellow fever; Swamp yellow fever; Paroxysmal congestive hepatic
hæmaturia (Harley).

Perhaps the most important form of hæmaturia and hæmoglobinuria
resulting from general causes is that due to malarial poisoning. I
prefer the term malarial to intermittent or paroxysmal, not only
because it more precisely indicates the cause of the condition, but
also because the condition itself is by no means always intermittent,
sometimes continuing without interruption until checked by appropriate
treatment; and I have known it to continue uninterruptedly for a year,
in spite of all treatment.

The first complete report of an undoubted instance of this affection
appears to have been published by Dressler in 1854,[2] although
incomplete and uncertain cases were reported prior to this date--one as
early as 1832 by Elliotson.[3] G. Troup Maxwell of Ocala, Florida,
writes me, in 1883, that he first observed cases in Florida thirty
years ago, and published an article on the disease in the _Oglethorpe
Medical Journal_, Savannah, Ga., July, 1860. George Harley[4] early
contributed to our accurate knowledge of the subject in 1865, and since
then numerous papers and reports of cases have appeared in English and
American journals, the southern part of the United States being a
fertile scene of the affection, while it is by no means rare in the
Middle States.

[Footnote 2:  "Ein Fall von intermittirender Albuminurie und
Chromaturie," _Virchow's Archiv_, Bd. vi. S. 264, 1854.]

[Footnote 3: "Clinical Lecture on Diseases of the Heart, with Ague (and
Hæmaturia)," _London Lancet_, 1832, p. 500.]

[Footnote 4: "Intermittent Hæmaturia," _Medico-Chirurg. Trans. London_,
1865.]

Two degrees of the disease are met with--a milder form, in which other
symptoms as well as the hæmaturia are less pronounced, and of which
instances occur in the Middle States as well as the South and West of
the United States. Of this kind seem to be the cases studied by Harley
and other English physicians. In addition to this, there is a second,
more malignant, form, attended by great prostration, vomiting, and
yellowness of the skin, along with copious discharges of bloody urine.
Instances of the latter are numerous in the Southern States of this
country, where they have recently been studied with much care; also in
the East and West Indies and in tropical countries generally. In
neither degree of the disease is it necessary that the red corpuscles
of the blood should be present. They may be represented by their
coloring matters alone, when the condition is called a hæmoglobinuria
or a hæmaturia.

The Milder Form.--The subjects, in my experience of eight cases, have
been, with one exception, men, and I believe the experience of others
included more men than women. They are generally able to recall a
history of exposure to malaria, and often of distinct attacks of
malarial fever, intermittent or remittent. The hæmaturia appears
suddenly, and when paroxysmal may occur daily or on alternate days or a
couple of times a week, or even at longer intervals. When the attacks
occur at longer intervals, say of ten days or two weeks, if the disease
is left alone the interval is apt to gradually diminish until the
passage of bloody urine becomes daily. The urine in the {108} morning
may be perfectly clear, and at two o'clock is evidently bloody. It
continues so through one or two acts of micturition, and then becomes
clear again; or it may be bloody on rising and clear up by noon.
Sometimes the bloody urine is preceded or accompanied by a sense of
weariness and chilly feeling, or sometimes simply by cold hands and
feet or by cold knees, or by pallor and blueness of the face, or by
accelerated pulse, or by no other symptoms whatever. There is sometimes
a sense of fulness in the region of the kidney and sacrum. The attacks
are often induced by exposure to cold.

Harley states that in one of the two cases which he reported there was
a slight jaundice, and in the second a "sallowness which appeared to be
due to a disturbance of the hepatic functions," but in none of the
cases which I have met was this symptom present. In the more malignant
form occurring in the tropics and the Southern States of America,
jaundice is a constant symptom.

While a majority of cases of malarial hæmaturia are intermittent, many
are continuous, and of my eight cases only three were distinctly
intermittent. One of these cases I published in a clinical lecture in
the _Philadelphia Medical Times_ as far back as September 1, 1871.

Negroes are not exempt from this milder form of the disease, as they
seem to be from the more malignant form of the South. While writing
this paper I was consulted by a negro thirty-one years old who had a
true malarial hæmoglobinuria, which yielded promptly to the treatment
by quinine. But this was the only negro out of seven cases.

The duration of the disease is very various, and if neglected may be
indefinite. Stephen Mackenzie[5] reports a case which lasted
twenty-three years.

[Footnote 5: "On Paroxysmal Hæmoglobinuria," _London Lancet_, vol. i.,
1884, p. 156.]

PHYSICAL AND CHEMICAL CHARACTERS OF THE URINE.--The urine is usually
acid in reaction when passed, sometimes neutral, rarely alkaline, and
ranges in specific gravity from 1010 to 1028. It is always albuminous,
and always tinged by blood coloring matters, the depth of color varying
from the trifling degree known as smoke-hued to a dark-red or claret
color. Sometimes it is even darker, and is often compared to porter,
though this degree of coloration is more characteristic of the
malignant form. The urine deposits a dark, reddish-brown sediment,
generally copious, but varies in quantity with the degree of coloration
of the urine. This sediment is made up chiefly of red blood-discs or
the granular débris resulting from their disintegration.

Casts of the uriniferous tubules are also often present. They are
usually made up of aggregated red blood-discs or the granular matter
referred to; but they may also be hyaline or hyaline with a moderate
amount of granular matter attached. Granular urates also at times
contribute to the sediment and also adhere to the casts. Renal and
vesical epithelium may occur. Crystals of oxalate of lime and of uric
acid are sometimes present, while blood-crystals have been found by
Gull[6] and Grainger Stewart, and a hæmatin crystal once by Strong.[7]

[Footnote 6: _Guy's Hosp. Reports_, 1866, p. 381.]

[Footnote 7: _British Med. Journ._, 1878, vol. ii. p. 103.]

That red blood-discs are at times exceedingly scarce, and even totally
absent at the very moment when urine is passed, is a well-recognized
fact; while that the coloring matter present is still that of the
blood, {109} even though no corpuscles are present, is easy of
demonstration by the production of Teichmann's hæmin crystals,[8] by
spectrum analysis, or by the guaiacum test.

[Footnote 8: Place a drop of the sediment upon a glass slide and allow
it to dry. Mix thoroughly with a few particles of common salt and cover
with a thin glass cover, under which allow two or three drops of
glacial acetic acid to pass. Carefully warm the slide for a few seconds
over a spirit-lamp, and when most of the acetic acid is evaporated,
examine by the microscope. Hæmin crystals will be seen to crystallize
out as the mixture cools.]

In the matter of the presence or absence of blood-discs, it is to be
remembered that these may be present at the moment the urine is passed,
but disappear by subsequent solution if the urine happens to be
alkaline or becomes so secondarily. It is an interesting fact, too,
that colorless blood-corpuscles are often present intact, even when red
discs are absent. While I have frequently examined urine sent me from
the South in which the coloring matter of the blood and no corpuscles
were present, only one of the cases coming under my own observations
furnished urine of this character. The proportion of urea varies, and
bears no evident relation to the condition itself.

PATHOLOGY AND MORBID ANATOMY.--The pathology of malarial hæmaturia
consists, as yet, chiefly of theoretical deductions. We can only
conclude that the malarial poison acts upon the blood and
blood-vessels, impairing the integrity of both. This goes so far
occasionally as to produce an actual destruction of blood-discs, and
always so alters the capillaries that they permit the transudation of
blood-elements ordinarily retained.

The morbid anatomy is scarcely more precisely defined. Ponfick[9] goes
so far as to say that the exudation of hæmoglobulin is not possible
without the concurrence of marked diffuse nephritis. Recently
Lebedeff[10] has sought to investigate the more minute alterations of
the kidney in hæmoglobin exudation, but without very definite results.
These, however, on the whole, seem to confirm Ponfick's view as to the
presence of an inflammatory process, as also do those of Litten[11] and
Lassar.[12]

[Footnote 9: "Ueber die Gemeingefährlichkeit der essbaren Morchel,"
_Virchow's Archiv_, Bd. lxxxviii. S. 476, 1882.]

[Footnote 10: "Zur Kenntniss der feineren Veränderungen der Nieren bei
der Hämoglobinausscheidung," _Virchow's Archiv_, Bd. xci. S. 267, Feb.,
1883.]

[Footnote 11: "Verhandl. des Vereins für innere Medicin," _Deut. Med.
Wochenschr._, No. 52, Dec. 29, 1883.]

[Footnote 12: _Ibid._, No. 1, Jan. 3, 1884.]

DIAGNOSIS.--The diagnosis of this condition is not usually difficult.
We have first to determine whether the hemorrhagic discharge is from
the kidney rather than the bladder or ureters. The former is the case
when tube-casts are found. But tube-casts are not always present even
when the hemorrhage is from the kidneys. The absence of clots and of
vesical irritation, and of pain in the course of the ureters, is
characteristic of blood from the kidneys. Finally, all hæmoglobinurias
are renal.

It being certain that the blood comes from the kidney, we have to
distinguish it from that due to cancer, to calculus-irritation, and to
cachexias, as purpura and scurvy; or to grave forms of infectious
disease, septicæmia, pyæmia, etc.; or, finally, to poisonous substances
introduced into the blood, such as arsenic, iodine, arseniuretted
hydrogen, carbonic acid and carbonic oxide gas, and even certain
species of edible fungi.

The diagnosis is greatly aided if it is found we have to do with a
{110} hæmoglobinuria rather than a hæmaturia. For although the former
condition is produced by toxic and septic agencies of another kind, the
attending symptoms, when it is thus produced, are so characteristic
that it is not likely that error can be made.

To aid in distinguishing it from cancer we have the history of malarial
exposure, and often that of other forms of malarial disease; and,
notwithstanding the seeming drain upon the system, none of the cases I
have ever seen present the profound anæmia of cancer. The bloody
discharge in cancer of the kidney is always a true hæmaturia; there are
always blood-discs in the urine. There is often pain in the region of
the kidney in cancer, but never in malarial hæmaturia.

In calculous disease there is almost always pain before or during the
hæmaturic attack, and characteristic crystalline sediments often appear
in the urine.

The disease, being comparatively rare in this latitude, is sometimes
overlooked on this account. Of the 8 cases which I have noted during
sixteen years, 5 originated in Pennsylvania, 1 in New Jersey, 1 in
Delaware, and 1 in North Carolina.

TREATMENT.--The treatment is distinctly that of malarial disease, and I
have seldom seen more brilliant and satisfactory results than have
followed the use of quinine in a case accurately determined, although
such success is not invariable; and I have known the disease to resist
for a long time the most thorough and judicious use of anti-malarial
remedies. Usually, however, I take hold of a case of this kind with
considerable confidence. When there are distinct remissions my practice
has been to administer 16 to 20 grains of sulphate of quinia in the
usual manner of anticipation of the paroxysm in intermittent
fever--from 3 to 5 grains every hour until the required amount is
taken; the whole amount may be taken in two doses, or even in one dose.
Where there is no distinct remission I more usually direct 3 to 5
grains every three hours, until the hemorrhage ceases or decided
cinchonism is produced.

The advantage well known to accrue in malarial disease from the
combination of mercurials with quinine applies to hemorrhagic malaria
as well, although I usually reserve the mercurial until I have
ascertained whether the simple quinine treatment answers the purpose.
If the usual method fails, I give 8 or 10 grains of calomel in the
evening, followed by a saline in the morning, before reinstituting the
quinine treatment. In the case of the colored man alluded to who had
malarial hæmoglobinuria 36 grains of quinine failed to break the
attack; but the same quantity, given after 10 grains of calomel had
acted, succeeded.

Where these means failed I have not found the other methods of
treatment commonly resorted to in obstinate malarial disease to be any
more efficient. I allude to the treatment by arsenic or by iron and
arsenic. Indeed, in the only two cases in which, after failure with the
quinine treatment, iron and arsenic were used at my suggestion, they
failed absolutely. In the one case, under the care of James L. Tyson,
this treatment was carried out most faithfully. After four weeks'
treatment with quinine without effect, Fowler's solution was given, at
first in 5-drop doses three times daily, subsequently increased to 10
and 15, along with 20- and 30-drop doses of tincture of the chloride of
iron, until oedema of the eyelids occurred, when the arsenic was
discontinued, but {111} the iron continued. In two or three days the
arsenic was recommenced in 3- and 4-drop doses for three or four weeks
longer without effect. Fluid extract of ergot in 20-drop doses was then
substituted for the iron, alternating with the arsenic for two weeks
longer, when some slight favorable change was apparent, but it was
temporary. Repeatedly throughout the treatment the patient complained
of weariness and backache, cold feet and knees, headache and
acceleration of pulse, and a feeling of utter wretchedness; and then
again he would feel quite comfortable for a day or two, but with little
or no change in the urine, except occasionally in the morning, when it
would sometimes be quite light-hued, but after breakfast would again
assume its bloody character. A sojourn at the seaside for two weeks was
without effect.

It will appear from the above that ergot, which has been found useful
in some forms of hæmaturia, is of little service here, as is attested
by two other cases in which I tried it faithfully. At the same time, it
is a remedy which should be tried in case of failure with others.

The usual astringents, mineral and vegetable, of known efficacy in the
treatment of hemorrhagic conditions, should be used alone or in
conjunction with the specific anti-malarial treatment after the latter
has been found of itself insufficient. To this class of remedies belong
the mineral acids, persulphate of iron, acetate of lead, alum, gallic
acid, catechu, kino, the astringent natural mineral waters, etc.

Rest is certainly an important adjuvant in the treatment of this form
of malarial disease. I have known a recurrence to take place after a
long drive.

It is claimed for many natural mineral waters that hemorrhage from the
kidneys is one of the affections cured by their use. Chalybeate and
alum springs might be expected to be of advantage by the local action
of these astringents in their transit through the kidneys, and they
frequently are. The following case illustrates their efficiency: The
patient was a lawyer who consulted me in June, 1881, at the suggestion
of W. W. Covington of North Carolina. He had frequently had chills, and
a congestive chill in 1873. Three months before I saw him he began to
pass bloody urine. He had no other symptoms, except a soreness and
weakness in the neighborhood of the sacrum, extending into the outer
part of the left thigh. The urine passed for me at the time of his
visit was dark reddish-brown in color, acid in reaction, had a specific
gravity of 1028, highly albuminous, and deposited a sediment of almost
tarry consistence, which was made up almost entirely of
blood-corpuscles. There were no tube-casts. He had been a dyspeptic
since seventeen years of age, and medicines disagreed with him; but he
was treated faithfully with quinine, iron, arsenic, ergot, benzoate of
lime, all without the slightest effect. At the end of about a year from
the time he consulted me he heard of the Jackson Spring, located in
Moore county, North Carolina, fifteen miles distant from Manly Station
on the Raleigh and Augusta Railroad. He went there, and remained one
week. He stated that for the first two or three days the water acted
decidedly on his kidneys, and he voided a number of clots of blood. On
the third day all traces of blood disappeared, and it recurred but once
since, on a very cold day in November last, but again disappeared after
a day or two in the house. Unfortunately, no precise analysis of this
water seems to have been made, but {112} from what my friend writes it
evidently contains iron and sulphur, and magnesia is also said to be
present. It is promptly diuretic. Since this occurred I have used the
water of alum springs in other instances with advantage.[13]

[Footnote 13: See the report of a case treated successfully by
Rockbridge alum-water by Radcliffe, _Med. News_, Jan. 12, 1884.]

The following are some of the chalybeate and alum springs the waters of
which may be expected to be of service in hæmaturia: Orchard Acid
Springs, New York; Rockbridge Alum Springs, Pulaski Alum Springs, Bath
Alum Springs, Stribling Springs, and Bedford Alum Springs, all in
Virginia. In all of these waters iron and alum are both present,
accompanied, in many instances, by free sulphuric acid, by which their
efficiency is increased. In one of my cases the hemorrhage disappeared
temporarily under the use of the water from the Bedford Springs,
Penna., but again returned. These waters contain a little iron, but no
alum. Subsequently, the same patient was promptly relieved by quinine,
which had not been previously tried.

But the cases most promptly relieved by the alum waters are the
non-malarial cases depending, upon hemorrhagic diathesis without other
local disease. A remarkable instance of this kind was related to me by
letter by J. Macpherson Scott of Hagerstown, Md. After enormous doses
of quinine had been used under the supposition that it was malarial, it
was promptly and totally cured.


Malignant Malarial Hæmaturia.

The second more serious form of this disease, as it occurs in the
tropics and the southern part of the United States, is characterized by
such increased intensity of all the symptoms that it may be well called
malignant. Singularly, however, the disease has seemed to be much more
prevalent during the last fifteen years. My attention was first called
to it in September, 1868, when I received specimens of urine and the
history of some cases from R. D. Webb of Livingston, Ala., who wrote
also that it was not known in that part of his State prior to 1863 or
1864.

In this, as in the milder form, there is a distinct but more invariable
history of malarial exposure, and the attack often begins as an
ordinary case of chills and fever, there being often one or two
paroxysms before the hæmaturia appears. At other times the hemorrhage
ushers in the disease suddenly. The urine is often black and almost
tarry in consistence, and passed in unusually large quantities--it is
said as much as a pint every fifteen or twenty minutes until a couple
of quarts have been passed, or one or two gallons in the course of
twelve hours. But after twenty-four hours the quantity diminishes.
Epistaxis sometimes occurs, but is not often profuse. Distressing
nausea, and vomiting of bilious and even black matter, like that of
black vomit, also occur. Intense jaundice rapidly supervenes--said to
come on sometimes in the course of an hour, often in from two to six
hours. The tongue is brown and dry. The bowels are at times
constipated, and at others loose. Although the patient may be feverish
at first, with a temperature of 104° to 106°, and the skin dry, the
pulse rapidly becomes small and feeble until it is {113} scarcely
perceptible. Drowsiness and coma sometimes intervene, and at others the
mind is clear until the moment of death, which frequently supervenes
within twenty-four or sixty hours; or the symptoms may subside, to be
repeated again the next day if not prevented by treatment. If recovery
takes place, which it sometimes does, and lately more frequently,
convalescence is slow and tedious, the patient remaining for weeks in
an enfeebled and anæmic state.

In this form, especially, of the disease it often happens that the
coloring matter and the débris of blood-discs only are found in the
urine, very few and often no entire ones being discernible: in other
words, we have a true hæmoglobinuria or hæmatinuria. The urine is of
course albuminous. A specimen recently received from North Carolina and
analyzed by Wormley contained no corpuscles, but revealed the
spectroscopic band characteristic of hæmoglobin. It contained 2½ per
cent. of urea. The specific gravity of the urine ranges between 1010
and 1020, being lower when it is copious.

As to the jaundice, it is evidently a hæmatogenetic, and not a
hepatogenetic, form with which we have to deal. It is due, not to the
retention of bile, but to the disintegration of blood-corpuscles and
the solution of their coloring matter, which diffuses through the
tissues and stains them yellow or yellowish-green. This form too,
apparently, is more frequent in males, and negroes appear to be exempt.
This is not the case with the milder form, for it will be remembered
that one of my patients was a negro.

Autopsies reveal the same intense yellow coloration of internal
organs--lungs, liver, spleen, stomach, kidneys--anæmia rather than
congestion, while the blood is dark-hued and is indisposed to
coagulate. The spleen is often enlarged.

The TREATMENT for the breaking of the paroxysm is pre-eminently quinine
or quinine with mercurials, and although this does not always succeed,
there seems to be no other remedy. The quinine may be given
hypodermically. The nausea has been controlled by morphia and
lime-water, by carbolic acid, and by creasote. In addition, restorative
measures are necessary, including the free use of stimulants.
Turpentine has been used in large doses (fluidrachm j), it is said with
advantage, in Alabama.




{114}

CHYLURIA.

BY JAMES TYSON, A.M., M.D.


The term chyluria is applied to a condition of urine in which the
secretion is admixed with fat in a minute state of subdivision, whence
the urine acquires a milky or chylous appearance. The proportion of fat
varies greatly between such as gives a mere opalescence to the
secretion and that which makes it absolutely indistinguishable, in
appearance, from milk, while even the characteristic odor and taste of
urine are often wanting. The further resemblance of such urines to milk
is found in the fact that, on standing, a cream-like substance rises to
the surface. On the other hand, a spontaneous coagulation into a
jelly-like substance containing fibrin proves an unmistakable relation
to blood.

The chemical composition of such a urine, having a specific gravity of
1013 and neutral in reaction, is given by Beale,[1] as follows:

  Water . . . . . . . . . . . . . . . . . . . . . . . . . . .     947.4
  Solid matter  . . . . . . . . . . . . . . . . . . . . . . .      52.6
                                                                  -----
  Urea  . . . . . . . . . . . . . . . . . . . . . . . . . .   7.73
  Albumen . . . . . . . . . . . . . . . . . . . . . . . . .  13.00
  Uric acid . . . . . . . . . . . . . . . . . . . . . . . .   0.00
  Extractive matter with uric acid  . . . . . . . . . . . .  11.66
  Fat insoluble in hot and cold alcohol, but soluble
    in ether  . . . . . . . . . . . . . . . . . . .   9.20 |
  Fat insoluble in cold alcohol . . . . . . . . . .   2.70 | 13.90
  Fat soluble in cold alcohol . . . . . . . . . . .   2.00 |
  Alkaline sulphates and chlorides  . . . . . . . . . . . .   1.65
  Alkaline phosphates . . . . . . . . . . . . . . . . . .  |
  Earthy phosphates . . . . . . . . . . . . . . . . . . .  |  4.66

[Footnote 1: _Urinary and Renal Derangements and Calculous Disorders_,
Philada., 1885, p. 73.]

Such urines are of course albuminous, as will have been seen from the
table. They therefore coagulate when boiled or on the addition of an
acid. They also exhibit a tendency to spontaneous coagulation more or
less complete, which is apt to be followed by later disintegration of
the clot. The proportion of solids is larger than in ordinary urines.

Microscopically, the urine is found to contain, in addition to its
usual elements, immense numbers of molecular particles easily soluble
in ether, and therefore fatty in their composition. It may be rendered
perfectly clear by the addition of ether, and again approximately milky
after evaporating the ether and shaking the residue; but now the
microscope shows the oil in the shape of oil-drops and not molecules.
Oil-drops are also sometimes sparsely present in the fresh fluid, but
the fatty particle is commonly molecular. Indeed, the molecules are
commonly so small that an {115} aggregated mass of them appears like a
delicate cloud under the microscope, rather than a collection of
individual particles. Blood-corpuscles may also be present, sometimes
in sufficient quantity to produce a distinct pink coloration, but no
unusual proportion of leucocytes is common. The pink tinge, and even an
almost bloody appearance, is very apt to precede the chyluria. This
bloody character sometimes gradually increases until the chyluria has
become a hæmaturia, so that we have sometimes a chyluria spoken of as a
first stage of hæmaturia. Tube-casts do not occur. Chyluria is seldom
constant, and a specimen of urine passed a couple of hours after one
white as milk may be, again, perfectly clear and in all respects
natural. Thus, a second specimen, passed by the same patient as that of
which the analysis is given above, was almost clear. It had a specific
gravity of 1010 and a slightly acid reaction, and contained a mere
trace of deposit, consisting of a little epithelium, a few cells larger
than lymph-corpuscles, and a few small cells, probably minute fungi.
Not the slightest precipitate was produced by the application of heat
or addition of nitric acid. The following is Beale's analysis:

  Water . . . . . . . . . . . . . . . . . . . . . . . . . . .     978.8
  Solid matter  . . . . . . . . . . . . . . . . . . . . . . .      21.2
                                                                  -----
  Urea  . . . . . . . . . . . . . . . . . . . . . . . . . .   6.95
  Albumen . . . . . . . . . . . . . . . . . . . . . . . . .   0.00
  Uric acid . . . . . . . . . . . . . . . . . . . . . . . .    .15
  Extractive matters with uric acid . . . . . . . . . . . .   7.31
  Fat insoluble in hot and cold alcohol, but soluble in ether|
  Fat insoluble in cold alcohol . . . . . . . . . . . . . .  | .00
  Fat soluble in cold alcohol . . . . . . . . . . . . . . .  |
  Alkaline sulphates and chlorides  . . . . . . . . . . . .   5.34
  Alkaline phosphates . . . . . . . . . . . . . . . . . . .   1.45
  Earthy phosphates . . . . . . . . . . . . . . . . . . . .    .15

DISTRIBUTION OF THE DISEASE.--By far the largest majority of instances
of the disease originate in tropical and subtropical climates. Thus,
India, China, and South America--and in South America, Brazil, and
Guiana--are countries in which it is common. It is said to be rarer on
the coast of South America than in the interior; yet it is especially
partial to insular countries, and most of the cases observed in this
country originate in the West Indies--in Barbadoes and Cuba, in Bermuda
and the island of Trinidad. Many cases occur in Bahia, Guadeloupe,
Madagascar, the Isle of Bourbon, and Mauritius. Indeed, the first
important study of the subject was based on cases observed in the
latter island by Chapotin.[2] In Africa both Egypt and the Cape of Good
Hope are favorite localities, and in Australia, Brisbane has furnished
many cases.

[Footnote 2: Thèse, _Topographie médicale de l'Ile de France_, 1812.]

At the same time, cases do originate in temperate climates, and
although the disease is rare in Europe and North America, Dickinson has
collected five cases from his own practice or that of others, which
undoubtedly originated in England. I know of but one case of certain
North American origin, that of a woman reported by McConnell to the
Medico-Chirurgical Society of Montreal, April 27, 1883. She was
thirty-three years old, a native of the province of Ontario, and had
had the disease eleven years. At the time of her death, which appears
to have been from tubercular phthisis, there were cavities in the
apices of both lungs.

{116} SUBJECT'S ATTACKED.--There seems no election as to nativity,
natives and foreigners being indiscriminately attacked in the countries
in which it occurs. There is some difference of opinion as to whether
the disease is more frequent in males or females; which is a reason for
believing that it occurs with nearly equal frequency in both.

It is more common in middle life, but Prout reports an instance in a
child eighteen months old, and Rayer one in a woman at seventy-eight
years. She had had it, however, since she was twenty-five, or about
fifty-three years. Dickinson was consulted with regard to a boy of
five, and mentions a case fatal at twelve. Roberts says: "Chylous urine
prevails mostly in youth and middle age."[3] Of 30 cases collected by
him, 3 were under twenty; 7 between twenty and thirty; 11 between
thirty and forty; 6 between forty and fifty; and 3 over fifty.

[Footnote 3: _Urinary and Renal Diseases_, 4th ed., Philada., 1885, p.
344.]

The subjects of the disease are apt to be pale and relaxed as to their
tissues, but while this may be a possible result of the disease, it can
hardly be regarded as a predisposing cause.

PATHOLOGY AND ETIOLOGY.--The precise mode in which chyluria is brought
about is unknown. It is to be inferred, in view of our existing
knowledge, that there has been produced, in some way, in each instance
a communication between the urinary and chyliferous systems, although
exactly where such communication is has as yet only been guessed at. It
may be in the kidney itself, or its pelvis, or the ureter, or in the
bladder. Cases originating in the tropics have been found associated
with elephantiasis, but this is not very frequent. Dilatation of
cutaneous lymphatics, producing cutaneous papules and vesicles and a
discharge of lymph from them, has also been noted coincident with
chyluria.

Prout,[4] among the earlier writers on this subject, and more recently
Bence Jones,[5] Waters, Bouchardat, Robin, Bernard, and Egel, did not
consider a positive lesion necessary, but ascribed the condition to a
vice of nutrition and blood-making, accompanied by a slight consequent
textural alteration in the blood-vessels of the kidney, through which
the elements of the chyle transuded. Waters[6] says that "the main
pathological feature of the complaint is a relaxed condition of the
capillaries of the kidney," which permits the transudation.

[Footnote 4: _Stomach and Renal Diseases_, 4th ed., London, 1843.]

[Footnote 5: _Lectures on Pathology and Therapeutics_, 1868, p. 256.]

[Footnote 6: _Med.-Chir. Trans._, vol. xiv. p. 221, 1862.]

The results of examination of the blood, in cases of chylous urine, by
Bence Jones, Rayer, and Crevaux, who found in certain instances an
excess of fat, have been quoted in support of these views, but these
examinations seem to have been microscopical and not chemical, and the
results have not been confirmed by recent observers. Such views were
also upheld on theoretical grounds by Bouchardat,[7] based on the
greater commonness of the disease in warm climates. He reasoned that
when the heat-producing elements, whether absorbed from food or
produced by metamorphoses of other proximate principles, are in excess,
and an elevated external temperature does not favor their consumption,
their elimination is attempted by certain organs, notably the liver and
kidneys. The effort by the kidneys seems, however, to be attended by a
structural change in the blood-vessels, as the result of which blood is
{117} eliminated with fat, especially at the beginning of the disease.
Later the blood disappears, but the albumen remains some time longer,
disappearing finally with the fat.

[Footnote 7: _Ann. de Thérapeutique_, 1862.]

Bernard and Robin also compared the blood of such cases to that of
geese artificially fattened, being that condition of blood which is
normal after digestion but transient. Egel also held similar views,
ascribing the imperfect elaboration to the effect of hot climates.

Gubler[8] first suggested that chylous urine was due to a passage of
chyle directly into the urinary passages, and that this was immediately
preceded by a dilatation of the renal lymphatics similar to that known
to occur on the surface of the body and attended by the local flow
alluded to.

[Footnote 8: _Gazette médicale de Paris_, 1858, p. 646.]

Vandyke Carter,[9] of Bombay, suggested that the communication was
between the lacteals and lymphatics of the lumbar region and those of
the kidney. Those who have seen the semi-diagrammatic drawing of a
dissection of the lymphatics as seen from behind, in the remarkable
case of Stephen Mackenzie,[10] cannot fail to be impressed with the
probability of such communication.

[Footnote 9: _Med.-Chir. Trans._, vol. xlv., 1862.]

[Footnote 10: _Trans. Path. Soc. of London_, vol. xxxiii. p. 394,
1882.]

That a chylous urine is the direct result of a discharge of chyle into
the urinary passages at some point between the kidney and the neck of
the bladder, is further rendered likely by the experience of W. H.
Mastin of Mobile, Alabama, with a case of chylous hydrocele: W. H. W.,
a native of Alabama, aged twenty-two, presented himself with a
hydrocele. Mastin tapped the sac and drew off a white milk-like fluid,
which was sent to me for examination. It was perfectly white and
undistinguishable by the eye from milk. Upon microscopical and chemical
examination, I found it presented all the physical and chemical
characters of chyle. Six months later, the sac having refilled, Mastin
evacuated eight ounces more of the same fluid--some of which was again
sent to me--and then laid open the sac freely. Examining the cavity
carefully, he found it smooth, polished, and pearly white, but at its
upper portion, just where it began to be reflected over the testis, was
a small, round, granular-looking mass about the size of an ordinary
English pea. This he sliced off with a pair of scissors, and at once
recognized the patulous mouths of three or four small vessels which did
not bleed. These he dissected back for a short distance, and found that
they passed into the connective tissue around the upper border of the
testis. He then passed a ligature around the mass and brought the ends
of the ligature to the outside, excised all the front wall of the
tunica, and closed the sac. The patient recovered, and there was no
return of the hydrocele. Although it is to be regretted that the
patulous vessels were not watched for a few minutes, I do not think
there can be any reasonable doubt that there was here a lymphatic
varix, and that the chylous fluid in the tunica was the result of
leakage through its walls. Since the patient had had gonorrhoea,
Busey,[11] in his remarks on this case, suggests that the obstruction
to the onward movement of the lymph, and the cause, therefore, of the
dilatation and rupture, was inflammation attacking a single gland or an
area of lymphatics.

[Footnote 11: _Occlusion and Dilatation of Lymph-Channels_, by Samuel
C. Busey: A series of papers reprinted for private distribution from
the _New Orleans Medical and Surgical Journal_, from Nov., 1876, to
March 1878.]

{118} If it be acknowledged, then, that in chyluria some direct
communication must exist between the lymphatic and urinary systems, how
is this communication brought about? Various causes have been supposed
at different times to be responsible for this condition, among them
traumatism in its various modes of occurrence, such as being thrown
from a horse. Mental shock has also been held responsible. So, also,
syphilis and hereditary tendency. But most cases still remained
unaccounted for when, on August 4, 1866, Wücherer first detected in the
chylous urine of a woman in the Misericordia Hospital at Bahia an
unknown worm. In 1872 it was announced that Timothy R. Lewis had found
in the blood, and also in the urine, of a person suffering with
chyluria in Calcutta, a delicate thread-like worm about 1/70 of an inch
long and 1/3500 of an inch wide. This observation was confirmed by
Palmer and Charles. Lewis named it Filaria sanguinis hominis. Since
then the filaria has been found in the blood and urine of many cases.
Lewis found six in a single drop of blood from the ear, and estimated
700,000 as approximately correct for the whole body. But Mackenzie
calculated that there were in the blood of his patient from 36,000,000
to 40,000,000 embryo filariæ. These minute nematodes, discovered by
Wücherer and Lewis, proved to be, as was indeed early suspected, the
larvæ of a larger filaria which was discovered by Bancroft of Brisbane,
Queensland, Australia, in December, 1876, first in a lymphatic abscess
in the arm, and afterward in the fluid of hydrocele of persons infested
with the smaller worm. The parent worm is about the thickness of a
human hair and three or four inches long. It was named, by Cobbold,
Filaria Bancrofti. Lewis himself found, in August following, a male and
female of the parent worm, in a scrotum infiltrated with chylous fluid,
in a case of elephantiasis. The female contained ova with embryos
precisely like those found in the blood and urine. The worms are
viviparous, but abortions seem frequent, ova being frequently
discharged unhatched.

It has been rendered highly probable, by the researches, first, of
Manson in China, and later of Lewis in India and Sonsino in Egypt, that
the filaria in its fully-developed form is introduced into the stomach
and intestines of man with water. Thence it makes its way into the
blood and lacteal system, where it reproduces the embryo filariæ. These
embryonic or larval filariæ are taken from the human blood by a
mosquito, in the body of which it undergoes further development, after
which the perfect Filaria Bancrofti is deposited in water, through
which it again reaches the stomach of man, and thus the disease is
perpetuated.

One of the most singular features in the history of the filaria is its
nocturnal habit. It is found in the blood only at night, unless, as
Mackenzie has shown, night be converted into day--that is, if the hours
of sleeping and waking be reversed. In Mackenzie's case the worms
appeared about seven o'clock in the evening, increased up to midnight,
and disappeared by eight or nine o'clock in the morning. What becomes
of them at the time when they are undiscoverable in the blood is as yet
unknown.

Acknowledging filariæ to be the essential cause of chyluria, the
precise method in which they operate to cause the obstruction,
dilatation, and rupture of the lymphatics is a matter of speculation.
The embryo filariæ are so lithe and small that they move among the
corpuscles {119} apparently without harming them, but the ova in which
the embryos lie coiled up, and which are often discharged unhatched,
are large enough to cause obstruction in the smaller lymphatics and
lymph-passages of the lymphatic glands, and thus cause the phenomena of
chyluria, as well as of the other diseases of the lymphatic system with
which it is often associated, or which may occur independently of it,
such as elephantiasis, cutaneous lymph-vesicles with their chylous and
lymphous discharges, lymph scrotum, chylous hydrocele, and other
diseases of the lymphatics. Indeed, the total number of affections
other than chyluria which are found associated with filariæ exceed
those of chyluria. Among the diseases with which it is said to be
associated is erysipelas.

It is evident, therefore, that notwithstanding the fact that the
discovery of the Filaria sanguinis hominis has shed a flood of light
upon the subject of chyluria, the fact must not be overlooked that not
a few cases of the disease have occurred in which the most careful
search has failed to find this parasite in the blood. Careful
examinations, during waking and sleeping hours, have been made without
result, so that we cannot deny altogether the possibility of the
disease occurring independent of filariæ as the cause. It is common,
therefore, to speak of parasitic and non-parasitic chyluria.

On the other hand, the filaria embryo is often found in the blood of
persons apparently in perfect health. Manson tells us that out of every
ten Chinamen taken at random, at Amoy, the blood of one will contain
filariæ.

MORBID ANATOMY.--There can hardly be said to be any morbid anatomy of
chyluria, unless we regard the lymphatic lesions which sometimes
accompany it as a part of the disease. Again and again do we read the
reports of autopsies at which the kidneys were found normal, and where
lesions have been noted they were such as are found due to other
causes, and the coincidence was accidental.

SYMPTOMATOLOGY.--Apart from the characteristic urine of the condition,
there are no symptoms which can be regarded as in any way peculiar to
the disease. The mode of onset is usually sudden, and yet many patients
experience no symptoms whatever, and would be quite unaware that they
were afflicted in any way, were they not aware of the fact that they
are passing lactescent urine. Since the discharge is, however, a drain
of very valuable nutrient and force-producing material, most patients
sooner or later gradually grow weaker; and this symptom of weakness
becomes sometimes very marked, so that they fall into a condition of
extreme debility, even to fainting on exertion.

Another symptom sufficiently frequent to deserve mention is pain in
lumbar region, sometimes very severe, sometimes on one side, at others
on both.

Painful micturition, due to obstruction, is also a symptom traceable
directly to the condition of the urine. The disposition of chylous
urine to coagulate has already been alluded to. The coagulation taking
place in the bladder, it is the clot which sometimes obstructs the
urethra and makes urination difficult or impossible. Plugs of coagulum
are ejected, sometimes with considerable force, after prolonged
straining, and with this comes relief to the symptoms, which may be
reproduced through the operation of the same cause.

{120} Other symptoms which are occasionally present may have an
accidental relation to the affection, while they may be due to it. Such
are headache, nausea, and other gastric symptoms.

Mention has been made, too, of the concurrence of superficial lymphatic
leakage, especially on the lower part of the abdomen, the thighs, and
the legs. Such leakage is often from little vesicular elevations which
are evidently dilated lymphatic vessels. The presence of such leakage
should suggest the examination of urine for lesser degrees of chyluria.
In like manner, the urine should be examined in case of elephantiasis,
lymph-scrotum, and chylous hydrocele, with which also chyluria is
sometimes associated.

The effect of intercurrent febrile states, whether symptomatic of local
inflammation, as of the lungs, or whether the result of the idiopathic
fevers, has often a singular effect on chyluria in causing its
disappearance for a time. It would seem that states of high vascular
tension, however induced, tend to make it cease.

While chyluria has made its appearance, for the first time, in a number
of cases during pregnancy, this condition in other instances has caused
it to disappear, especially toward the later months; whence it would
seem that the pressure of the rising womb has a favorable effect.

The DIAGNOSIS of chyluria consists in the recognition of the chylous
state of the urine. This, ordinarily very easily recognized, might be
taken in its slight degrees for phosphatic or uratic or purulent
conditions of the urine, and vice versâ. The disappearance of the first
on the addition of acids, of the second on the application of heat or
alkalies, will resolve any doubt, while the microscope will detect the
pus-corpuscles in the last. None of the reagents named will dissolve
the fatty molecules of a chyluria, while ether will cause the fluid to
clear up completely.

The PROGNOSIS is usually favorable. Very rarely is an attack fatal, and
when such is the case it is from exhaustion--from the drain to which
the system is subject. Tubercular phthisis is therefore a not
infrequent immediate cause of death.

TREATMENT.--On the supposition that filariæ are the essential cause of
the disease, the rational indication would be first to destroy them by
the introduction into the blood of some parasiticide; and, second, to
repair the lesion of communication between the lymphatic system and the
urinary passages. As yet no agent is known which would not be as fatal
to the host as to the filaria, if used in sufficient quantity to
destroy the latter; nor has it ever been possible to find the point of
communication between the two systems, although treatment has been
directed to producing closure of such communication, and with some show
of success. Thus, in a case under his care Dickinson of London injected
into the empty bladder twelve ounces of a solution of perchloride of
iron, containing at first two drachms of the tincture to the whole
quantity, gradually increased to four drachms. The solution was
retained in the bladder for from eight to twelve minutes with little or
no inconvenience. The operation was repeated almost daily for twelve
days. The effect was always to check the milky flow and to substitute a
clear urine. But after the operation had been repeated a certain number
of times there was a decided rise of temperature, with headache,
nausea, lumbar pain, hæmaturia, and albuminuria which continued a short
{121} time after the hæmaturia ceased. Singularly, too, with the
subsidence of these symptoms, the chyluria remained absent for some
time. The injections were resumed on its return, and each time were
followed by relief. In the course of their use, however, the strength
of the solution was increased to an ounce of the perchloride to twelve
ounces of water, and the strongest solutions were retained in the
bladder for as much as an hour, the weaker longer. Ultimately, however,
the use of the injections became so painful that they had to be
discontinued.

Another measure, employed by Bence Jones, was abdominal pressure by
means of a belt. This also, in his experience, relieved the lumbar
pain. In his case, which was about eight years under observation,
Dickinson applied the pressure by a sort of tourniquet about an inch
below the umbilicus. This lessened, though it did not stop, the
pulsation in the femoral arteries. It also was successful at first, the
chylosity lessening, and finally ceasing, but on the removal of the
belt the chylous character gradually returned, and in sixteen hours was
as bad as before. Repeated trials were followed by the same transient
effect, but no cure. Under this treatment, however, combined with a
liberal diet and rest, the patient gained many pounds in weight, and
was able to leave the hospital and resume her occupation as dressmaker,
the pursuit of which, and the absence of the favorable conditions of
hospital-life, as invariably caused a return of the symptom and its
resulting debility, which again caused her to seek admission.

Rest, therefore, and an abundance of good nourishing food, tend at
least to counteract the exhausting effects of the disease, and even to
cause the discharge to cease. Tonics, and especially chalybeates, are
indicated for the former purpose.

As the relaxing effects of warm climates and warm weather seem to
predispose to the condition and to aggravate it, removal to cooler
latitudes and places is indicated.

Astringents, internally administered, naturally suggested themselves at
an early date, and were used by Prout, Priestley, and Bence Jones. The
latter especially thought gallic acid useful. He reports a case in
which the disease did not return after its long-continued use. Goodwin
of Norwich, England, also reports a case in which the chyluria was
controlled by the gallic acid, but returned in four or five days after
the remedy was discontinued. It again disappeared on resuming the drug,
and the patient could at any time render the urine nearly normal in
appearance by taking it. The case was lost sight of before it could be
regarded as cured. Waters also reports a case which apparently
recovered completely after nine weeks' treatment by gallic acid. He
gave at first 30 grains a day, which were gradually increased to 135 a
day, and then gradually reduced.

Other astringents which have been used are tannic acid, matico, or
acetate of lead, nitrate of silver, the mineral acids.

Mangrove was successfully used in a case related by Bunyan of British
Guiana. It was used in the shape of a decoction at the suggestion of a
negress, an ounce being taken four times a day. In seven days the
patient was so much relieved that the remedy was discontinued for two
days, but the symptoms returned. They again disappeared when the drug
was resumed, and two subsequent attacks were immediately cut short by
the remedy. Roberts suggests that it may act as a parasiticide, {122}
and suggests larger and sustained doses of the iodide of potassium for
the same purpose.

Retention of urine, when present, should be treated like the same
symptoms under other circumstances, by catheterization, washing out the
bladder with tepid water, warm fomentations, and similar measures. It
has even been suggested to wash out the bladder with ether under these
circumstances.

As it seems impossible for the embryo filariæ to develop in the human
body into the fully-developed Filaria Bancrofti, it is evident that
with the death of the latter, which must occur sooner or later, the
production of embryos must cease, while those previously produced must
sooner or later also die, and in this way a spontaneous cure take
place--just as a person infested with trichinous disease will
ultimately recover if the introduction of the trichinæ cease and he is
able to survive the irritation caused by the presence of the parasite
in his muscles. In this manner we may account for the spontaneous
disappearance of the disease in so many instances where all treatment
has proved unavailing.




{123}

DISEASES OF THE BLADDER.

BY EDWARD L. KEYES, M.D.


Inflammation.

The bladder is a patient organ, and rather slow to resent injuries from
within or without. It never inflames on account of such general causes
as the influence of cold, anæmia, cachexia, or a depressed state of the
general system. Any of these causes may act as adjuvants, but alone
they are not effective. Thus a chilling of the legs, inoperative upon
an individual with a healthy bladder, is a prime factor in exciting
inflammation in the bladder of an old man with an enlarged prostate;
while the simple passage of a sound upon an individual suffering from
anæmia might provoke a cystitis which the same traumatic cause would
not have produced upon a patient in a thoroughly healthy condition.

Yet inflammation of the bladder is very common. It is sometimes a
malady, more often a symptom produced by some other malady (stricture,
prostatic enlargement, stone), and only to be overcome by detecting and
removing its cause. The causes of inflammation of the bladder therefore
include nearly all the maladies to which the bladder is liable.

The varieties of cystitis take name from that tissue of the viscus
which is involved, and from the modality of the inflammation.

We have--

                                | suppurative;
                     | Acute----| diphtheritic;
  1. Cystitis mucosa |          | gangrenous.
                     |
                     | Chronic--| catarrhal;
                                | membranous.

  2. Interstitial cystitis, where the muscular coat of the bladder is
       involved.

  3. Peri-cystitis, para-cystitis, where the peritoneal surface or
       surrounding structures are inflamed.

This short section upon a surgical subject, only being granted a few
pages in a medical work, cannot include a description of all these
conditions, or more than a general outline of acute and chronic
catarrhal cystitis. Suffice it to say for the other varieties that
interstitial cystitis depends upon mucous cystitis or peri-cystitis,
and is an inflammation of the muscular coat of the bladder, sometimes
culminating in abscess, sometimes in concentric hypertrophy--_i.e._
contracture of the bladder. Peri-cystitis and para-cystitis occur in
connection with peritonitis and pelvic cellulitis, and the peripheral
inflammation may extend inward and involve the muscular and later the
mucous coat.

{124} All these conditions are grave only in proportion to the
intensity of the malady causing them and to which they are subordinate.

Gangrenous cystitis occurs after injury, and occasionally in profound
septicæmic conditions (puerperal) or after intense cantharidal
poisoning. It is fatal.

True diphtheria of the bladder occasionally, but very rarely,
accompanies general diphtheritic conditions, and is a very grave
malady. Membranous cystitis is less grave, may be partial or complete.
I have a fibrinous cast of a female bladder which was extruded through
the meatus. This malady occurs sometimes as a late complication of
advanced chronic cystitis mucosa in the male. Recovery is quite
possible.

Cystitis mucosa is a common disorder, constantly encountered by the
physician as well as the surgeon. The irritable bladder, sometimes
called cystitis, demands description here, as it may go on to become
subacute or even acute cystitis of the vesical neck.

Irritability of the bladder is a neurotic and not an inflammatory
condition, although it may lead to the latter state and terminate in
it. The bladder is said to be irritable when the calls to urinate are
too frequent, generally with little or no pain. As a rule, the urine is
clear, containing no pus or a quantity entirely disproportionate to the
frequency of the call to urinate.

In true irritability of the bladder the patient sleeps all night,
although he may have to empty his bladder every hour or two by day.
There is sometimes a sense of weight, heat, or throbbing, more or less
intense, in the perineum; the desire to urinate is normal but
imperious; the satisfaction after the act is complete, and no pain
accompanies its performance.

This condition of things is generally either neurotic directly, or
indirectly (reflex). In children it may be caused by a tight prepuce,
especially if irritated by retained smegma, by teething, by the
existence of intestinal worms; and it may accompany chorea. It gets
well by lapse of time or is cured by removal of the cause. In the adult
it is most common in young men and recent widowers, and is often an
expression of sexual distress due to sexual stimulation without relief,
to sexual excess, or to improper sexual hygiene. The irritation of
acrid urine will also cause it, as well as such peripheral troubles as
a narrow meatus urinarius, a tight prepuce, urethral stricture,
moderately enlarged prostate, kidney irritation (stone in the kidney,
etc.). It appears in old men, sometimes, apparently, as a forerunner of
organic prostatic changes.

Such stimulation as a glass of wine or beer, pleasant company,
absorbing occupation, may cause it to disappear temporarily. It is
habitually better in dry, clear weather, and worse in damp seasons when
the wind is east. Worry, anxiety, fatigue, depression of spirits, and
similar causes aggravate the condition. It is better for the first
twenty-four hours after sexual intercourse, and worse than it was
before during the next following twenty-four hours.

The SYMPTOMS of pure irritability are simply a frequent desire to
urinate during the waking hours, the act not being attended by pain and
the urine being reasonably clear.

The PATHOLOGY of this affection is not definitely known. It seems {125}
to be an essential neurosis involving the sensitive nerves of the deep
urethra and neck of the bladder, attended, if long continued, by
surface congestion of the deep urethra and neck of the bladder, and
ultimately the phenomena of inflammation; for the very mechanical act
of allowing the bladder incessantly to empty itself too often, and to
squeeze its own neck, will, in many cases, after a time, lead to
traumatic inflammation of mild type.

TREATMENT.--Marriage is a very effective treatment of pure vesical
irritability when there is a sexual element in the case.

If any peripheral or local cause exists (stricture, contracted meatus,
dense acid urine), its removal will effect a cure. Alkaline diluents,
notably the citrate of potassium in gr. v-xxx doses, administered
midway between meals, copaiba, or cubebs in moderate doses, often gives
relief. Tonics, the tincture of the chloride of iron, and arsenical
preparations are often of great value. The tincture of hyoscyamus in
minim x-lx doses may be combined advantageously with any of these
remedies.

One of the most efficient of all methods of treatment is the use of the
conical steel sound, as large as the urethra will admit without
violence. The sound should be warmed, lubricated, and gently carried
into the bladder at intervals of two to four days. The daily passage of
the sound is objectionable, even if it gives relief at first, for it is
liable to kindle a slow inflammation in a urethra unaccustomed to its
use. When a sound is inserted it should not be left an instant in the
bladder, but should be gently withdrawn as soon as it has been fully
inserted. If left in the urethra, it does no good, and may act upon the
cut-off group of muscles in the membranous urethra, causing them to
contract spasmodically, as in the physiological performance of the
coup-de-piston after urination. Such contraction bruises the sensitive
mucous membrane of the urethra against the hard sound, and does
mechanical damage.

The sound acts in three ways: It (1) mechanically distends the
irritable contracted cut-off muscle and seems to quiet its contractile
tendency. It (2) squeezes all the blood from the passively congested
vessels of the irritated mucous membrane, thus ensuring a new supply of
blood to the part and an improved circulation in the reaction which
follows the irritation. It (3) mechanically, by contact, blunts the
sensibility of the terminal sensitive nerves in the mucous membrane of
the deep urethra. In this way the sound acts, and its effects generally
last several days, often a week. Its good effect is also instantaneous.
The slight feeling of weight and discomfort in the perineum which the
patient has before its use is gone instantly, and replaced by a feeling
of comfort. When this immediate sense of relief is not experienced, it
is doubtful whether such a case will yield to the simple treatment by
sounding.

It is a mistake to suppose that any ointments smeared upon a sound do
good in this condition. Mercurial, belladonna, and other ointments are
used, but they are all and entirely rubbed off the sound before it
reaches the deep urethra, and their good effect probably resides solely
in the imagination of the physician and the credulity of the patient.
Ointments are undoubtedly of service in some obstinate cases, notably
strong tannic-acid mixtures, and sometimes iodoform, but these cannot
be carried to the deep urethra by being rubbed upon a sound. The cupped
sound may be used to effect this very neatly, the little cups on the
sides of the {126} curve of the sound being filled with the ointment
which it is proposed to carry down and apply to the affected spot. A
few drops of a mild nitrate-of-silver injection also give decided good
results in some cases. The solution should vary between two and ten
grains in the ounce of water, and may be accurately applied by means of
a Bigelow or an Ultzmann syringe, a few drops being thrown into the
membranous urethra. After the application, which should be made only
when the patient has a full bladder, urination will wash out the canal
and good effects may be looked for--not immediately, as after sounding,
but after the irritation produced by the stimulating application has
subsided.


Acute Cystitis.

Acute cystitis sometimes involves only the neck of the bladder; in
other cases the whole mucous lining of the bladder is included in the
morbid process.

The causes of acute cystitis may be grouped under six heads:

1. Traumatic.--Under this head may be ranged all injuries from without,
with or without fracture of the pelvic bones--wounds, rupture of the
bladder, the pressure of the child's head during labor; injuries from
within, as during the use of instruments, by stone, or pedunculated
tumor. The list may be increased by such chemical traumatisms as those
produced by ammoniacal urine in cases of atony or paralysis, by
excessively acid urine in neurotic conditions of the neck of the
bladder. Such chemical causes, it will be observed, commonly act in
conjunction with another cause. Irritating injections without any
co-operative cause are capable of lighting up acute cystitis.

2. Extension of neighboring inflammation--gonorrhoeal cystitis and that
attending prostatic inflammation, pelvic abscess, pelvic cellulitis,
peritonitis from neoplasms growing at the vesical neck, tubercle,
cancer, etc.

3. Medicinal--from cantharides, sometimes cubebs or turpentine.

4. Specific--in diphtheritic, puerperal, septicæmic conditions.

5. The influence of cold when chronic inflammation already exists.

6. Neurotic--actual, from extreme and long-continued neuralgia of the
vesical neck; reflex, from irritation at a distance, tight meatus,
stricture, inflammation of the seminal vesicles, kidney irritations.

SYMPTOMS.--The symptoms of acute cystitis are (1) frequent painful
urination by night as well as by day, the pain being greatest at the
close of, and immediately after, the act, and the pain persisting more
or less between the acts, radiating from the perineum; (2) moderate
fever, sometimes announced by chill; (3) commonly great despondency and
a depression of spirits totally disproportionate to the degree and
significance of the local inflammation; (4) the urine invariably is
milky, with pus: it may at first be acid and of normal odor; it is
often tinged with blood, especially toward the end of the act of
urination. In extreme cases the urine may contain membranous or sloughy
shreds or gangrenous gases. The urine eventually becomes alkaline, and
finally deposits lumps of pus and abundant triple phosphate crystals.

Complications occurring with the cystitis yield appropriate symptoms.
{127} Such possible complications are congestion and engorgement of the
prostate, possibly going on to abscess; epididymitis, orchitis,
inflammation of the seminal vesicles, inflammation running up the
ureters, pyelitis, surgical kidney; abscess in the walls of the bladder
or in the connective tissue about the same; very rarely peritonitis or
suppurative phlebitis in the veins about the neck of the bladder.

The pathological changes produced by acute cystitis are similar to
analogous changes upon the other mucous membranes: patches of more or
less brilliant uniform or punctate redness, perhaps surrounding small
ecchymotic areas; a softened, swollen mucous membrane; enlarged
follicles near the neck of the bladder, perhaps ulcerated spots;
possibly false or true diphtheritic exudations (such exudations have
been especially noted in cantharidal cystitis); possibly interstitial
abscess of the bladder-wall, or even suppurative phlebitis in the veins
about the prostate and neck of the bladder, as observed by Walsham[1]
in a case of cystitis due to over-distension. This last complication is
happily exceptionally rare.

[Footnote 1: _London Lancet_, May 10, 1879, p. 665.]

The PROGNOSIS varies with the cause of the cystitis, and as the latter
often cannot be entirely removed, the acute cystitis may only be
moderated so as to be made to assume the chronic form. When the cause
can be entirely removed, acute cystitis gets well and leaves the
bladder absolutely sound.

TREATMENT.--Acute cystitis from whatever cause requires a uniform
general line of treatment. Anodynes are essential both for the
patient's comfort and to prevent the constant straining to empty the
bladder to which the unremitting, painful desire to urinate impels him.
Hyoscyamus is a favorite in the form of tincture in minim xx-drachm j
doses, or any of the opiates by the mouth, or in suppository preferably
combined with extract of belladonna in small dose. Sometimes
quarter- or half-grain suppositories of extract of belladonna alone at
intervals of six to eight hours keep the tenesmus more in check than
anything else, but belladonna used too freely may bring on retention by
causing spasm of the cut-off muscles. Camphor is useful, especially in
strangury from cantharides. Rest in bed is essential in most cases,
preferably with the hips raised. Heat in some form, as a hot poultice,
fomentation, spongio-piline, hot-water rubber bottle, etc. over the
hypogastrium preceded by a mustard plaster, gives great comfort.
Hot-water hip-baths of short duration and frequently repeated are of
service in most cases.

Alkalies are valuable, especially in the beginning of an attack--liq.
potassæ minim v-xx doses, citrate of potassium gr. x-xx, combined with
an anodyne or some demulcent drink.

Infusions and extracts of corn-silk, dog-grass root, buchu, pareira
brava, uva ursi, etc. are of some assistance, but generally not so
comforting as some of the bland diuretic waters--Bethesda, Mountain
Valley, Poland, Glenn, Vichy, Wildungen, Buffalo Lithia. Distilled
water or rain-water, especially if taken warm, is a good diluent
diuretic. On the advent of acute cystitis all instrumentation upon the
bladder should, if practicable, be postponed, all stimulating drugs
(cantharides, turpentine, cubebs, alcohol) stopped, and stimulating
foods avoided. Asparagus, coffee, salt, pepper, mustard, acids, and a
highly nitrogenized diet are not allowable. The rectum should be kept
empty and complications treated as they arise.


{128} Chronic Cystitis (Catarrh of the Bladder).

Catarrh of the bladder is chronic inflammation of the mucous membrane
of the urinary reservoir, with more or less thickening of the walls of
the bladder. This malady, so apt to persist for years, is probably more
commonly encountered by the physician than acute cystitis. Acute
cystitis, however, frequently complicates the chronic malady by
occasional outbursts of acute symptoms. Thus an attack of the stone is
acute calculous cystitis interrupting the course of chronic vesical
inflammation due to stone. Catarrh of the bladder may follow acute
cystitis, or it may commence insidiously as a subacute disorder, and be
catarrh, in the popular sense, from the first.

The causes of catarrh of the bladder are never single. It always takes
two causes to produce true catarrh of the bladder--one mechanical, and
one chemical. After a traumatism inflicted on a healthy bladder, with
proper care the patient recovers entirely. If, however, he insists upon
keeping up and about, continues to drink liquor, and does not avoid
straining at urination, the membrane about the neck of the bladder,
irritated by the ammonia from the decomposing urine, secretes an excess
of viscid mucus, the pus becomes gelatinized by the ammonia, the
constant straining leads to hypertrophy of the muscular coat, the
nerves lose their acute sensitiveness, and the milder persistent
malady, chronic catarrh, is set up, to continue perhaps for an
indefinite period.

Infiltrations of the bladder-walls with tubercle or cancer, urinary
calculus, and, notably, enlarged prostate, stricture of the urethra,
tumors of the bladder, hernia of the bladder, exstrophy,
over-distension of the bladder from stricture, spasm of the urethra,
coma, paralysis, or other cause, may be the traumatic element, while
the liberated ammonia from the alkaline decomposing urine furnishes the
chemical element; and the two causes, if continued, occasion and
maintain the condition known as chronic catarrh of the bladder. In coma
or the delirium of typhoid fever or paraplegia or hemiplegia
(sometimes) the bladder becomes over-distended and atonied, perhaps
paralyzed. Here the use of the catheter appropriately, with great
gentleness, may relieve the patient without even the intervention of
acute cystitis; while, on the other hand, acute cystitis may come on
and be cured, or, if ammoniacal urine be allowed to accumulate and the
bladder be not washed out so long as it is unable to entirely expel its
contents, chronic cystitis, catarrh, results. I have known several
cases of partial paraplegia and other disorders in which the patient
could void no drop of urine except through a catheter, where there
never had been any chronic catarrh, no stringy mucus, hardly a
pus-corpuscle, through long years of the disability, owing to
intelligence in the attention to emptying and washing out the bladder
instituted by the physician having first charge of the case.

As prominent among the causes of chronic catarrh in a purely medical
aspect it may be well to insist upon the ease with which this condition
is sometimes brought about by the physician himself. A man with a
weakened bladder may carry a pint or much more clear urine in his
bladder constantly during many years as a residual deposit which his
weakened bladder cannot throw off. Excess over the fixed residuum
produces a desire to urinate, and the patient, mainly by voluntary
contraction of the {129} abdominal walls, voids that excess. If now the
physician finds this globular accumulation in the patient's belly, and
in his zeal to do all that is possible forgets his caution, he may
throw the patient first into an acute cystitis (if haply he escapes
collapse), and then into chronic vesical catarrh--an affair perhaps of
a lifetime. Surgeons have noticed, and especially Sir Henry Thompson
has pointed out, that a dirty catheter may poison the urine and bring
about a cystitis which otherwise might have been avoided; and observers
from all time have noticed that the sudden entire evacuation of the
contents of a bladder long accustomed to over-distension is in itself a
grave cause of serious inflammatory disturbance to the mucous membrane
of the bladder. Recently much attention has been called to this
condition and its possible fatal termination by Sir Andrew Clarke,
under the name of catheter fever.

The deductions from a knowledge of these facts are obvious: they
are--(1) always to thoroughly cleanse, and then to disinfect, a
catheter on each occasion before its use; and (2) never to empty
entirely at a first sitting a bladder which has been long habituated to
over-distension; and when, finally, the bladder is emptied, always
irrigate it with a disinfecting solution (borax) after each emptying.

SYMPTOMS.--Chronic cystitis varies in grade, and its symptoms vary with
the grade of the inflammatory process. There is probably no pain more
intense than that endured by a man with severe general cystitis in its
last stages, when the unceasing tenesmus wrings groans from his lips,
the sweat from his body, doubles his frame in agony, and converts his
facial expression into a distorted tragedy. The sight is pitiable and
never to be forgotten. On the other hand, a man may continue about and
at his work with a patient flabby bladder containing constantly more or
less stringy mucus and ammoniacal urine, suffering little or no pain or
tenesmus, and perhaps having no subjective symptoms except a slight
sense of weight in his lower belly and a rather frequent desire to
urinate.

Between these limits the symptoms range, but in a general way it may be
said that the symptoms of chronic vesical catarrh are these: frequent
calls to urinate, attended by more or less pain, especially toward and
after the termination of the act. The sense of satisfaction normally
felt after urination is generally absent. Motion, particularly jolting
as in rough riding, causes pain. This pain is referred to the lower
part of the belly, to the perineum, to the end of the penis, the
urethra, the anus. The straining after urination may be absent or of
the most intense character, leading to prolapse of the rectum and
causing excruciating torture. The urine always contains pus scattered
through it, and generally also more or less pus in that semi-solid
condition known as stringy mucus. Stringy mucus is pus gelatinized by
the ammonia of the decomposing urine. These clots of muco-pus contain
gritty crystals of the ammonio-magnesian phosphate. More or less blood
is to be found in the urine, especially during acute paroxysms. Pure
blood sometimes follows the urine after each act of urination. Bacteria
abound in the fluid, which varies in odor greatly in different cases,
not always strictly in accordance with the severity of the actual
inflammatory process. Thus, the urine may be simply sweetish in its
odor, ammoniacal, flat, and stale, or be possessed of a putrid,
sickening sweetness of indescribably nauseating power. Again, it may be
rankly rotten. The bottom of the chamber in some cases becomes {130}
covered with a thick coating of the viscid muco-pus, which strings out
and reluctantly follows the fluid when the vessel is inverted.
Sometimes the urine contains shreds of false membrane or putrid masses
of sloughy tissue.

PATHOLOGY.--In chronic cystitis the mucous membrane of the bladder
undergoes gradual thickening, loses its pink salmon tint, and becomes
gray in color. The thickening extends to the submucous layer, and more
or less to the muscular walls as well. In cases of prolonged chronic
cystitis attending atony of the bladder, notably with hypertrophied
prostate, the cavity of the organ is large, its walls seemingly thinned
and flabby, its internal coat roughened by the crossing of bundles of
muscular fibres or perhaps perfectly smooth. In other conditions
(concentric hypertrophy), where there has been a serious obstacle to
the free outflow of urine without any atony of the muscular coat
(stricture of the urethra, some cases of stone and of enlarged
prostate), the walls of the bladder may be enormously thickened to the
extent of an inch or more, the inside surface rough, perhaps ulcerated.

The thickening of the muscular bands within the bladder often causes
them to stand out in bold relief, like the muscular bundles in the
heart-cavity. These prominent bundles enclose spaces of various sizes
and shapes, and from the bottoms of these spaces sometimes the mucous
membrane protrudes between the muscular bands and forms pouches of
varying size (sacculated bladder). These pouches consist of mucous
membrane alone covered with peritoneum, and may become the seat of
encysted stone.

If there has been a subacute grade of the surface inflammation before
death, there may be livid spots on the mucous surface of the bladder,
punctate or larger ecchymoses, reddened areas from which the epithelium
is more or less detached, ulcers with or without sloughs or
diphtheritic covering, perhaps perforations of the bladder and
infiltration of urine, enlarged mucous follicles, granulations,
fungosities, etc. Heterologous deposits, tumor, cancerous and
tubercular ulcers, cysts, stone, complete the possibilities of what may
be encountered in the bladder at an autopsy upon a patient with chronic
cystitis.

The chronic like the acute varieties of cystitis may involve the whole
of the inside of the bladder or only a portion of it.

The PROGNOSIS, like that of acute cystitis, varies mainly with the
cause. If the latter can be entirely removed (stone), the bladder gets
perfectly well. Not so, however, unless all the causes are removed.
Thus, a phosphatic stone may grow in a bladder as a result of enlarged
prostate and chronic cystitis. The presence of the stone excites the
chronic cystitis, and subjects the patient to a crisis of acute
cystitis from time to time. The removal of such a stone will by no
means cure the chronic cystitis; its removal is only one step in the
treatment of the cystitis.

As far as life is concerned, the prognosis of chronic cystitis is good.
A patient may live many years with chronic cystitis, particularly if he
treats his bladder properly. Although, as generally encountered,
chronic cystitis is not curable, few maladies yield results to
treatment more gratifying to the physician and the patient than the one
under consideration.

The legitimate ultimate termination of chronic cystitis is by chronic
{131} inflammation of the ureter and pelvis of the kidney on both
sides, interstitial kidney changes, and finally death by suppression.
Generally, this end may be almost indefinitely postponed by
well-directed efforts of palliative treatment.

TREATMENT.--The acute outbursts of inflammatory disturbance occurring
during the course of chronic cystitis require the same means for their
relief as those already indicated when considering the treatment of
acute cystitis--all the prohibition of stimulants, the use of bland
mineral waters, demulcent decoctions, infusions, and alkaline draughts.
The anodynes, the rest, the heat, the hip-bath, are all indicated here
for the acuter symptoms, just as they are in the acute malady, but very
much more can be done both in a prophylactic and in a curative way. A
milk diet, even an exclusive milk diet, is an element of great value in
cases of chronic cystitis. I have two patients, both old men, now under
observation, one of whom recovered entirely from cystitis with complete
atony, necessitating the constant use of the catheter, by means of an
exclusive milk diet. He takes one gallon of milk a day, and nothing
else, and lives among his fellow-men at his work and amusements in
entire contentment. He has remained absolutely well on this diet during
many years. The other patient could not take milk after fair trial, but
gradually emerged from the very jaws of death, due to prolonged chronic
cystitis and double pyelitis, by the free use of koumiss, which his
wife daily prepared for him. Vichy and milk in equal parts, taken cold,
is another form of using the milk diet, and the more modern peptonized
milk another.

Light white and red wines, or even a little gin or old brandy, are of
decided advantage in the majority of enfeebled old men with chronic
cystitis. The patient should be clothed with the utmost care. The feet
and legs should be clad in wool unless in the very hottest season, and
flannel should constantly encase the belly and loins. Nothing is more
detrimental to chronic cystitis than chilling the legs.

Another word is necessary in favor of the internal use of alkaline
remedies. Even where the urine is alkaline, ammoniacal, putrid, if the
stomach will take an alkaline medicine kindly the effect is generally
beneficial, for the urine, especially in old men who are prone to these
maladies, is quite certain to be acid at the fountain-head. And even if
the urine is immediately altered by chronic pyelitis through ammoniacal
decomposition before it enters the ureter, yet it will generally
irritate the pelvis of the kidney and the ureter and the bladder less
if it be secreted in a bland alkaline state than if it be discharged
into the irritated area full of uric acid.

Turpentine, copaiba, cubebs, and the muriate of iron are of service in
selected cases, but ordinary astringents seem to possess little or no
value. Benzoic acid, in ten-grain doses in capsules, sometimes improves
the ammoniacal condition of the urine, but the stomach often rejects
it. Boracic acid, which has of late been much talked about, in five- to
ten-grain doses in water, three or four times a day, is of value
occasionally. Quinine is serviceable where the nerve-force is failing.
I have been unable to procure any very decided advantage from the use
of salicylic acid or the salicylate of sodium by the mouth.

The most important general surgical principle in connection with {132}
chronic vesical catarrh is that which concerns emptying the bladder
thoroughly and ensuring its cleanliness. In many, perhaps most,
conditions of chronic inflammation of the bladder from atony,
paralysis, obstruction, or other cause the bladder fails to empty
itself entirely. There remains, therefore, a fixed residuum always in
the bladder; and although this is diluted and partly evacuated at each
act of urination, yet some of the pus, the bacteria, the ammoniacal
ferment, remains constantly in the bladder ready to contaminate each
new portion of urine as it descends from the kidneys. This must be
disposed of, and the bladder washed out, if a permanently satisfactory
treatment is to be instituted.

The soft-rubber catheter is to be preferred where it will pass,
otherwise the woven silk or the French Mercier instrument, and the
bladder should receive attention at least once in the twenty-four
hours, and oftener if required. The last drops of urine should be drawn
off and the bladder washed with water at about 100° F., in which is
dissolved some borax--a heaping teaspoonful to the pint--or other
substance capable of disinfecting the contents or mildly stimulating
the circulation of the bladder.

Carbolic acid has not yielded good results in my hands. A host of
remedies have been employed, but it is doubtful whether anything can do
more good than the water mechanically, borax as a disinfectant, dilute
nitric acid, minim i-x to the pint, as a stimulant, or, in some cases,
nitrate of silver, gr. ½-x to the ounce, used with caution. The
injections should be practised through the catheter which withdraws the
urine, and repeated according to their effect. For cleansing purposes
an injection of simple warm water may be used at each introduction of
the catheter. A fountain syringe with two-way stopcock is the most
convenient instrument to use for the purpose of simply washing the
bladder, because the wash may be repeated indefinitely until it returns
clear, without readjusting the nozzle in the catheter.

Very extreme, long-protracted cases of chronic vesical catarrh justify
the performance of lateral cystotomy for their relief, or the
modification quite recently proposed by Thompson[2]--a median perineal
incision involving only the membranous urethra, through which a large
soft-rubber catheter is passed and tied in for a few days or longer.

[Footnote 2: _Brit. Med. Journ._, Dec. 9, 1882, p. 1131.]


Neurosis of the Bladder.

The most common vesical neurosis is neuralgia of the neck of the
bladder, with or without the accompaniment of irritability of the
bladder, spasmodic stricture, or vesical spasm. Irritability of the
bladder has been already considered at the beginning of the section on
Cystitis. The other neurotic conditions are always more or less
interwoven with each other, and they may each and all of them
complicate inflammatory states of the deep urethra, prostate, and
vesical neck.

The CAUSES of this set of affections are most varied, and range from
irregular sexual hygiene (the most common of all) through inflammatory
local conditions, peripheral irritations (the most obstinate of which
is {133} chronic inflammation of the seminal vesicles, with or without
true spermatorrhoea), up to organic changes in the spinal cord and
brain.

The PROGNOSIS in neurotic states varies with the cause. Some cases are
easily controlled; others absolutely defy all and every treatment of
which I have any knowledge.

The TREATMENT involves a removal, if possible, of the cause. Local
measures which have been found most effective in subduing the deep
urethral irritation are--(1) the gentle passage of a soft bougie or
conical steel sound into the bladder at intervals of one to seven days.
The instrument should be removed at once. Sometimes it is necessary to
cut a narrow meatus or a stricture in the pendulous urethra in order
that a sound of large-enough size may be employed to put the sensitive
deep urethra sufficiently on the stretch. (2) The application to the
deep urethra and prostatic sinus of pastes of tannin or iodoform with
the cupped sound or other apparatus, or the injection of the deep
urethra with strong solutions of tannin or mild solutions (gr. i-x to
ounce j) of nitrate of silver. (3) In the most extreme cases, those
furnishing all the symptoms of stone, even cystotomy is justifiable. It
nearly always furnishes a temporary, sometimes permanent, relief.

Medical measures include all the bland diluent mineral waters, alkaline
and tonic remedies, already considered in discussing Irritability of
the Bladder.


Atony and Paralysis.

Atony of the bladder is more or less lack of expulsive force, due to
failure in power of the muscles of the bladder, the nerves remaining
sound. Paralysis is the same condition perhaps more pronounced, but due
to central origin. A patient may be unable to pass water in more than a
dribbling stream, but if he has true organic stricture or spasm of the
deep urethra, the muscular coat of his bladder may perhaps not be to
blame for his imperfect urination. The question of atony may be decided
in such a case by introducing a catheter of any size that will pass. If
there is atony, the stream flows sluggishly from the mouth of the
catheter, and toward the end is influenced by the breathing of the
patient. If there is no atony, the stream rushes through the catheter,
and maintains its force until the last drop flows away. In paralysis
and extreme atony the influence of the descent of the diaphragm during
inspiration is noticed during the whole course of the flow of the
sluggish stream through the catheter.

The CAUSES of atony are over-distension of the bladder, voluntary (by
persistently neglecting the call to urinate), involuntary retention
(from fever, coma, stricture, large prostate), and a certain intrinsic,
sometimes inherited, tendency to weakness on the part of the bladder,
noticed by some people during their entire lives.

Atony is most common, often a part of their malady, in old men with
enlarged prostate. Paralysis of the bladder accompanies certain organic
changes due to injury or disease in the spinal cord or brain. Both in
atony and in paralysis the bladder may be constantly distended to a
certain extent, perhaps to its utmost limit, as a passive sac, and the
excess of urine over this uniform residuum may dribble away
involuntarily {134} (false incontinence), or may be expelled in small
portions by repeated acts of urination performed in the ordinary way or
by the aid of great straining and assistance from the voluntary
contractions of the muscular walls of the abdomen. No condition of
incontinence of urine can be considered proved until demonstrated by
the passage of a catheter. Both atony and paralysis may get well under
proper treatment in favorable cases. Many cases are incurable, but the
discomfort they tend to cause may be almost entirely counteracted.

TREATMENT.--Under all circumstances where the bladder cannot empty
itself, the catheter should be used, and the bladder should be washed
out, kept clean, and disinfected. All the suggestions laid down for
catheterization and vesical injection in the section on Chronic
Cystitis are applicable here and need not be repeated. It is
particularly necessary to disinfect the catheter on each occasion
before it is introduced. This is best effected by washing the catheter
outside and inside with a 5 per cent. solution of carbolic acid in
water, and finally washing it outside with clean water, before its
introduction. If the bladder is over-distended, it should not, as a
rule, be entirely emptied at the first introduction of the catheter,
for fear of possible collapse, or, what is more to be dreaded, setting
up acute cystitis by suddenly taking off all the internal pressure from
the vessels in the walls of the weakened bladder, to which pressure the
circulation has become accustomed. If, therefore, the bladder is
emptied inadvertently, it is better to inject a few ounces of warm
water containing borax in solution (a teaspoonful to the pint), and
leave it in until the next catheterization. The quantity left in may be
reduced at each sitting. By careful attention to these means most cases
of over-distension due to atony or paralysis may be relieved without
the intervention of cystitis, or with so little that it does not become
a serious factor in the case.

The medical treatment of these cases is less important than the
mechanical. Under the latter alone and improvement in general health
curable cases often get well. Milk diet is of service, and iron and
tonics of considerable value in proper cases. Electricity has not
yielded satisfactory results in my hands, and I have not derived the
advantage from ergot which is often claimed for it. In cases of atony I
think I have seen good results sometimes follow the use of strychnine
internally in pretty full doses. The same remedy under the skin acts
more promptly and more effectively if it is to do any good at all. In
true paralysis of central origin the cure of the bladder depends upon
relief of the original disease and local treatment to the bladder.

Hysterical women sometimes feign paralysis in order apparently to
secure the sympathy and personal attention of the physician. The
application of the actual cautery above the pubes, and entrusting a
female nurse with the function of catheterization, is generally
effective treatment in these cases.


Hemorrhage from the Bladder.

After all sorts of wounds and injuries to the bladder, and in cases of
rupture of the viscus, blood is found in the urine. In certain medical
{135} conditions, in scurvy, hemorrhagic eruptive diseases, cases of
vicarious menstruation, it has been noticed. In strangury due to
cantharides, or in any condition of acute or chronic cystitis with
considerable spasm of the bladder, the urine contains more or less
blood. Especially is this true if ulceration exist at or near the neck
of the bladder, as in tubercular or cancerous cystitis.

In cases of stone in the bladder one of the cardinal symptoms is
vesical hæmaturia, while in villous growth often the only symptom of
the malady is repeated attacks of more or less profuse bleeding from
the bladder coming on unexpectedly, without obvious exciting cause, and
showing no regularity in the length of the intervals between the
hemorrhages or the intensity or duration of the latter. Outbursts of
unexpected hemorrhage are not uncommon in connection with some cases of
enlarged prostate and chronic cystitis, while these outbursts are the
rule, sooner or later, in most cases of true cancer of the bladder.

The DIAGNOSIS is often very important--that is, in a given case to
decide whether the blood comes from the bladder or from the kidney.
This may usually be ascertained by a very simple manoeuvre, especially
when the flow of blood is not excessive: a silver catheter of short
curve is introduced and the urine drawn off, the bladder gently washed
several times without moving the catheter, and the shade of red in the
wash noted. Now, the bladder being slightly distended with warm water,
the point of the catheter is moved somewhat roughly in all directions
and made to touch different portions of the wall of the bladder. The
water is now allowed to escape, and its deepened color will decide that
the hemorrhage has a vesical origin, for manipulations of a silver
catheter in a healthy bladder will not occasion a flow of blood. In
doubtful cases on two occasions I succeeded in locating the point
whence the blood escaped as follows: In one I passed a soft catheter,
and washed the bladder until the wash escaped nearly clean; I then
withdrew the catheter until the point reached the membranous urethra
(the bladder having been left full of clean water), and immediately
passed the instrument again and withdrew the contents of the bladder,
which were now brilliantly colored, thus locating the bleeding point in
the prostatic sinus. In the other case, that of a young man with
moderate stricture, whose urine was nearly solid with blood, I noticed
that no blood escaped by the meatus between the acts of urination;
therefore the bleeding point was posterior to the membranous urethra.
Was it in the prostate, the bladder, or the kidney? To decide this I
passed a soft catheter and washed the bladder until the wash flowed
clear. I then injected some warm water, withdrew the catheter, and
caused the patient to empty the bladder. The flow was brilliant with
blood. In both these cases I effected a cure by one application of
solid nitrate of silver through the urethra to the prostatic sinus.

The TREATMENT of vesical hæmaturia is the treatment of the cause,
which, if possible, must be ascertained. For the symptom itself the
internal use of iron, turpentine, opium, gallic and tannic acids, are
of service. I have not derived any advantage from ergot. Locally, rest
in bed, ice over the region of the bladder, and avoidance of straining
at urination are generally all that is necessary. I have had good
results from injecting the bladder with a solution of alum, gr. i-ij to
ounce j of warm {136} water, and cures have been effected by injecting
nitrate of silver in solution. It is not well to inject iron in
solution, since this substance makes a hard clot, and a soft clot is
preferable. When the bladder fills up with a solid clot of blood, the
best treatment, according to my experience, is to administer opium
freely and diluent drinks. The urine slowly dissolves the clot, which
has already arrested the hemorrhage, in most cases by its pressure, and
the blood flows away as a dark coffee-ground material, sometimes nearly
black. If the catheter is used, the clot broken up or dissolved with
pepsin or other substance, and washed or pumped out, a new clot is apt
to form at once; and although this treatment is based on high
authority, and is often practised successfully, it is a question
whether the patient would not in many cases do as well, or better, by
being let alone, soothed by opium, until the urine dissolves the clot
and nature relieves him.


New Growths in the Bladder.

These belong strictly to the province of surgery, but they fall also
under the notice of the physician. Tubercular disease may involve the
whole mucous surface or only the neck of the bladder; cancer may
infiltrate its walls or grow out as a solid tumor in the vesical
cavity; fibrous, sarcomatous, and myomatous new formations, polypi, and
cysts, simple and hydatid, have been encountered; villous growths, both
benign and cancerous, may occur. These morbid deposits give rise either
to recurrent hemorrhage or to varying grades of chronic cystitis. The
diagnosis is often difficult, the treatment generally palliative. Much
has been done of late in an operative way for the relief of tumors of
the bladder, and some brilliant results have been secured by operations
through the perineum as well as above the pubes. A tumor of moderate
size may be detected by the searcher within the bladder, and often may
be grasped in a lithotrite and measured. Such a tumor can generally be
plainly felt by conjoined palpation in a thin subject, one hand pressed
firmly down behind the pubes and two fingers of the other hand passed
into the rectum. Recently, Sir Henry Thompson has advocated vesical
exploration for purposes of diagnosis through a median incision in the
perineum, as for median lithotomy, and has practised it a number of
times with a large measure of success. I have made the same exploration
several times, and have encountered and successfully removed one tumor.
The expedient is worth bearing in mind for use in any obscure cases. It
is probably less objectionable and more likely to yield valuable
information than the exploration by introducing the whole hand into the
rectum (Simon's method).




{137}

SEMINAL INCONTINENCE.

BY SAMUEL W. GROSS, A.M., M.D.


DEFINITION.--By the term seminal incontinence, which is synonymous with
involuntary or abnormal seminal emissions, pollutions, and
spermatorrhoea, is meant the involuntary discharge of semen beyond the
limits of health. Although usually described as a distinct disease, it
is symptomatic of, and, as a rule, primarily dependent upon, weakness
or exhaustion, along with exaggerated irritability, excitability,
impressibility, or mobility of the centres which preside over erection
and ejaculation. Hence it should be regarded as a motor neurosis, and
not as a functional disorder of the testes.

CLASSIFICATION.--Involuntary seminal losses embrace three conditions,
which constitute as many varieties of the affection, and which may
exist separately, or pass into one another, or be combined. These
varieties are, first, nocturnal losses or pollutions, which occur
during sleep, and are generally attended with an erection, erotic
dream, and pleasurable sensation; secondly, diurnal pollutions, which
take place when the patient is awake, are excited by trivial mechanical
or psychical causes, and are associated with imperfect erection and
diminished sensation; and, thirdly, spermorrhagia, or spermatorrhoea,
in the strict acceptation of that term, which is characterized by a
constant escape of a slight amount of seminal fluid, without the
orgasm, pleasurable sensation, or impure thoughts, or during
micturition and defecation.

1. Nocturnal Pollutions.--By far the most common of the varieties of
seminal incontinence is the first, or that in which the emissions occur
during sleep under the influence of an erotic dream, and which may,
therefore, be regarded as an exaggeration of the normal or
physiological condition. In health, provided the subject leads a
continent life, the number of emissions varies greatly, and as they are
merely reflex signs of distension of the seminal passages, they are not
pathological nor are they attended with ill effects. The knowledge of
this fact is of great practical importance, as it frequently enables
the physician to assure his patient that the emissions are not
abnormal, thereby relieving his mind of a great weight. It is, of
course, to be remembered that the frequency of nocturnal pollutions
depends upon age, climate, habits, temperament, constitution, diet, and
predisposition, and that young men who suffered during childhood from
nocturnal incontinence of urine are particularly obnoxious to them.
Their frequency also varies greatly in the same person, and it is
scarcely possible to determine what constitutes the standard {138} of
health merely by the intervals of their repetition, since a number
which would be normal in one person would be abnormal in another. In
men, however, who possess sound nervous systems and who do not trouble
themselves with sexual matters an emission every fortnight is a sign of
excellent health; and even if they should occur at intervals of several
days, they are not inconsistent with temporary good health. The latter
statement is well exemplified by a case which came under my observation
in 1882. A druggist, twenty-seven years of age, had had for six years
from three to live emissions a week, and occasionally two during a
single night, attended with erections and voluptuous dreams, without
the slightest evidence of impairment of his health. In all such cases,
however, as well as in those in which the emissions have occurred at
longer intervals for a number of years, it only requires a little
longer time for general symptoms to manifest themselves.

Nocturnal pollutions are to be regarded as pathological when they occur
in married or single men who indulge in regular intercourse; when they
are followed by backache, headache, enfeeblement of the functional
powers of the brain, mental depression, and bodily or mental lassitude;
when they take place without erections or dreams; when they accompany
or follow acute or chronic diseases; when they coexist with diurnal
pollutions or spermorrhagia; and, finally, when they are complicated by
one of the varieties of impotence, which may be the only indication
that the emissions are abnormal or one of the effects of impairment of
the functions of the genital nervous centres. The associated symptoms
of myelasthenia and cerebrasthenia vary very much in degree in men of
apparently the same amount of vigor and tolerance, and in whom the
pollutions occur with equal frequency, or they may even be absent
altogether.

2. Diurnal Pollutions.--Ejaculation of semen during the day is
fortunately of comparatively infrequent occurrence, since it indicates
a more serious condition than do losses of seminal fluid occurring when
the patient is asleep, the genital organs and the centres which preside
over them being highly impressible or in a state of irritable weakness.
In what may be regarded as the lesser form of the affection the
ejaculation is due to slight peripheral irritation, induced, for
example, by friction of the clothing, crossing of the legs repeated
several times, horseback exercise, driving over rough streets, riding
in railway-cars, or even shaving, combing the hair, or shampooing the
head; while in the more aggravated variety an emission is induced by
psychical irritation, such as reading libidinous books, the sight of
indecent pictures, dwelling upon sexual ideas, or the mere sight of a
female. In the former of these varieties there is a fair erection, but
the sensibility is blunted; in the latter the erection is flabby or the
penis is flaccid and there is little if any pleasure.

3. Spermorrhagia.--In the third phase of the affection, which is still
more uncommon than the second variety, there is a continuous passive
loss of semen, without erection or sensation--a condition which depends
upon paralysis and dilatation of the orifices of the ejaculatory ducts,
and which is most conspicuous during the acts of micturition and
defecation. The existence of spermatorrhoea, in the restricted sense of
the term, is denied by some authors, but I have myself met with it in
five instances, and typical cases have been recorded by other modern
writers.

CLINICAL HISTORY.--Seminal incontinence usually supervenes upon {139}
the interruption of sexual intercourse, especially when the subject has
been accustomed to excessive venereal indulgence, or, as more
frequently happens, upon the abandonment of the habit of masturbation.
Any one of these varieties may exist separately, but they gradually
pass into each other, and are variously intermixed in the advanced
grade of the affection. In the mild type there is increased frequency
in the occurrence of nocturnal pollutions, ejaculation taking place at
intervals of several days or for two or three nights in succession,
when there is a respite for a week or ten days. The emissions are
associated with disturbances of the nervous system, referable to the
brain or spinal cord or to the cerebro-spinal axis, of which mental
lassitude and muscular debility are the most common signs. When, as the
result of the increase in the irritability of the ejaculatory centre
and of the progressive weakness or exhaustion of the entire nervous
system, the case goes on from bad to worse, it usually pursues the
following course: Abnormal frequency of the nocturnal pollutions is
associated with pain in the back, headache, muscular fatigue, and
incapacity for sustained mental effort. With the increase in the number
of the emissions erection becomes imperfect, ejaculation on coition is
frequently precipitate, and the patient complains of dulness of
perception, impairment of memory, mental dejection, a dull pain in the
occipital region, weakness of vision, vertigo, palpitation of the
heart, trembling and numbness of the limbs, shortness of the breath,
flatulence, constipation, and other signs of gastric derangement.
Diurnal pollutions are now superadded, and intercourse is
impracticable, either from failure of erection or from premature
ejaculation. The general symptoms, too, are more serious. The patient
constantly broods over his condition, assumes that he has permanently
lost his virility, and the mental anxiety and dejection verge upon or
merge into a condition of sexual hypochondrism. The gait is unsteady;
the hands and feet are habitually cold; he is subject to wandering
neuralgic and rheumatoid pains; passes restless nights; loses flesh and
color; shuns society; imagines that every one recognizes his condition,
and fears to look one in the face; and is utterly incapacitated for
mental or physical exertion. With the still further increase of the
irritable weakness of the genitalia and nervous centres the semen flows
continuously out of the urethra, and its discharge is augmented during
defecation and micturition. Finally, the man becomes a confirmed
hypochondriac, and should he have inherited a tendency to insanity,
epilepsy, ataxia, or other nervous disorders, he may lapse into one of
these conditions.

In the early stage of seminal incontinence, when the nocturnal
pollutions overstep the natural limits, the ejaculated fluid is
unchanged. When, however, the pollutions are more frequent and diurnal
discharges coexist, the semen is watery and scanty; the spermatozoids
are smaller, comparatively few in number, and their movements are
liable to be abolished in less than an hour, while spermatic crystals
form more rapidly and more abundantly than in health. In the worst
cases, or those characterized by diurnal and nocturnal pollutions and
by the presence of semen in the urine, the spermatozoids are either
entirely absent, or, if they are present, they are motionless, stunted,
or variously deformed. In these advanced cases the ejaculated fluid,
which consists principally of the secretions of the seminal vesicles
and the prostate, frequently undergoes fatty {140} degeneration, as
indicated by granular epithelium, by molecular detritus, and even by
oil-globules in the protoplasm of the altered zoosperms. The entire
absence of spermatozoids, constituting the condition known as
azoospermatorrhoea, is of infrequent occurrence.

An examination of the genital organs discloses elongation of the
prepuce in nearly one-fourth of all cases; a rigid and pointed penis in
one-tenth; relaxation of the scrotum in about one-eighth; irritable
testes in 1 example out of every 25; varicocele in 1 case out of every
50; coldness of the genitalia in 1 case out of every 17; a feeling of
heat in 1 case out of every 33; and irritability of the bladder in 1
case out of every 25. It will, moreover, be found that seminal
incontinence is complicated by feebleness of erection, with precipitate
ejaculation on coition, in 22 per cent. of all cases; by the occurrence
of ejaculation on attempting intercourse, before penetration,
simultaneously with erection, or even before erection, in 16 per cent.;
and with total impotence in 5 per cent. of all cases. Prostatorrhoea is
also a not infrequent complication, while urethral strictures and
hyperæsthesia are nearly always present.

ETIOLOGY AND PATHOGENY.--Seminal incontinence is not a separate entity,
but one of many symptoms of general or local disorders, or of both
combined. In the majority of instances it must be looked upon as a
neurosis, diurnal and nocturnal pollutions representing a motor
neurosis with spasm of the seminal vesicles, and spermorrhagia
indicating a motor neurosis with dilatation and paresis of the orifices
of the ejaculatory ducts. In all of the varieties there is increased
susceptibility of the cerebral and spinal genital centres to factors
which in healthy persons are not productive of ill effects.

Like other nervous disorders, involuntary seminal emissions sometimes
manifest themselves in several members of the same family through
several generations, being the result of inherited predisposition. In
this class of cases the subjects are of a nervous, excitable, or
irritable temperament, somewhat anæmic, and possibly suffered during
infancy from nocturnal enuresis. Among the predisposing causes the most
common is indulgence in erotic fancies, which terminates in increased
reflex impressibility of the centres which preside over the genital
organs.

The affection is, however, usually acquired, being met with
particularly in single subjects toward the termination of the second
decade and between the second and third decades. Of these cases, at
least nine-tenths can be traced to masturbation, while the remainder
will be found to have had gonorrhoea or to have masturbated, suffered
from gonorrhoea, or indulged their sexual propensities in various ways.
Seminal incontinence is not common as the result of sexual coition, and
it is highly probable that when married men are affected the sexual
excess is engrafted upon a previously vicious habit. From a practical
point of view, it is of the first importance to be aware of the fact
that one or more strictures of the urethra will be found in 80 per
cent. of all cases, and that decided hyperæsthesia of the prostatic
portion of the urethra is present in 94 per cent. of all instances.

The rational explanation of morbid seminal emissions seems to be as
follows: Under the influence of erotic ideas, masturbation, sexual
excesses, or unsatisfied sexual excitement produced by dallying with
women, exaggerated irritability of the genital organs is induced, and
is {141} followed by subacute or chronic inflammation and abnormal
sensibility of the urethra, particularly of its prostatic division,
which terminate, in cases characterized by diurnal pollutions and
spermorrhagia, in relaxation and dilatation of the orifices of the
ejaculatory ducts. As the natural result of the constant excitability
of the terminal filaments of the nerves distributed to the prostatic
urethra, these nerves are alive to the slightest impressions, act as
peripheral sources of irritation, and induce permanent increased
mobility or irritability of the cerebral and spinal genital centres,
through which the motor nerves of the ejaculatory apparatus are thrown
into action, and an emission ensues.

Seminal incontinence is an occasional accompaniment of injuries of the
spine, and it is also met with during the progress of or convalescence
from acute and chronic diseases which are marked by disturbances or
exhaustion of the central nervous system. Thus, it may be symptomatic
of phthisis, variola, typhus, progressive muscular atrophy, and
incipient bulbar paralysis, ataxia, and paraplegia; while the habitual
use of opium and chronic alcoholism predispose to its occurrence.

Of the local causes referable to the genitalia, by far the most
important and most frequent are hyperæsthesia and inflammation of the
prostatic portion of the urethra, which are generally induced by
masturbation. These lesions constitute the primary source of the
trouble in the large majority of cases, and tend not only to excite
reflex pollutions, but to maintain the disorder by keeping the mind
occupied with sexual matters. Other common local causes are found in
congenital narrowing of the meatus, organic stricture of the urethra, a
redundant prepuce, balanitis, and the accumulation of smegma. Among the
more infrequent etiological factors may be mentioned herpes of the
prepuce, congenital shortness of the frenum, spasmodic stricture,
polypus of the deep urethra, spermato-cystitis, and epididymitis.

Among the remaining exciting causes of pollutions are diseases of the
anus and rectum, as hemorrhoids, morbid growths, ascarides, fissures,
ulcers, pruritus, and painful eruptions. The nerves of the rectum and
anus being derived from the same region as those of the genitalia, it
is not surprising that the ejaculatory centre should respond to an
impulse transmitted from them. In habitual constipation straining at
stool may also excite an emission through the consentaneous action of
the muscles of the abdomen, rectum, and seminal vesicles; but this is
only observed when the orifices of the ejaculatory ducts are paralyzed
and patulous.

ANATOMICAL CHARACTERS.--There are no records of the morbid appearances
which appertain to seminal incontinence in its early stage, but that
the hyperæsthesia of the prostatic urethra depends upon chronic or
subacute inflammation is rendered certain by the concomitant symptoms,
by exploration with the sound, aided by the finger in the rectum, and
by the results of treatment. In the advanced stage, post-mortem
inspection has disclosed stricture of the urethra, injection of the
mucous membrane of the deep portion of the urethra, dilatation and
excoriation of the orifices of the ejaculatory ducts, and suppuration
of the prostate and the seminal vesicles. The changes which occur in
the nervous centres are unknown.

DIAGNOSIS.--The microscope affords the only positive mode of
determining whether the fluid which is discharged from the urethra
during {142} pollutions, or constantly moistens that canal in
spermorrhagia, or is expelled at stool or with the urine, or is brought
away by the bulb of the explorer, is seminal in its character. Should
spermatozoids be detected, there can be no doubt as to its true nature,
but their absence is not an evidence that the case is not one of
spermatic incontinence, since in the condition known as
azoospermatorrhoea the exhausted sexual apparatus furnishes a thin,
transparent, watery fluid which may be entirely devoid of fertilizing
elements, and contains cylinder epithelial cells, epithelium which has
undergone fatty or colloid degeneration, a few lymph-corpuscles, an
abundance of fatty detritus, and a few small shining bodies which are
the remains of the badly-evolved spermatozoids. Under these
circumstances, the history of the case, the fact that the subject is or
was a masturbator, and the associated nervous symptoms are aids in
forming a diagnosis; and this is especially true of cases in which a
fluid is expressed at stool, and which in the majority of instances is
the altered secretion of the prostate. Under the microscope the thin,
more or less milky prostatic fluid will be found to contain cylinder
epithelium, numberless colorless and refracting granules of lecithin,
and minute yellowish concentric amyloid concretions; and, after it has
slowly dried upon the slide, crystals of phosphate of magnesium or of
ammonio-magnesian phosphate will make their appearance.

Should a microscopical examination be impracticable, we may assume that
the discharge which occurs during defecation in the subjects of too
frequent nocturnal pollutions is an evidence of coexisting
prostatorrhoea; while we may frame the rule that the flocculent
sediment contained in the urine and the discharge at stool of persons
suffering from both nocturnal and diurnal pollutions, and a slight
continued discharge from the urethra represents semen. In the last
event we may moreover assume, especially if the patient be impotent,
that the orifices of the ejaculatory ducts are relaxed.

PROGNOSIS.--Nocturnal emissions are very amenable to treatment,
particularly when they are kept up by appreciable local lesions, the
only cases which are, as a rule, rebellious being those in which the
pollutions are associated with chronic inflammation of the seminal
vesicles. In expressing an opinion in a given case the physician
should, however, be influenced by the severity of the signs of nervous
exhaustion. If the general symptoms point to involvement of the cord
alone, the prognosis is far better than when signs of cerebrasthenia
are present; but the outlook is bad if, in addition to cerebral and
spinal exhaustion, the patient is a sexual hypochondriac. Nocturnal
pollutions occurring during the progress of acute or chronic general
disorders are also, as a rule, readily checked. The prognosis in the
same class of cases is, moreover, far better when the usual local
lesion--namely, morbid sensibility of the prostatic urethra--has been
induced by gonorrhoea rather than by masturbation; and it is also more
favorable when the pollutions occur in mature years from sexual
excesses than when they are due early in life to masturbation.

Even when the emissions occur during the day from trivial psychical or
mechanical causes, ample experience has convinced me that the prognosis
is far better than many writers would lead one to believe. These cases
are, however, less tractable than those of nocturnal pollutions, but
{143} they finally recover with the exercise of a little patience. The
worst outlook is when the emissions are passive, or occur without the
orgasm, or during urination and defecation. In this class of cases not
only are the ordinary remedies applicable to the other varieties
demanded, but measures will have to be resorted to to overcome the
paralyzed and dilated orifices of the ejaculatory ducts. Although the
prognosis is not as favorable, I have never seen an example of
spermorrhagia that did not finally yield to treatment.

TREATMENT.--Certain hygienic and moral rules must be observed in the
management of all the varieties of seminal incontinence. The diet
should be plain, nutritious, and digestible; the evening meal should be
light and dry; and spirits and malt liquors, as well as stimulating
articles of food, should be eschewed. As the morning fulness of the
bladder is very liable to produce an erection, that organ should be
thoroughly emptied on retiring; and as pollutions usually occur toward
morning, the patient should set an alarm-clock one hour before the time
at which he has generally observed that the emissions take place, in
order that he may be awakened to relieve the bladder of its contents.
He should also sleep upon a hair mattress without much covering.
Everything calculated to induce a flow of blood to the genitalia, such
as horseback exercise, driving over rough roads, and railway
travelling, should be interdicted. Masturbation and sexual intercourse
must be abandoned, and the subject should be informed that the enforced
rest of the organs will possibly result in temporary increased
frequency of the pollutions. Chaste associations should be cultivated,
and erotic thoughts and desires be banished. To attain this end the
mind and body should be kept pleasantly occupied by gymnastic exercises
and the study of any subject which the patient may fancy. If, however,
he be not in full health, or if there are commencing or marked signs of
spinal or cerebral exhaustion, mental and physical exercise should be
taken in moderation.

In the treatment of involuntary seminal emissions a thorough
examination should be made of the genital and associated organs, with
the view of detecting and getting rid of any reflex or eccentric
lesions or causes which predispose to, or even excite and maintain,
them in impressible subjects. If the patient has a redundant prepuce,
it should be removed; if the meatus be contracted, it should be
enlarged; while balanitis, herpes, hemorrhoids, rectal fissure or
ulcer, or pruritus should be treated in the usual way. In not a few
mild cases, particularly those dependent upon phimosis, a contracted
meatus, or a stricture just behind the orifice, it will be found that
operative interference is quite sufficient to bring about relief.
Habitual constipation, which is met with in about one-third of all
instances, demands particular attention, either by enemata of temperate
water or a pill composed of one-tenth of a grain each of aloin and
extract of belladonna, administered every eight hours.

In the section on the etiology and pathogeny of seminal incontinence
attention is called to the fact that hyperæsthesia of the prostatic
urethra is nearly always present. While it is undoubtedly true that the
genital nervous centres may be highly impressible without the
intervention of hyperæmia, inflammation, and abnormal sensibility of
the prostatic urethra, it is none the less true that those lesions are
the most constant and most important of all the causes which excite and
maintain the {144} disorder, especially in masturbators, in whom,
moreover, strictures may be looked for in about eight-tenths of all
cases. As a rule, the coarctations will be formed just behind the
meatus, but others may be present posteriorly. Be this as it may, a
knowledge of their existence is of the first importance, as they
aggravate the morbid condition of the prostatic urethra and serve to
keep up a peripheral source of spinal neurasthenia.

For the detection of a stricture the exploratory or acorn-headed soft
bougie should be resorted to, as it is the only instrument with which
coarctations of large calibre and granular patches can be accurately
defined, and with which abnormal discharges can be withdrawn for minute
examination. One being selected which fills the meatus, it is warmed
and well oiled, and inserted as far as the bladder. Should its
introduction be arrested, smaller sizes are successively employed until
one will pass without difficulty. On its withdrawal the abrupt shoulder
of the bulb coming in contact with the posterior face of the stricture
imparts to the touch a sensation as if it had jumped over a band, while
a granular patch conveys the impression of a limited roughness of the
canal. Hyperæsthesia of the urethra is readily determined by the
nickel-plated steel bougie, and its existence should never be based
upon the passage of the soft explorer alone, as the latter is
productive of far more pain than the former. In conducting these
examinations a contracted meatus or a stricture just behind the orifice
should first be divided, in order that the instruments for exploration
may correspond to the normal calibre of the urethra. Unless this point
receives attention the examination will be likely to prove valueless.
Should one or more strictures be present, the case must be referred to
a surgeon.

From the preceding considerations it follows that the treatment,
whether it be local or general, must at the outset be of a calming and
sedative nature, the end in view in the great majority of instances
being to overcome the exaggerated irritability of the genital nervous
centres and the abnormal sensibility of the deep urethra. By the
indiscriminate employment of strychnia, cantharides, phosphorus, and
cold ablutions great harm is done, and the management of involuntary
seminal emissions is brought into disrepute.

Of the local remedies to overcome the hyperæsthesia of the prostatic
urethra, there is not one entitled to so much confidence as the
nickel-plated conical steel bougie, passed at intervals of four days,
and at once withdrawn for the first few insertions, after which, with
the decrease of the sensibility, the intervals should be shortened, and
it should be retained longer, until it is inserted every forty-eight
hours and permitted to remain in the canal for a few minutes. The size
of the first instrument is to be gauged by that of the meatus if it be
normal, and if it be found necessary during the course of the treatment
the orifice should be enlarged, in order that bougies of progressively
increasing sizes may be introduced until they correspond to the full
calibre or distensibility of the urethra, as indicated by the
urethrameter. Unless these precautions be observed the measure will not
bring about the desired result.

As a rule, the bougie will meet the indication, but in exceptional
instances a small, circumscribed area of tenderness remains, which
comprises the sinus pocularis, and which proves rebellious to
instrumentation. Under these circumstances it becomes necessary to
apply a drop or two of {145} a solution of nitrate of silver to the
spot, which is best done with a small syringe attached to a perforated
bulbous explorer. The ordinary forms of porte-caustique charged with
the fused nitrate are objectionable, as the remedy does not come in
contact with the orifices of the ejaculatory ducts contained within the
sinus pocularis, and its application cannot be properly controlled.
From an ample experience I can confidently recommend the use of a
thirty-grain solution, repeated every four days. Provided the patient
be kept in bed for a few hours, the pain and desire to urinate will not
last more than thirty minutes. When the affection proves to be more
than ordinarily obstinate, flying blisters, made by pencilling
cantharidial collodion first on the one side of the perineal raphé,
and, after the surface has healed, on the opposite side, will prove
serviceable.

In addition to these measures great assistance will be derived on
retiring from the hot sitz-bath, or from a sponge or cloth dipped in
water at a temperature of at least 105° F. and applied to the perineum
and lower part of the spine. Cold applications are to be studiously
avoided.

Of the general remedies, not a single one is comparable to bromide of
potassium, which not only diminishes the reflex excitability of the
cord and suspends sexual desires and the power of erection, but
corrects the acidity of the urine and exerts an anæsthetic effect upon
the mucous membrane of the urethra. I am in the habit of administering
from three to four scruples of the salt at bedtime, and if I find that
it sets up signs of bromism I diminish it for a time, and afterward
promote its excretion by the kidneys by combining with it about fifteen
grains of bitartrate of potassium. Should the patient be anæmic, the
dose should be reduced to one drachm, and three grains of quinine along
with twenty-five drops of the tincture of the chloride of iron should
be ordered every eight hours. When, on the other hand, the patient is
robust and plethoric or in full health, I frequently add to the bromide
ten drops of veratrum viride or tincture of gelsemium, or administer
the bromide in half an ounce of the infusion of digitalis.

Another remedy which diminishes the reflex mobility of the
genito-spinal centre, at the same time that it reduces the secretion of
the seminal fluid, is the sulphate of atropia. Given in the average
dose of the one-sixtieth of a grain on retiring, so that the patient
may sleep through its disagreeable action, it will be found to be an
invaluable addition to the treatment.

When the bromide of potassium and atropia do not agree with the
patient, I substitute the monobromide of camphor and extract of
belladonna in the proportion of ten grains of the former to one-third
of a grain of the latter. In the remaining anaphrodisiacs, such as
lupulin, camphor, and conium, I have not the slightest confidence.

Under the plan of treatment thus outlined the majority of cases of
nocturnal and diurnal pollutions recover; but if the spinal genital
centre still remains too impressible, galvanization with the anode to
the lumbar region and the cathode to the perineum will prove highly
serviceable. When the condition is one of spermorrhagia, after the
hyperæsthetic symptoms have subsided the relaxed and paralyzed orifices
of the ejaculatory ducts may be restored to their normal condition by
the continuous current, the negative reophore being placed in the
rectum and the positive on the perineum or the lumbar vertebræ. Should
galvanization fail, {146} the induced current may be passed through a
negative catheter electrode in the prostatic urethra to the anode
resting on the perineum or spine; but this mode of application requires
great caution, and a feeble power should be employed at the
commencement. For this reason the rectal is preferable to the urethral
reophore. In the absence of electrical apparatus the tonicity of the
muscles of the ejaculatory ducts may be greatly improved, and even
restored, by the use of the cooling sound, by the application of a
thirty-grain solution of nitrate of silver, and by cold sitz-baths. In
these cases half a drachm of the fluid extract of ergot after each
meal, or fifteen drops of a mixture composed of six drachms of the
tincture of the chloride of iron and two drachms of the tincture of
cantharides, will also prove valuable. The operations of castration and
excision of portions of the vas deferens need only be mentioned to be
condemned.

To sum up the results of my experience in the management of seminal
incontinence, I may add that the steel bougie, bromide of potassium,
and atropia are especially adapted to cases of nocturnal and diurnal
pollutions, and that after the hyperæsthesia has been relieved
electricity, ergot, and strychnia are the most reliable agents in
spermorrhagia. The end having been accomplished, moderation in sexual
intercourse should be enjoined if the patient is married; continence in
thought and action should be observed if he remains single; and
matrimony should be advised if his circumstances and inclination
warrant it. Marriage should not, however, be encouraged if the
emissions are not arrested, as I have met with several cases in which
the patient was rendered miserable by this act, from the fact that he
deemed his case beyond all hope, as the emissions still continued.




{147}

DISPLACEMENTS OF THE UTERUS.
BY E. C. DUDLEY, A.B., M.D.


The title of this article is not to be taken in a restricted sense,
inasmuch as the uterus is anatomically so connected with adjacent
organs that the displacements of the uterus cannot be intelligently
considered or satisfactorily presented without at the same time
incidentally taking into account the displacements, causative,
resultant, or concurrent, of the ovaries, Fallopian tubes, rectum,
vagina, and bladder.


Normal Location and Position of the Uterus.[1]

[Footnote 1: The importance of a distinction between location and
position will become apparent hereafter: by the former is meant the
situation of the organ regardless of its attitude, by the latter is
meant the attitude alone. To change an object from one place to another
is to change its location; to turn it over or bend it upon itself is to
change its position.]

In the works on anatomy and gynecology which we are accustomed to
consult the uterus is represented as having a straight or nearly
straight canal--as lying about midway between the symphysis pubis and
the hollow of the sacrum, its axis corresponding to that of the pelvic
inlet. They generally agree that its position is one of slight, and
only slight, anteversion; some admit that slight anteflexion may not be
injurious, but most would pronounce the organ anteverted or anteflexed
to a degree that would endanger health if by conjoined manipulations
its anterior wall could be felt through the anterior wall of the
vagina. The classical idea of the normal position of the uterus
presupposes a distended bladder and rectum occupying the anterior and
the posterior thirds of the pelvic cavity. Such an arrangement would
leave for the uterus only the intermediate space, and would constitute
a condition seldom or never realized in health.

Suppose a straight line coincident with the vesico-vaginal wall (Fig.
1) to be continued through the cervix to the sacrum. This line
represents approximately the antero-posterior diameter of the pelvis.
The length of the vesico-vaginal wall is two and a half inches, and,
supposing the cervix to be just midway between the symphysis and the
sacrum, the distance from its posterior wall to the sacrum must also be
two and a half inches. Add to the sum of these two parts of this
antero-posterior diameter one inch for the cervix, and the
antero-posterior diameter of the pelvis becomes six inches instead of
the normal four and one-third; which proves that the cervix must
normally be much nearer to the hollow of {148} the sacrum than to the
symphysis. Since the length of the vesico-vaginal wall plus the
diameter of the cervix measures three and one-half inches, it follows
that the distance from the posterior wall of the cervix to the hollow
of the sacrum must be the difference between four and one-third and
three and one-half inches, or five-sixths of an inch.

[Illustration: FIG. 1. The Classical Representation of the Pelvic
Organs.]

Again, suppose the uterus (Fig. 1) to be carried bodily upward and
backward, its axis remaining the same, until the cervix reach its
normal position near the hollow of the sacrum; then would the body of
the uterus impinge upon the bony sacrum. It is therefore clear that the
anteversion must be the normal position, because the uterus and sacrum
would otherwise occupy the same space.

Fig. 2 represents, according to Schultze,[2] the location and position
of the virgin uterus and its surroundings, the bladder, rectum, and
vagina being empty and collapsed. The angle of about 90° which the
cervix forms with the vagina measures the forward inclination of the
cervix, but is subject to slight variations in consequence of the
physiological {149} movements of the uterus. The body is furthermore
bent forward upon the cervix, so that its anterior surface rests upon
the empty bladder. The angle of the normal anteflexion, according to
careful measurements by Schultze, is about 48°; Fritsch says that 90°
is the physiological limit. This question will be further considered
under the subject of pathological anteflexions.

[Footnote 2: _Archiv für Gynäkologie_, 1875, Band viii. p. 134, and
_Lageveranderungen der Gebarmutter_, Berlin, 1881.

Ely Van de Warker makes a full and critical study of the normal
movements of the unimpregnated uterus in the _N. Y. Medical Journal_,
xxi. p. 337, and of the normal position and movements of the
unimpregnated uterus in the _American Journal of Obstetrics_, xi. p.
314. His conclusions substantially agree with those of Schultze.

Frank P. Foster (_American Journal of Obstetrics_, xiii. p. 30)
presents a valuable paper giving a résumé of the literature, with
original observations, in which he takes exceptions in part to the
views of Schultze.]

[Illustration: FIG. 2. The Correct Representation of the Pelvic
Organs.]


Normal Movements of the Uterus.

Strictly, the uterus can have no absolutely normal position or
location, because it has a certain normal range of movements which
depend to some extent upon respiration, intra-abdominal forces, and
locomotion, but more especially upon the varying quantity of material
in the rectum and bladder. Its normal position, then, varies within the
limits of its normal movements. If the body of the uterus rest upon the
bladder, it must rise as the bladder becomes distended, and,
conversely, if the urine be drawn through a catheter while the woman is
lying on her back, the uterus, notwithstanding the opposing influence
of its own weight, immediately follows the receding wall of the bladder
and returns through an angle of 45°, or possibly even 90°, to its
accustomed position. The dotted lines in Fig. 2 indicate the degree of
version and flexion consequent upon the varying quantity of fluid in
the bladder.

{150} The full rectum forces the uterus in the opposite direction,
toward the symphysis, and thereby counteracts the influence of the
bladder. This anterior movement is, however, somewhat limited, and is
confined to the cervical portion, except when the body has been forced
back into close proximity with the rectum by the over-distended
bladder.


Normal Supports of the Uterus.

The uterus is maintained in its normal position and location by the
following agents:

_a_. The uterine ligaments;

_b_. The pelvic floor.[3]

[Footnote 3: For a description of the female pelvic floor see Hart's
_Atlas_.]

_a_. Physiologically, these ligaments are relaxed; the state of tension
would be pathological; they do not fix the uterus; they only tend to
limit its movements to their normal range. Backward displacement of the
body is resisted by the round ligaments, backward displacement of the
cervix by the utero-vesical ligaments and by the vesico-vaginal wall.
Forward and downward displacements are resisted by the utero-sacral
ligaments, and excessive lateral motion by the broad ligaments. This
restraining power is doubtless greater in the utero-sacral than in any
of the other ligaments.

_b_. The pelvic floor, which is the chief support of the uterus, is
divided into two segments, the pubic and the sacral. The pubic
segment[4] is composed of bladder, urethra, anterior vaginal wall, and
bladder peritoneum. It is attached in front to the symphysis pubis and
laterally to the anterior bony walls of the pelvis. The sacral
segment[5] is composed of rectum, perineum, posterior vaginal wall, and
strong tendinous and muscular tissue. It is attached to the coccyx, to
the sacrum, and to the posterior wall of the bony pelvis.

[Footnote 4: Hart and Barbour's _Manual of Gynecology_.]

[Footnote 5: _Ibid._]

Permeating the pelvic floor in all directions, entering into the
composition of its single parts, binding them together, and sending its
processes to the bony pelvis, is the pelvic connective tissue, upon the
integrity of which depends the integrity of the pelvic floor as a
uterine support. Its pernicious influence as a pathological factor will
be considered hereafter. The old idea that the uterus is supported by
the vaginal walls or by the perineum or by the uterine ligaments is
obsolete; they are important parts of the pubic and sacral segments,
and as such contribute their share, but the pelvic floor as a whole
supports the uterus. The various uterine supports are to a great extent
the seat of motor influence. They consequently not only resist
excessive movement, but also serve to return the organ from its
physiological migrations.

DEFINITION AND NOMENCLATURE OF DISPLACEMENTS.--In the foregoing pages
the normal location, position, movements, and supports of the uterus
have been defined. Those conditions are pathological which induce
changes to positions or locations beyond the defined limits, or which
so fix the organ that its normal movements are prevented. The
displacements are divided into mal-locations and malpositions.

The mal-locations in which the entire uterus occupies a place outside
{151} its normal limits are as follows: ascent, retro-location,
ante-location, lateral location, descent.

The malpositions are determined by excessive change in the inclination
of the uterine axis. They are further divided into flexions, in which
the organ is bent upon itself in an abnormal degree, manner, or
direction; and versions, in which the axis of the unflexed uterus
inclines in an abnormal degree or direction. The malpositions are
retroversion, retroflexion, lateral version, lateral flexion,
anteversion, anteflexion.

SYMPTOMS AND DIAGNOSIS IN GENERAL.--Each variety of displacement may be
indicated by its own group of symptoms and physical signs. These will
be presented in the study of the special lesions. To avoid repetition,
those symptoms and signs which pertain to no special displacement, but
which belong to all alike, will be mentioned at once. They may arise
either from the displacement itself or from its possible complications,
of which the following are examples: Metritis, ovaritis, salpingitis,
atresia and stenosis, cystitis, vesical catarrh, rectitis, rectal
catarrh, peri-uterine cellulitis and peritonitis, uterine catarrh,
tumors, cicatrices, etc.

Uterine displacement may be a cause or an effect of associated
complications, or together with them it may be a concurrent result of
some common cause, or it may have had primarily no pathological
connection with them. The symptoms of displacement refer to the pelvic
organs or to the nervous system. Among the symptoms which refer to the
pelvic organs are--difficulty in walking and standing; pelvic pain,
more or less constant; dysmenorrhoea, menorrhagia, sterility, frequent
abortion, constipation, painful or difficult defecation, dysuria,
polyuria, tenesmus, etc. Among the symptoms which refer to the nervous
system are--neuralgia in various parts, paralysis, hysteria, nervous
dyspepsia, anæmia, chlorosis, spinal irritation, etc.

The final diagnosis must always depend upon direct examination of the
uterus itself. The first division of the above group of symptoms is not
likely to escape notice as indicative of displacement, but the nervous
symptoms are constantly disregarded or treated without reference to
their possible pelvic origin. The frequent dependence of these nervous
phenomena upon displacement is proved by their persistence in many
cases after ordinary treatment, by their prompt disappearance upon
permanent replacement and retention of the uterus by mechanical means,
and by their equally prompt recurrence upon removal of the support. The
presence, therefore, of the second division of the group or any part
thereof, even though the first be absent, will justify, may even
necessitate, a careful investigation into the state of the pelvic
organs.

That examination which results only in giving the name to a special
variety of displacement, and does not include the complicating lesions,
would not furnish a sufficient guide to the therapeutic indications,
and is therefore inadequate. The successful treatment, for instance, of
an anteflexion dependent upon inflammation of the utero-sacral
ligaments must include the removal of the inflammation.

An important prerequisite to examination is the absence of material in
the rectum and bladder. The full rectum distorts the vaginal walls,
deprives the examiner of the space necessary for the introduction of
the speculum, and throws the uterus out of its accustomed position.
Much more troublesome is the presence of even a small quantity of urine
in {152} the bladder, because it causes the patient to render the
abdominal muscles tense when the hand is placed over the lower portion
of the abdomen for bimanual palpation, and makes it impossible to
engage the uterus between the hand and the examining finger. The
distended bladder by pushing the uterus upward and backward makes
bimanual palpation almost useless. It is not surprising that
conflicting opinions are common, when one day the patient is examined
with rectum and bladder full, another day empty; one day in the dorsal,
another in Sims's or the knee-chest position; one day with the
cylindrical or bivalve speculum, another day with Sims's or Simon's.

For digital examination the dorsal position is preferred: the patient
should be drawn close to the edge of a bed, or preferably a table, the
thighs being flexed, the feet about fifteen inches apart, and the knees
widely separated. The examiner should stand facing the patient, never
at the side. The index finger of the left[6] hand, lubricated with
vaseline or oil, then slowly advances over the perineum into the
vagina, noting the condition of the perineum, the presence or absence
of cicatrices or of sub-involution of the vagina or perineum, the
capacity of the vagina, the condition, size, and direction of the
cervix, its distance from the sacrum and vulva, its mobility or
fixation. Now, for the first time, the right hand is pressed well down
behind the pubes, and the uterus is engaged between it and the
examining finger. (See Figs. 16 and 17.) In this way the examiner may
determine more accurately the position, location, and size of the
entire organ; may detect the possible presence of complicating tumors,
both inflammatory and non-inflammatory; may also note, if possible, the
location and condition of the ovaries, which, especially in the
posterior displacements, are liable to be prolapsed and excessively
sensitive, and to constitute, therefore, a most intractable
complication. The index finger sweeps around the cervix in search of
tender places which may be the result of former cellulitis or the
expression of some neurosis. Above all, the digital examination
requires a light, gentle, delicate touch.

[Footnote 6: The left-hand method of examination is incomparably
superior to the right. The palmar surface of the index finger is more
easily directed toward the left side of the pelvis, which is especially
subject to disease. Its tactile sense is more acute and more easily
educated. The stronger right hand should be free to palpate the surface
of the abdomen in conjoined manipulation.]

In exploring the uterine cavity to learn its position the fine
silver-wire probe of Emmet--not the sound--should be used. The uterus,
if freely movable, is liable to be thrown out of its accustomed
position by the heavier, unyielding sound. The sound also causes much
more pain and exposes the patient to great danger of cellulitis. The
frequent lighting and relighting of pelvic inflammation by injudicious
slight manipulations of the uterus doubtless led Emmet to the utterance
of a prophecy which ought to become classical: "A great advance in the
treatment of the diseases of women will be made whenever practitioners
become so impressed with the significance of cellulitis as to apprehend
its existence in every case. The successful operator in this branch of
surgery will always be on the lookout for the existence of cellulitis,
and take measures to guard against its occurrence."

When the probe or the sound is used without the speculum, the patient
{153} should be on the back and the index finger of the left hand
should be used as a guide. The bivalve and cylindrical specula are
almost useless in explorations of the interior of the uterus. The
exploration is most effectually and gently made with Sims's speculum,
the patient being in the left latero-prone position. In some cases the
probe cannot be passed by any other method.


Ascent of the Uterus.

This mal-location may result from traction above or from pressure
below. The organ may be drawn upward and backward by shortening of the
utero-sacral ligaments, which results from inflammation and which
usually induces a troublesome form of anteflexion. The enlarged
pregnant uterus sometimes becomes attached by adhesive inflammation to
a portion of the peritoneum in one of the higher zones of the pelvis or
in the abdomen, and the organ may consequently remain fixed in its
elevated position after involution. A tumor connected with the uterus
or its appendages which has grown too large to be retained in the
pelvis may, upon rising into the abdomen, drag the uterus with it.
Pressure below may come from excessive distension of the rectum or
bladder, or from a large accumulation of menstrual fluid in the vagina,
or from a tumor originating in any portion of the pelvis below the
level of the uterus. In diagnosis, prognosis, and treatment this
displacement is wholly subordinate to the more significant lesions of
which it is only the incidental result.


Retro-location of the Uterus.

The uterus may be forced back into a post-normal location by the
presence of a tumor in front or by the distended bladder, or it may be
drawn back and fixed by peritoneal adhesions. Retro-location is liable
to induce vesical irritation by putting the vesico-vaginal wall on the
stretch and thereby dragging on the neck of the bladder. This
intractable symptom is sometimes relieved by Emmet's buttonhole
operation of urethrotomy, for an account of which see section on
Anteflexion. This operation would obviously be applicable also for the
relief of the same symptom when caused by ascent of the uterus.


Ante-location of the Uterus.

The causes of this displacement are similar to those which produce
retro-location; they are--distension of the rectum, post-uterine
hæmatocele, post-uterine tumors, and peritoneal adhesions.
Ante-location often causes vesical irritation, consequent upon the
invasion by the uterus of that space which belongs to the bladder.


Lateral Locations of the Uterus.

The entire uterus is often displaced to the right or the left by a
tumor or by an inflammatory exudate. The latter occurs as a product of
{154} cellulitis, usually in the left broad ligament, and crowds the
organ toward the opposite side of the pelvis. After resolution the
ligament, shortened by inflammatory contraction, draws the uterus to
the affected side and fixes it there. Lateral displacement from this
cause often accompanies laceration of the cervix, the cellulitis having
occurred on the side corresponding to the laceration.


Descent or Prolapse of the Uterus.

The nature of this displacement is clearly indicated by its name. It is
convenient to distinguish three degrees of descent: In the first the
organ is displaced downward and forward until sufficient space has been
gained between the cervix and the sacrum to permit the body to turn
back into extreme retroversion; in the second the cervix descends to
the vulva; in the third the uterus protrudes partially or wholly
through the vulva, constituting a condition sometimes called
procidentia.

ETIOLOGY AND CLINICAL HISTORY.--Descent may be the result of any or all
of the following causes: I. Pressure from above; II. Weakening of the
supports; III. Increased weight of the uterus; IV. Traction from below.
Either of the above conditions being the primary cause, the others
singly or combined may result.

I. Pressure from above may depend upon the presence of a pelvic or
abdominal tumor, ascites, fecal accumulations, tight or heavy clothing,
etc.

II. The uterine supports may be weakened and relaxed in consequence of
subinvolution, senile atrophy, abnormally large pelvis, increased
weight of the uterus, pressure from above, traction from below, etc.

III. Increased weight of the uterus may be caused by congestion,
subinvolution, hypertrophy, hyperplasia, pregnancy, fluid in the
endometrium, uterine tumors, etc.

IV. Traction from below may be due to vaginal cicatrices, abnormally
short vagina, falling of the pelvic floor, etc.

Obviously, descent of the vesico- and recto-vaginal walls, or, more
comprehensively, the sacral and pubic segments of the pelvic floor,
involves also concurrent descent of the uterus. Descent of the vagina,
therefore, must be studied in connection with the descent of the
uterus. Excessive descent of the vaginal walls usually originates with
parturition.

In labor the anterior wall of the vagina is so depressed, stretched,
and shortened by the advancing head that during and after the second
stage the anterior lip of the cervix may be seen behind the urethra. If
the puerperium progress favorably, with prompt involution of the
uterus, vagina, perineum, and peritoneum, the relaxation of the
vesico-vaginal wall and of the utero-sacral supports disappears and the
uterus resumes its normal multiparous location and position.[7] But if
the enlarged uterus remain in the long axis of the vagina, with its
fundus incarcerated in the hollow of the sacrum between the
utero-sacral ligaments, and with its sacral supports so stretched that
they cannot recover their contractile power, and with involution of all
the pelvic organs arrested, the descent {155} may not only persist, but
may even progress with constantly increasing cystocele to the third
degree of prolapse. The downward influence of the above conditions may
be materially increased by rupture of the perineum, and consequent
prolapse of the recto-vaginal wall into a pouch called rectocele.

[Footnote 7: The anteflexion of the multiparous uterus is less than
that of the virgin.]

In the great majority of cases of complete prolapse the posterior
vaginal wall in its descent is peeled off from the rectum, leaving the
latter in its normal position. In rare instances the lower portion of
the rectum is also found to have extruded in extreme rectocele, making
a pouch below and in front of the anus, where fecal matter may
accumulate and remain in hard scybalæ.

Obviously, complete prolapse of the uterus is only an incident to the
prolapse of the pelvic floor. The whole mechanism is in all respects
analogous to that of hernia. The extruded mass drags after it a
peritoneal sac, which, hernia-like, contains small intestine. This sac
forces its way to the pelvic outlet and extrudes through the vulva,
having the inverted vagina for its covering.

[Illustration: FIG. 3. First Degree of Prolapse of the Post-partum
Uterus. The posterior vaginal wall has been changed from its normal
forward direction to a vertical direction by perineal rupture and
anterior displacement of the cervix; the vesico-vaginal wall descends
in cystocele, becomes hypertrophied, and drags the heavy uterus after
it. The descending uterus carries with it a reduplication of the
vaginal walls.]

In descent of the first degree the location of the uterus is either
changed to a lower level, the position remaining normal, or, as is more
common, the cervix having moved nearer to the symphysis and the organ
turns back into retroversion. In a given case suppose the vaginal walls
from some cause to have become relaxed and to have settled {156} to a
lower level in the pelvis. As an associated fact the uterus to which
these walls are attached must then also occupy a place correspondingly
nearer to the vulva--_i.e._ the location of the uterus has changed, so
that space enough intervenes between it and the hollow of the sacrum
for the former to turn back into the position of retroversion or
retroflexion. If, on the contrary, the descending uterus still
maintains its normal anteversion and anteflexion, it must occupy space
which belongs to the bladder. The vesical irritation consequent upon
this mal-location has generally been ascribed to the anteversion and
anteflexion, which are therefore oftentimes wrongly pronounced
pathological. The prompt relief which follows permanent replacement of
the organ in the normal location, even though in so doing its
anteposition be exaggerated, proves that the symptoms depend upon the
mal-location, not upon the anteposition. The importance of a clear
distinction, therefore, between location and position becomes apparent.
Vesical irritation, moreover, is sometimes caused by the dragging of
the uterus upon the neck of the bladder. This traction occurs not only
in ascent, but also when the organ descends below a certain level.

[Illustration: FIG. 4. Showing Extreme Descent of the Uterus and of the
Pelvic Floor, and the Hernial Character of the Lesion.]

In the foregoing paragraphs traction due to the falling pelvic floor
has been discussed as a cause of descent. The impairment of the uterine
supports may, however, be such that instead of falling and dragging the
uterus after them, they simply permit it to descend along the vaginal
canal by the force of its own weight, and to carry with it the
reduplicated vaginal walls. This influence is generally enforced by the
increased weight of the diseased organ. The vagina more readily becomes
a track for the descending uterus when from any cause the normal
forward direction of the vaginal canal changes toward the vertical:
this change may occur either as the result of a forward displacement of
its upper extremity, involving anteposition of the cervix, or of a
retro-displacement of its {157} lower extremity in consequence of
rupture or subinvolution of the perineum. (See Fig. 3.) Descent in the
track of the vagina is obviously combined with some degree of
retroversion, because the axes of the uterus and vagina then
correspond.

The PATHOLOGICAL ANATOMY may involve all the displaced organs. The
circulation throughout the pelvis is impeded by traction upon the
vessels, and the entire pelvic contents therefore become the subject of
venous congestion, with consequences disastrous to local innervation
and nutrition.

The ovaries may suffer concurrent displacement, with resulting
inflammatory and cystic enlargement. The peritoneum which enters into
the formation of the uterine ligaments and of the pelvic floor is
dragged along with the uterus.

The vagina is hypertrophied and swollen. Its mucous membrane becomes
the seat of acute vaginitis and chronic catarrh. In the third degree of
descent the exposed vagina, no longer lubricated by the normal
secretions of the uterus, becomes dry, parchment-like, oedematous,
eroded, and ulcerated. Sometimes the cul-de-sac of Douglas is distended
by downward pressure of the intestines, by a small tumor, or by ascitic
fluid, and a consequent hernial sac may protrude into the vagina
through some portion of the posterior vaginal fornix. The anterior
fornix is subject to a similar accident. These conditions are
designated enterocele vaginalis, anterior and posterior.

The rectum and bladder are subject to inflammation and chronic catarrh,
and the bladder especially to concurrent descent. The uterus may be
enlarged from any one or all of a variety of causes--congestion,
subinvolution, hypertrophy, and hyperplasia. Its cervix is often the
seat of extreme erosion or so-called ulceration. The endometrium, in
order to relieve the organ of its surplus blood, gives forth an
excessive secretion of mucus, which upon being increased in quantity
becomes vitiated in quality. This is termed uterine catarrh. The
enlargement of the uterus often pertains more to the cervix than to the
body, especially in prolapse of the second and third degrees. An
explanation of this may be found in Figs. 5 and 6.

[Illustration: FIG. 5. Descent of the Virgin Uterus into the Vaginal
Canal, showing the Reduplicated Vaginal Walls. The utero-vaginal
attachment, points _X_ and _Z_, appears to be at _X'_ and _Z'_. The
apparent increase of length in the vaginal portion of the cervix due to
the reduplication is measured by the distance from _X_ and _Z_ to _X'_
and _Z'_.]

[Illustration: FIG. 6. Descent of the Uterus, showing Excessive
Circular Enlargement of the Lacerated Cervix, consequent upon
Reduplication of the Vaginal Walls and Out-rolling of Intracervical
Tissues. The divided fragments of the os externum are at _a_ and _b_.
The curved lines forming the angles 1, 2, 3, 4, and 5 indicate the
gradual process of the eversion. The angle of the laceration at point 1
has been forced by the swelling and out-rolling of the mucous and
submucous tissues of the cervix to point 5. The apparent os externum is
at point 5. The utero-vaginal attachment _X_ and _Z_ seems to be at
_X'_ and _Z'_. The vaginal portion of the cervix therefore appears much
larger and longer than it actually is.]

Apparent elongation and disproportionate circular enlargement of the
cervix are conditions which almost every standard author wrongly calls
hypertrophic elongation and circular hypertrophy. The question of
elongation is easily settled by placing the patient in the knee-chest
position. Then the uterus by its own weight falls toward the diaphragm,
the vagina unfolds, and the apparent utero-vaginal attachment _X'_ _Z'_
(Figs. 5 and 6) disappears, disclosing the actual attachment, _X_ _Z_.
Further, the point of the sound, passed into the bladder while the
{158} cervix is exposed by Sims's speculum, may be placed against the
anterior wall of the cervix at _Z_, which would be impossible if the
attachment were at _Z'_.

The comparatively small amount of hypertrophy in disproportionate
circular enlargement is proved by the operation of trachelorraphy or by
bringing the points _a_ and _b_ (Fig. 6) together with uterine
tenacula, the organ being exposed by Sims's speculum. Then the
out-rolled intracervical mucous tissues are rolled back, the proper
diameter of the cervix is restored, and a laceration on one or both
sides, extending past the vaginal attachment, becomes apparent.

Hypertrophy or hyperplasia usually causes a nearly symmetrical
enlargement of the entire organ. At any rate, those cases in which the
reduplication of the vaginal walls does not almost entirely explain the
great elongation so called, or in which great disproportionate circular
enlargement has not been caused by laceration of the cervix, are the
rare exceptions. The great merit of having secured general assent to
the foregoing proposition, and of having given to the subject a new and
right direction, must be accorded to Emmet. The cervix now is seldom
amputated except for malignant disease.

Congestion of the uterus consequent upon obstruction in the stretched
and displaced veins is often so extreme as to induce a state analogous
to erection. Measurements by the probe just before and a few minutes
after replacement generally show an appreciable decrease in the length
of the uterine canal. If the prolapse has been of the third degree, the
difference may amount to one or even two inches. It is important not to
confound the enlargement of congestion with increase in the solid
constituents of the organ.

SYMPTOMS AND COURSE.--A dragging sensation and pelvic and abdominal
pain are generally present. Rectocele and cystocele and rectal and
vesical catarrh often cause painful and severe functional disturbances
of the rectum and bladder. In descent of the third degree excoriations
of the exposed vagina and cervix sometimes cause extreme suffering. The
course is ordinarily chronic, but attacks of acute vaginitis and pelvic
peritonitis are not uncommon. The peritonitis sometimes effects a
spontaneous cure by peritoneal adhesions which fasten the uterus in an
elevated position and hold it permanently. The symptoms of descent may
be so severe as to necessitate absolute rest in bed. In other cases
they are often attended with very little discomfort.

{159} DIAGNOSIS is by inspection, palpation, and exploration. The
prolapsed uterus may be distinguished from cystocele, rectocele,
inverted uterus, and fibroid tumor by the presence of the os externum.
The sound may be passed through the urethra into the cystocele, and the
finger through the anus into the rectocele. The length of the uterus
may be determined by the sound, the size, shape, position, extent of
descent, and difficulty of replacement by conjoined manipulation.

PROPHYLAXIS.--This requires such measures during labor as may be
necessary to prevent long and powerful pressure upon the pelvic floor.
After labor any injury to the perineum should be promptly repaired. The
vagina should be kept clean by irrigations. The urine, if necessary,
should be regularly drawn and the bowels moved daily without straining.
If conditions be present likely to induce subinvolution--such, for
example, as pelvic inflammation or laceration of the cervix--they
should receive treatment at the proper time. Undue relaxation of the
pelvic floor necessitates a more prolonged rest in bed, the use of
astringent douches, and the application of a pessary when the patient
resumes the upright position.

TREATMENT.--The first indication is replacement, which in the first and
second degree of descent is not difficult unless the uterus be held
down by cicatrices or by a tumor. Complicating pelvic cellulitis and
peritonitis may render replacement dangerous or impossible, and may for
a time contraindicate all direct treatment. Replacement of the organs
from the third degree of prolapse is accomplished in the inverse order
of their descent: first, the posterior vaginal wall, then the uterus,
and last the anterior vaginal wall. Not infrequently the completely
prolapsed uterus and pelvic floor, hernia-like, become strangulated.
Then taxis will usually suffice if supplemented by hot applications,
elastic pressure, anodynes, and the knee-chest position. Should these
fail anæsthesia may be required.

Undue pressure from above should if possible be removed. The clothing
should be loose, and the weight of the skirts supported from the
shoulders either by straps or preferably by buttoning them upon a waist
made for the purpose. This waist is a good substitute for the corset,
which under all circumstances and in all its forms is injurious.
Increased uterine weight from subinvolution or congestion is to be
overcome by appropriate means. Enlargement of the uterus when due to
hypertrophy or hyperplasia is generally incurable. Amputation of the
cervix for what was formerly considered circular hypertrophy and
hypertrophic elongation is now seldom or never required for the purpose
of decreasing uterine weight. Amputation except for malignant disease
has given place to the operation of trachelorraphy. Tumors exerting
pressure above or traction below should if possible be removed.
Regulation of the bowels and general tonics are usually necessary. The
knee-chest position assumed several times a day causes the uterus to
gravitate toward the diaphragm, and thereby gives temporary rest to the
overburdened supports. While in this position the patient should
separate the labia, so that the air may rush in and the vagina become
expanded. The measures enumerated above, together with rigid care of
the diet and of such other hygienic requirements as the individual case
may demand, are essential as adjuvants to the more special treatment
which almost every case requires.

{160} In exceptional cases of sudden descent, even to the third degree,
replacement alone is sometimes followed by permanent relief; but if the
descent has been gradual it always recurs immediately after
replacement. Measures are therefore required for the maintenance of the
uterus in its normal location and position. This indication is
fulfilled by pessaries and by operations.

Pessaries.--The function of the pessary is not only to maintain the
uterus on the health level in its normal location, but also, if
possible, in its normal position, which requires the cervix to be about
one inch from the sacrum. The cervix being thus placed, the organ
cannot turn back into retroversion, because in so doing the fundus
would encounter the sacrum. The direction of least resistance would
then be forward into the normal anterior position. The application of
the pessary is then based upon the general proposition that if the
cervix be normally placed the body of the uterus will in the absence of
complications take care of itself. Since the vagina at its upper
extremity is attached to the cervix, displacement of the latter is
clearly impossible if the upper extremity of the vagina be sustained in
its normal location. The pessary restores and maintains the relations
of the relaxed vaginal walls by crowding the posterior vaginal
cul-de-sac backward into the hollow of the sacrum. It thereby also
holds the attached cervix within a proper distance of the sacrum. The
Hodge pessary or some modifications thereof fulfils this purpose in
ordinary cases more satisfactorily than any other.

[Illustration: FIG. 7. The Emmet Curves.]

[Illustration: FIG. 8. The Albert Smith Curves.]

The curves of the pessary demand careful attention in its application.
When the uterus is below the normal level, the broad ligaments are
necessarily rendered more tense than natural, and the blood-vessels,
more especially the veins, which are looped one upon the other, and
which traverse these ligaments to and from the uterus, are made to
collapse. This causes venous congestion and consequent increase in
weight of the uterus--a condition favorable to malposition, uterine
catarrh, and pathological changes in structure. A pessary which will
raise the uterus to the health level clearly fulfils an indication. A
pessary which raises it above the health level renders the broad
ligaments tense and reproduces a condition which it was designed to
relieve. Maintenance of the uterus upon the health level depends
largely upon the curves of the pessary. The accompanying cuts
illustrate the shape and curve of the Hodge pessary as modified by
Emmet and Albert Smith. Fig. 7 represents the curve of Emmet, and Fig.
8 that of Albert Smith. For convenience let us characterize that curve
which rests in the posterior vaginal cul-de-sac as the uterine curve,
and that which occupies that part of the vagina {161} adjacent to the
pubis the pubic curve. The acuteness and length of the uterine curve
determine the height to which the pessary will lift the uterus. The
longer and more acute the curve, the higher the uterus will be lifted,
and vice versâ. The smaller curve of the Emmet modification will answer
the average indication more nearly than the sharper curve of the Albert
Smith modification, which may lift the uterus too high. The pubic
should generally be proportioned to the uterine curve; that is, the
greater the uterine, the greater the pubic curve. A pessary properly
adjusted in all other respects may, by pressure upon the urethra and
neck of the bladder, create vesical tenesmus and urethral irritation.
This calls for increase in the pubic curve. The pubic curve may,
however, be so great that the lower part of the pessary occupies the
centre of the vulva, where it may create irritation. For this condition
lessening of the pubic curve is the remedy. The pessary should not be
so wide as to distend the vagina. Its length should be measured by the
distance from the lower extremity of the symphysis pubis to the
posterior vaginal cul-de-sac, less the thickness of the finger. If
properly adjusted it should sustain the pelvic floor in its normal
relations and the uterus in stable equilibrium.

The uterus in the first and second degrees of descent is usually either
retroverted or retroflexed. The reader is therefore referred to the
remarks on the application of pessaries in the treatment of these
displacements.

In advance prolapse dependent upon extensive injuries to the perineum
and other parts of the pelvic floor, and usually associated with
extreme subinvolution of all the pelvic organs, the axis of the vagina
is often changed from its forward oblique to the vertical direction.
(See Fig. 3.) The downward traction of the prolapsing cystocele and
rectocele upon the fornix of the vagina may then be so great that the
pessary is inadequate to maintain in place the upper extremity of the
vagina. The cervix then moves forward, the corpus turns back, and the
whole uterus easily descends in a vertical direction along the
prolapsing walls of the vagina to the second or third degree of
prolapse. In this condition pessaries which disappear within the vagina
are liable to be forced out with the prolapsing pelvic floor, or if
retained seldom maintain the uterus in position. In such cases the
various cup pessaries which are supplied with external attachments and
abdominal belts are often used, but they are inadequate, because they
either so fix the uterus as to prevent its normal movements, or they
hold it in such unstable equilibrium that it may assume any one of the
various malpositions, anterior, posterior, or lateral; and they are
open to the further serious objection of constantly reminding the
patient of their presence. As an expedient the uterus may sometimes be
held within the pelvis by means of a large Albert Smith pessary with
extreme uterine and pubic curves. The rational treatment, however,
requires first an operation on the anterior vaginal wall to restore the
fornix of the vagina to its normal place in the hollow of the sacrum,
and with it the attached cervix; and second, an operation at the
vaginal outlet to bring the posterior wall in contact with the
anterior, and thereby to restore the lower extremity of the vagina to
its normal place under the pubis.

ANTERIOR ELYTRORRHAPHY.--Numerous operations on the vaginal {162} walls
have been devised for the purpose of narrowing the vagina, and thus
preventing descent along the vaginal canal, but they are temporary in
their results, because, as long as the direction of the vagina remains
vertical, its walls again become dilated by the prolapsing uterus and
the former condition is re-established. The operation to be effective
is performed as follows: A Sims's speculum of long blade, perforated at
its extreme end, to which the cervix has been attached by a piece of
silver wire, passing through the perforation and the posterior lip, is
introduced, the patient being in Sims's position. The cervix is thereby
drawn by the point of the speculum far back into the hollow of the
sacrum. The author finds this preferable to the method described by
Emmet, who has the cervix held back by a sponge probang in the hand of
an assistant. The space in the anterior part of the pelvis is now so
increased that the uterus readily falls forward into decided
anteversion. While the uterus is thus held in position by its
attachment to the blade of the speculum, the operator with two uterine
tenacula finds in the loose vaginal tissue on either side of the cervix
two points which can be brought together in front of the cervix. Then
at each of the two lateral points a surface is denuded with the curved
scissors about one-half inch square, and in front of the cervix a
surface an inch long by half an inch wide across the anterior vaginal
wall close to the uterine attachment. A No. 26 silver-wire suture is
then passed, as shown in Fig. 9, and twisted as shown in Fig. 10, so as
to secure the lateral denuded surfaces in contact with the larger
surface in front of the cervix.

[Illustration: FIG. 9. The First Suture before Twisting in Emmet's
Operation for Procidentia (Emmet).]

[Illustration: FIG. 10. Folds on the Anterior Vaginal Wall formed after
Twisting the First Suture (Emmet).]

Inasmuch as the operation often fails at the point of the first suture,
the author has usually introduced two or three of this kind instead of
one. Two longitudinal folds are now formed on the anterior vaginal
wall, which serve as guides for denuding and turning in the remaining
redundant tissue by a line of sutures, which should extend forward
along the centre of the vesico-vaginal wall until the folds are lost in
the vaginal surface near the neck of the bladder. Sometimes the
redundant tissue about the urethra cannot be disposed of by turning it
in from side to side. Then it is desirable to make a crescentic
denudation across the lower portion of the vagina, its concavity being
on the uterine side, and {163} to unite the margins below to those
above by means of a curved line of sutures. The completed operation is
shown in Fig. 11.

[Illustration: FIG. 11. Emmet's Operation for Procidentia and
Urethrocele completed. Sims's Speculum, Left Latero-prone Position
(Emmet).]

The after-treatment requires the self-retaining Sims's sigmoid catheter
in the urethra for a week or frequent catheterization, absolute rest in
bed, hot-water vaginal douches, regulation of the bowels, and the
removal of the sutures on the twelfth day. After the completion of the
operation the cervix is maintained near the hollow of the sacrum, and
the organ remains normally anteverted and anteflexed, making an acute
angle with the vesico-vaginal wall, which has now been restored to its
normal direction and length. Unfortunately, it is not unusual to
abandon the patient after this operation, in the vain hope that the
uterus and anterior vaginal wall will maintain their normal relations
without the support of the perineum and posterior vaginal wall. This is
a great mistake, because the cystocele and procidentia almost always
completely reappear within a few months. Anterior elytrorrhaphy,
therefore, is simply one of the steps in the treatment.

PERINEORRHAPHY.--This is the name usually applied to the repair of the
ruptured perineum, but the scope of the operation has been extended to
include also the surgical treatment of rectocele and relaxation of the
posterior vaginal wall. The most scientific operation yet devised is
the one proposed by Emmet,[8] which is performed as follows: The
patient being etherized and in the lithotomy position, the operator
seizes with a tenaculum the crest of the rectocele or posterior vaginal
wall at a point which can be drawn forward without undue
traction--point _a_. With another tenaculum the lowest caruncle or
vestige of the hymen (point _b_), {164} and with another the posterior
commissure of the vulva (point _c_), are hooked up. The triangle
included between these points defines one-half of the surface to be
denuded. The three tenacula are now placed in the hands of assistants,
the sides of the triangle are made tense by traction, and the included
surface denuded. The tenaculum at _c_ is then removed, and the middle
point of the line _a b_ is caught and drawn toward the interior of the
vagina in the direction of the vaginal sulcus on that side, and the
sutures are introduced, as in Fig. 13. The same thing is then repeated
on the other side, and the sutures are all tightened, forming a line of
union running back into each sulcus, as shown in Fig. 14.

[Footnote 8: _Trans. Am. Gynæcological Society_, 1883; _Principles and
Practice of Gynecology_, 3d ed.]

[Illustration: FIG. 12. _a_ is at the crest of the rectocele; _b_ at
the caruncle just within the labium; and _c_ at the posterior
commissure. The cut represents that half of the surface to be denuded
which is on the operator's right. The dotted lines represent the other
half, on the left.]

[Illustration: FIG. 13. The Sutures in Place. When secured they will
unite _a d_ with _b d_, and lift the perineum up in contact with the
anterior vaginal wall.]

[Illustration: FIG. 14. All the Vaginal Sutures Twisted. One suture,
including the crest of the rectocele and the labium majus on either
side, and three superficial external sutures, are yet to be secured.
The lines _a d_ and _d b_, Fig. 13, have been brought into coincidence
by means of the sutures, and now form the line of union _d b_. The
tissues between the lines _a c_ and _c b_, Fig. 13, have been so lifted
up and are so held under the line of union _d b_ that the line _c b_,
Fig. 13, has been reduced to _c b_, Fig. 14, which makes the external
portion of the wound insignificant in extent.]

The essential part of the operation inside the vagina almost always
succeeds, but the external part of the rupture at the posterior
commissure often fails to unite; furthermore, the operation as
described by Emmet does not overcome the patulous condition of the
introitus vaginæ in case of great relaxation of the vagina. The author
has sought to obviate the first of these difficulties by the use of
deep silver sutures instead of the superficial ones described by Emmet.
They should be introduced before tightening the vaginal sutures, and
should be passed far around in the posterior vaginal wall, their points
of entrance and exit being the same as for the three lower unsecured
superficial external sutures in Fig. 14. The second difficulty may be
overcome by further denuding a triangular surface in the vaginal sulcus
on each side, the base of the triangle corresponding {165} to the line
_a b_, Fig. 12, and its apex being in the vaginal sulcus at a distance
corresponding to the degree of relaxation. This increases the length of
the lines of union running into the sulci represented by _d b_ and
_e f_, Fig. 14. In the vaginal portion of the wound silk or catgut is
preferable to silver, the latter being difficult to remove.

Emmet is entitled to great credit for having given to the profession an
operation which brings the posterior vaginal walls up against the
anterior more perfectly than any other, and which, being mostly inside
of the vagina, is therefore followed by very little of the pain during
convalescence which formerly rendered perineorrhaphy one of the most
trying operations in gynecology. The operation furthermore has
demonstrated the former teachings relative to the direction of perineal
rupture[9] and the tissues involved to be incorrect, or at least
inadequate.

[Footnote 9: At the meeting of the American Medical Association in
June, 1883, the author presented a paper describing the transverse
laceration of the perineum and its operative treatment, which was
published with illustrations in the transactions by the journal of the
Association, Dec. 22, 1883. This communication referred only to the
recent rupture and the immediate operation.]


Retroversion.

Retroversion is that position of the uterus in which the fundus is
posterior to the axis of the pelvic inlet. If the cervix be in its
normal place near the sacrum, retroversion is scarcely possible,
because it is prevented by the proximity of the over-arching sacrum.
(See Fig. 2.) The first degree of prolapse must therefore precede any
considerable backward turning of the uterus. When the cervix has been
displaced downward {166} and forward so far that its distance from the
sacrum is equal to or greater than the length of the uterus,
retroversion to any extent becomes possible. (See Figs. 3 and 16.)

ETIOLOGY AND HISTORY.--From the above it follows that the causes of
commencing retroversion must be identical with the causes of the first
degree of prolapse. After the puerperium the relaxation of the supports
and the weight of the organ may persist, and spontaneous replacement
may be prevented by the pressure and weight of the intestines upon the
anterior surface. Every act of defecation forces the cervix forward and
downward, and the uterus, being in the axis of the vagina, and having
therefore little support below, must depend upon the subinvoluted
peritoneal suspensory ligaments and pelvic fascia, which are
inadequate. This condition is very often induced by abortions, with
resulting increased weight and relaxation of the vaginal walls. Local
peritonitis and cellulitis may permanently fix the corpus in its
retroverted position by cicatricial bands and adhesions.

SYMPTOMS AND COURSE.--The displacement and its complications usually
cause bearing-down sensations, a feeling of heaviness in the pelvis,
exhaustion upon walking and standing, especially the latter, and
constipation. After the puerperium the extreme engorgement of the
pelvic organs often produces uterine hemorrhage, which should not be
confounded with the returning menstruation. Especially after abortion
the hemorrhage often persists for a long time unless cured by
treatment. Gradual or sudden replacement may occur spontaneously, or
the causes may continue active, and even be enforced by cystocele and
rectocele. The displacement may also be complicated by disease and
displacement of the ovaries. Organic disease of the uterine walls may
induce a superadded retroflexion. The heavy organ may descend along the
relaxed subinvoluted vaginal walls even to complete procidentia.

DIAGNOSIS AND PROGNOSIS.--The symptoms outlined in the preceding
paragraph indicate the probability of displacement, but the diagnosis
depends upon direct examination of the uterus. Conjoined manipulation
and the probe will usually show the retroverted organ with the cervix
displaced toward the pubes and with the corpus in the hollow of the
sacrum. The introduction of the probe is contraindicated by cellulitis
and peritonitis. In certain cases of anteflexion, as represented in
Fig. 23, the cervix is bent forward in the vaginal axis as in
retroversion. The condition is in reality one of retroversion of the
cervix with high anteflexion of the corpus, which may usually be
detected by careful conjoined examination. The prognosis with treatment
is generally favorable both for speedy relief and ultimate recovery.

TREATMENT.--As in descent, the treatment consists in removing
cellulitis, peritonitis, and other complications, in the use of
pessaries, and in operations on the anterior and posterior vaginal
walls if needed. Inasmuch as the treatment corresponds to that of
retroflexion, it will be presented under that subject.


Retroflexion.

ETIOLOGY AND PATHOLOGY.--Retroflexion is that displacement in which the
organ is bent backward upon itself. It usually results from, {167} and
is associated with, retroversion, but for convenience the double
displacement will be termed retroflexion. It may be caused by the great
weight of the corpus, the soft flexible state of the uterine walls
during and after involution, intra-abdominal forces, downward pressure
during defecation, tight clothing, and not commonly by the obstetric
bandage.

The ovaries, unless fixed elsewhere by adhesions, are displaced with,
and held down on either side of, the corpus, sometimes enlarged from
inflammation, often adherent, and always extremely sensitive. Chronic
metritis, cellulitis, and peritonitis, with adhesions more or less
firm, are usually present, and not infrequently as the result of
gonorrhoea, abortion, or injudicious treatment. Peritoneal adhesions
between the corpus and the cul-de-sac of Douglas sometimes make
replacement impossible. In rare cases the displacement is congenital.

[Illustration: FIG. 15. Extreme Retroflexion, with Hypertrophy of the
Corpus, which impinges upon the rectum and compresses the recto-vaginal
wall.]

SYMPTOMS AND COURSE.--Among the most pronounced symptoms are profuse
uterine catarrh, menstrual disorders, sterility, abortion, weakness,
pain in the back, painful defecation, rectal tenesmus, the symptoms of
pelvic inflammation, neurasthenia, and other nervous symptoms. The
uterine catarrh is due to an effort on the part of the engorged pelvic
organs to relieve themselves by an exaggerated secretion of mucus from
the uterus, which upon being increased in quantity becomes vitiated in
quality, and therefore pathological. Menorrhagia and abortion may also
result from congestion. Dysmenorrhoea and sterility result from the
{168} general anæmic condition and from the inflammatory complications,
and from the obstruction in the uterine canal or in the blood-vessels
at the angle of flexure. (See Pathology of Anteflexion.) The rectal
symptoms are caused by the pressure of the corpus uteri upon the
rectum, which gives the sensation to the patient of an overloaded
bowel.

Should pregnancy occur, the rapid growth of the uterus may induce
spontaneous reposition at about the fourth month, when the fundus rises
out of the pelvis, but if the corpus be incarcerated under the sacral
promontory from adhesions or from any other cause, the uterus will,
unless manually replaced, relieve itself by abortion.

Abdominal pains, nervous dyspepsia, and neuralgia in distant parts of
the body are often present; indeed, the nervous symptoms may be of the
most exaggerated character, and may comprise all that is implied by the
word hysteria in its most comprehensive signification.

DIAGNOSIS.--Digital touch discloses the cervix low in the pelvis, and
the fundus uteri is felt through the posterior vaginal wall in the
cul-de-sac of Douglas. Conjoined manipulation with the index finger of
the left hand, first in the vagina and then in the rectum, and the
right hand over the hypogastric region, will show the size, form,
consistency, and location of the uterus, the degree of the flexure, and
the difficulty of replacement. An inflammatory exudate or hæmatocele,
posterior to the uterus, or a fibroid in the posterior uterine wall,
may be mistaken for the retroflexed corpus. The probe will always
verify the diagnosis, but if there be great tenderness with fixation in
the cul-de-sac of Douglas, treatment should be directed against the
inflamed condition, and the final diagnosis made by repeated
examinations or after the disappearance of the inflammation. Great and
lasting injury is often done in the attempt to complete the diagnosis
at the first examination. The presence of a fibroid in the posterior
uterine wall with post-uterine inflammation is a serious complication
both in diagnosis and treatment. If the rectum be overloaded with fecal
matter, the diagnosis should be deferred. The displacement is
distinguished from the presence of an ovary or small ovarian tumor in
the pouch of Douglas by careful bimanual examination and by the probe.

TREATMENT OF RETROVERSION AND RETROFLEXION.--The objects of treatment
are replacement and retention of the uterus. The obstacles to
replacement are cellulitis, peritonitis, and fixation of the uterus,
and these complications often require weeks, and in severe cases
months, of treatment preparatory to replacement. Some of the general
therapeutic suggestions under the subject of descent are also
applicable to the retro-positions. Rest, massage, careful regulation of
the bowels, feeding, and general tonics are essential. For the
inflammation small blisters over the inguinal regions frequently
repeated, and the daily application of the cotton and glycerin plug to
the cervix, and dry cupping over the sacrum, are most efficacious. The
glycerin may be combined with alum, tannin, chloral hydrate, or
iodoform. Thymoline in small quantities partially destroys the
disagreeable iodoform odor. The most useful and essential topical
application is the hot-water vaginal douche, but its use will be
followed by failure and disappointment if it be applied in the ordinary
way. The following is quoted from a paper by the author which was
published in the _Chicago Medical Gazette_, Jan. 1, 1880: {169}

  "_Ordinary Method of Application_. | "_Proper Method of Application_.
                                     |
  "I. Ordinarily, the douche is      | "I. It should invariably be
  applied with the patient in the    | given with the patient lying on
  sitting posture, so that the       | the back, with the shoulders
  injected water cannot fill the     | low, the knees drawn up, and the
  vagina and bathe the cervix uteri, | hips elevated on a bed-pan, so
  but, on the contrary, returns      | that the outlet of the vagina
  along the tube of the syringe as   | may be above every other part of
  fast as it flows in.               | it. Then the vagina will be kept
                                     | continually overflowing while
                                     | the douche is being given.
                                     |
  "II. The patient is seldom         | "II. It should be given at least
  impressed with the importance of   | twice every day, morning and
  regularity in its administration.  | evening, and generally the
                                     | length of each application
                                     | should not be less than twenty
                                     | minutes.
                                     |
  "III. The temperature is           | "III. The temperature should be
  ordinarily not specified or        | as high as the patient can
  heeded.                            | endure without distress. It may
                                     | be increased from day to day,
                                     | from 100° or 105° to 115° or
                                     | 120° Fahr.
                                     |
  "IV. Ordinarily, the patient       | "IV. Its use, in the majority of
  abandons its use after a short     | cases, should be continued for
  time."                             | months at least, and sometimes
                                     | for two or three years.
                                     | Perseverance is of prime
                                     | importance."

"A satisfactory substitute for the bed-pan may be made as follows:
Place two chairs at the side of an ordinary bed with space enough
between them to admit a bucket; place a large pillow at the extreme
side of the bed nearest the chairs; spread an ordinary rubber sheet
over the pillow, so that one end of the sheet may fall into the bucket
below in the form of a trough. The douche may then be given with the
patient's hips drawn well out over the edge of the bed and resting on
the pillow, and with one foot on each chair; the water will then find
its way along the rubber trough into the bucket below." The Davidson
syringe, which has an interrupted current, is preferable to any of the
fountain syringes.

As the tenderness disappears the cotton plugs may be increased in
quantity, and thereby made to serve as temporary support for the uterus
until a more permanent pessary can be substituted. The sluggish
circulation in the pelvis and torpid condition of the bowels may be
much relieved by the daily application of the wet pack. A small flannel
sheet folded lengthwise to the width of two feet, dipped in very hot
water, and dried by passing it through a wringer, is wound about the
hips and covered by another dry one. At the end of a half hour, during
which time the patient maintains the recumbent position, the sheets are
removed. When the tenderness has been sufficiently reduced, gentle
attempts at replacement may be made every day or two by conjoined
manipulation. The patient's tolerance of manipulation may thus be
observed and the way prepared for complete replacement and permanent
retention after the subsidence of the inflammation.

In retroversion and retroflexion always replace the uterus before
adjusting the pessary, otherwise the instrument will press upon the
sensitive uterus, when one of three unfortunate results must occur: (1)
The pessary may not be tolerated on account of pain; (2) the pessary
may be forced down by pressure from above so near to the vulva that it
will fail to do the least good; (3) the uterus, finding it impossible
to hold its position against the pessary, instead of taking its proper
position will often be bent over it in exaggerated retroflexion, with
the cervix between {170} the pessary and the pubes and the body between
the pessary and the sacrum, or the whole organ may slip off to one side
of the instrument into a malposition more serious than the one for
which relief is sought. The safest and most effective method of
replacement is by conjoined manipulation, as represented in Figs. 16
and 17. The dotted lines in the former indicate the gradual elevation
of the corpus out of the hollow of the sacrum to the pelvic brim, where
it may be anteverted by the fingers of the right hand pressed well down
behind its posterior wall. During the process of anteversion the index
finger of the left hand in the anterior fornix of the vagina presses
the cervix back to its place in the hollow of the sacrum, as in Fig.
17. Efficient reposition of the uterus is very often impossible without
anæsthesia.

[Illustration: FIG. 16. Commencing Reposition of the Retroverted or
Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).]

[Illustration: FIG. 17. Completed Reposition of the Retroverted or
Retroflexed Uterus by Conjoined Manipulation (modified from Schultze).]

The replacement is not usually accomplished by drawing the fundus
forward and pushing the cervix back directly in the median line. In
most cases the fundus sweeps around the arc of a circle on the left
side of the pelvis, and the cervix on the right. This is owing to the
greater frequency of cellulitis on the left side, and consequent
shortening of the left broad ligament. After replacement the organ is
to be held in position by a suitable pessary.

Bimanual replacement has two great advantages over the more familiar
methods of the sound or repositor: first, it is more effective and more
{171} permanent; second, the lever action of the sound or repositor, by
which the operator may unwittingly use an undue and dangerous amount of
force, is avoided in the use of the hands, through which the operation
is not only constantly under his control, but also within his
appreciation.

Inasmuch as the pessary fulfils its indications by sustaining the
pelvic floor, and thereby holding the cervix in the hollow of the
sacrum, the same general principles, and in fact the same pessaries,
which are applicable to prolapse apply also to retroversion and
retroflexion. Indeed, the first step in the genesis of the
retro-positions has been shown to be prolapse. The student is therefore
referred to the general remarks on the adjustment of pessaries for
prolapse.

The operations of elytrorraphy and perineorraphy, especially the
latter, already described in the treatment of descent, are often of the
utmost importance in the treatment of the posterior displacements, and
should therefore be carefully studied in this connection.

In the adjustment of the pessary it is desirable, if possible, to avoid
direct pressure upon any part of the uterus. Pessaries designed to prop
up the body of the uterus by pressure upon the posterior wall to
correct the posterior malpositions, and upon the anterior wall to
correct the anterior malpositions, are very liable to induce metritis
and perimetritis, and are therefore generally unsafe. In certain cases,
however, the vaginal walls, {172} especially the posterior, may be so
relaxed from subinvolution and other causes that the instrument, though
very long, fails to maintain the cervix in its normal place. Under such
conditions a pessary may be required to act directly upon the uterus.
The Schultze's sleigh pessary represented in Fig. 19 fulfils this
indication. Schultze's figure-of-eight pessary, or a long Albert Smith
pessary with its uterine curve made so extreme as to bring the upper
part of the instrument in front of the cervix instead of behind,
answers the same purpose.

[Illustration: FIG. 18. Showing the Pelvic Organs sustained by the
Emmet Pessary alter reposition of the prolapsed, retroverted or
retroflexed uterus.]

Thomas's retroflexion pessary, with its bulbous upper extremity, is a
long narrow instrument of extreme uterine curve. It lifts the uterus
very high, and is specially applicable in cases of great relaxation of
the pelvic floor and of complicating prolapse of the ovaries (Fig. 21).
The bulbous portion is sometimes made of soft rubber.

A properly-adjusted pessary gives to the patient no consciousness of
its presence. If the instrument cause pain it should be removed and
search made for the tender places; it should then, if possible, be
remoulded into such shape that it will not exert pressure upon them.
Often a slight indentation at some point will enable the patient to
wear it with comfort.

Sometimes when the corpus has been firmly bound back by peritoneal
adhesions they may be broken up by very forcible conjoined manipulation
under ether, but the operation is dangerous, and should therefore be
{173} undertaken only by an expert operator. In place of this operation
Lawson Tait has proposed to open the abdomen, break the adhesions, and
stitch the fundus uteri to the abdominal wound. This operation in the
hands of such an operator as Tait is probably not more dangerous than
breaking up firm adhesions by forcible conjoined manipulation.

[Illustration: FIG. 19. Schultze's Sleigh Pessary in place, as adjusted
for prolapse, retroversion, or retroflexion with great relaxation of
the vaginal walls (after Schultze).]

In certain cases in which replacement is impracticable or impossible on
account of inflammation or adhesions a soft rubber ring may be
inserted, and will often give decided relief by lifting the uterus and
pelvic floor nearer to the health level. In the treatment of all
displacements coition should be forbidden or permitted only with great
moderation, and the pessary should be kept clean by copious daily
applications of the vaginal douche. Every three or four weeks the
instrument should be removed and the pelvic organs carefully examined.

It should be urged that no man can safely apply the pessary until he
has fully appreciated its indications and contraindications. Few
practitioners possess naturally the mechanical skill necessary to its
proper adjustment. Of this thousands of unfortunate women bear witness.
Its dangers in inefficient hands are in striking contrast with its
usefulness when judiciously employed.

Many cases of displacement, both anterior and posterior, are so
complicated by prolapsed and adherent ovaries, by advanced disease of
the ovaries and Fallopian tubes, and by peritoneal adhesions, that not
only {174} replacement, but even palliation, is impossible; then, as a
final resort, the activity of the pelvic organs, both physiologically
and pathologically, may be put at rest by the removal of the ovaries
and Fallopian tubes.

[Illustration: FIG. 20. Front View of Schultze's Figure-of-Eight
Pessary. The upper opening is intended to hold the cervix. This pessary
has the uterine and pubic curves, as in Figs. 7 and 8.]

[Illustration: FIG. 21. Thomas's Retroflexion Pessary.]

William Alexander of Liverpool has devised an ingenious operation of
shortening the round ligaments for the radical cure of descent and of
the posterior displacements. He reports twenty-two cases of the
operation in his own practice and several more in the practice of other
surgeons, with almost uniform success in completely curing the
displacements. The operation, although new, gives promise of a
brilliant and successful future.


Lateral Versions and Flexions.

The lateral malpositions which often complicate retroversion and
retroflexion are usually the result of inflammation in a broad ligament
or in the uterus itself, or in both. Their treatment is that of the
causative inflammation, and follows the general principles which have
been laid down for the treatment of other versions and flexions.


Pathological Anteversion.

Sometimes the physiological angle of flexure becomes obliterated in
consequence of chronic metritis, resulting in permanent straightening
of the uterus, and the cervix becomes elevated and fixed above, or the
corpus depressed and fixed below, the normal level. This constitutes
pathological anteversion (Fig. 22).

[Illustration: FIG. 22. Pathological Anteversion.]

ETIOLOGY.--The exaggerated anteversion of early pregnancy is
physiological, the exaggerated anteversion of the uterus in chronic
metritis is pathological. Elevation of the cervix and depression of the
corpus may be induced by peritoneal adhesions. Increased weight from a
mural fibroid may also depress the corpus.

{175} The SYMPTOMS are due to the pelvic inflammations already
mentioned and other complications. The increased weight of the uterus,
which is usually hypertrophied from metritis, generally causes a
dragging sensation, especially if the organ be also prolapsed. The
enlarged corpus occupying the territory of the bladder often induces
persistent vesical irritation or even cystitis. Menorrhagia, when
present, is the result of the metritis or a fibroid rather than of the
displacement per se.

DIAGNOSIS AND PROGNOSIS.--The displacement is recognized by digital
touch, which discloses the anterior wall of the uterus parallel to the
anterior wall of the vagina, with the fundus close to the symphysis and
the cervix elevated. Conjoined examination will show the size, shape,
hardness, and degree of fixation. Exaggerated anteversion of the
healthy uterus is not necessarily pathological in its results. This is
illustrated by the anteversion of early pregnancy. The prognosis is
therefore good if the causes can be removed.

TREATMENT.--Inasmuch as exaggerated anteversion is the position taken
by the uterus in chronic metritis, it follows that the treatment is
often that of chronic metritis. For the treatment of metritis,
perimetritis, fibroids, menorrhagia, etc. the reader is referred to the
special literature of those subjects. Irritable bladder, which is often
a mechanical result of the displacement and enlargement, may sometimes
be relieved by means of an Albert Smith or Hodge pessary, which lifts
the organ to a higher level away from the bladder. In thus elevating
the uterus the {176} anteversion may be rather increased than
diminished, which proves that the symptoms were dependent not upon the
anteposition, but rather upon descent and antelocation. Should the
parts be too sensitive to tolerate the hard-rubber pessary or a
flexible rubber ring, the daily application of medicated pledgets of
cotton will give support to the uterus and decrease the tenderness
until the more permanent instrument can be worn. The numerous
anteversion pessaries designed to elevate the corpus by direct pressure
on the anterior wall of the uterus generally irritate the organ, and
thereby aggravate the inflammatory complications. They are therefore to
be used with extreme caution.


Pathological Anteflexion.

DEFINITION.--The normal forward bending of the corpus upon the cervix
uteri when the bladder is empty makes an angle of which the approximate
physiological limits are between 45° and 90°: the flexure would
generally be pathological if less than 45° or more than 90°.
Furthermore, if the flexure, whether it be normal or abnormal in
extent, does not disappear upon filling the bladder, but remains
constant under all conditions, the rigidity makes the flexure
pathological. Anteflexion is therefore pathological if the mobility at
the angle of flexure is increased or diminished or absent.

{177} ETIOLOGY AND PATHOLOGY.--Anteflexion may be congenital or
acquired. By congenital is meant not defective foetal development, but
failure of the immature child uterus to develop at puberty, a failure
which usually pertains alike to the uterus, Fallopian tubes, ovaries,
and vagina. In congenital anteflexion the uterus is bent upon itself
almost double, the body and cervix both pointing in the direction of
the pelvic outlet, with the cervix somewhat elongated and situated in
the long axis of the vagina. (See Fig. 23.)

[Illustration: FIG. 23. Congenital Anteflexion. Both cervix and body
are flexed forward.]

Acquired anteflexion may be simply an exaggeration of the normal
flexure, due either to increased weight of the corpus from the presence
of the uterine fibroid near the fundus or to unequal growth of the
uterine walls or to unequal involution. A very frequent cause of
anteflexion is thickening of the posterior wall of the uterus from the
products of inflammation, and a corresponding atrophy of the anterior
wall from prolonged pressure at the angle of flexure. Post-uterine
cellulitis and peritonitis involving the utero-sacral ligaments is a
frequent and discouraging complication. Sometimes the inflamed
ligaments contract and drag the anteflexed uterus upward and backward,
where it may be permanently fixed by peritoneal adhesions. (See Fig.
24.)

[Illustration: FIG. 24. Anteflexion with Post-uterine Fixation.]

A constriction of the uterine canal at the point of flexure may, by
confining the secretions above, produce inflammation in the body of the
uterus, Fallopian tubes, and ovaries analogous to the cystitis,
ureteritis, pyelitis, and nephritis which follow stricture of the male
urethra. The {178} peri-uterine inflammations, having the relation
either of cause or effect of the flexure, often bind the pelvic organs
together in a mass of exudate, with resulting failure of nutrition,
nerve-irritation, and constant pain, which sometimes render the
patient's life miserable and useless.

SYMPTOMS AND COURSE.--The numerous symptoms due to the inflammatory and
other complications should not be confounded with those of the
displacement. The symptoms of anteflexion are polyuria and dysuria,
dysmenorrhoea and sterility.

The vesical symptoms are produced either by the rigidity of the uterine
tissue at the angle of flexure, which prevents the body from rising out
of the way of the filling bladder, or by the inflammatory shortening of
the utero-sacral ligaments, which, by drawing the uterus upward and
backward, put the vesico-vaginal wall on the stretch, thereby causing
traction upon the neck of the bladder.

The dysmenorrhoea may depend upon the presence of constriction of the
uterine canal at the angle of flexure. This causes the blood to
accumulate and to coagulate in the body of the uterus, from which it is
expelled at intervals by uterine contractions simulating labor-pains.
The pain when due to this cause is therefore always very severe just
before the passage of a clot. Furthermore, the dysmenorrhoea may be
caused by obstruction in the veins at the angle of flexure, which
causes intense venous congestion of the entire body of the uterus; pain
is then due to the pressure of the swollen vessels upon the
nerve-filaments and to a consequent irritable condition of the muscular
tissue of the uterus. Sometimes upon the establishment of the flow the
uterine canal becomes temporarily straightened; this removes the cause
of the vascular obstruction, and together with the flow gives relief.

Sterility is very commonly associated with anteflexion. The fact that
dilatation and incision of the constricted canal have frequently been
followed by conception has been accepted as proof that the sterility is
due to the constrictive obstruction. This mechanical theory is
questioned by many, who say that the dilatation cures sterility by
straightening the uterus and thereby removing the venous obstruction
and the consequent congestion.

DIAGNOSIS.--The educated touch which distinguishes the normal version,
flexion, and movements of the uterus will appreciate the anatomical
differences between pathological and normal anteflexion. The degree of
flexure, the mobility or rigidity, and the size, shape, location, and
consistency of the uterus may be ascertained by conjoined manipulation.
The presence of post-uterine cellulitis is recognized by the pain
caused in dragging the uterus slightly forward and by increased
thickness and tenderness in the region of the utero-sacral ligaments,
which may be felt by vaginal or rectal touch. Anteflexion is
distinguished from a fibroid in the anterior wall of the uterus by the
probe. When the diagnosis of anteflexion is obscured by the presence of
cellulitis, it is usually better to wait for absorption of the exudate
than to subject the patient to needless danger from the probe. Should
it be necessary to pass the probe, the danger is decreased by gentle
manipulation, which is facilitated by Sims's speculum and the
latero-prone position. The common error of mistaking the normal version
and flexion of a prolapsed uterus for pathological {179} version and
flexion has been exposed in a previous paragraph. (See Etiology and
Clinical History of Descent.)

TREATMENT.--If complicating cellulitis or peritonitis exist, in the
relation of either cause or effect to the flexure, its removal becomes
the prime indication, because unless removed it is a positive
contraindication to the more direct treatment of the malposition
itself. Chronic metritis, hyperplasia, hypertrophy, and irremovable
tumors sometimes render cure impossible. Improvement of the general
health, treatment of complications, and palliation then become the only
resources.

The direct treatment of pathological anteflexion has for its object the
straightening of the uterine canal, which is usually accomplished
either by division of the cervix or by dilatation. But before
considering the treatment more specifically, it should be remembered
that surgical treatment of anteflexion in cases of dysmenorrhoea and
sterility is only justifiable when the anteflexion is pathological. To
say that most women who suffer from dysmenorrhoea and sterility have
anteflexion is only saying that in the majority of such cases the
uterus is in its normal position.

The Marion-Sims operation of dividing the cervix is open to two
objections: first, its results are apt to be only temporary, in
consequence of rapid contraction upon healing of the wound; second, it
has frequently been followed by death. Dilatation by means of tents is
also transient in its results, and dangerous to life. Both Sims's
operation and dilatation by tents have given frequent and serious
warnings in the shape of pelvic inflammations, which, if not
destructive to life, have been almost as disastrous in their influence
upon health.

The following, with some modifications, is an abstract of a valuable
contribution[10] by Goodell of Philadelphia, in which he gives positive
endorsement to rapid dilatation as proposed by Ellinger and others. The
instruments recommended are two Ellinger dilators, which are preferred
on account of the parallel action of their blades. The dilatation is
commenced with the smaller instrument and completed with the larger,
which has powerful blades that do not spring or feather. The light
instrument needs only a ratchet in the handle, but the stronger one has
a screw which forces the handles together and the blades apart. To
prevent injury to the fundus when the instrument is open, the length of
the blades is limited to two inches. The larger instrument has a
dilating power of one and a half inches, and has a graduated arc in the
handles which indicates the divergence of the blades. Goodell's
modification of Ellinger's dilators is provided with serrated blades,
to prevent them from slipping out of the canal during the process of
dilatation.

[Footnote 10: _American Journal of Obstetrics_, 1884, p. 1179.]

For dysmenorrhoea or sterility due to flexion or stenosis the method of
operation is as follows: A suppository containing a grain of the
aqueous extract of opium is introduced into the rectum, the patient
etherized, and the uterus exposed by Sims's speculum. The cervix is
held by a tenaculum, and the smaller dilator is introduced as far as it
will go. Upon gently stretching open that portion of the uterine canal
which it occupies, the stricture above so yields that when the blades
are closed they will pass higher. By repeating this manoeuvre a
cervical canal is tunnelled out which before would not admit the finest
probe. Should the os {180} externum or cervical canal be too small to
admit the instrument, a pair of pointed scissors may be substituted,
and by the same opening and closing motions the canal may be prepared
for the introduction of the smaller dilator. As soon as the cavity of
the uterus has been entered the handles are brought together. This
dilator is then withdrawn, the larger one introduced, and its handles
slowly screwed together. If the flexure be very marked, the larger
instrument after being withdrawn should be introduced with its curve in
the opposite direction to that of the flexure, and the final dilatation
made with the dilator in this position. But in reversing the curve the
operator should take care not to rotate the organ upon its own axis,
and not to mistake a twist thus made for a reversal of the flexure; the
ether is then withheld, and the instrument allowed to remain in place
until the patient begins to flinch, when it is removed. The best time
for the dilatation is midway between the monthly periods. In the
majority of cases the dilatation should be carried to about one and a
quarter inches. The infantile uterus which has failed to develop at
puberty has thin, unyielding walls, and should therefore not be dilated
more than three-fourths of an inch or an inch. In using the larger
instrument it is usually necessary to have the assistant make decided
counter-traction with the vulsella forceps to prevent the blades of the
dilator from slipping out. The cervix is sometimes lacerated, but not
sufficiently to produce unpleasant results.

Goodell's statistics include one hundred and fifty operations of full
dilatation under ether, with no fatal result and without serious
inflammatory disturbance. As precautions against cellulitis,
peritonitis, and metritis the patient should be fortified for the
operation with moderate doses of opium and full doses of quinine, and
for two or three days after the dilatation this should be continued and
supplemented by the application of an ice-bladder over the abdomen.

After forcible dilatation under ether the cervical canal rarely returns
to its previously angular or contracted condition. The cervix shortens
and widens, and the plasma thrown out thickens and stiffens the uterine
walls. In a small minority of cases the operation must be repeated.
Dysmenorrhoea or sterility, if dependent solely upon the flexure, is
cured by the dilatation. The comparative safety of forcible dilatation
in the hands of a skilful and experienced gynecologist may be
contrasted with its great danger when undertaken by an operator
unacquainted with the special requirements of uterine surgery.
Peri-uterine inflammation is a positive contraindication to the
operation.

Post-uterine inflammation, which has drawn the anteflexed or anteverted
uterus upward and backward by the contraction of the utero-sacral
ligaments, often produces traction upon the vesico-vaginal wall and
neck of the bladder, with a constant desire to micturate. For the
relief of this intractable symptom, which sometimes goes on to
cystitis, Emmet has proposed a most satisfactory remedy known as his
buttonhole operation of urethrotomy.[11] He makes a longitudinal
opening about five-eighths of an inch long through the urethro-vaginal
wall, between the meatus and the neck of the bladder, without cutting
through either. To prevent the opening from healing together, the
margins of the mucous membrane of the urethra are united with fine
catgut sutures to the {181} margins of the mucous membrane of the
vagina. According to Emmet, the operation relieves irritation due to
traction on the neck of the bladder by freeing the pelvic fascia at the
fixed point where it converges to its pubic attachment. The operation
is equally applicable for the relief of this symptom when due to
inflammation in any other part of the pelvis. The same result may be
secured, but less satisfactorily, by forcible dilatation of the
urethra.

[Footnote 11: Emmet's _Principles and Practice of Gynecology_, 3d ed.,
pp. 275 and 761.]

From personal experience the author can testify to the gratifying
effects of this operation. Vesical irritation caused by post-uterine
inflammation and consequent contraction of the utero-sacral ligaments
is often wrongly attributed to the mechanical pressure of the
anteflexed fundus uteri upon the bladder, which is manifestly
impossible, if the contracted utero-sacral supports hold the entire
uterus back away from the bladder.

The various anteflexion and anteversion pessaries which have been
devised for the purpose of propping up the corpus are almost useless.
Their false reputation depends upon the relief which they frequently
give to complicating prolapse, the symptoms of which have been wrongly
attributed to anteflexion or anteversion. The same pessaries therefore
may be applied as in descent. (See Etiology and Clinical History of
Descent.) Intra-uterine stem pessaries designed to straighten the
flexed uterus are sometimes effective, and always dangerous.




{182}

DISORDERS OF THE UTERINE FUNCTIONS.

BY J. C. REEVE, M.D.


Menstruation with its disorders is the only subject to be considered
under this head. In its monthly recurrence it is most intimately
connected with, and dependent upon, ovulation, each menstrual discharge
being the sign and evidence of the maturation and expulsion of one ovum
or more. This proposition is denied by some, but the evidence adduced
against it, while sufficient to show that the two processes may be
dissociated, and may sometimes occur independently, is not strong
enough to invalidate the truth of the general statement.

Menstruation may be entirely absent, the flow may be excessive, or it
may be accompanied by severe pain; and these derangements have been
designated from time immemorial as amenorrhoea, menorrhagia, and
dysmenorrhoea. The time is long past, however, when these affections
could be treated as distinct diseases. Each of them may be caused by
influences so various--and, above all, may depend upon pathological
conditions so different, and even dissimilar--that the name applied to
each is indefinite, and, like the term dropsy, only incites inquiry as
to some abnormal condition of which the deranged flow is the symptom. A
due appreciation of this fact is of prime importance, because treatment
cannot be instituted with expectation of success until the particular
form of each derangement has been distinguished.

The great majority of cases of uterine derangement depend upon changes
of structure. Those considered purely functional are largely in the
minority, and would be still less in number with a more intimate
knowledge of pathology or with greater skill in examination. No
argument is needed, therefore, to show that a direct and thorough
examination of the organs concerned is essential to rational treatment
of this class of affections. There are obvious difficulties in the way
of such an investigation, different from and far greater than attend
the investigation of the diseases of any other organ of the body. With
tact and proper demeanor, however, these difficulties can be generally
overcome, but in any other than trifling cases, and especially in those
continuing for any considerable time, the practitioner will do
injustice to himself as well as to his patient if he do not insist upon
this indispensable investigation.

A due appreciation of the influence of uterine disorders and diseases
upon other and remote parts of the body is necessary to a correct
estimate of their importance, and often of great practical value in
treatment. Through the sympathetic nervous system pathological
conditions of the uterus modify the processes of organic life, and by
direct or reflex action {183} affect the cerebro-spinal system in its
centre or at any point of its terminal ramifications. That the stomach
responds readily to uterine excitations is shown in pregnancy, and
uterine disease often causes disorders of the digestive organs the
origin of which may not be suspected. Eructations, vomiting, and the
various forms of indigestion are not uncommon. The bowels are irregular
in action, constipation alternating with diarrhoea, and flatulent
distension may occur even to a degree demanding special treatment.
Failure of general nutrition and impoverished blood are the
consequences of this disturbed digestion; without good blood there is
no sound innervation, and the nervous system is soon in such a
condition as to respond unduly to even insignificant impressions.
Normal menstruation is marked by a nervous erethism which shows itself
by irritability, fits of despondency, and exhibitions of temper. There
are therefore abundant reasons why nervous diseases should be very
frequently seen as a remote effect of uterine disorders.

A very large proportion of these reflex diseases first occur at the
period of puberty, many present striking exacerbations at every
menstrual period, and some are so closely associated with this function
as to be cured only by remedies addressed to it. Headache, neuralgia,
hysteria in its varied forms, chorea, catalepsy, epilepsy, and even
mania, have been repeatedly shown to have their origin in the sexual
organs. The reproach often directed at gynecologists, of a disposition
to magnify their specialty, falls pointless before such important
facts; and since it is not uncommon for diseases of organs in close
proximity to the uterus, as those of the urethra, bladder, and rectum,
to be mistaken for or confounded with diseases of the uterus itself,
there is abundant warrant for urging the closest scrutiny as to a
possible uterine origin of remote diseases, especially those of a
nervous character.


Amenorrhoea.

The term amenorrhoea signifies the absence of menstruation. It occurs
in two different forms: First, those cases in which menstruation has
never occurred--emansio mensium; second, those in which it has
disappeared after having been established--suppressio mensium.

The following pathological schedule may assist in the study of the
subject. It need scarcely be said that it is not presented as correct
in every particular, nor with the idea that the dividing-lines between
physiological and pathological conditions can be always determined, but
as a convenient guide to follow in the study of the subject:

  A. Amenorrhoea (absent menstruation) from
      _a_, anatomical conditions: want of development of organs,
           atresia of passages;
      _b_, physiological influences: delayed puberty, idiopathic;
      _c_, pathological causes: constitutional diseases, disease of the
           sexual organs, the cachexiæ.
  B. Amenorrhoea (secondary or suppressed menstruation):
      _a_, anatomo-pathological: atresia of passages, atrophy of
           organs;
      _b_, physiological: pregnancy, nursing, premature change of life;
      _c_, pathological: besides those given above--A-_c_--are
           psychical influences and exposure or taking cold during
           menstruation.

{184} Absence or want of due development of some of the sexual organs
is not of very infrequent occurrence. The ovaries are very rarely found
wanting; they are more often checked in development and present the
characteristics of early life. This condition may be the cause of
delayed, irregular, or scanty menstruation, making a more or less near
approach to amenorrhoea. Absence of the uterus is often combined with
absence or with an undeveloped condition of the vagina, but this canal
may be perfect and no change of the external organs be present to
indicate that the uterus is wanting. It may also exist in a rudimentary
form, and may be found corresponding in size and shape to the uterus of
any period of early life.

Absence of the ovaries not only causes amenorrhoea, but checks the
progress of the bodily development and prevents the sexual changes of
puberty. When the ovaries are wanting there is almost always absence of
the Fallopian tubes, uterus, and vagina. The symptomatology of absence
of the uterus is not generally striking, the lack of menstruation being
the principal sign; exceptionally, however, it is otherwise. In some
cases where the ovaries are present and the uterus wanting, the most
aggravated affections of the nervous system show themselves.

Congenital atresia of the genital canal may occur in any part of its
course. Imperforate hymen is the most frequent as it is the least
dangerous form, being more than twice as common as atresia of the
vagina and three times as frequent as that of the cervix uteri. The
vagina may be extremely small in calibre, closed in part or the whole
of its course, or only a fibrous cord indicate where it should be. The
uterus may be closed at the internal or external os; the latter is the
more frequent. An occlusion at one point does not preclude the
existence of other closures higher up. The effect of a closed canal
with a recurring secretion above is evident, and gives rise to a
well-marked class of cases. The organs above become distended, and the
distension increases until an opening is made by art or the retained
fluid bursts a passage for escape. This may occur outwardly with
immediate relief and cure, or into the peritoneal cavity, causing
speedy death. The time at which the uterus may be expected to give way
under such distension cannot be stated, as the power of resistance of
the organ differs and the amount of secretion each month may vary
widely. Scanzoni in one case evacuated eight pounds of blood, the
result of seven months' accumulation, and found the uterine wall as
thin as paper. Bernutz states that the average time before interference
is necessary is three or four years, and gives a case first operated
upon in the tenth year of its course.

Menstrual retention is not at first indicated by pronounced symptoms.
Suspicion of the nature of the case may be first excited by the
severity of those symptoms which at every period announce the approach
of menstruation and known as the menstrual molimen. As distension
increases these become extreme, with rectal and vesical tenesmus and
severe uterine colic. The nervous system sympathizes, as with all
menstrual derangements, and there may be rigor, fainting, or even
convulsions.

Whenever a patient presents such symptoms an examination should be
insisted upon. It will generally reveal a smooth, soft, and fluctuating
tumor, projecting externally if the case be one of imperforate hymen,
or higher up if the vagina be occluded. If the uterus has become
distended, {185} there will be a round, smooth, elastic tumor above the
pubes. Diagnosis will be more or less difficult according to the seat
of the obstruction. Cases of imperforate hymen may be readily diagnosed
by sight, if touch and the history are not sufficient. When the
occlusion is deeper, the patient should be placed under the influence
of an anæsthetic. By one finger in the rectum and the thumb in the
vagina, and a sound in the bladder, the seat and extent of the
obstruction may be determined. Should it be necessary, the urethra may
be dilated and a finger passed into the bladder in order to make a
diagnosis. Rectal exploration is of great assistance in discovering the
uterine enlargement and its character. Scanzoni calls attention to the
difference in the cervix when the atresia is at the internal or
external os. In the latter case the cervix will be obliterated; in the
former, it will be unchanged. With a perfect vagina and a cervix of
this character retention may be taken for an early pregnancy,
especially as it is not uncommon for sympathetic mammary symptoms and
gastric troubles to be present. Time will demonstrate the nature of the
case if a diagnosis cannot be made at once.

The age at which the menstrual flow is established varies greatly. The
average age of puberty in this country, as appears from Emmet's tables
made up of 2330 cases, is 14.23 years, and these are believed to be the
only American statistics. A close correspondence may be noted between
this and the statistics of the four largest cities of France, which
give 14.26 as the average. But that it is not unusual for the
appearance of menstruation to be delayed is shown by the fact that of
the above 2330 cases, 288 only menstruated at sixteen years and 254
more between that age and twenty-three. The circumstances which may
influence, within physiological limits, the appearance of menstruation
should be considered in connection with cases of this kind. Climate and
social position are the principal ones. The epoch of puberty descends
in the scale of age in proportion to the average height of the
temperature of various countries, and vice versâ. Social position and
city life show a marked effect in hastening puberty as compared with
the simpler manners and plainer life of rural populations. It amounts
to an average of something over a year, and is explained by the
influence of enervating and luxurious habits, of light reading and the
drama, the chief subject of both being the grand passion, but
especially of a freer intercourse between, and the co-education of, the
sexes, and the greater extent to which music is cultivated and enjoyed.

Among pathological conditions giving rise to amenorrhoea it would seem
that disease of the ovaries should occupy the first rank in frequency
and importance. The reverse is the truth. The ovaries are rarely
inflamed, and when so amenorrhoea is not always the result. They are
frequently the seat of cystic degeneration, producing tumors of large
size, yet so long as but a small portion of one of the organs remains
unaffected Graäfian vesicles may still be furnished and menstruation
continue. It is by the influence of remote pathological conditions that
the menstrual flow is most frequently restrained, and especially by
those general affections known as cachexiæ, all of which exhibit marked
depression and low grade of vital power and activity, if not more
pronounced pathological processes. Chlorosis, the relations of which to
menstruation are intimate, and which seems to be sometimes the
offspring of {186} amenorrhoea, exerts a marked retarding influence,
amounting to an average of one year and a half. The scrofulous cachexia
is still more potent: Scanzoni states that of 31 well-marked cases, in
19 menstruation did not occur until the twenty-first year.

Amenorrhoea which is the result of pulmonary tubercular disease comes
frequently under observation. It may occur at a very early period of
the disease, before there is any great amount of deposit in the lungs,
when it is rather the expression of want of vital force than of the
exhausting effect of the disease. Under these circumstances it is only
to the laity a subject of serious consideration; to the physician it is
but a symptom.

The suppression as well as the absence of menstruation may be caused by
atresia of the passages, this form differing from the congenital only
etiologically, and in the fact that the flow has been once established.
The acquired atresiæ are mostly the result of violent inflammations or
traumatic influences. The vulva and vagina, or either, may be closed
from sloughing after difficult labors or gangrene following the septic
fevers. Occlusion of the cervix uteri may follow labor or amputation of
the part, but a far more frequent cause is the application of severe
caustics, happily less frequent now than formerly. Lawson Tait says he
has never met with atresia of this part from any other cause.

The mode of diagnosis has already been given, and in regard to
symptomatology there is only to be noted the statement of Bernutz, that
there is far greater intolerance of retention from acquired than from
congenital atresia.

Atrophy of the uterus is a normal process after the menopause, but it
sometimes occurs much earlier in life, and then causes scanty and
irregular menstruation or amenorrhoea. Attention was first called to
this condition by Simpson as a process sometimes following parturition
under the name of super-involution. Several labors in rapid succession
have been stated to be a cause, but Simpson and Courty both give a case
after a single birth. Uterine atrophy may also result from the pressure
of tumors, and it has been observed in paraplegias the result of
defective innervation.

The deranged menstruation is the one prominent symptom of this
condition, and a diagnosis is to be made by exploration. The cervix is
found small and the body light when lifted on the finger. Bimanual
examination and the introduction of the sound will reveal the true
condition of the organ. The latter process should be cautiously
conducted on account of a frequent change of texture in the uterine
walls which allows the instrument to pass through them with the use of
but very little force.

Amenorrhoea is physiological during nursing and pregnancy. The former
needs no attention, the latter only in regard to diagnosis. A sudden
cessation of menstruation, the patient presenting all the appearances
of good health, should immediately excite suspicion as to the nature of
the cause. It needs but little experience to distinguish and manage
these cases in the lower social ranks. The case is different, however,
in a family of good position, with an anxious mother urgent for active
measures, where no suspicions will be tolerated and the imputation of
possible pregnancy be warmly resented. Time is here the sure ally of
the physician, and an examination should be deferred until such a
period {187} has been reached that pregnancy can be positively
negatived or determined.

The influence of acute diseases in suppressing menstruation is not
marked. During convalescence from them the flow frequently ceases from
general debility. All chronic diseases depressing and exhausting in
nature cause suppression, as albuminuria, cirrhosis, and cancer.
Tuberculosis is as fruitful in interrupting the return as in preventing
the appearance of the flow, and suppression from this cause is very
frequent. Under impaired nutrition and depressed powers vital force is
engaged wholly in maintaining existence; there is none for any function
relating to the propagation of the species. In this class the
disappearance is gradual; the flow becomes scanty and irregular in
recurrence, and finally ceases. This form of amenorrhoea differs in no
material point from the similar class already considered; it is but a
symptom of disease of some vital organ or of some general abnormal
condition.

Suppression from psychical influences is not at all uncommon. Fright,
grief, bad news, sudden or prolonged anxiety, frequently cause this
disturbance of function. The mental impression need not be very
profound. Amenorrhoea is a common event with girls who go away from
home to boarding-school. In these cases it is not probable that there
is any pathological condition of the sexual organs; a change in their
innervation is a phrase which will best serve to explain the origin of
the derangement or to express our ignorance. The diagnosis of this form
may be a matter of deep interest when it occurs directly after
marriage, as it not infrequently does, and gives ground for the belief
that pregnancy has occurred. Still more important is it when the
suppression follows illicit intercourse, the fear of pregnancy then
exerting a powerful emotional influence. Some cases are on record, and
the writer has met with two: in both the function resumed its course
after a time without remedies.

Exposure to storm, getting the feet wet, and the sudden application of
cold to the genitals frequently cause suppression. All the conditions,
however, are not well understood. The bathing- and fishing-women of
Europe are said to ply their vocation without reference to
menstruation, and to suffer no inconvenience. In these cases the
increased flow of blood to the pelvic organs oversteps the narrow line
which separates physiological from pathological congestion, and may
even pass on to inflammation.

The SYMPTOMS are well marked--at first, local, as severe backache,
increased heat and pressure in the pelvic region, discomfort passing on
to pain, even uterine colic. If the impression be severe enough to
affect the general system, there will be febrile action more or less
intense, and various nervous symptoms, spasmodic or convulsive.

The therapeutics of amenorrhoea must be directed in accordance with the
conditions which cause it. But the strictly scientific method cannot be
followed at the outset. This method presupposes a direct examination of
the organs as the first step. For obvious reasons this must be deferred
until special symptoms show its necessity. For treatment the cases may
be classified, in some instances according to the schedule, but more
frequently according to the cause or leading features, and very
generally without reference to whether there is absence merely or
suppression of the function.

In amenorrhoea from atresia the measures of relief will be purely {188}
surgical; the treatment, therefore, does not fall within the scope of
this article.

The physician is frequently consulted in cases where menstruation has
occurred once or twice, perhaps at long intervals, and not appearing
regularly the fears of friends are excited. This is the normal course
of establishment in a large proportion of cases. Time and assurance and
regimen are alone needed, provided there is no evidence of deteriorated
health. Absence of the function alone does not demand treatment--a fact
which should be kept steadily in mind.

In a still larger class of cases the amenorrhoea depends upon, and is
the direct result of, some pronounced cachectic condition, as
chlorosis, scrofula, or a more or less active tubercular disease of the
lungs. The treatment of this class resolves itself into that of the
disease causing the derangement, and the reader is referred to the
articles on the corresponding subjects.

The cases requiring more direct consideration therapeutically are those
closely allied to the preceding, in which delay in appearance depends
upon want of development of the body or general feebleness of
constitution, or those in which absence follows and continues unduly
after some severe disease. In all these cases the treatment is to be
indirect rather than direct. The absent function is to be restored by
improving nutrition, by increasing bodily vigor, and by using every
means to establish the general health on a firm basis. Measures for
this purpose should be addressed to every particular of the habits,
occupation, and surroundings of the patient. They do not differ from
those of a general tonic course, but in some particulars a special
influence may be exerted upon the function at fault. The clothing
should be warm, especially about the pelvis and lower extremities, due
care of the feet being impressed in proportion to the universal neglect
shown by girls and women in regard to these important parts of the
person. The diet should be of plain, wholesome, substantial food, and
in many cases one of the lighter wines may be added to the principal
meal of the day with decided advantage. Gymnastics may be prescribed,
but outdoor life should be urged, with horseback riding as the very
best mode of exercise for promoting the flow. A change of air and scene
exerts a well-known and powerful influence in improving nutrition and
modifying vital actions. It should be rather from the city to the
country for these cases. Special advantages may be derived from a
residence at the seaside on account of the beneficial effects of
surf-bathing. A scientifically-conducted hydropathic establishment is
very desirable for its regular hours, well-ordered diet, and treatment
by baths and douches. Or a watering-place may be preferred where a
chalybeate water may exert a special influence in addition to those of
moderate indulgence in the gayety and amusement of such a place.

Inquiry as to school-life and educational work should never be omitted.
The general mode of education of girls is faulty in the extreme. No
attention is paid to the great change of puberty, which amounts to a
revolution in the economy, and instead of aiding the vital forces drawn
upon for effecting this change, they are still further depressed by
sedentary life in close rooms or strongly urged in another direction.
No two leading organs of the body can be pushed in development at the
same time with impunity. There is no exception here: either the brain
and nervous {189} system or the sexual organs will suffer. In this
direction is often found a potent cause of all the forms of uterine
derangement--a fact which cannot have escaped the observation of every
physician. The writer has always urged an entire break in the
school-life of girls of at least one year's duration at the time when
signs of puberty begin to manifest themselves; and this period is too
short rather than too long.

Tonics should supplement these regiminal measures. They may be hæmatic,
stomachic, and nervous--either or all. There is a chain of diseased
actions, and it may be attacked at any of its links. Iron stands at the
head of the list. It is not only an hæmatic tonic, and in proper
conditions a promoter of digestion, but decidedly promotes pelvic
congestion, and has therefore an emmenagogue action. The forms at
command are so numerous as to meet the requirements of any case or to
satisfy any fancy. The standard preparations, as a rule, deserve the
preference over more modern ones, in which efficacy is often sacrificed
to elegance. Among the best are those which contain the remedy in a
nascent state, as the compound mixture or the compound pills of iron of
the Pharmacopoeia. Dialyzed iron, the tincture of the chloride, and the
pyrophosphate are reliable, while the addition of manganese, as in the
syrup of the iodide of iron and manganese, is believed by some to
increase the efficacy. With iron may be combined nux vomica or
strychnia and quinia. In large sections of our country malaria is a
constantly-acting depressant of vital force, and the latter medicine
may be given for a time with a free hand, and may be followed by or
combined with arsenic to great advantage.

Constipation is almost universally present in women. It deserves
especial consideration in treating all disorders of the sexual organs.
When attention to habits and appropriate laxative food, as fruits,
oatmeal, Indian meal, cracked wheat, and salads, do not suffice, resort
must be had to enemata or drugs. Aloes has always had a reputation of
special virtue in amenorrhoea which is doubtless well founded. In pill
form it may be combined with any or all the other medicines. Pills of
aloin, one-fifth or one-third of a grain, have the advantage of very
small bulk.

Before considering more direct measures for establishing menstruation
it may be well to recall to mind the two elements of the
function--ovulation and the uterine flow. The first, the prime factor,
we can not influence by any medicines nor by any mode of treatment
except, perhaps, by electricity. Observation of animals shows that mere
proximity of the male influences it plainly, but this only indicates a
line along which we cannot prescribe. An opinion may, however, be asked
in regard to the propriety or advisability of marriage for a woman who
has never menstruated. In such case no advice should be given until
after a thorough local examination, and its tenor will then be in
accord with the condition of the organs. With such atresia or absence
of organs as not to permit sexual intercourse marriage should be
positively negatived. In such cases as those of partially-developed or
absent uterus the facts should be laid before the parties interested
and the decision referred to them. In the former class of cases some
hopes of improvement may be entertained.

The second factor of menstruation, the flow, we can influence by such
measures as cause a more or less intense pelvic congestion. The ovaries
sharing in this congestion, it is not impossible that ovulation is in
some {190} degree also promoted, but it can be only to a minor degree
and when the ovaries are in a favorable condition. The uterus is the
principal organ to be affected, and to it the most of these measures
are addressed.

Direct treatment for the establishment of menstruation should be first
of a character rather to solicit than to force the flow. These measures
act best where, the general health having been restored, the flow does
not appear, but the premonitory symptoms are present. Rest in bed,
warmth to the pelvic region by poultices or other means, and hot
drinks, are to be prescribed; among the latter infusions of pennyroyal,
some of the mints, tansy, and cotton-root have a high domestic
reputation and should be preferred. Hot pediluvia or hot sitz-baths,
prolonged to twenty or thirty minutes, may be taken at bedtime. These
may be rendered sufficiently stimulating to irritate the skin by the
addition of mustard. More active measures are stimulating enemata and
vaginal injections--for the former ten grains of aloes in mucilage, and
for the latter liquor ammonia in milk, fluidrachm j-pint j, gradually
increasing the strength to production of slight leucorrhoea. Both these
have the endorsement of high authority.

Such measures should be used or plied more assiduously about the
period, when that is known. During the interval a tonic course is
almost always required, and a powerful local influence can be exerted
by cold sitz-baths of brief duration, say one or two minutes, once
daily, followed by vigorous rubbing with a coarse towel or a
flesh-brush.

There are a few drugs known as emmenagogues from the reputation they
have of promoting the menstrual flow. They all are powerful stimulants
or irritants, and as they are also nearly all abortifacients, their
reputation is probably well founded. Modern physiology, by exploding
the doctrine of peccant humors to be carried off by menstruation, and
by establishing the doctrine of ovulation, has greatly diminished their
importance, while the varied conditions and causes of amenorrhoea
already given show at a glance how restricted is the field for their
administration. To give them when the anatomical conditions are unknown
is blind work; to force a function relating to reproduction when the
general system is struggling for existence is folly; and to goad
diseased organs with special stimulants is certain to do injury. Now
and then, however, special stimulants of this class and of the class
next to be considered are required. There are some cases which fail to
respond to the measures already detailed; there are others, generally
recognized by writers, when menstruation is absent without any
deterioration of health, known as cases of sexual atony or torpor; and
others in which the flow fails or disappears earlier than the usual
age. In these latter atrophy of the ovaries may be suspected, but
cannot be verified during life, and treatment should be faithfully
continued so long as there is reasonable probability of success. One
case occurred in the experience of the writer in which the menses
appeared occasionally during two years, each time apparently brought on
by special stimulants, but ceased at thirty-two, the general health
remaining excellent.

The principal emmenagogue drugs heretofore relied on, besides iron, are
saffron, apiol, rue, and savin. The first, from impurity and
costliness, is rarely prescribed, yet Trousseau says it is a fact of
public notoriety that women engaged in picking saffron suffer from
frequent attacks of uterine hemorrhage. Apiol may be given in capsules
in doses of five or six {191} drops twice daily for a week before the
expected flow, or fifteen drops may be administered in the course of
the few hours immediately preceding. The oils of savin and rue are
generally prescribed in doses of minim ij-v, three times daily. Ergot
and iodine figure sometimes as emmenagogues. The efficacy of the former
is denied by very high authority. The latter was esteemed very highly
by Trousseau. Its influence upon the scrofulous constitution may
possibly explain its action in promoting menstruation.

The permanganate of potassium is a recent addition to emmenagogues, and
the testimony in its favor is already sufficient to make it probable
that it is the most efficient of the list. The indications for its use
are want of action or atony of the organs. It should be administered
during a few days or a week preceding the time for menstruation, in
doses of from two to four grains three times daily; or two grains three
times daily may be administered during the whole month. The union of
its elements is but feeble, so that in pills as ordinarily made it
would be very likely to undergo decomposition, while in solution it is
unpleasant. Compressed tablets of the pure drug are now placed at
command of the profession, and are an unexceptionable form for
administration. The best time for taking the medicine is toward the
close of the digestive process, and each dose should be followed by
drinking at least a wineglassful of water. Pain in the stomach has been
sometimes observed even when every precaution has been taken. The
liability of the remedy to decomposition and its irritating powers are
objections to it, but the testimony in favor of its power to bring on
or promote the menstrual flow is at present very strong.

More decided measures of local stimulation than those already given may
be resorted to, and are far more reliable than drugs. They are--tents,
cupping the uterus, and electricity. A sea-tangle or tupelo tent may be
kept in the uterus over night just previous to the time of the flow. In
cases where stimulation rather than dilatation is needed a tent of
slippery-elm bark may be used. Thomas recommends a rubber exhauster for
cupping the cervix uteri. Simpson fashioned one for acting on the
lining membrane of the body. These measures are most likely to be
efficacious just before an expected period.

Electricity is the most reliable emmenagogue, and has such an amount of
testimony in its favor as not to permit a doubt as to its value. It is
the only direct uterine or menstrual stimulant except permanganate of
potassium. Statical electricity is now but little used, although
Golding-Bird published striking instances of its efficacy in
amenorrhoea at an early day in its therapeutic history. Faradization is
now most frequently resorted to. One pole is to be applied to the
sacrum and the other above the pubes or over either ovary. The internal
application of the current is much more powerful as well as less
painful. It is administered by applying a cup-shaped electrode to the
cervix, or by introducing an insulated sound into the uterus, the other
electrode being external as before. The séances should be repeated
every second or third day, and should be more frequent just before the
periods when their time is known. Beard and Rockwell insist that
general electrization should be administered at the same time, and Mann
passes the constant current through the organs during the intervals and
the faradic at the periods. Simpson originated {192} a galvanic
intra-uterine pessary, which Thomas has modified. It is doubtful
whether the feeble current generated by these instruments produces any
effect, or whether they act simply as mechanical irritants. When they
are used, it should be borne in mind that there is eminent and high
authority against the use of intra-uterine pessaries of any kind, and
that all agree that a patient to whom one is applied should be kept
under careful observation.

It must be stated that good results have been obtained with this class
of local remedies in cases which would seem extremely unpromising--even
in those in which amenorrhoea depends upon partially-developed organs.
There is most positive testimony of the highest character as to good
effects obtained in increasing development and promoting the flow.

Cases of acute suppression are to be treated by rest in bed, warmth
locally by baths and applications, and hot drinks, as already detailed.
Steaming the lower part of the body by placing the patient over the
vapor arising from aromatic herbs upon which boiling water has been
poured is a remedy which dates back to Hippocrates. Early in the case a
drink of spirituous liquor, taken hot, is often efficacious. If,
however, there is febrile action, diaphoretics should be administered,
such as the liquor ammonii acetatis with spirits of nitrous ether, and
aconite if required. Dry or wet cupping may be used if there is
evidence of intense uterine congestion. Should internal metritis or
inflammation of some pelvic organ result from acute suppression, the
treatment will be that for the disease thus caused. If efforts to
restore the suppressed flow do not prove speedily successful, special
measures should be postponed until the next period, the general health
meantime receiving due attention. At the return of the next period such
of the remedies for amenorrhoea should be administered as may seem best
adapted to the case, considered as to cause, condition of the organs,
or constitution of the patient.

Vicarious menstruation is so closely allied to amenorrhoea as to demand
some consideration here. The term is applied to a sanguineous flow,
recurring at regular intervals, from some organ or part of the body
other than the uterus. This flow has taken place from almost every
organ or part of the body; most frequently, however, it has been from
some mucous membrane, a wound, scar, or some part which by structure is
favorable to the exit of blood. Amenorrhoea is frequently present, and
is sometimes followed by acute suppression. Puech found 11 cases
attended by vaginal atresia congenital, and in 42 others the uterus was
absent or but partially developed. The treatment does not differ from
that of amenorrhoea. While measures are used to restore normal
menstruation, active repression of the abnormal flow should not be
attempted, unless the organ from which it proceeds is one likely to be
injured by its continuance.


Dysmenorrhoea.

Dysmenorrhoea, according to derivation, signifies a monthly flow with
labor or difficulty; its modern synonym is painful menstruation.

In but a very small proportion of women is menstruation painless. Not
only general and local distress attends it, but more or less pain.
{193} When the suffering reaches such a degree as to demand relief, the
case is one of dysmenorrhoea. In such cases the period generally
commences with a more pronounced molimen than ordinary; as it
progresses pain makes its appearance and gradually increases in
severity. Its seat is the pelvic region, the back and loins, and down
the thighs. It may be paroxysmal or continuous; in some cases the flow
is accompanied by expulsive efforts like those of labor. The pain may
last during the whole period, or relax very much, or even cease as soon
as the flow is freely established. In degree it may reach any height,
often causing the severest agony, taxing the powers of endurance to the
utmost, and requiring the most energetic measures for relief.

The organs in proximity to the uterus, partaking as they do of the
menstrual congestion, are also markedly affected. There is rectal
tenesmus, and on the part of the bladder frequent micturition and
dysuria. Remote organs are influenced either directly or by sympathy.
The breasts become tumefied and tender. There is flatulence, nausea, or
even vomiting. The nervous system, during normal menstruation in a
state of erethism, responds readily to the painful impressions, and
presents symptoms of the most varied character and degree, amounting
even to general convulsions.

Attacks of severe pain recurring at short intervals cannot but exert a
powerful deleterious influence upon the general health. Digestion is
interfered with, nutrition and sanguification are imperfectly
performed, and there is a continuous chain of deranged function. The
results to the nervous system, indirect and direct, and sometimes also
from the measures of relief resorted to, are most deplorable. From
every point of view this class of cases presents the strongest claims
for relief.

The discharge in dysmenorrhoea varies very widely in amount and
character. It may be so scanty as to border on amenorrhoea or so
profuse as to be menorrhagic. It may be more or less fluid than usual.
The expulsion of clots is a frequent feature, and the size and shape of
these sometimes give indications of value. Like other uterine
derangements, dysmenorrhoea is not a disease per se, but a symptom of
some pathological condition the exact nature of which is to be
ascertained whenever possible. Cases may be classified as follows: I.,
Obstructive or mechanical; II., congestive; III., neuralgic; IV.,
membranous. It cannot be too distinctly kept in view that this
classification, like many others, cannot be rigidly followed. The
dividing-lines are sometimes but faintly drawn by nature; some cases
present the features of more than one class; some by natural progress
pass from one class into another. Based upon leading clinical features,
this classification will assist in the study of the subject, facilitate
diagnosis, and aid in directing therapeutic measures.

Two classes given by some authorities are not included in the above
classification. They are spasmodic and ovarian dysmenorrhoea. If by the
former is implied painful contractions of the uterus during
menstruation, the cases fall into the first class given above, the
obstructive; and if irregular nervous action is implied, they belong to
the third, the neuralgic. The term ovarian has been applied to those
cases in which an abnormal condition of the ovaries exists, such as
inflammation, enlargement, or dislocation. Such conditions are not
easily ascertained during life; if ascertained, the fact throws light
on the etiology of the case; but for {194} treatment the case will
range itself, according to the clinical features it presents, among
those in which the vascular or the neurotic element predominates.

Obstructive or mechanical dysmenorrhoea is that form in which some
impediment exists to the free escape of the menstrual discharge. The
genital canal presents no exception to the general rule that when an
excretory channel is obstructed violent and painful expulsive efforts
are excited.

The causes which give rise to the obstruction are various. Among them
are the following: fibroid tumors of the uterus distorting, and polypi
obstructing, its cavity or neck; stenosis of the cervical canal, either
congenital or acquired, the latter often the result of the injudicious
use of strong caustics; a long and conical cervix; a contracted os,
sometimes so small as to be justly termed the pinhole os; versions and
flexions of the uterus.

The seat of obstruction is almost always uterine, but may be in the
vagina or at its entrance. There is much difference of opinion as to
the relative frequency of occurrence of obstruction at the internal or
external orifice of the cervix.

The pain in this form of dysmenorrhoea generally does not precede the
flow. In character it is sometimes like colic, but its leading feature
is expulsive effort. It occasionally so nearly resembles abortion as to
require care to distinguish between them. It is frequently
intermittent, presenting intervals of complete relief. In severity it
varies widely. In some cases the patient assumes and maintains a
certain position which she has learned affords her some relief. This
indicates with great probability uterine distortion from fibroid tumor.
The writer has met with a marked instance of this kind.

The flow is more irregular in this than in other forms. It is sometimes
extruded drop by drop; more often it appears in gushes, the fluid
accumulating and distending the uterus until expulsive efforts are
excited. Clots are often thrown off under these circumstances in shape
and size corresponding to the cavity of the uterus.

Absence of prodromata, presence of the fluid being necessary to excite
the pain, the intermittent and especially the expulsive character of
the pain, and the kind of clots, indicate the nature of the case. A
certain diagnosis, however, rests alone on physical examination. This
should be by the touch, bimanual and rectal, and the sound. Sometimes
additional aid will be derived from the speculum. By touch the form,
size, shape, and direction of the cervix are ascertained, and its
relations to the body of the uterus. The sound will give evidence as to
the patency and direction of the cervical canal and uterine cavity.

A diagnosis of obstructive dysmenorrhoea should not be rejected because
the patient occasionally passes a period without pain. In the male an
enlarged prostate may for a long time interfere but little with
micturition, and then all at once completely obstruct the flow of
urine. A diagnosis cannot be based alone upon the condition of the
cervical canal as found during the intermenstrual period. Two elements
are to be considered, each of which may, and doubtless often does, play
a part: tumefaction from the congestion attendant on the process, and
spasm. The latter, caused by reflex action excited by irritation in the
body of the uterus, assumes a leading position with those who claim
that obstruction is the {195} sole cause of dysmenorrhoea. That it
plays an active part in many cases cannot be doubted; that it is a
necessary condition of even spasmodic dysmenorrhoea is disproved by the
positive statement of Matthews Duncan, that in some cases he could pass
a sound freely into the uterus during the paroxysms.

A due estimate of the part which a uterine flexion plays in producing
the dysmenorrhoea is important, but very difficult. Theoretically, the
narrowing of the canal at the point of flexion should account for the
symptoms, but experience does not accord with theory. All cases of
flexion are not accompanied by dysmenorrhoea, and when so accompanied
removal of the deformity does not always cure. Siredey in 52
observations found only 22 cases of dysmenorrhoea. Emmet's
carefully-prepared tables show that in nearly 50 per cent. of
anteflexions menstruation is painless. The conditions necessary seem to
be extreme flexion, producing an acute angle. In less-pronounced cases
it is maintained by many that the flexion is an unimportant factor, and
that the dysmenorrhoea depends upon secondary conditions produced by
it, as endometritis and congestion. The problem is difficult, and each
individual case requires careful study. The facts indicate that there
is much in the pathology of this form of disease not yet fully
understood.

Congestive dysmenorrhoea depends upon an advance of the menstrual
congestion beyond the physiological limits. In these cases the patient
generally suffers for a few days before the period from a sense of
fulness, weight, and heat in the back and pelvic region. Pain follows,
is more or less severe, and varies somewhat in character, although
generally dull and heavy. The hypogastric region usually becomes
distended, and is sometimes very tender to the touch over the ovaries,
"especially on the left side, without any reason for the difference
being known." After a longer or shorter duration of these symptoms the
flow appears, and this is often, especially if free, followed by an
amelioration of the pain. In many cases, however, there is no remission
of the suffering upon the discharge occurring. Not infrequently the
general circulation is affected, the face is flushed, the skin hot, and
there is more or less fever.

The flow may vary widely as to quantity. It is often at first and for a
time more profuse than normal. Leucorrhoea frequently precedes and
follows it, persisting during the entire interval. During that time
also the patient suffers much from backache and bearing down, with
difficulty of walking or of remaining on her feet.

Upon examination the vagina is found hot and tumefied, and increased
arterial action is evident to the touch. The uterus is tender,
enlarged, and heavier than usual. In cases associated with or dependent
upon chronic inflammation or areolar hyperplasia the increase of size
of the uterus during menstruation is marked. The sound may be used to
determine the amount of enlargement and also the amount of tenderness.
In cases dependent on endometritis touching the interior of the organ
causes severe pain. Dyspareunia is frequently a symptom in this class
of cases.

The conditions upon which congestive dysmenorrhoea depends are various,
and may be either general or local or both combined. Plethora is rare
in females, and local congestions are much more frequently dependent
upon anæmia, the abnormal condition of the blood favoring them {196}
directly and also indirectly by its effect on the nervous system. In
past times gout and rheumatism were considered to act frequently as the
cause of dysmenorrhoea. They have almost disappeared from view since
the era of direct examination began. Malaria, however, as a possible
cause or a powerful factor should never be overlooked in regions where
it prevails. The sexual instinct plays an important rôle; enforced
abstinence, especially when suddenly brought about, and excess, being
alike effective etiological factors. Young widows and prostitutes are
both subject to this form of disease.

The local causes are numerous. Pelvic inflammations, as cellulitis or
pelvic peritonitis, give rise to the disease. Affections of the uterus
are frequent causes; displacements, as retroversion or prolapsus; and
inflammation, either parenchymatous or of the endometrium. Quite a
moderate grade of inflammation, as found during the interval, may,
under the increased congestion of menstruation, become extreme. Many
cases doubtless depend upon an ovarian influence even when no affection
of these organs can be made out. Scanzoni hazards the theory that the
maturation of Graäfian vesicles lying deeper than usual in the stroma
of the ovary is one cause of this form of dysmenorrhoea.

In neuralgic dysmenorrhoea the neurotic element preponderates. The
nerves play a part corresponding to that of the vessels in the
congestive form. In some cases of this class no organic lesions can be
discovered, and they are then termed idiopathic.

This form of dysmenorrhoea depends upon either a peculiar condition of
the general nervous system or upon hyperæsthesia of the sexual system,
or both combined. Either or both may have been inherited or acquired.
It is frequent in subjects of the hysterical temperament, and in those
presenting that preponderance of the nervous system so often seen as
the result of over-refinement, luxury, habits of idleness, and other
violations of hygienic law. Those subject to it often suffer from
severe headaches, neuralgia, and other nervous affections. It is often
caused by anæmia or chlorosis. Sexual influences, psychical or
physical, and especially those that excite without satisfying, are
sometimes efficient causes. Ovarian influence is often an important
factor; some authorities designate all those cases in which no
anatomical change can be found, ovarian. The prodromata of this form
are very apt to be some of those nervous attacks to which such patients
are liable, as headache or neuralgia, and they may be psychical, as
aberration of temper, undue irritability, or tendency to melancholy. In
character the pain is generally stated to be more acute than in the
other forms. It is subject to great and sudden alternations. In
acuteness and irregularity it often justifies the term spasmodic. From
these characters and from the absence of anatomical change a
differential diagnosis may be made. As in this form the most marked
nervous symptoms are witnessed, so are also the most pronounced
complications on the part of the general nervous system. They are often
hysterical in character, but may be of every kind and degree, even to
general convulsions, and mental aberration is sometimes a complication
or result.

Membranous dysmenorrhoea is characterized by the expulsion at the
menstrual periods of organized membrane, either as a whole or in
pieces. In the former case it is like a cast of the interior surface of
the {197} uterus. The expulsion of this membrane is accompanied by
pain, often of the most severe character. The pain presents well-marked
features; it is markedly expulsive, identical with that of the
obstructive form, closely resembling an abortion, to which the membrane
adds an additional element of similarity. This pain and these expulsive
efforts may continue twelve, eighteen, or twenty-four hours, and then
cease, to be renewed only at the next period.

This form of disease is rare--so rare that observers having a large
field of observation may never meet with over half a dozen cases. In
regard to many points very diverse views are held, and the limits of a
practical work do not permit even a statement of all of them. The
nature of the membrane is one of these points too important to pass
over. When thrown off entire, its internal surface is smooth and marked
by the openings of the utricular glands; its external or uterine face
is rough and villous. It presents the exact shape of the interior of
the uterus, with openings corresponding to the Fallopian tubes and the
os. It is impossible to escape the conviction that this membrane is the
lining membrane of the uterus, thrown off as a whole, instead of by
gradual melting down of its superficial layers, as in normal
menstruation. The microscope sustains this view, and this is the
generally received opinion; yet that the membrane is not always such is
testified by competent observers from observations with the same
instrument. It seems probable that this disputed point will be settled,
as have been so many others in medicine, in favor of both parties.
Siredey suggests the possibility of different kinds of membrane in
these cases, while Barnes boldly states this as a fact.

Various theories have been advanced to account for the formation of the
membrane. An abnormal course of conception, a changed ovarian
influence, a peculiar endometritis, have been from time to time
favorite terms in which to express our ignorance. Only in regard to the
first has unanimity been obtained. That the membrane is always a
product of conception is not now maintained by any respectable
authority. It is a well-established fact of the utmost importance that
such membranes may be expelled when there has never been sexual
intercourse.

The membrane of dysmenorrhoea is to be distinguished from fibrinous
masses, the remains of blood-clots from which the corpuscles have been
squeezed; from mucus coagulated into shreds by astringent injections;
and from the products of membranous vaginitis. Neither of these will
present much difficulty with the aid of the microscope. The case is
very different, however, when the membrane is to be distinguished from
the decidua of an early pregnancy. From a single specimen or a single
attack a diagnosis cannot be made. Thomas gives an instance of
disagreement as to the nature of the same membrane by two of the
highest microscopical authorities. The recurrence of the attacks at the
regular menstrual periods will establish the diagnosis.

The prognosis of dysmenorrhoea varies in the different classes. In the
obstructive form it will depend upon the curability of the lesion upon
which it depends, and the same may be said of the congestive. The
neuralgic cases do not yield readily to treatment, especially when
dependent upon a peculiar and perhaps inherited nervous constitution.
Caution should be exercised, however, in expressing an unfavorable
prognosis. {198} Like all nervous diseases in the female, it is subject
to great mutations without apparent adequate cause, and will sometimes
suddenly disappear in an inexplicable manner.

The membranous form affords still less promise of cure: the
unsatisfactory results of treatment are generally acknowledged.

During an attack of dysmenorrhoea the patient should remain in bed for
the benefit of rest and warmth. In those cases where the flow is not
too free, and especially when relief follows its appearance, active
measures to promote this end may be instituted by hot drinks and hot
fomentations. In married patients a hot sitz-bath, during which the
vaginal syringe is used to douche the uterus, is an efficient measure.
Pain being the prominent symptom, and remedies for its relief being at
hand and reliable, the indication is clear and the treatment can be
briefly stated. In execution, however, it is not a simple problem:
immediate relief is not alone to be considered. If opiates be resorted
to for frequently-recurring pain, a habit will soon be formed that is
no less a calamity than the disease itself. While, therefore, opium and
its preparations are reliable remedies, and in many cases
indispensable, they should be administered as seldom and as sparingly
as possible, and always with an appreciation of possible injurious
consequences. Many cases can be successfully managed with chloral
hydrate, or belladonna, or Indian hemp. When opiates are resorted to,
they should be combined as much as possible with other medicines by
which their effects are modified, and relief afforded with the smallest
possible dose. Thus in cases attended with vascular excitement these
ends may be attained by the union of opium with tartar emetic or
aconite; when there is marked disturbance of the nervous system, it may
be combined with an antispasmodic, as the compound spirit of ether.
Administration by the rectum will produce a local as well as a general
effect, and injections of starch and laudanum or suppositories of opium
and belladonna may be administered. The speediest and most certain
relief is afforded by the hypodermic syringe. Resort to it should,
however, be rigidly controlled; it should be used as a miser uses his
gold, and it need scarcely be added that only very exceptional, if any,
circumstances will ever justify placing the syringe in the hands of
friends or attendants, no matter with what restrictions. Unfortunately,
this is sometimes done, but very rarely without great injury resulting.

During the intervals general treatment should be instituted according
to the indications. All functions at fault are to be regulated. Anæmia
is to be corrected, the debilitating effects of malaria counteracted,
good digestion promoted, and a weakened nervous system strengthened.
These indications are met by tonics in various forms, notably iron and
zinc; by antiperiodics, as quinia and arsenic; by stomachics; and by
the judicious use of wine. There are other remedies quite as useful as
drugs--cold sponging and shower-baths, followed by vigorous rubbing,
general electrization, and, when the patient cannot or will not take
outdoor exercise, massage. Change of scene and air is sometimes
beneficial or even necessary. In many cases of pronounced neuralgic
form, or in which the nervous system has been shattered by the severity
or long duration of the attacks, there can be but little hope of
amelioration without a thorough change of habits and mode of life in
every respect.

The local treatment will be according to the conditions present. In the
{199} obstructive form, polypi are to be removed if present, and in
stenosis the patency of the canal restored. Dilatation may be
accomplished by tents. Should these fail, resort may be had to surgical
measures, as the frequent passage of bougies gradually increasing in
size, forcible dilatation with steel dilators under an anæsthetic, or
by incision. Each of these measures has its advocates, and with all
cures have been effected. Flexions should be corrected as far as
possible by a vaginal pessary. Intra-uterine pessaries more certainly
correct the deformity, but great care should be exercised in their use.
If inflammation be present, uterine or pelvic, they will not be
tolerated or will do positive injury; nor should a patient with any
instrument of this kind ever be allowed to pass out of reach of the
physician unless she can herself remove it.

The treatment of many cases of congestive dysmenorrhoea is very similar
to that of suppressed menstruation from cold--warm drinks, hot
foot- and sitz-baths, fomentations, and douches.

Particular attention should be paid to the bowels, not alone to correct
constipation, but to give full relief to a clogged portal system by
saline purgatives. If there be prolapsus, a pessary should be adapted
so as to keep the uterus up in its place; by this means passive
congestion is much relieved. Bromide of potassium is a reliable remedy
as a corrector of pelvic congestion. In the congestive cases of anæmic
subjects iron will act beneficially; in inflammatory congestion it does
injury. Dysmenorrhoea dependent upon hyperplasia or endometritis should
receive the treatment appropriate to those affections.

In neuralgic dysmenorrhoea the general treatment is far more important
than the local. All those hygienic and therapeutic measures already
detailed should be faithfully persevered with. For the relief of pain
and control of the nervous symptoms enemata of asafoetida are useful.
Chloral may also be administered in the same way or by the stomach,
with camphor, valerian, and the æthers as required. In this form apiol
has been successfully used; the evidence as to its value is clearer
than the explanations of its mode of action. It may be given in
capsules, each containing five grains, one, two, or three daily.

Some local measures often render good service: among them is the
passage of bougies, which sometimes modify the sensitiveness of the
cervical canal, as they do that of the male urethra. The galvanic
current, both continuous and Faradic, has effected cures, but the cases
to which it is best adapted or in which it is most likely to be good
cannot be clearly indicated. A galvanic stem-pessary may be used,
observing due caution. This instrument has been modified and much
improved by Thomas: being made like a string of metallic beads, it is
extremely flexible, and many of its former objectionable features are
removed.

A successful treatment of membranous dysmenorrhoea has not yet been
promulgated. The great difficulty of its cure is admitted by the
highest authorities. Some cases associated with stenosis of the cervix
have been cured by dilatation--a fact which but strengthens the general
principle of correcting all anatomical changes whenever possible.
Strong caustics have been applied to the interior of the uterus with a
view of exerting an alterative influence upon the seat of the disease.
The course seems correct in theory, but in practice it has not proved
fruitful of good results, and treatment in the majority of cases is
limited to palliation.

{200} In regard to marriage in females afflicted with dysmenorrhoea, it
may be stated to be advisable in many cases of the neuralgic form and
in anæmic subjects where the flow is so scanty as to border on
amenorrhoea. In cases of the congestive form, if dependent on
inflammation or on organic lesions, as fibroids, there is very great
probability that the symptoms will be aggravated by this radical change
of mode of life.


Menorrhagia.

The term menorrhagia signifies excessive menstrual flow. The excess may
be by increased rate of discharge during the usual time, by lengthened
duration, or by too frequent returns of the periods.

There are wide physiological limits to the amount of discharge and the
duration of a menstrual period. While the average time is from three to
five days, and the average amount from three to five fluidounces, both
these terms may be doubled, or, on the other hand, they may be
diminished to a single day and a single ounce, without detriment to the
health. Menorrhagia may be said to exist when the flow is in excess as
compared with what is usual with the individual, or when the loss is so
great as to affect her general health.

The periodical return of the flow is of prime importance in
establishing the existence of menorrhagia. Repetition at periods
approximating the menstrual is the keynote of diagnosis. By this
menorrhagia is distinguished from the hemorrhage of a miscarriage and
from metrorrhagia. A profuse flow of blood after an absence of
menstruation for one or two months is held by patients, in perfect good
faith, to be the effect of taking cold: with almost absolute certainty
such a train of events indicates an abortion. Metrorrhagia is uterine
hemorrhage occurring independently of the menstrual periods. More
surely indicative of organic disease than menorrhagia, it is often most
closely allied to it; many cases which in the early stages present an
increased menstrual flow as a symptom are at a more advanced period
accompanied by metrorrhagia.

Thus far the diagnosis of menorrhagia is easy. Not so that differential
diagnosis upon which alone can therapeutic measures be based.

This derangement depends upon as many and as widely diverse causes as
the others. It is often one expression of affections of the general
system, is sometimes caused by disease of organs neither pelvic nor
generative, is a common symptom of a number of organic diseases of the
uterus, or it may be simply functional. The necessity for a thorough
physical examination is apparent. By touch, single and bimanual, by the
speculum, and by the uterine sound the condition of all the pelvic
organs should be investigated. These means failing to reveal the cause
of the menorrhagia, the examination should be pushed farther. The
cervix should be dilated by tents and the cavity of the uterus
explored. Very frequently this measure, and this alone, will reveal the
cause of the derangement. Such an examination is often as valuable for
its negative as for its positive results. No practitioner fulfils his
duty to his patient or is just to himself who treats a menorrhagia for
any length of time without making a physical examination. It may seem
unnecessary to emphasize so plain a duty, yet consultants very
frequently find cases in {201} which palpable causes of the disease
exist and where a direct examination has not even been proposed.

The following schedule will indicate the widely diverse conditions
which may give rise to menorrhagia, and will serve as a guide to the
study of the subject:

  CAUSES OF MENORRHAGIA.--
       I. Diseases of the General System:
          Plethora;
          Chlorosis and anæmia;
          Debility, as from excessive lactation;
          The exanthemata and typhoid fever;
          Hæmophilia;
          Scorbutic, uræmic, and malarial cachexiæ.
      II. Local Affections, not Uterine:
          Cerebral, as psychical influences;
          Cardiac and pulmonary affections, as valvular disease,
            emphysema, and phthisis;
          Hepatic diseases, as cirrhosis and the changes produced by
            residence in tropical climates;
          Splenic and renal disease;
          Abdominal tumors and loaded bowels;
          Peri-uterine inflammations;
          Ovarian influences.
     III. Uterine Causes:
          Subinvolution;
          Areolar hyperplasia;
          Endometritis, with fungous growths;
          Laceration of the cervix, with eversion;
          Ulceration of the cervix;
          Displacement of the uterus;
          Polypi and fibroid tumors;
          Retention of products of conception;
          Malignant disease;
          Congestion.

I. Menorrhagia, the result of the first class of causes, but rarely
occupies more than a subordinate position. The acute affections, as the
exanthemata, do not afford time for more than a single flow, and this
has been well termed uterine epistaxis. The condition of plethora is
manifest. The cachexiæ are generally well marked and evident. An
exception may be made in this regard as to the effect of prolonged
residence in malarious locations. There can be no question that
menorrhagia is frequently of malarial origin, and even when the patient
does not present a cachectic appearance. The disease may be produced by
hepatic and splenic derangement, by deteriorated sanguinification, or
by depression of nervous force. Menorrhagia is not infrequently a
result of Bright's disease; an examination of the urine would determine
this point. That the opposite conditions of plethora and anæmia should
both cause menorrhagia is not difficult of explanation; in the one
there is excess of blood with increased vascular pressure; in the
other, a changed condition of the blood favoring transudation, with
loss of tone of the vessels.

II. That menorrhagia, as well as amenorrhoea, may have a purely {202}
emotional origin there can be no question, although this cause is not
generally recognized. The following case is an illustration: A healthy
young married woman, while menstruating, saw a neighbor's son thrown
from his horse; his foot became entangled in the stirrup, and he was
trampled to death before her eyes. She was immediately taken with
flooding, and profuse menstruation occurred for several succeeding
periods. Siredey expresses doubts as to cardiac and pulmonary diseases
so frequently causing menorrhagia as they are generally believed to do.
In a considerable experience during several years, and paying special
attention to this point, he found but one case thus caused. The
mechanical effect of disease of the abdominal organs in producing
passive congestion in distal parts is more direct and the influence in
producing menorrhagia more apparent. The same may be said of
accumulations in the bowels and the pressure of abdominal tumors.
Peri-uterine inflammations rank very high in the list of causes: their
presence and results, direct and indirect, as abscesses, displacements
of the uterus, etc., should never be overlooked. Ovarian influence is
naturally a potent etiological factor; menorrhagia is a frequent result
of sexual excesses, and is often seen in prostitutes and where there is
great disparity of age between the husband and wife.

III. Affections of the uterus itself are by far the most frequent cause
of menorrhagia. The necessity of investigating accurately the condition
of the great central organ of menstruation, and of ascertaining to what
particular disease the derangement of the flow is to be attributed,
will bear repetition. That an anatomical or pathological diagnosis can
always be made is not maintained, but when examination has failed to
reveal a basis for such a diagnosis, the practitioner should distrust
his position and consider his diagnosis provisional only, awaiting more
information from renewed examination or from further progress of the
case. The cases are few in which such a diagnosis cannot be made. They
are recognized by the term congestion as a cause in the schedule given
above. Congestion is of course the prominent factor in many cases of
menorrhagia, as in those from polypi and fibroids, those produced by
ovarian influences, and others which are evident. But the class here
recognized consists of those cases in which no anatomical or other
cause can be found, excess of the congestive element of menstruation
alone affording a rational explanation. Such cases occur most
frequently at the two extremes of life--at puberty and at the
menopause. During both these periods menorrhagia often occurs
unexpectedly and inexplicably.

The grosser forms of uterine growths, as malignant disease, polypi, and
fibroid tumors, are generally discovered without difficulty. The touch
reveals them, or the sound or bimanual examination indicates their
possible presence, which is confirmed by dilatation of the cervix and
exploration of the cavity of the uterus. This class of cases gives rise
more frequently to metrorrhagia; only exceptionally is the hemorrhage
confined to the menstrual periods.

A recent delivery in the history of the patient will indicate with some
probability one of several conditions which may give rise to
menorrhagia. Especially is this the case if the complete generative
cycle has been broken in any part of its course. If there has been a
miscarriage, there will be great probability of retained portions of
the placenta or membranes; {203} if from death of the child or other
cause nursing has not been performed, the conditions will be favorable
for subinvolution of the uterus; if labor has been instrumental or
precipitate, laceration of the cervix may be suspected. The first two
far exceed in frequency the last as causes of menorrhagia. Laceration
of the cervix exists often without producing this functional
disturbance, while subinvolution and retention of products of
conception are very often active agents.

Displacements of the uterus, either prolapsus or versions and flexions,
often have menorrhagia as a symptom.

The chronic inflammatory affections of the uterus are fruitful causes,
and menorrhagia is often found associated with, and sometimes dependent
on, the condition known as chronic corporeal metritis or areolar
hyperplasia, with consecutive erosions or ulcerations. Inflammation of
the lining membrane of the uterus accompanied by granulations or
fungous growths is one of the most frequent causes of menorrhagia.
Opinions differ as to the part inflammation plays in producing this
condition. Its entire absence in some cases is not improbable, the
fungosities springing from the seat of the placenta. By Winckel the
affection is termed adenoma diffusum et polyposum corporis uteri; by
Olshausen it is called endometritis fungosa. Under various names the
condition is well known and recognized as one of the most frequent of
all the uterine causes of menorrhagia; Siredey believes it to be the
origin of nearly one-half the cases. Due consideration of this cause is
especially important, because especial investigation is required for
its detection. The cervix must be dilated and the blunt curette passed
over the internal uterine surfaces. This will furnish ocular and
tangible evidence by detaching and bringing away some of the fungous
growths, and a diagnosis will thus be made impossible in any other way.

In considering the treatment of menorrhagia the management of the
patient during the intermenstrual periods must first engage attention.
The general health is to be promoted in every possible way and sound
hygienic regimen enforced. Two points demand especial attention--the
clothing and the bowels. All tight bandages around the abdomen should
be loosened, and all skirts and underclothing which hang upon the hips
be supported from the shoulders. The beneficial influence of free
action of the bowels cannot be overrated. Regular daily movement is
required in all cases, but much more is often of decided benefit. In
menorrhagia of the menopause in patients who have accumulated
considerable adipose tissue, especially about the abdomen, in those
where there is evident hepatic derangement, and in some others free
purgation with salines is one of the most efficient measures of
treatment.

During the menstrual intervals cachexiæ are to be treated according to
their nature. Chlorosis and anæmia will require iron, quinine, nux
vomica, and other tonics--the malarial cachexia the same, with the
addition of arsenic, which often renders especial service under these
circumstances. Then, too, the various uterine lesions giving rise to
menorrhagia must be corrected. Subinvolution is to be remedied, polypi
removed, the evil effect of fibroids combated by hypodermic injections
of ergot, displacements corrected by suitable pessaries, the tone of
the vessels and tissues of the pelvis increased by cold bathing, and
all indications fulfilled according to the nature of the case. For
details of treatment the reader {204} is referred to the articles upon
the various general, local, and uterine diseases which have been shown
to cause menorrhagia.

Especial attention should be given to girls whose menstrual life begins
with menorrhagia, lest a vicious habit become fixed. The evils of
school-life or those of sedentary indoor occupations should be
corrected, and rest in the recumbent position during menstruation
enforced. For the menorrhagia of puberty tonics, especially nux vomica
and brief applications of cold to the pelvic region, are particularly
indicated.

During an attack of menorrhagia the first remedy, and one without which
all others are useless, is rest in the recumbent position. If the
attack be severe recumbency should be absolute. Food should be light in
quality and moderate in amount, while all drinks are to be taken cold,
as ice-water, iced lemonade, or water acidulated with sulphuric acid
and sweetened to the taste, the beneficial effect of acids in addition
to cold being generally recognized. The bed should be hard and the
clothing light, and the foot of the bedstead may be raised some inches.
Many cases require no more active measures of repression. In subjects
about the menopause, in some cases of malignant tumor, and in some
others the hemorrhage seems to be a vent, and in moderate degree is
rather beneficial. Such cases are to be watched, but need not
necessarily be actively treated, certainly not with repressants and
astringent applications, until regimen and mild measures have been
tested.

In proceeding to medication the state of the general system first
demands consideration. If there be increased vascular action and
temperature, with evidences of active congestion of the pelvic region,
manifested by pain, distension, and tenderness of the hypogastric
region, with heat and throbbing of the passages, arterial sedatives and
relaxants will be demanded. Aconite or veratrum viride may be given
until an effect is produced on the pulse, and they may be combined to
advantage with salines, as the liquor ammonii acetatis. It is in these
conditions, of rare occurrence, that nauseants, such as ipecacuanha,
are of service.

Medicines having a more direct action in checking uterine hemorrhage
produce their effect by exciting contraction of the uterine walls and
blood-vessels, moderating congestion, and modifying the condition of
the nervous system. They are ergot, digitalis, bromide of potassium,
quinine, cannabis indica, and cinnamon.

Ergot stands at the head of the list from its well-known effect in
causing uterine contraction, and although reliable in proportion to the
increased size of the uterus and the distension of its cavity, it is
indicated in almost all cases for its hæmostatic action on the
capillaries, as well as for its specific action on the uterus.
Digitalis slows the action of the heart and excites the contractility
of the arterioles, while experience has proved it to be an efficient
remedy for menorrhagia. Bromide of potassium moderates vascular and
nervous excitement of the pelvic organs, and is especially indicated in
cases having an ovarian origin. Several of the French writers give very
strong testimony in favor of the efficacy of cinnamon as a remedy,
having tested it in a large number of cases without other medicines. It
may always be used as an adjuvant.

All these medicines may be combined in various proportions, and they
should be given in full doses. Infusion is the best form for the
administration of digitalis. Sulphate of quinia in doses of gr. vj-x is
often an {205} efficient remedy, and especially in cases where there
have been malarial influences. Cannabis indica is stated, by very high
authority, to be one of the best remedies, although its mode of action
is not clear. Iron should be administered as an hæmostatic tonic, and
not merely because there is some uterine disease or derangement.

The action of medicines may be supplemented by local applications.
Cloths wrung out of cold water or vinegar and water may be applied to
the hypogastric region or to the vulva. A bladder or rubber bag filled
with pounded ice may be laid on the abdomen above the pubes, or applied
to the lumbar region for its effect upon the spinal cord. One of the
most efficient means of applying cold is by an enema of cold water, or,
this failing, of ice-water. The rectum and uterus being contiguous, the
cold is applied almost directly. Siredey speaks highly of the cold
douche to the soles of the feet, the water being projected in jets from
a sprinkler. During the application uterine contractions are felt and
the flow stops. This is more especially adapted to debilitated and
anæmic patients with loss of vascular tone. Patients will often object
to the application of cold to check a flow of blood from the uterus,
knowing well the bad effects of suppression of menstruation which often
results from exposure to this agent. It is believed that evil results
never follow the application of cold when the flow is excessive;
perhaps because the system and the organs concerned have been relieved.

The application of heat is also an efficient remedy--hot-water bags to
the spine on Chapman's plan, or hot vaginal injections may be
administered, as recommended by Trousseau and Emmet, the water being at
a temperature as high as the patient can bear. To be properly
administered the aid of a nurse is required, as the flow should be kept
up for some time, at least a gallon of water being used.

There is only apparent contradiction in the use of both cold and heat
to check uterine hemorrhage. Various explanations of the action of both
have been given, and much argument presented why one should act better
than, or be preferred to, the other. The truth is, that both are
efficacious, and the value of both is based upon clinical experience.

The flow in menorrhagia is sometimes, if rarely, so excessive as to
demand mechanical means of restraint. A well-applied tampon gives
absolute control, and should never be omitted when the hemorrhage is
severe and the practitioner is not within easy reach of the patient.
Plugging the cervix with a sponge tent, supported by a vaginal tampon,
is to be preferred as most reliable, and also because upon its removal
the uterus can be explored for diagnosis or is prepared for direct
applications. Should a vaginal tampon alone be trusted, it must be
thoroughly applied to be reliable. This can only be done through a
speculum, preferably with Sims's duckbill. Pledgets or discs of cotton,
the first provided with strings to facilitate removal, squeezed out of
a carbolized saturated solution of alum, should be packed carefully and
firmly around and over the cervix, and the vagina filled. A folded
napkin to the vulva, supported by the usual T bandage, sustains the
whole. Such a tampon may remain, if necessary, thirty-six hours, the
catheter being used to relieve the bladder.

Direct applications to the interior of the uterus are sometimes
necessary both to check the flow and, in some cases, especially those
dependent {206} upon fungous growths of the endometrium, as a means of
cure. They may be either fluid by application or injection, or solid.
The former may be by swabbing the interior of the uterus by means of an
applicator armed with cotton dipped in the liquid, or by injection. The
drugs used for application are carbolic acid diluted with glycerin or
pure tincture of iodine, or the stronger tincture known as Churchill's,
Monsell's solution, or the liquor ferri perchloridi diluted or of full
strength. The preparations of iron are objectionable from the hard,
gritty, and disagreeable coagula formed, and the tincture of iodine is
generally quite as efficient as a hæmostatic and more active as an
alterative.

For efficient application the cervix should be dilated if not
sufficiently patulous, and a cervical speculum should be used, or the
solution will be squeezed out of the cotton before it reaches the seat
of the disease. For injection the same articles are used, beginning
with weaker solutions and gradually increasing the strength. They
should never be resorted to without the utmost caution. The os should
be patulous as a sine quâ non, and the injection carefully
administered. In case the os is open the instrument may be the common
extra long-pipe rubber syringe bent to a suitable curve by heating.
This having been charged with a drachm or so of the liquid, the end is
served with cotton like an applicator; over this several clove-hitch
turns with a string are taken, so that the cotton may be withdrawn if
pulled off in the uterus. The pipe is then carried to the fundus and
the piston very slowly depressed. Buttle's syringe is a more elegant
and a safer instrument in cases where the os is not thoroughly opened.
The terminal pipe of this instrument is very slender and perforated
with minute openings, and the piston is forced in by screw-action of
the handle, so that the fluid is expelled drop by drop.

Nitrate of silver is sometimes applied in solid form to the interior of
the uterus, both as a means of checking excessive hemorrhage and to
effect a cure by modifying the condition of the endometrium. It may be
done with a probe, the end of which has been coated with the substance,
passed in detail over the inner surface of the organ. A piece of the
solid caustic is also sometimes carried into the uterus and left there,
the application à demeure of the French, some of whom claim that in
their hands this measure has never failed to check the hemorrhage.

In those cases where positive evidence has been gained that the disease
depends upon fungous growths of the endometrium there is yet another
and a more reliable remedy. It is the curette. By this instrument the
growths which are the origin of the menorrhagia can be certainly and
safely removed, their return prevented by a thorough application of
iodine to the surface from which they spring, and a cure often effected
when all other means have failed.

Intra-uterine applications, injections, and surgical measures affecting
the interior of the uterus have been detailed, as they are advised and
used by authorities. It remains to give an opinion as to their merits,
and to state the precautions which should be taken when they are
resorted to.

First, it must be said that there is a very considerable difference of
opinion as to the safety of these measures. While some do not hesitate
to apply to the interior of the uterus fuming nitric acid, and
introduce pieces of nitrate of silver to dissolve there, others are
extremely careful {207} about making any applications to this part, and
reject intra-uterine injections altogether. Nor can it be denied that
very severe symptoms have frequently, and death sometimes, followed the
application of these remedies. In resorting to them, therefore, the
practitioner cannot be too minute in observing every precaution, and
they should never be resorted to if evidence of peri-uterine
inflammation exists. No intra-uterine injection should be given unless
the os be patulous, and the fluid should be thrown in with the utmost
gentleness. The milder articles should be tried first, and the severer
only as the temper of the uterus is tested. Always treat the patient
afterward as the subject of an operation, keep her in bed strictly, and
combat the first symptoms of trouble with opium.

While the writer would not be just to the reader if he did not state
that some very high authorities are strongly opposed to intra-uterine
injections and applications, he would not be just to himself did he not
state that his own experience has been favorable to them. While he once
saw severe and dangerous symptoms follow syringing the cervix with
water to cleanse it of mucus, he never in a single instance saw any
evil effects from intra-uterine injections properly administered, nor
from nitrate of silver à demeure or the application of nitric acid. But
while these measures have often ameliorated cases of menorrhagia where
the endometrium was affected, they have seldom cured, as compared with
the curette. Indeed, the general statement may be made that as of late
years the value of the curette has become more and more recognized,
resort to severe intra-uterine applications has proportionally
diminished. From his experience he is fully prepared to believe with
Courty, that "there are cases of uterine hemorrhage which cannot be
mastered in any other way," and with Siredey, that "the operation cures
in the great majority of cases." It should be noted, in this
connection, that some of the warmest advocates of the instrument
explain its beneficial effects otherwise than by the removal of
fungosities. Thus, Thomas attributes them to "the fracture of tortuous
and distended blood-vessels," and Siredey to "the irritation and
excitation produced by its introduction and action during reflex
contractions."




{208}

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC PERITONEUM.

BY B. F. BAER, M.D.


The subject of inflammation of the tissues surrounding the uterus and
its appendages would be very much simplified, especially for the
general practitioner, by debarring it of all new and superfluous names
and subdivisions, and by treating it on a broad clinical basis. It will
be my aim in this paper to keep that idea constantly in view, rather
than to follow the history and varying pathological views by which it
has been surrounded and complicated.

The importance of this disease is probably greater in its influence on
the health and future usefulness of the woman than any other; and its
causes and prevention, as well as its early recognition and treatment,
should be fully understood by the physicians who are most likely to be
first consulted in the matter, those engaged in general practice. I
feel safe in making the statement that were this so, many of the
chronic cases of almost incurable displacement of the uterus, Fallopian
tubes, and ovaries, resulting from thickened, indurated, and contracted
ligaments, with their distressing symptoms, would never reach the
gynecologist, because they would not then exist. In many cases the
disease would have been prevented; in others it would have been
arrested in its incipiency.

Whether we understand the primary pathological lesion to be
inflammation of the cellular tissue, the peritoneum, the lymphatics, or
the veins, matters very little, practically, if we recognize the
immediate location of the process; for there can be no doubt that the
disease, once started, soon involves to a greater or less degree all of
the tissues and organs adjacent to it, and the therapeutic requirements
will be much the same in either case.

That inflammation of the cellular tissue can exist without also
involving the peritoneum in its neighborhood is scarcely to be
conceived, and vice versâ; but the one has always a predominating
influence over the other, and differs somewhat in its cause, course,
and consequences. When the inflammatory process has its origin in the
cellular tissue, it is more likely to run through a regular course and
end in abscess than if it had started as a peritonitis, in which case
the course of the disease is often more chronic, resulting in the
formation of false membranes which bind the uterus and other pelvic
organs in permanent displacement. For these reasons, and for the more
systematic study of the subject, I think it best to follow the plan of
those authors who describe the disease separately under the two general
heads, Parametritis and Perimetritis.


{209} Parametritis.[1]

[Footnote 1: Virchow, Duncan.]

DEFINITION AND SYNONYMS.--By parametritis is understood an inflammation
of the cellular or connective tissue near the uterus and beneath the
pelvic peritoneum, including principally the locality close to the
lateral margin of the uterus between the layers of the broad ligaments,
although embracing also all of the various spaces where connective
tissue abounds--viz. between the peritoneal folds which form the
utero-sacral and utero-vesical ligaments. I think it a better name than
pelvic cellulitis or peri-uterine inflammation, because it more
correctly expresses the primary location of the disease than any other.
The disease has been described under many other appellations, among
which have been pelvic abscess and peri-uterine phlegmon.

ETIOLOGY.--Parametritis does not occur before puberty, and rarely
before the great predisposing causes, abortion and injury at
parturition, have prepared the parts--opened up the channel--for the
more ready advance of the inflammatory process. This is easily
understood when we remember how compactly bound together are these
ligamentous folds, and how small the cellular-tissue spaces are before
impregnation when compared with the condition of the parts after the
function of gestation has been performed. Even were no accident to
occur to interfere with the perfect involution of the parts which enter
into the process of the expulsion of the product of conception, the
tissues would probably always remain more vulnerable than before the
gestation had occurred. But when the retrograde change which is
necessary to perfect involution is retarded, a condition of relaxation
and looseness of the parts results which increases many fold the
liability to the affection. The blood-vessels and lymphatics remain
large, and the connective-tissue cells are not only larger in size, but
a cell-proliferation is probably induced as a result of the increased
amount of blood-supply. Then a certain low condition of the general
nutrition, a diathesis or an inflammatory tendency, no doubt act as
predisposing causes of this disease. Now, add to the predisposing
causes the injury which probably always attends abortion, and that
which so often results from parturition proper, and a condition results
which I believe to be the cause of parametritis in the majority of the
cases.

Abortion the result of accident or design is a most prolific cause of
parametritis, because abortion is so often followed by endometritis,
which is frequently the starting-point of the former. Abortion results
in a wounding of almost the entire surface of the uterine cavity, from
which the placenta is torn, and often also in direct injury to the
tissues of the neck of the womb. This almost necessarily interferes
with involution; and if nothing worse follows immediately, there is
left a strong tendency to a low grade of inflammation or
hyper-nutrition, which may practically result in the same condition of
induration and thickening of ligaments. It is seldom that the subject
of an abortion of this character escapes from a certain degree of
parametritis. If it does not manifest itself at the time in violent
symptoms, the results are found afterward, when the patient is forced
to consult her physician for the relief of suffering the consequence of
the thickening and induration mentioned above.

{210} Parturition without injury or accident is a predisposing cause,
as before mentioned, of parametritis, and renders the patient more
susceptible to the disease from cold, fatigue, etc., and from septic
influences; but when the labor has resulted in injury to the soft
parts, as laceration of the cervix, endometritis, injury to the vessels
outside of the uterus, in the broad ligaments from pressure, the
disease is far more liable to follow.

Parametritis may result from the various operations on the perineum,
vagina, and uterus; from the application of medicines to the uterine
cavity; and it is even said that the disease has been excited by the
introduction of the uterine sound. I cannot believe that the simple
introduction of the sound, when properly done, can be the means of so
much harm. If harm follows, it must result from carelessness or want of
skill. Of course there are contraindications to the use of the sound,
and if these are violated evil will often follow. The use of the
instrument ought not to be thought of if a suspicion of pregnancy
exists, or when there is marked tenderness of the uterus or of the
parts around it, or just before, during, or immediately after
menstruation, and certainly not when active inflammation is present.
Then the awkward manipulation of the sound when the uterus is fixed as
a result of a former inflammation is very apt to relight anew the
process.

If the same restrictions are applied and care used in the medication of
the uterine cavity, the cases in which parametritis will follow as a
result will be almost nil. The same will apply to operations. The
danger lies in proceeding with the treatment of cases as they present
themselves, by a hurried method and without fully investigating the
condition of the tissues and organs outside of the uterus itself.

There is probably no place where experience is of more value than in
the manipulations and instrumental measures necessary for the diagnosis
and treatment of the various diseases of the pelvic organs--where more
depends upon the skill and care of the operator. I believe, with
Duncan, that pelvic inflammation and abscess are always secondary, and
that these tissues are not specially inclined to idiopathic
inflammatory action. But, undoubtedly, certain low conditions of the
system or certain individual peculiarities furnish such a strong
predisposing influence that a mechanical cause otherwise inactive will
be sufficient in some of these cases to produce the disease. We
probably see this expressed most fully in the low types of puerperal
inflammations which develop gradually and without apparent cause, so
far as injury at labor is concerned, and which often persistently
progress to a fatal termination. It will be said that these are cases
of septic origin; and it may be true, but I believe the poison is
developed autogenetically.

COMPLICATIONS.--Parametritis is usually associated with perimetritis,
and it may be complicated by ovaritis, endometritis, and salpingitis.
Uterine displacement also often complicates this disease; and I wish
here to emphasize the statement that no attempt should be made at
restoring the organ to its normal position until all evidence of active
inflammation shall have subsided. I have seen great harm result from
such attempt having been made on the supposition that the symptoms were
due to the displacement rather than to the parametritis.

ANATOMY, PATHOLOGY, COURSE, AND TERMINATION.--Everywhere in the pelvis,
below the peritoneum, connective tissue is found in sufficient {211}
abundance to serve the purposes for which it exists--viz. first, as a
bond of union between the pelvic viscera and organs, bladder, uterus,
rectum, ovaries, and Fallopian tubes; second, to surround, support, and
protect the numerous blood-vessels, lymphatics, and nerves from injury
during the mechanical disturbances to which the pelvic tissues are
subjected in the performance of their various functions.

If it were not for the padding of the pelvic connective tissue, which
allows a free range of movement to the pelvic contents, the ordinary
sudden jars from walking, coughing, etc. could not be sustained without
pain, nor could the functions of the rectum and bladder be fulfilled
properly; much less could the functions of coition and gestation be
performed. This cellular tissue most abounds where it is most
needed--in the locality or spaces where the vessels and nerves are
found in greatest number; viz. at the sides of the uterus and upper
portion of the vagina, extending outward between the folds of the broad
ligaments toward the pelvic wall and the under surface of the Fallopian
tubes and ovaries; next, within the folds of the utero-sacral ligaments
and the vesico-uterine space beneath the peritoneum. There is little
between the peritoneum and posterior vaginal wall, between the bladder
and its peritoneal investment, as well as between the rectum and
peritoneum; and there is none between the latter membrane and the
posterior, superior, and anterior surfaces of the body of the uterus.

This areolar tissue is the seat of the disease under consideration, and
from a priori reasoning it would be inferred that the inflammatory
process would be found most frequently and in greatest severity in the
locality where this tissue and the vessels most abound; and this is
true, for parametritis almost always has its starting-point immediately
at the sides of the uterus, in the lower inner edge of the broad
ligaments.

But there is another reason why the disease so often begins here. It is
the point, which, with the cervix, must bear the brunt of the pressure
and injury during parturition and abortion, as well as from many of the
operations which are performed upon the uterus. That inflammation of
these tissues is secondary to injury is proven by the fact that we so
often find the results of it, induration and thickening of the broad
ligaments, in the cases of laceration of the cervix which come under
our care. I have constantly observed that the inflammatory indurations
were greatest on the side on which the laceration was most extensive,
and that were the laceration unilateral the evidences of inflammatory
action would be unilateral also. I have so frequently met with this
condition in connection with laceration of the cervix that I have come
to regard its entire absence as quite exceptional. I refer now to the
deeper lacerations. Of course these inflammatory products are met with
when the cervix is entire and apparently healthy, but this does not
disprove the statement that they are probably invariably secondary, and
very often secondary to injury at labor; for while the cervix may have
escaped laceration, the tissues and vessels may have been so contused
from pressure and instrumental measures as to result in the disease.
But, however originated, the inflammation and infiltration advance in
the direction of least resistance--_i.e._ along the course of the
connective-tissue spaces between the various ligaments. The product of
the inflammation, the pus, would therefore most likely follow these
channels in making its exit. If the primary inflammation arise at {212}
the base of the broad ligament, it may travel within the folds of the
ligament outward to the lateral wall of the pelvis and upward to the
iliac fossa. This is probably the course which is most commonly taken
by the process in puerperal parametritis, and to which is due the
induration and tumor which so often exist in that region during the
course of the disease. Tumor in the iliac fossa, however, is not at all
uncommonly met with in the course of a severe parametritis in the
non-puerperal state, and it is doubtless of the same pathological
character. Or the infiltration may propagate in the folds or under
surfaces of the utero-sacral ligaments, resulting in the formation of a
tumor which may eventually surround the rectum. In rare cases, and
probably only in the puerperal, the process may develop higher up and
more anteriorly, finally taking the direction and following the course
of the round ligaments; but I have never met with an instance of it.
And it would be impossible to tell correctly in a case opening in the
groin--without a post-mortem demonstration, the opportunity for which,
fortunately, does not often occur--whether the pus had not descended
subperitoneally along the pelvic brim toward the inguinal region. Of
course the inflammation and infiltration may be general, so that the
uterus may be surrounded by exudation tumors, but this is the
exception. Inferiorly, the parametritic process is limited by the
pelvic fascia which covers the levator ani muscle.

Parametritis, as phlegmonous inflammations elsewhere, has three stages:
1st, that of active congestion; 2d, that of effusion of serum; 3d, that
of suppuration. But the disease does not reach the third stage in all
cases. It may be arrested in the first stage or end by resolution in
the second. I believe, however, that resolution in the second stage is
the exception and not the rule. First, because to end in suppuration is
the natural course of the disease; and secondly, because in many of
those cases which are carefully observed the ordinary symptoms of the
formation of pus, as chill, etc., are usually manifested, and followed
by its evacuation. The fact that pus is not discovered should not be
accepted as proof that the disease has not advanced to the suppurative
stage; for it may be so small in quantity as to escape observation, or
it may be discharged into the bowel so high up as to mix with the fecal
matter, so that its character is lost by the time it is expelled from
the anus, or the point of exit may be so small as to allow it to escape
guttatim, and thus elude detection.

Further, pus is sometimes formed and reabsorbed harmlessly, or it may
remain deeply seated in a cavity--usually, under these circumstances, a
number of small cavities--where it may undergo decomposition and result
in the absorption of septic material and destruction of the patient
before it finds exit. Then, again, it may become encysted and be
retained indefinitely, when it is a source of constant and sometimes
obscure suffering, as well as an abiding cause of a renewed attack of
the disease.

It is probable also that the process is sometimes arrested in the
second stage, neither resolution nor suppuration taking place, the
serous portion of the liquor sanguinis being absorbed, the remainder
undergoing a change to plastic lymph, so called, which proceeds to
organization, resulting in persistent induration of the affected parts;
or, instead of being absorbed, the serum may remain encysted within
cavities formed for it by the lymph. This likewise subjects the patient
to the constant menace of a renewal of the inflammation. The late D.
Warren Brickell of New {213} Orleans has called special attention to
what he named the serous form of pelvic inflammation, and which he
thought had been too much neglected.[2] I have met with at least one
well-marked case which supports Brickell's views.

[Footnote 2: "The Treatment of Pelvic Effusions," _Amer. Journ. of the
Med. Sciences_, Philada., April, 1877.]

The usual course, however, of an acute parametritis which has advanced
to suppuration is evacuation of the pus by the most favorable
channel--_i.e._ through the rectum or vagina. If through the latter
organ, the point of perforation is either directly posterior to, or a
little to the side of, the cervix. But if the inflammation be located
in the vesico-uterine space--which is rare, however--the point of
rupture may be anterior to the cervix. Less frequently the bladder is
perforated and the pus discharged with the urine. More rarely the
abscess is discharged through the abdominal wall, groin, or saphenous
opening, and still more rarely through the sacro-ischiatic and
obturator foramina. It may also find exit through the floor of the
pelvis near the anus, and it may rupture into the peritoneal cavity,
but the latter termination is fortunately the least common. This is
probably due to the fact that the slightest irritation and pressure,
under these circumstances especially, result in adhesive inflammation
between the peritoneal surface of the abscess and that of the intestine
with which it may be in contact, thus favoring rupture into the
intestinal tract. Then, rupture into the intestine is conservative and
protective, and the other is not, for should the pus be discharged into
the peritoneal cavity the patient would most likely perish.

When the abscess opens at its most dependent portion, which is the
rule, it is kept thoroughly drained of the pus, and if a single cavity
exists it gradually contracts, and under favorable circumstances soon
disappears, the trouble ending by absorption of the wall of the
abscess. This is the most favorable termination of a parametritis, and
belongs only to the acute form.

When the pus has not been evacuated from the bottom of the sac, or when
there is more than a single cavity and only one is drained, or where
the pus has taken one of the circuitous routes mentioned above, the
disease merges into the chronic form, and may then be indefinitely
prolonged by the formation and evacuation of abscess after abscess,
until the pelvic cellular tissue becomes involved throughout and
riddled by fistulous tracts connecting them.

SYMPTOMATOLOGY.--Pain is probably the first symptom to attract the
attention of the patient, and if the attack is sudden or acute the pain
is usually attended by a chill of more or less severity. The pain may
be so sharp and lancinating as to cause the patient to cry out in
agony, or it may be of a throbbing, aching character. If the former, it
indicates either intense congestion of the vessels and tissues
involved, or that the peritoneum is largely implicated, probably both.
Where the pain is of this character the attack is usually of shorter
duration, since it is soon followed by the second stage, exudation,
when the symptom is at once modified, becoming less acute and
resembling now the pain attending an attack of less severity. Of course
the location of the pain corresponds to the seat of the inflammatory
process. If it is in one or the other broad ligament, the pain is
greater in the right or left iliac regions, most {214} frequently in
the left. Pain is often experienced in the hypogastric and sacral
regions in the beginning of, or preceding, an attack of parametritis,
and it is due to congestion of the endometrium and uterus, from which
the disease is spreading to the looser cellular-tissue spaces in the
ligaments. If, however, sacral pain persists throughout the course of
the disease, or exists in that region chiefly, it indicates that the
inflammation has become general or has invaded the utero-sacral
ligaments. But it would not be correct to estimate the extent of the
disease by the amount of pain complained of, for that symptom depends
so largely upon the temperament of the patient and her station in life
that it is not trustworthy. Some women suffer so much that they become
inured to it or acquire the habit of suffering in silence; others, from
temperament, do not actually experience pain; whilst others, again,
from a love of hardihood, do not complain, although they may be
enduring constant and severe pain. To one of these classes those cases
must belong which are said to pass through an attack of parametritis
without suffering. That cases do rarely present themselves, on account
of mild but persistent symptoms, which are found on examination to
contain a large pelvic exudation, I can attest; but I have so
constantly found on careful questioning that the usual symptoms of
pelvic inflammation were present at some time during the course of the
existing illness that I cannot agree with the statement made by some
authors that this disease may develop "without causing any particular
disturbance" (Emmet).

As a rule, the bladder and rectum are reflexly affected, the former
sometimes becoming very irritable, so that there often exists a
constant desire to micturate. Constipation is the rule, though I have
known a severe diarrhoea to accompany the disease, the result, I
thought, of reflex irritation. The stomach also is often
sympathetically affected, nausea, and sometimes vomiting of an
aggravated form, being present.

With a subsidence of the chill the temperature begins to rise, and
continues to increase, with evening exacerbations, until it reaches
102° to 103°, usually its highest point. It may, however, rise suddenly
and reach as high as 104° or even 105°--rarely above the latter point.
The pulse is usually full, and beats from 112 to 120 per minute,
sometimes oftener.

In severe cases tympanites exists, with great tenderness in the
hypogastric region; the thighs are also flexed upon the abdomen to
protect the parts from pressure and to relieve the abdominal muscles
from tension. But when these symptoms are marked it may be confidently
concluded that the peritoneum is extensively involved.

Within a few days to a week from the initial symptoms the stage of
effusion is probably completed or well advanced, when the symptoms are
usually ameliorated. Pain is diminished and the temperature decreased,
and if, happily, resolution begins, the patient may gradually recover
during the succeeding two or three weeks. But, unfortunately, this very
favorable course is not the usual one. Instead of it, the disease often
advances to the third stage, that of suppuration. This stage is very
commonly ushered in and manifested by rigors or chill, followed by a
rise in temperature and an increase in the pulse-rate. There may now be
daily afternoon exacerbations of temperature, followed by sweating,
until the pus is disposed of, usually by evacuation.

PHYSICAL SIGNS.--If an opportunity is afforded for making a vaginal
{215} examination during the first stage, it will be found that the
local temperature is markedly increased, that great tenderness exists,
and that the parts involved are rigid from congestion. A little later
this rigidity or erection subsides, and a bogginess may be discovered
at the point or points where effusion is now taking place. Still later,
a rather firm and, it may be, irregular swelling of variable size and
location can be detected, usually in one of the broad ligaments, and
from the size of a hen's to that of a goose's egg. If the inflammation
has existed on both sides of the uterus, the pelvic roof, so called,
may be found as hard and firm as a board. If pus has formed,
fluctuation may be felt, and later a softening process may be detected,
indicating the point where Nature is attempting to rid herself of the
product of the inflammation.

The uterus is usually displaced by the exudation to an extent depending
upon the size of the swelling, to which it is fixed more or less
firmly. If the effusion has taken place in one of the broad ligaments,
the organ will be displaced to the opposite side, but if the
inflammatory process has extended to the cellular tissue in the
posterior region of the cervix and in the utero-sacral ligaments, the
organ may be displaced forward as well as laterally. If the cellular
space between the bladder and cervix alone be involved in the
inflammation, the resulting effusion may displace the uterus backward,
but the disease is rarely met with in this location. Retroversion of
the uterus frequently complicates parametritis, but in that case the
abnormal position is not necessarily due to displacement by the
exudation. It may have existed previous to the attack.

It must not be forgotten, however, that the symptoms and physical
signs, as described above, apply only to the acute form of the disease,
and that they do not exist in the same degree nor in the same regular
order when the inflammatory process has been subacute, as it often is,
from its commencement. When the disease is subacute from the start, the
patient may be enabled to go about, and even to pursue a laborious
occupation, but not without suffering. There will always be more or
less pain experienced in the affected region, and the temperature and
pulse will be slightly increased. In rare cases the manifestations of
the disease may be so slight or so little complained of that the
physician is surprised to find, on examination, a large exudation in
one or both broad ligaments.

DIFFERENTIAL DIAGNOSIS.--It is of the greatest importance that this
disease should be recognized early, so that prompt measures may be
taken to arrest it if possible, or at least to modify the severity of
its course. Fortunately, as a rule, the subjective symptoms of pelvic
inflammation are so marked that the attention is at once directed
toward seeking for their confirmation by eliciting the physical signs;
and for diagnosis these local manifestations of the inflammatory
process are to be relied upon entirely, as the subjective symptoms of
inflammation of the other tissues and organs of the pelvis somewhat
resemble those of parametritis.

The diseases the local signs of which approach more nearly those of
parametritis are--pelvic hæmatocele, fibrous tumor, the early stage of
extra-uterine pregnancy, the early stage of parovarian and ovarian
cystic degeneration, and perityphlitis.

In pelvic hæmatocele the symptoms occur suddenly, and often with
hemorrhage; there are also constitutional signs of loss of blood, as
pallor and coldness of the surface of the body, and if the hemorrhage
is great {216} failure of the pulse and syncope. The tumor caused by
the escape of blood into the pelvic cavity is generally post-uterine,
distending Douglas's cul-de-sac and crowding the uterus forward toward
the symphysis pubis, while that formed by parametritis is oftenest
located at the side of the uterus. The hæmatocele at first is soft and
compressible, becoming hard within a short time--a few days--as a
result principally of the surrounding wall of lymph which nature throws
out as a protection. The symptoms of parametritis, on the other hand,
are more likely to come on gradually, and to present the pulse- and
temperature-signs of inflammation, while the resulting swelling or
tumor is rigid at first from congestion of the tissues, then hard,
becoming soft later as the process advances to suppuration. Mere
location of the tumor, however, cannot be depended upon; we must be
guided by the history of the case and the special character of the
tumor.

Fibroid tumor is not attended with the usual acute symptoms of
parametritis, such as pain, increase of temperature, and accelerated
pulse; the tumor is hard from the beginning, or at least never soft; it
is circumscribed, usually smooth, and not sensitive to the touch. Its
attachment to the uterus is also different from that of the tumor
caused by parametritis. The former shows a tendency to pedunculation,
while the latter has always a broad surface attachment.

The tumor resulting from the arrest and development of a fecundated
ovum in the Fallopian tube or ovary resembles very much in its
locality, and somewhat in its characteristics, a parametritic tumor;
for usually more or less inflammatory exudation is present in
connection with extra-uterine pregnancy, giving at times a fixity and
hardness to the gestation-sac not unlike that sometimes observed in a
tumor parametritic in origin; besides, there may also be constitutional
signs of an inflammatory action. But the presence of some of the
ordinary signs of pregnancy and a little time will clear up the
difficulty; for as the case progresses the tumor will increase in size
and change in character, while the mammary and other signs of gestation
will develop. In addition, the pain attending tubal pregnancy is never
like that of parametritis: it is more persistent, lancinating, and
cramp-like in character, and is unattended by rise in temperature. Soon
also the placental bruit may be detected, which of course never exists
in parametritis.

The early stage of normal pregnancy is said to have been mistaken for
this disease. I can hardly conceive how this mistake in diagnosis could
be made, although I have met with several cases where the congestion
consequent upon fecundation was so violent as to result in actual
pelvic inflammatory symptoms with subsequent exudation.

The following case, which I saw with H. A. M. Smith of Gloucester,
N. J., markedly illustrates and confirms this opinion: Mrs. B----, æt.
21, had been married five years, but had never conceived. Her catamenia
had always been regular in time, but the flow had been slight in
quantity. In the latter part of November, 1884, or about three months
before I first saw her, she was attacked with severe pain in the
pelvis, accompanied by rise in temperature and accelerated pulse. She
was compelled to go to bed, where she had remained up to the time of
coming under my care. During this time she suffered from great
tenderness over the hypogastrium, some tympanites, and considerable
nausea and vomiting. She {217} did not menstruate in November--the
period was due when she was first attacked with pain--but in December
she had severe uterine tenesmus and a profuse metrorrhagia--symptoms of
abortion. Pregnancy had not been suspected, however, as she had been so
long sterile, and the inflammatory symptoms had been so violent that
the signs of gestation had been masked by them. At the time of my first
visit (March, 1885), there was great tenderness of the hypogastrium
with slight tympanites; nausea and at times vomiting; great nervous
prostration; loss of flesh; menses absent since November, except the
uterine tenesmus and hemorrhage in December, as above stated; and at
each menstrual cycle afterward she had the symptoms of uterine
contraction with a profuse leucorrhoeal discharge, but no hemorrhage.
The mammary glands showed the usual signs of gestation at about the
fourth month; the vagina was purplish; the cervix uteri low down on the
floor of the pelvis, and the mucous membrane around the os
hypertrophied, soft, and abraded. The body of the uterus was anteverted
and symmetrically enlarged to about the size of the organ at the third
month of gestation. The uterus seemed to be fixed--incarcerated within
the pelvic cavity--by an indurated exudation in the lower portion of
the right broad ligament. I diagnosticated pregnancy, and accompanying
parametritis as a result. The treatment consisted in painting the right
side of the fundus of the vagina opposite the base of the broad
ligament with iodine; the application of iodized glycerin on pledgets
of cotton, together with the use of the hot-water douche; internally,
opium enough to relieve pain and an alterative tonic in the form of the
four chlorides, the formula for which will be given at another place.
She began to improve at once, but as she was still threatened with
abortion and the uterus was still incarcerated within the pelvis, ether
was administered for the purpose of attempting to release it. With two
fingers of the left hand in the vagina and the right hand upon the
hypogastrium to exert counter-pressure, gentle manipulation was made
with the view of stretching the adhesions. This resulted in a slight
elevation of the womb, and from this time pregnancy went on to full
term without further trouble.

This case is introduced chiefly to show the possibility of the
existence of parametritis with normal gestation. It is true that the
inflammation, which developed simultaneously with fecundation, may have
had a latent existence before the occurrence of that event, and that
the stimulus of pregnancy served simply to bring about an attack of an
active character, but nothing in the previous history of the case
indicated such a condition.

Perityphlitis may somewhat resemble in its subjective symptoms, as pain
and rise of temperature, an attack of parametritis. A careful study of
the physical signs, and also of the exact position of the tumor in each
case, however, ought to be sufficient to differentiate between the two
diseases. The tumor of perityphlitis is always on the right side, and
situated high up in the false pelvis; that of parametritis may be on
either side--it is oftenest on the left--and is usually located low
down in the true pelvis. The latter is easily reached per vaginam,
while the former is almost or quite out of reach from this direction.

Parovarian cystic disease in the early stage, before the tumor has
developed sufficiently to rise above the pelvic brim, resembles in its
location parametritic exudation; but the history of development and the
physical {218} characteristics of each are different. There is an
absence of hardness and tenderness to the touch in the former, which
always exist in the latter. Parovarian tumor develops without the
constitutional phenomena of inflammation; parametritis, I believe,
never.

It must not be forgotten, however, that either one or more of these
various diseases may exist in connection with, and as complications of,
parametritis, rendering the diagnosis at times exceedingly difficult,
requiring time and patience to clear the way. A case in point may be
stated in brief as follows: Mrs. H---- was sent to me some months ago.
She complained of great pain in both iliac regions--more in the
right--extending into the pelvis and sacrum and down the limbs. There
were also menorrhagia, and profuse leucorrhoea during the
intermenstrual periods. She dated the trouble from an abortion which
had occurred nine years before, and which was followed by symptoms of
acute parametritis, from which she never fully recovered. Physical
examination showed the uterus to be considerably hypertrophied and
fixed, as in a vise, by an indurated mass on either side of it, which
seemed to occupy both broad ligaments or to be closely adherent to
them. The cervix uteri was also badly lacerated; its mucous membrane
presented a surface so hypertrophied, abraded, and jagged that I was at
first strongly impressed with the fear that epitheliomatous
degeneration had begun to develop. I pursued a plan of treatment
designed to reduce the congestion and hypertrophy of the diseased neck,
and at the same time to induce an absorption of the plastic and
indurated lymph around the uterus, to render the organ mobile, so that
an operation might be made safe. I only partially succeeded, for while
the uterus became much more mobile, there still remained a swelling or
tumor on either side of it. These tumors had ill-defined borders--were
not circumscribed, but elongated and rather cylindrical in form, and
fixed to the lateral pelvic walls as well as to the uterus, though not
very firmly to either. I now suspected disease of the Fallopian tubes,
and probably also of the ovaries. The patient entered my private
hospital in February, 1885, when I operated upon the cervix, dissecting
away a large quantity of tissue for the purpose of making proper
adjustment of the labia and to get rid of the cicatricial tissue; it
was not epitheliomatous. I had hoped by this operation to not only
restore the cervix to health, but at the same time to induce, by a
derivative action, a retrograde metamorphosis in the diseased tissues
and organs appended to the uterus. I succeeded in the former, and also
in modifying all of the symptoms except the pain in the ovarian
regions. This seemed to be made worse, or at least to become more
prominent, as the other symptoms were improved. The patient was sent to
her home, and advised to rest in the recumbent position for at least a
part of every day. Later, when she did not improve, a local treatment,
consisting of an application of the tincture of iodine to the fundus of
the vagina at intervals of a week, with boro-glyceride tampons almost
daily, was renewed. At the same time, counter-irritation, applied to
the hypogastrium by means of blistering, was faithfully pursued. But
nothing proved of more than temporary avail. She began to lose flesh
and to fail in strength. The old fulness at the sides of the uterus,
instead of diminishing, had increased. She again entered my private
hospital. Under the influence of ether I now determined that the {219}
Fallopian tubes were distended to the size of a small sausage, that the
ovaries were also enlarged, and that the tubes, ovaries, and ligaments
were all adherent to one another by plastic lymph. I now advised
laparotomy for the removal of the diseased uterine appendages. The
patient very readily assented; indeed, she urged the operation.

A week later I made an incision three inches in length through an
abdominal wall fully two inches in thickness, and came upon the
omentum, which was very fat. This was adherent by its lower border to
the pelvic tissues and organs, so that I was compelled to dissect it
off on the right side before I could reach the uterus with my fingers.
All the parts--Fallopian tubes, ovaries, broad ligaments, uterus,
omentum, and intestines--were so adherent and matted together that it
was difficult to differentiate between them. The tubes were greatly
distended and contained--the right pus, and the left serum. The
fimbriated extremities were glued to the lateral pelvic walls. The
ovaries were as large as a good-sized hen's egg, and closely adherent
to the posterior surface of the broad ligaments. I dissected with my
fingers--two being introduced--until the right tube and ovary were
released, when they were drawn to the incision, ligated, and removed.
The left ovary and tube were released with still greater difficulty,
but I finally succeeded in ligating and removing them.

It will be sufficient to say here that the patient recovered without an
untoward symptom, and that she has been entirely free from pain--since
her recovery--for the first time within the last nine years.

PROGNOSIS.--A very guarded prognosis should always be given as to the
course and termination of a case of pelvic inflammation. The disease
may run a very acute course, and result in recovery by resolution or
suppuration, or it may become chronic and be indefinitely prolonged. An
acute parametritis without complications usually runs its course and
ends in recovery in from four to six weeks. But the cases which are
acute and uncomplicated are vastly in the minority; certainly this is
my experience. The course of the disease, as has been stated above, is
often chronic, and requires all the patience and fortitude which can be
mustered, both by the patient and physician, to bring about a cure.
Generally, the prognosis is good where a rational treatment can be
pursued. The tendency of the disease is toward recovery, and
comparatively few cases die. It is less favorable in cases occurring
just after parturition, and which are probably of septic origin. Where
the disease is complicated by peritonitis the prognosis, as to life,
becomes less favorable.

TREATMENT.--In the acute form, if the patient is seen during the first
stage--_i.e._ before exudation has begun--she must immediately be
placed in a warm bed. All sources of excitement must be at once
removed, the nervous system quieted, and pain relieved by a full dose
of morphia administered hypodermatically. I never give less than a
quarter of a grain of the sulphate, and seldom more, but I repeat it
within an hour if pain is still severe. If reaction from chill has not
yet occurred, it should be hastened by the application of dry heat to
the lower extremities in the form of vessels filled with hot water,
preferably, while moist heat, in the form of a hot flaxseed poultice or
some other convenient vehicle, should be applied to the hypogastrium.
Great care must be taken that the moisture from the poultice does not
escape and wet the clothing of the patient, for that {220} would not
only be a source of great discomfort, but it might also be the means of
inducing another chill. The heat and moisture are best retained in the
poultice by a covering of waxed paper or oiled silk. At the same time,
a hot lemonade, to which may be added a teaspoonful of the sweet spirit
of nitre, will often be found useful. According to Emmet, hot water per
vaginal injection is a sine quâ non in the treatment of this disease.
He says: "It is the only means we possess for aborting an attack of
cellulitis, which it will do, if thoroughly employed at the
beginning."[3] This is strong language, and doubtless the eminent
author feels warranted in its use from his experience with the remedy;
but I am sure that I have seen reaction brought about and the disease
arrested in the first stage by the plan recommended above, and without
the use of hot water by injection. There can be no doubt that the first
principle to be carried out in the treatment of this disease is
rest--absolute and persistent physical and mental rest. This can be
obtained by the use of morphia hypodermically or by opium--administered
best by the rectum--and probably by nothing else; certainly by nothing
else so well. Hot-water injections are objectionable during the first
stage of the disease, because of the fuss and movement of the patient
necessarily connected with their administration. Further, I think it is
impossible to say of any remedy that it aborted an attack of pelvic
inflammation, for the disease cannot be said to be unquestionably
established until the stage of exudation has been reached. Indeed,
intense pelvic congestion may occur, giving rise to symptoms of the
first stage of inflammation, and subside spontaneously.

[Footnote 3: _Prin. and Prac. of Gynæcology_, 3d ed., p. 261.]

When it is found that the disease cannot be arrested in the congestive
stage, or when it has already passed into the stage of effusion before
the patient is seen--which is often the case--exudation should be
facilitated by the exhibition of the proper remedies. Happily, the
principle to be followed in the treatment of this stage of the disease
is the same as that of the first stage--viz. rest, relief of pain, and
the local application of heat and moisture, with the addition now of
counter-irritation. The first and second are to be obtained by the use
of opium. The patient must not be allowed to suffer pain, and immunity
can only be secured by the free use of the remedy. This drug is of more
value in controlling the heart's action and quieting reflex
irritability than all the others combined. The patient should be kept
under its influence as long as pain lasts. I usually order twelve
suppositories, as follows:

  Rx. Ext. opii aq.,   gr. xij;
      Ol. theobromæ,   q. s.;
  M. et ft. supposit., No. xij.

Sig. One to be placed in the rectum every two hours if necessary to
quiet pain.

But we should not wait for the rather slow action of the opium
administered in this way. It is best to begin with the administration
of morphia hypodermically, as stated above, repeating it until the
desired result is secured. It is then not difficult to keep up its
influence by the use of the suppositories. If the suppositories cannot
be obtained, the tincture of opium may be administered by injection
into the rectum. The opium should not be given by the mouth where it
can be avoided, as it is more apt to interfere with the appetite and
digestion when thus {221} administered. The proper action of the skin
and kidneys should be maintained by the administration of the liquor
ammoniæ acetatis in dessertspoonful doses. Irritability of the bladder
is often a troublesome symptom during the progress of the disease, and
is best relieved, in my experience, by the following formula, which
combines a diaphoretic and diuretic as well as an antispasmodic:

  Rx. Tr. belladonnæ,                  fluidrachm j;
      Sodii bicarbonatis,              drachm iij;
      Spts. etheris nitrosi,           fluidounce j;
      Mist. potass. citratis, q. s. ad fluidounce vj.

M.--Sig. Dessertspoonful three or four times a day, or half the
quantity oftener. I have also known this combination to relieve the
persistent nausea which often accompanies this disease.

As soon as the skin becomes moist the remedy should be given at longer
intervals, and if sweating is induced it should be discontinued
entirely for the time, as that only serves to weaken the patient.

If the pulse does not beat oftener than 112, and the temperature does
not rise above 102°, nothing more in the way of medication will be
required. The patient will recover best if not treated too much. On the
other hand, should the pulse be strong and rapid and the temperature
high, quinine becomes a valuable remedy. It is more efficient when
given in large doses at long intervals than when given in small doses
at short intervals. If the temperature rises above 102°, it is my rule
to administer ten grains and wait six hours, when, if it has not
decreased, the quinine is repeated. If, however, the temperature has
increased instead of diminishing, twenty grains are given at the second
dose, and the effect carefully noted. Should marked cinchonism result,
the remedy must be withheld, even though it has had no influence on the
temperature. Quinine is said to have the power of so contracting the
capillaries as to prevent the migration of the white blood-corpuscles.
If this is true, the remedy ought to have great value in modifying or
limiting the third or suppurative stage of the disease.

The tincture of aconite-root is also of value in controlling the pulse
and lowering the temperature in certain cases. But its use should be
limited to those cases of marked sthenic character, for, as a rule, the
tendency of the disease is toward depression. It may be given in doses
of two to five drops, repeated every two hours until three or four
doses are taken, when, sometimes, the pulse will be found to have
decreased ten to twenty beats per minute. The remedy should then be
withheld until the effect is shown to have passed off by an increase of
pulse-rate, when it may be again exhibited; provided always that the
heart continues strong and vigorous and that it has shown no sign of
weakness. In the latter circumstance the continued use of the medicine
would be extremely dangerous. Under any circumstances its use should be
limited to the first and early part of the second stage of the disease.

The diet should be carefully attended to, and should be of the most
nutritious character, as milk, eggs, beef-essence, etc.

Locally, in addition to the poulticing, but not to the exclusion of it,
counter-irritation by means of iodine will be found useful. The whole
surface of the hypogastrium should be painted each time the poultice is
changed until the skin shows signs of irritation, when it should be
{222} discontinued and the poulticing alone kept up. The abdomen must
not be exposed longer than is just necessary to remove one and place
another poultice, which should be at hand and not in another room. The
poultice must never be permitted to become cool on the patient.
Turpentine may be used instead of iodine, and if tympanites is a
troublesome symptom it will be found valuable. A few drops should be
sprinkled over the poultice, or its action may be more quickly obtained
by the use of the remedy in the form of the stupe until marked redness
of the surface is produced, when the poultice can be resumed.
Tympanites is most troublesome when the disease occurs during the
puerperal state, and in these cases I regard the turpentine as a most
valuable remedy, not only as a counter-irritant, but also when
administered internally. It should be given by enema in teaspoonful
doses, repeated every six hours until the desired effect is produced.
It improves the secretions and allays pain by relieving distension. If
the bowels should move as a result of the enemata, it is all the
better. If fecal matter occupies the lower bowel, it should be removed
under any circumstances.

Blistering, by means of cantharidal collodion or by the pure
cantharides spread in the form of a plaster, I regard as the most
efficacious counter-irritant; and if the beneficial effects of the
remedy could be obtained without the discomforts, and often positive
suffering, attending its action, I would probably employ it to the
exclusion of all others. But these cannot be obtained. During the acute
stage of the disease, when the pulse and temperature are high and the
skin hot, the blister should not be used. It is then more likely to
produce strangury; if not that, the other sufferings of the patient are
at least increased in the pain and burning produced on the surface of
the abdomen. This is not compensated for by relief of pelvic pain, for
we have relieved this long since by opium. I think blistering should be
confined to the chronic stage or form of the disease.

Resolution by reabsorption of the effused product may now terminate the
disease; but that is not the rule when the process has once advanced
beyond the first or congestive stage. If it is found that suppuration
is likely to take place, that the disease is following its natural
course, the third stage must be facilitated. The therapeutic plan laid
down above will serve to limit the amount of pus-formation and tend to
concentrate it to one point for evacuation. The hot fomentations should
be continued, as well as the counter-irritation by the iodine. It will
probably be observed that the patient has rigors of more or less
severity, followed by rise in temperature. These symptoms should be
looked upon as an indication of pus-formation. The patient should be
examined from time to time by the digital touch per vaginam and by the
combined vagino-hypogastric palpation for the purpose of determining
the presence of an abscess and its location, so that the proper
treatment may be applied and at the proper time.

These examinations must be conducted with the greatest care and
gentleness, and the patient protected from undue exposure. When the
disease has advanced to the third stage means for the disposition of
the pus should be kept constantly in view, and the case treated as one
of pelvic abscess.

Treatment of Pelvic Abscess.--Authorities differ widely as to the
proper method of disposing of the contents of a pelvic abscess. Some
{223} favor a let-alone plan, believing that Nature is competent to
relieve herself more effectually and better than art can do; others,
equally eminent, believe that the pus should be evacuated when pointing
has positively occurred and made the evacuation easy and safe; while
others, again, more radical in their views, believe that much can be
gained by liberating the pus as soon as it is known to exist, although
it may be deep-seated and as yet have shown no tendency toward
pointing.

The same therapeutic principle should guide us in the management of a
pelvic abscess that we would unhesitatingly apply in the treatment of
an abscess in any other portion of the body. It is a settled law in
surgery that if a pus-cavity is evacuated and not allowed to burrow,
much tissue may be saved, the duration of the disease shortened, and
the prognosis rendered more favorable. I believe that the pus should be
liberated promptly as soon as it is certain that an abscess has been
formed and can be reached without danger to important
structures--emphatically so when the way is being pointed out. True,
Nature is competent in some instances to discharge the accumulation,
and usually by the least dangerous channel. But it is also true that in
many other cases she is not. Instead of taking the shortest, most
direct, and safest course to the surface, the pus frequently takes the
most indirect route, riddling and destroying the tissues in its track;
or it may rupture into the bladder or peritoneal cavity, in the latter
case to be followed by death from peritonitis. Evacuation of the pus by
artificial means when the way has been shown, if done carefully by
aspiration, is attended with almost no danger. Where, on the other
hand, the abscess is deeply seated and there is no tendency toward
pointing, the question of evacuation becomes one requiring great
deliberation; for the dangers of puncture increase as the thickness of
the tissues to be traversed in reaching the abscess is greater. But,
even though the pus be deeply located, when a positive diagnosis of its
presence can be made I still favor early evacuation. Mere exploratory
puncture in the hope of finding pus is a most dangerous practice, and
should not be thought of in connection with pelvic abscess. Delay, even
at the risk of spontaneous rupture, is the proper course until the
diagnosis can be rendered positive; for when the abscess is deep-seated
the progress of the disease is often slow. Of course the condition of
the patient should always be taken into account in deciding the
question whether or not to interfere. If signs of septic absorption
appear, or evidences of constitutional failure become prominent in
spite of the means used for staying the progress of the disease, prompt
measures must be taken to get rid of the product of the inflammation.
The strongest argument in favor of early operative evacuation of the
abscess is the danger that the disease may become chronic when the pus
is not promptly discharged. Many cases have occurred in which abscess
after abscess had been formed and discharged, until the patient became
a mere wreck of her former self, and finally died from septicæmia or
exhaustion. This is the result of non-interference. I am so fully
convinced of the value and necessity of operative measures in the
treatment of pelvic abscess that the following questions at once
present themselves to me when called upon to decide in a case where
spontaneous evacuation has not already taken place: 1st. When shall the
abscess be opened? 2d. Where shall the opening be made? and 3d. How
shall the operation be done?

{224} The first of these questions has been answered in a general way
by the preceding remarks, and it is only necessary to add here, by way
of recapitulation, that the time for opening the abscess will depend
upon its location and the condition of the patient. If the pus is near
the surface and can be easily and safely reached, whether pointing has
occurred or not, it is ripe for evacuation and should be liberated at
once, even though the patient be in the best possible condition and
show no evidence of deleterious effect from its presence. Nothing
whatever can be gained by permitting it to open spontaneously, but much
may be lost. If, however, the situation of the abscess be such that it
would be necessary to traverse healthy tissues to a considerable extent
in order to reach it, and the patient shows no evidence of septic
absorption, it would be highly injudicious to attempt to open the
abscess: first, because under the circumstances you could not be
positively certain that a collection of pus existed; and, secondly,
because it is doing no harm. Delay, with careful observation, is now
the proper course. Within a few days the apparent abscess tumor may
either show decided signs that it is diminishing in size and undergoing
resolution, or it may approach the surface, so that evacuation will
become safe. On the other hand, should symptoms of blood-poisoning
develop and the patient show signs of rapid exhaustion, our attitude
must be one of action instead of delay. The pus must then be liberated
even at some risk. I still insist, however, that a positive diagnosis
must be established, and that the operative measure shall be in no
sense exploratory.

2d. Where shall the opening be made? This question is often decided for
us by Nature. The puncture, as a rule, should be made where pointing
has occurred. If pointing has not occurred, a position from which the
abscess can be most easily reached through the vagina or abdominal wall
should be selected. The vagina should be given the preference, because
the opening would then be at the most dependent portion. The rectum
should not be selected as the channel through which to evacuate the pus
artificially, although spontaneous discharge into that tube occurs
almost as frequently as into the vagina. The patient does not recover
as quickly, however, when the abscess opens into the rectum, and more
cases of septic poisoning occur from decomposition of the pus as a
result of the entrance of air and fecal matter into the abscess-cavity.
Further, it may become necessary to keep the opening patulous and to
wash out the cavity of the abscess. This could not be done properly if
the opening were in the rectum. I believe it to be the best practice to
open from the vagina rather than from the rectum, even at greater risk
to intervening structures, because it may greatly facilitate the
after-management of the case.

If the tumor should be located high up in the iliac fossa or in the
hypogastrium, the point of election for opening must be somewhere on
the abdominal surface in the region of the abscess.

3d. How shall the operation be done? The opening of a pelvic abscess
should never be regarded as a simple operation. As much care and
deliberation should be taken in the selection of the proper method of
evacuation of the pus, and in the operation itself, as was previously
given to the diagnosis of its presence. Always begin with the
administration of an anæsthetic. This not only protects the patient
from unnecessary mental agitation and physical pain, but it better
enables the {225} physician to confirm his previous opinion of the
case, as well as to be more deliberate in the election of the point of
puncture. With the patient in the dorsal position, if it be determined
that the pus is contained in a single cavity, and there be no evidence
of its decomposition, shown by the absence of symptoms of systemic
poisoning, it should be liberated by aspiration. By this means a
smaller puncture will be required and the entrance of atmospheric air
prevented. If, happily, the operation has been performed early, before
the formation of the so-called pyogenic membrane, or at least before
sinuous tracts have resulted from burrowing, the abscess-cavity may
then collapse and disappear. But should the patient not improve after
the pus has been removed, or should the cavity again fill up, it is
probable either that there is another pus-cavity, which had not been
reached by the trocar, or that there has been developed on the internal
surface of the sac an unhealthy fungous, granular condition. Under
these circumstances a free incision should be made into the cavity of
the abscess, so that a drainage-tube may be introduced and the cavity
washed out by an antiseptic fluid. The opening should then be kept
patulous, so that healing can take place from the bottom of the sac. It
may become necessary to introduce a finger and scrape away with the
nail the fungosites from the wall of the sac. But great care must be
used in this manipulation, as well as in making the incision, for there
is danger of wounding large blood-vessels and of rupturing the wall of
the sac. If the cavity be now kept pure by daily injections of a 1:1000
solution of the bichloride of mercury or of a 2½-5 per cent. solution
of carbolic acid, its surface may become healthy, the secretion
diminish, and the sac close up.

The best method of washing out the cavity is by the fountain syringe,
to which a long double canula can be attached; or, probably better, the
syphon. It would be unsafe to force water into the sac.

It is well for the patient if the situation of the abscess be such as
to render its evacuation through the vagina feasible, for then the
opening is made at the most dependent portion, and consequently
drainage is more easily and thoroughly accomplished; but,
unfortunately, the location of the tumor may be so high up as to compel
the removal of the pus through the abdominal wall.

Almost the same rules as to the selection of the method of operating
and of the election of the point for puncture or incision will apply
here as in the operation through the vagina, provided pointing has
taken place. I am less favorable to aspiration, however, when the
puncture must be made through the walls of the abdomen--first, because
reaccumulation is almost certain to take place; and, second, because
there is danger of leakage of pus into the peritoneal cavity, since it
is difficult by this means to thoroughly empty the sac, and impossible
to wash it out and keep it drained.

If pointing has occurred, a free incision should be made at once and
the cavity thoroughly emptied, and, if necessary, washed out. The
opening must not be permitted to close until the cavity has healed from
the bottom.

Where pointing has not occurred and the abscess is so deeply seated
that it cannot be safely reached from the vagina, and does not distend
the abdominal walls, I would urge greater delay, in the hope that it
may {226} approach the surface more nearly. If, however, the condition
of the patient be such as to demand immediate action, the operation of
laparotomy should be selected as the more thorough and less dangerous
method of releasing the pus and of after-treating the abscess.

An incision two inches in length should be made through the linea alba,
midway between the umbilicus and pubes, and, after all bleeding is
stanched, the peritoneal cavity opened. The index finger should then be
passed in and the surface of the abscess-wall explored. It will be a
fortunate circumstance if the sac be found adherent to the peritoneal
surface, where the incision is made, for it can then be opened without
entering the peritoneal cavity. To prevent the escape of pus into this
cavity the sac should now be evacuated with great care. For this
purpose the aspirator is well adapted, but a small trocar, to which a
few feet of rubber tubing has been previously attached, through which
to conduct the pus into a convenient receptacle, will answer almost as
well. The opening in the sac should next be slightly enlarged by an
incision (not torn); it should then be included in the sutures, which
are now placed to close the abdominal wound. After the sutures have
been introduced the pus-cavity should be washed out with the bichloride
or carbolic-acid solution, and a glass drainage-tube placed in the
lower angle of the incision, when the edges can be brought together and
adjusted around it.

The after-treatment required will be the same as if the opening had
been made through the vagina.

The sac must be made to close from the bottom. It may become necessary
to stimulate the surface by the injection of a weak solution of nitrate
of silver, four to eight grains to the ounce of distilled water, or
with the tincture of iodine, one part to four of water.

Cases are sometimes met with in which the pus has burrowed and formed
sinuous tracts which are difficult to reach and drain. It may then be
necessary to make a counter-opening in the vagina after first cutting
through the abdominal wall. These are usually old, neglected, chronic
cases, in which the abscess has discharged spontaneously into the bowel
too high up to be properly emptied, or which have opened into the
bladder or somewhere on the abdominal wall, or possibly taken one of
the circuitous routes alluded to under the head of Pathology.

No fixed rule can be set down for the management of these grave cases.
Each one must be treated on its individual merits. A ripe experience
and judgment are necessary here to decide whether it is best to operate
or to pursue a course of masterly inactivity, depending upon the use of
hygienic and tonic remedies and time to bring about a cure. I have
known instances where patients have recovered spontaneously after
having been reduced to the lowest extremity. I have also known others
who have died soon after submitting to operative interference. Some of
the spontaneous recoveries, however, are only apparent, for the old
sinuses often reopen and discharge pus as before, or the pus may be
discharged at some new and remote point, the patient finally succumbing
to the ravages of a disease from which she flattered herself she had
escaped.

The most careful attention must be given to the hygienic surroundings
of the patient, the diet liberal and of the most nutritious character.
The appetite should be sharpened by the administration of the bitter
tonics, {227} the best of which is probably the old tincture of bark
(Huxham's). Quinine should be given in doses sufficient to control the
temperature when necessary, and for its tonic properties. The blood
should be improved by the exhibition of iron, arsenic, and the
bichloride of mercury in the form of the mixture of the four chlorides,
first used, I believe, by Tilt of London. There can be no doubt as to
the value of the combination in cases of plastic exudations. The
following is the formula which I am in the habit of using:

  Rx. Hydrarg. chloridi corrosivi, gr. j;
      Liq. arsenici chloridi,      fluidrachm j;
      Tr. ferri chloridi,
      Acid. muriatici diluti,  aa. fluidrachm iv;
      Syr. simplici,               fluidounce ij;
      Aquæ,               q. s. ad fluidounce vi.

M.--Sig. Dessertspoonful, well diluted, after meals.

The dose of the arsenic and bichloride of mercury can be increased,
after it is found that the mixture does not disagree with the stomach,
to six drops of the former and a sixteenth to a twelfth of a grain of
the latter. The effect of the medicine must be carefully watched,
however. After the remedy has been taken two weeks it should be
discontinued and some other form of tonic substituted for a week or
two. The syrup of the iodide of iron, or the iodide of iron in pill
form, will serve well as the substitute. If the patient should tire of
the above or the remedies should not agree, some other form of tonic
must be given. I have found the following an excellent tonic pill:

  Rx. Strychniæ sulphatis, gr. j;
      Acidi arseniosi,     gr. j;
      Quininæ sulphatis,   gr. xlviii;
      Ferri sulphatis,     gr. xlviii;
      Ext. hyoscyami,      gr. xij;
      Ext. gentianæ,       q. s.

M. et ft. pil. No. xlviii.--Sig. One to two pills after each meal.

As soon as practicable the patient should have a change of air and
scene.


Perimetritis.

Having treated the subject of inflammation of the pelvic tissues
generally, in the acute form, under the head of Parametritis, with
sufficient fulness to answer the purposes of the practical physician,
whether the disease dominate the connective tissue or the peritoneum
covering it, I shall, under the head of Perimetritis, consider the
subject in its chronic aspect principally.

DEFINITION AND SYNONYMS.--I have defined parametritis to be an
inflammation of the cellular or connective tissue near the uterus and
beneath the pelvic peritoneum, including principally the locality close
to the lateral margin of the uterus between the layers of the broad
ligaments, although embracing also all of the various spaces where
connective tissue abounds--viz. between the peritoneal folds which form
the utero-sacral and utero-vesical ligaments. I cannot more clearly or
more simply define perimetritis than by stating that it means an
inflammation of the peritoneum {228} which serves as a covering and
boundary-line for the connective-tissue spaces involved in
parametritis. As the term parametritis is used to conveniently express
the idea of the existence of an inflammation in the connective tissue
near the uterus, so the term perimetritis conveniently and tersely
expresses the idea that the inflammatory process exists around the
uterus in the pelvic peritoneum. In the acute form it is difficult to
differentiate between them clinically, nor is it necessary, from a
therapeutic standpoint, to do so. The term perimetritis is synonymous
with pelvic peritonitis.

ETIOLOGY.--All of the causes which have been enumerated as capable of
producing parametritis may be included in the etiology of perimetritis.
If, however, the great predisposing causes of the former--abortion and
injury at parturition--be absent, the woman be non-parous, the
inflammation will affect the peritoneum rather than the connective
tissue. Parametritis is rare before pregnancy has occurred, except in
so far as the connective tissue always becomes more or less involved
when the peritoneum covering it is inflamed. Perimetritis, on the other
hand, is frequent in the single and sterile woman. But, as a rule, it
does not run the same typical acute course. It is usually subacute or
chronic from the beginning, and results in the formation of false
membranes which bind the pelvic organs to one another.

Perimetritis of the adhesive form may be produced by the pressure and
irritation resulting from displacement of the pelvic organs, as
retroflexion of the uterus, incarcerated fibroid or ovarian tumor,
prolapse of the ovary and Fallopian tube, fecal impaction, and from
ill-fitting and improperly-adjusted pessaries. Under these
circumstances the disease usually comes on insidiously, with no acute
symptoms, and runs a slow course. It may be discovered accidentally
when making an examination on account of pelvic pain obscure in
character, or when the attention has not been called especially to it
by the presence of specific symptoms.

Perimetritis may result from regurgitation of menstrual fluid through a
too patulous Fallopian tube. This is most likely to take place when the
egress to the flow has been prevented by a flexion of the uterus sharp
enough to practically destroy the calibre of the cervical canal, as
when the organ has become retroflexed from subinvolution or some other
cause of hypertrophy of the body of the organ. It may, however, occur
as a result of the intense engorgement which sometimes attends acute
suppression of the catamenia. It may occur from disease in the tube
itself, as where a collection of pus or serum has been formed and
thrown into the peritoneal cavity either from rupture of the tube or
discharge through the natural opening at the fimbriated extremity. Or
it may result from hemorrhage following the rupture of a Graäfian
follicle, especially where the disease of the tube has resulted in the
destruction of its calibre or the power of the fimbriæ to grasp the
ovary so as to convey the discharge safely to the uterine cavity.
Hemorrhage from any other source, as from the rupture of a blood-vessel
or of an extra-uterine gestation-sac, usually results in the
development of perimetritis.

Coitus is capable of causing perimetritis when the act is awkwardly
performed, or where there is a disproportion in the relative sizes of
the organs involved, or where the physiological mechanism of copulation
is destroyed by displacement of the uterus, free mobility being lost as
a result.

{229} According to Noeggerrath,[4] a very common cause of perimetritis
is what he is pleased to call a latent gonorrhoea in the male. He
believes that the disease, once contracted, is probably never entirely
eradicated, but that it always exists in a latent form, and that it is
capable of producing a specific inflammation of the pelvic peritoneum
years after an apparent cure had been effected. It is of course
impossible to positively verify this, although he gives some very
striking cases in support of his position. That gonorrhoea in the acute
form may extend by propagation from a vaginitis through the uterine
cavity and Fallopian tubes to the peritoneum, and produce an
inflammation of that membrane, is probable. Cases have been met with
where a history of specific infection was undoubted, in which an attack
of perimetritis followed soon after the initial symptoms and physical
signs of gonorrhoea were manifested. But it is quite another thing to
believe that the specific poison may remain latent and harmless in the
genital system of the male to be transferred years afterward to that of
the female.

[Footnote 4: "Latent Gonorrhoea, etc.," _Trans. Amer. Gynæc. Soc._,
vol. i. p. 268.]

Tuberculous or carcinomatous disease of the pelvic organs is nearly
always complicated by a certain degree of perimetritis.

Perimetritis may result from external injuries, as blows, kicks, and
the like; and under the head of traumatic agencies most of the causes
which have been enumerated would stand as examples; but under this head
I wish also to emphasize the statement that I believe that perimetritis
may result from an unwarranted and unnecessary force used on the part
of the physician in his efforts to outline and locate the position of
the pelvic organs, especially that of the ovaries and tubes. When the
latter organs are in their normal position and not enlarged, it is
usually impossible to outline them by the bimanual touch, nor is it
necessary. When they are diseased the greatest care in manipulation
should be used; and it is often best to administer an anæsthetic, so
that less force may be necessary to determine their exact condition.
The disease may also result from injury inflicted in the medication of
the uterine cavity and in the various operations on the uterus. A most
prolific cause is induced abortion.

Recurrent perimetritis should be regarded as the result of the
persistence of one of the above-mentioned causes. It sometimes recurs
with each menstrual period. Such attacks are often associated with
dysmenorrhoea of the congestive type.

PATHOLOGY, COURSE, AND TERMINATION.--When the pelvic peritoneum becomes
inflamed, and the disease runs through an acute course, the pathology
and termination will be much the same as that described under
Parametritis, for the connective tissue will then be involved in the
process, as well as the peritoneum; not to the same extent, however, as
when the disease begins as a cellulitis. The position of the exudation
tumor, should one form, will be more directly posterior to the uterus
in Douglas's cul-de-sac; it is sometimes larger, and may displace the
uterus far forward. This is more especially the case where the disease
has advanced to the third stage and resulted in abscess.

In the subacute and chronic forms of the disease the course is usually
a slow one. The exudation soon becomes plastic, or is so from the
beginning. This leads to the agglutination of the pelvic organs to one
another, and finally to the production of organized pseudo-membranes
{230} of more or less strength. If the Fallopian tubes and ovaries are
displaced, which is frequently the case under these circumstances, they
are bound more or less firmly in the abnormal position. The adhesions
are sometimes extremely delicate, and embrace the displaced organs as a
net. At other times, or later, they may be so large and firm as to be
readily felt through the vagina. Again, the false membranes may be
broad and ribbon-like, and occupy a position so as to imprison the
displaced organs as though elastic bands were stretched from the
anterior to the posterior portion of the pelvic brim. When Douglas's
cul-de-sac is bridged over and shut off from the abdominal cavity
proper, serum or pus, sometimes both, may collect within it and give
rise, from its round, fluctuating character and rather insidious
formation, to the supposition that it is an incarcerated ovarian cyst;
especially so since it may progressively increase in size and attain
such dimensions as to distend the abdominal walls. This course of the
disease is rare, however.

Under favorable circumstances the course and termination of chronic
pelvic inflammation would probably be much the same as where the
disease is acute--_i.e._ it would run its natural course and end in
resolution by absorption of the effused product. But, unfortunately,
the symptoms of the disease are not violent enough to compel the
patient to go to bed and remain at rest, so as to place the organs in
the most favorable condition for recovery. The affection comes on so
insidiously sometimes that when the patient is finally compelled to
seek relief it may be found that extensive adhesions and considerable
displacement, if not serious disease--especially of the ovaries and
Fallopian tubes--exists. The inflammatory process is progressive, and
will continue to be so until its cause shall be rendered inactive by
the continuous and increasing severity of the symptoms, which force the
sufferer to give up the struggle to remain on her feet and pursue her
usual round of duties.

SYMPTOMS.--If the attack is acute the subjective symptoms of
perimetritis will differ from those described as belonging to
parametritis only in the greater violence of their onset and progress.
The pain, which is usually preceded by a chill, is likely to be sudden,
sharp, and persistent--sometimes agonizing. The pulse, especially
during the first stage of the disease, is small, wiry, and quick,
ranging from 120 to 140 beats per minute. But its character is likely
to change as the affection progresses, and to become full, as when the
connective tissue is the seat of the inflammation. The temperature also
reaches a higher point, rising frequently as high as 104°-105°,
sometimes even higher.

When the disease is chronic from its commencement, the pain is more
obscure, and cannot so certainly be relied upon as a diagnostic sign.
True, a sharp pain existing low down in the pelvis in either iliac
region--pain persistent in character and coming on rather
suddenly--should always direct attention to the probable existence of
an inflammatory condition. The pain of chronic pelvic inflammation is
not attended with the rise in temperature and acceleration of pulse
which have been described as accompanying the acute form of the
disease. There is, doubtless, a slight degree of increase in both, but
not enough to attract attention as a rule. There may be many reflex
symptoms, chief of which are irritability of the bladder and stomach,
the latter manifesting itself in nausea and sometimes vomiting.

{231} PHYSICAL SIGNS.--Physical examination may reveal no evidence of
exudation or of the presence of an inflammatory condition, and may lead
the physician to infer that the attacks are not inflammatory in
character, but that they are of a neuralgic nature. As a rule, however,
examination will show a thickening or an absence of the usual mobility
of the surfaces, and deep pressure may elicit considerable tenderness.
On the other hand, the physical signs may be marked, and the surfaces
may be felt to be quite thickened and very rigid, so that it will be
evident that there is exudation on the surface of the peritoneum.
Usually, the vaginal examination reveals a fixation and induration
posterior to the uterus. If that organ is retroflexed, it is bound
firmly in that position. If the uterus is in its normal position, there
will not usually be the same amount of fulness posteriorly. If an ovary
and Fallopian tube have been displaced, it will probably be fixed in
the post-broad-ligament space or in the cul-de-sac of Douglas. The
pelvic roof, so called, may be found as hard and tense as a deal board,
as was first described by Doherty. The exudation may be so great as to
displace the uterus forward or laterally, and to fix it as though it
were surrounded by hardened lymph. This is especially felt in the
post-uterine space, gluing the uterus, ovaries, tubes, and broad
ligaments together. If there is a small ovarian or fibroid tumor, it
may be likewise fixed in this posterior position.

A later examination may show a change in this condition. The exudation
material may have been reduced by absorption, or there may have been an
increase. If the latter, the disease will probably run an acute course
and end by resolution or suppuration--more likely the latter--and
practically it will then run the course described under the head of
Parametritis.

DIAGNOSIS.--The diagnosis of perimetritis is made with comparative
ease. The subjective symptoms are sometimes obscure, but the physical
signs are perfectly plain. When there is exudation posterior to the
uterus, especially if it has bound the organ in a retroverted position
or incarcerated a foreign body, it is almost absolutely certain that
agglutination is due to peritoneal exudation. This exudation is, as a
rule, not so extensive as that which occurs in parametritis, and if a
tumor is present--which is uncommon--its location is different. Where a
tumor is present as the result of pelvic inflammation, I think that it
may be safely ascribed to connective-tissue inflammation rather than to
peritoneal. On the other hand, where there is simply agglutination, and
where the effusion seems thin and spread out, the organs and ligaments
rigid and thickened, instead of a somewhat circumscribed tumor, the
disease may be ascribed to perimetritis rather than to parametritis.
Where the condition just described is found there can be no doubt as to
the existence of perimetritis.

A small ovarian tumor, abscess of the ovary, pyo-salpinx, fibroid
tumor, fecal impaction, and hæmatocele might be mistaken for this
disease, but these tumors are, as a rule, more or less circumscribed,
while the exudation due to perimetritis is not often so. Perimetritis,
however, may coexist with any of the conditions just mentioned. These
tumors may be bound to adjacent tissues, forming one large mass, as the
result of intercurrent attacks of perimetritis. In such cases the
peritoneal inflammation would exist as a complication.

{232} PROGNOSIS.--When the inflammation is acute, or where the
peritoneum becomes largely involved, the disease may run a very violent
and fatal course. Those cases in which pelvic inflammation is of such
severity as to cause death are usually of this character. As a rule,
however, the prognosis, so far as life is concerned, is favorable.

The prognosis regarding the restoration of the ligaments and the
thickened surfaces to their natural condition, and the restoration of
the displaced organs which complicate the disease, will depend upon the
extent and duration of the affection and upon the treatment. As a rule,
the prognosis is good where the patient has sufficient courage and
fortitude to submit to a prolonged course of treatment, with the
abstemious habits of life which may be necessary.

TREATMENT.--In order to present systematically the therapeutics of
perimetritis it should be divided into the acute and chronic forms, and
the treatment of the latter form will necessarily include to a certain
degree the management of the complications. All that has been said
under the head of the treatment of parametritis will apply to the
treatment of acute perimetritis. As the symptoms of acute perimetritis
are ushered in with greater violence than where the connective tissue
is simply involved, so the remedies for the relief of these symptoms
must be more vigorously applied. The patient must be placed at absolute
rest, and be kept there, for the favorable termination of the disease
will be largely dependent on the faithfulness with which this measure
is carried out. The pain, which is usually great and acute in
character, must be relieved at once by the administration of morphia
subcutaneously in full dose, and the remedy is to be repeated until the
pain is under control, when the effect of the drug may be maintained by
the administration of opium in the form of suppositories containing one
grain of the aqueous extract. As in the treatment of parametritis, so
here, I insist upon the administration of the drug by the above method,
rather than by the mouth, because nausea and interference with the
function of digestion are less likely to follow.

In the peritoneal form of pelvic inflammation the pulse is usually more
rapid and the temperature higher than where the connective tissue alone
is involved. Both of these symptoms may be controlled by the free
administration of opium. If this is not successful, a resort to the
tincture of aconite in small and repeated doses will be indicated. If
necessary, quinia should be administered. This remedy, however, should
not be given unless the temperature remains persistently high; and, as
advised under the head of Parametritis, the dose should not be less
than ten grains, repeated in from four to six hours if the temperature
is not decreased. The action of the tincture of aconite should be
carefully watched, and if its administration is not soon followed by a
lowering of the pulse-rate, its use should be abandoned.

If the disease is of a marked sthenic character, the local abstraction
of blood by the application of leeches to the hypogastrium is often of
great benefit, and poulticing should be most faithfully and
persistently carried out, together with hot applications to the lower
extremities in the form of hot water, as previously directed. I
strongly recommend the application of heat to the hypogastrium in
preference to cold. If the patient be seen quite early in the first
stage of the disease, which is unusual, the application of cold might
be more beneficial than heat; but when the {233} process has advanced
toward the second stage, that of exudation, the application of heat
will facilitate this process, while cold would probably retard it.

By the above plan of treatment--viz. the immediate relief of pain by
full and repeated doses of morphia--it is possible to arrest the
disease in the first stage, but this is not the rule. It usually
advances to the second stage, that of exudation, if it has not already
reached this stage before the patient is seen. A vaginal examination
may now show the uterus to be fixed, but there may be an entire absence
of tumor. Should an exudation tumor exist, it will probably be found
posterior to the uterus, crowding that organ forward rather than
laterally, as would be the case were the inflammatory process seated in
the cellular tissue; or, what is oftener the case, we have mere fixity
of the organ, with thickening of the pelvic peritoneum lining Douglas's
pouch and the posterior surface of the broad ligaments. Later an
exudation tumor will more likely be found. If this is so, it should be
inferred that the connective tissue has become largely involved in the
process, and it should rather be expected that the disease will pass
through the regular course of pelvic inflammation and advance to the
third stage, that of suppuration, as though the disease had originally
begun as a parametritis. It should then be treated on the general
principle laid down for the management of that form of pelvic
inflammation. The case should, however, be regarded with greater
solicitude as to prognosis where the peritoneum has been largely
involved, and the symptoms should be more carefully watched and
counteracted by the application of the proper remedies. There is in
such cases more danger of the disease spreading and involving the
peritoneum generally, and of course becoming an affection of great
gravity. When the peritoneum is largely involved, tympanites, as a
rule, becomes a troublesome symptom, more especially if the disease has
occurred during the puerperal period, and it requires special
attention. The remedy which I have learned to rely upon in the
treatment of this troublesome complication is turpentine, administered
preferably by enema.

Should the disease advance to the suppurative stage, the case then
becomes one of pelvic abscess, and should be managed on the principle
enunciated for that stage of the disease. (See Treatment of Pelvic
Abscess.)

Treatment of Chronic Perimetritis.--When the disease exists in its
chronic form, the uterus, ovaries, and Fallopian tubes may be found
fixed either in the normal position or in some form of displacement,
usually the latter. The peritoneum lining Douglas's pouch, as well as
that covering the uterus, broad ligaments, tubes, and ovaries, will be
found more or less thickened, or the ovaries and tubes may be prolapsed
and retained by false membranes; or the uterus itself may be
retroflexed and fixed by adhesion of the peritoneal surfaces lining
Douglas's pouch and that covering the uterus; or false membranes may
have been formed so as to roof over the pelvis, thereby incarcerating
the uterus and its appendages within that cavity. This condition gives
rise to pains which are rather diffused throughout the pelvis, at one
time affecting the ovarian region in which the disease exists, and at
another being experienced low down in the pelvis and radiating along
the course of the sacral nerve down the posterior portion of the thigh,
always sharp and distressing in {234} character. Where the ovary and
tube are involved the pain usually radiates to the groin and anterior
portion of the thigh. Examination should be conducted with great care,
because, although the uterus and its appendages seem to be fixed
firmly, there are often new adhesions forming or weak ones existing
which may be easily severed; and this especially applies to
manipulation of the ovary and tube, the adhesions of which are, as a
rule, not so firm as those fixing the uterus.

The management of these cases must of course be different from that of
the acute form of the disease. The patient often suffers from nervous
exhaustion, indigestion, and loss of flesh as a result of the long
suffering which she has endured during the course of the disease. I
believe that here the most efficacious plan of treatment is that which
embraces REST as its guiding principle, for the disease probably had
its origin in over-exertion and derangement of the proper relations of
the organs one to another, as in those cases in which it is developed
as a result of prolapse or retroflexion of the uterus or the ovaries,
or from the presence of a tumor incarcerated in the pelvis, which
displaces and holds in malposition the above organs. It is
unquestionably true that where the patient is allowed to exercise and
follow her usual avocation the attrition of the inflamed surfaces upon
each other will tend to keep up the inflammatory condition. It is my
plan, where I can get the consent of the patient, to place her at
absolute rest, and begin the treatment by paying strict attention to
the evacuation of the bowels, for constipation is one of the most
troublesome accompaniments of perimetritis. It often stands in a
causative relation, and nearly always as a complication of the disease;
and of course first attention should be paid to the relief of this
condition.

Strict attention should be paid to the diet. The food should be of the
most nutritious character, calculated to improve the digestive organs,
and through them to build up the general system.

The Local Treatment.--The local treatment should embrace those remedies
which are thought to possess the power of producing absorption of
plastic material, either by a counter-irritant or stimulating action.
The persistent use of the tincture of iodine, both to the hypogastrium
and to the fundus of the vagina opposite the seat of exudation, is of
great value. Where the iodine is found to be so irritating to the skin
as to make it necessary to discontinue its use, and also for the relief
of pain, I have found the following formula very useful:

  Rx. Tincturæ aconiti,
      Tincturæ opii, aa. drachm j;
      Tincturæ iodinii,  drachm vj. Misce.

Sig. Poison. To be applied externally as directed.

This may also be applied to the fundus of the vagina instead of the
iodine alone, either by a camel's-hair brush or by the cotton-wrapped
uterine applicator. The vaginal application of iodine should be made
not oftener than once in three days, and sometimes a longer interval is
advisable, especially if the remedy is used in a concentrated form. If
it is found that irritation or ulceration has been produced, its use
must be discontinued for a time, and remedies of a milder form
substituted, as, for instance, the application of iodoform and glycerin
(one drachm to the ounce), or of glycerin alone on the cotton
tamponade.

{235} In the intervals between the application of iodine and the other
remedies the hot-water douche should be used daily. When the hot water
is administered the patient must be in the recumbent position. I am
opposed to indiscriminately advising walking patients to use hot water,
because, as a rule, it is not given as intended--that is, hot and in
large quantity--and the object for which it has been recommended is not
attained. The water is either used at too low a temperature or in too
small a quantity, or both. When administered by the patient herself she
becomes tired of the pumping and of the position which she must assume,
and fails to keep it up during the length of time required for the
injection of the quantity of water usually advised--that is, a gallon
or two--and the constrained squatting position is of itself injurious.
I believe that the long-continued use of hot water is followed by
relaxation of the pelvic organs, and this would constitute another
objection to the indiscriminate recommendation of this measure, for
when it is placed in the patient's hands she is apt to continue its use
for too long a period. The remedy is no doubt most efficacious in the
treatment of these chronic cases of pelvic peritonitis, and great
credit is due Emmet for introducing it to the profession. It should,
however, be administered in accordance with fixed rules and under
certain restrictions, and these I would class as follows: 1, the
patient must always be in the recumbent posture; 2, she must not
administer the injection herself; 3, the water should be at a certain
temperature, which is best determined by the sensations of the patient.
It should be used as hot as can be easily borne, and the temperature
gradually increased during the administration of the injection, for the
patient will be able to bear it at a higher temperature after the
current has been flowing a few minutes than when the application is
first made. I believe that the douche is better than pumping, as by
Davidson's syringe, because the application is more likely to be
thorough and the effect to be maintained longer, for even when the
injection is given by the physician or nurse the hand is apt to become
tired and the application stopped, for a time at least. It is the
continuous application of the remedy which is beneficial. In other
words, the organs should be kept as it were in a hot bath. For use in
my private hospital I have had constructed a tripod five feet high,
with a hook in the centre on which a bucket is easily hung. This bucket
holds two gallons of water, and near the bottom is placed a stopcock,
to which is attached a tube provided with a nozzle and stopcock at its
distal end. The patient is placed on a bed-pan, which is modified after
that devised by Meriman. The nozzle is then introduced into the vagina,
and the stopcock at the bucket turned by the nurse, the water being at
a temperature of at least 110°. The patient can then regulate the flow
herself. The water is allowed to enter the vagina, dilating it and
flowing off slowly, so that the tissues are in a continuous hot bath,
which may be kept up as long as desired--from ten minutes to an
hour--care being taken to see that the proper temperature of the water
is maintained by the addition of a fresh supply from time to time. The
important point is not so much the amount of water as its temperature
and constant contact. If the vagina could once be filled to distension
and the temperature kept up, it would not be necessary to renew the
water, but to keep up the temperature a regular flow of hot water must
be provided for. The rapidity of the flow may be regulated by the
stopcock. The {236} application of this remedy should be made once or
twice a day, depending on its effect upon the patient.

After all tenderness has subsided much may be accomplished by gentle
massage of the pelvic organs. This is best carried out by the
introduction of one or two fingers of the left hand into the vagina,
while the right hand is placed upon the hypogastrium; then the
contracted ligaments, thickened membranes, and fixed uterus, ovaries,
and tubes should be gently manipulated and moved from side to side or
upward and downward, care being taken that the force used is not
sufficient to lacerate adhesions or even to so stretch them as to cause
their irritation. The proper amount of force is best regulated by the
sensation of the patient, and if pain is produced by the manipulation
it should not be persisted in. This massage may at first be employed at
intervals of two or three days, but later it may for a time be used
almost daily, and it will almost invariably be found that the organs
gradually become more mobile--that the adhesions become attenuated, and
in many cases finally absorbed. On the other hand, adhesions of such
size and strength may exist that many months may be required to produce
any marked effect, and in some cases the adhesions may be of such a
character as to be permanently organized and almost incurably fixed.

I have also found the stretching of the fundus of the vagina by firmly
packing it with absorbent cotton, sometimes repeated almost daily or at
intervals of two, three, or four days, of great benefit in stretching
the adhesions and promoting their absorption. Sometimes, where
adhesions are persistent, the use of the rubber colpeurynter distended
with hot water is of value.

Where there is a foreign body, as a tumor, fixed posteriorly to the
uterus, or where the uterus is fixed in a retroflexed position, the
patient may be placed in the knee-chest position, Sims's speculum
introduced, and the vagina packed with cotton while the patient is in
that posture; or, instead, the vagina may be simply distended with air.
The air may be admitted by the introduction of Campbell's glass tube or
by the separation of the walls of the vagina with the fingers, which
may be done by the patient herself. These measures are often of decided
benefit.

I wish to repeat what has already been stated, that the treatment of
chronic perimetritis, to be carried out successfully, requires that the
patient should be in bed and placed under such circumstances and
surroundings that the physician may be enabled to pursue personally the
plan of treatment. Of course much will be gained if he is aided by a
trained nurse. This in many cases involves the removal of the patient
from the cares of her home.

Advantage may often be derived from the application of small blisters
to the hypogastric and iliac regions, the counter-irritation being kept
up almost continuously for two weeks at a time. The blisters should not
be larger than two inches square, and should be moved from place to
place; for instance, one blister may be placed on the hypogastrium, and
before this has healed a second should be placed one side of it. This
should be kept up for two weeks at a time, or until four or five
blisters have been applied, when, if benefit is to follow, it will be
apparent.

When the organs which are agglutinated to one another become more
mobile, and the thickened membranes more flaccid, much benefit {237}
sometimes results from the application of a pessary if a displacement
of the uterus, ovaries, or tubes exists and persists; but before the
use of this instrument is thought of, it must be positively ascertained
that no tenderness remains as a result of the inflammatory process; the
inflammation must have entirely subsided, the effects alone remaining.
It is sometimes advised that an instrument large enough to constantly
stretch and over-stretch the false membranes and adhesions is
advisable. It has also been recommended to over-stretch these adhesions
by manipulation. Of the two, I much prefer the latter method; that is,
stretching by manipulation rather than by continuously acting upon them
by means of a pessary large enough to stretch the vagina and through it
the adhesions. In stretching by manipulation, with the patient under
ether, you have your own sense of touch to guide you, and the action of
your efforts ceases with the cessation of the manipulation, while that
carried out by means of a pessary is continuous and may result in great
harm from irritation, if not from ulceration of the vaginal surface
from pressure; or it may result in rupture of the adhesions. If a
pessary is adjusted, it should be used, not for the purpose of
over-stretching adhesions, but simply for its stimulating effect on the
pelvic circulation, or as a support to the pelvic circulation rather
than as a support to the uterus. A larger instrument should not be used
than one which will occupy the vagina without stretching it--simply
unfold any doubling up which may have resulted from retroversion or
prolapse of the uterus--and its action should be carefully watched. It
should be learned, not from the sensation of the patient, but from
actual examination, that it is not making undue pressure; this
examination should be made daily at first, and afterward at longer
intervals. The use of the pessary should be discontinued as soon as
possible. This statement should be qualified by saying that the words
as soon as possible mean when all symptoms have subsided, and the
uterus and other organs are maintaining a normal or nearly normal
position, or when the pessary seems to have ceased to be of value. It
may then be removed on trial.

There is a method of using the pessary, in which it is advised that the
instrument shall be large enough to span the angle of flexion which may
exist, for the purpose of making pressure on the fundus of the uterus,
which is incarcerated in the cul-de-sac of Douglas by adhesions between
its peritoneal surface and that lining the sac. This I believe to be a
bad principle, for an instrument long enough to do this must either
take its point of support against the pubic arch or from an external
attachment--a principle of using the pessary which should be most
emphatically condemned.

The above treatment should be carried out with the patient in bed, if
possible, during which time general measures for the improvement of the
muscular and nervous system should also be employed. The application of
electricity to the thickened peritoneum and adhesions is another
measure which should not be allowed to pass without comment. Much good
may be done by the daily application of faradism, with one electrode in
the vagina and the other on the hypogastrium, and continued for from
fifteen to thirty minutes. I have thought that in some cases great
benefit followed this application. Galvanism is also of service, and by
some is thought to be of more value than the faradic current.

{238} The time for getting up should be determined by the results of
treatment; usually a period of from four to six weeks is sufficient to
determine whether or not the treatment at absolute rest is going to be
of benefit. Of course it is not to be understood that cure will follow
in severe and long-standing cases within this period, because if this
hope is entertained disappointment will follow nearly always. What we
hope and expect to attain is rest, both physical and physiological,
during which time local treatment can be carried out with greater
facility and thoroughness and the general condition improved. As a
rule, the ligaments soften, the false membranes become attenuated, and
during the time stated the patient is very much benefited, and
sometimes cured. She should now begin to sit up and to exercise
moderately; the amount of exercise should be regulated by its effect.
If pain follows walking or riding, it should not be persisted in until
such time as exercise can be taken without the production of these
symptoms.

There are no specific remedies for internal administration. The general
medication of the patient should consist in the use of such remedies as
we have learned to depend upon as capable of building up the blood and
nervous system, embracing especially that class of tonics which are
said to have the power of inducing such changes in plastic material as
favors its absorption. To this class belong the chlorides, as the
chloride of arsenic, the chloride of iron, the chloride of ammonium,
and the bichloride of mercury. These remedies should be placed at the
head of the class. The next are the iodides, as the iodide of iron, the
iodide of potassium, and the bromide of potassium. Whether or not these
remedies have the powers ascribed to them is questionable, and their
administration for this purpose must always be, to a certain extent,
empirical. As tonic remedies the administration of iron and the
bichloride of mercury is of course always indicated. Cod-liver oil is
also a remedy of much value in some cases where it can be digested. The
whole plan of treatment should rather be of a local than of a general
character, while at the same time very great importance should be given
to the building up of the general system, without which nothing can be
gained by local treatment. The patient should have a change of scene
and air as soon as practicable. A sojourn at the seaside for a time,
and then in the mountains, will be of great benefit always.

The fact should always be borne in mind by the physician and impressed
upon the patient that a previous attack of perimetritis will serve as a
predisposing and abiding cause for a recurrence of the disease, so that
all exciting causes may be avoided as far as possible.




{239}

PELVIC HÆMATOCELE.

BY T. GAILLARD THOMAS, M.D.


HISTORY.--Prior to the present century the pathological condition which
we are about to investigate had no place in the category of diseases
peculiar to the sexual organs of the female. Very slowly have its
pathogenic features, its etiology, and its importance as a not uncommon
factor in pelvic disorders, assumed a systematic basis, and even now
considerable diversity of opinion exists upon these points. The reasons
for this are not far to seek. In the first place, hæmatocele is a
symptom of an accident occurring in the pelvis and resulting in
hemorrhage; in the second, the source of the flow which creates the
hæmatoma or tumor of blood cannot ordinarily be recognized by any
diagnostic measures known to science; and in the third, death rarely
occurring from the accident and as a direct consequence of it, autopsic
evidence is wanting upon which to base accurate and scientific data.

Although these statements are undoubtedly true, it may nevertheless be
asserted with confidence that we are to-day no longer in the dark as to
the general pathology of this interesting disorder, and that we are in
position to map out a plan of treatment which meets the indications
which present themselves in an intelligent and reliable manner. There
are, however, several sources of hemorrhage which result in pelvic
hæmatocele, and it is highly probable that the day will never come when
that one which has created the accident can be ascertained with
certainty. But while such accuracy of diagnosis would be gratifying to
the ambition of the modern diagnostician, neither the prognosis nor
treatment of the disorder would be influenced by it.

Long before our day practitioners had recognized by touch the
occasional presence of tumors, more or less marked by fluctuation,
which occupied the pouch of Douglas, and by their mechanical influence
pushed the uterus out of its normal place; but it was not until the
early part of our century that it was discovered that these tumors were
sometimes, and that not rarely, composed entirely of coagulated blood;
and, curious though it may appear, it was not until the year 1850 that
pelvic hæmatocele became a well-recognized disorder.

As early as 1737, Ruysch of Amsterdam appears to have come to the verge
of discovering it, but it was left for Récamier, to whom gynecology
owes so much besides, to make it known when in 1831 he opened a
post-uterine tumor, gave vent to a large accumulation of coagulated
blood, and described the case in the _Lancette Française_ for that
year. In 1850 the {240} subject attracted the attention of Nélaton,
became a recognized pathological condition, and has since received a
great deal of attention in all the civilized countries of the world.

DEFINITION AND SYNONYMS.--Pelvic hæmatocele--which has likewise
received the names of retro-uterine hæmatocele and uterine
hæmatoma--may be defined as an effusion of blood into the pelvic cavity
of the female, either into or under the peritoneum. Some authors have
limited this definition to blood escaping from utero-ovarian vessels
and to blood enclosed either by anatomical structures or by
previously-existing inflammatory products. I do not adopt these
restrictions, because their assumption appears to me to be unwarranted
and the validity of the reasons given for their adoption more than
doubtful. The location of the blood-mass differs widely in different
cases: sometimes, and usually, it is behind the uterus--high up when
obliteration of Douglas's pouch has occurred, low down and near to the
perineum where such obliteration has not occurred; at other times it
exists both behind and in front of the uterus; and at others still, in
front of the uterus alone, adhesions preventing its percolation to the
posterior parts of the pelvis.

FREQUENCY.--It may be said, in general terms, that this affection is by
no means rare, every one of large experience in gynecology meeting
necessarily with a large number of cases of it. But no reliable
statistics of its frequency have been collected up to the present time.
Olshausen of Halle declares that in 1145 gynecological cases he saw 34
hæmatoceles; Beigel in 2000 cases found 38; Schroeder, 7 in 1000; and
Seiffert of Prague reports 66 seen in 1272 cases of female pelvic
diseases. Barnes says that in ten years' practice he met with 53 cases,
and in twenty years Tilt has seen but 12.

Without doubt, the validity of the statistics of this disorder is
vitiated by erroneous diagnosis, as is the case with all affections
which generally end in recovery. Here cases of cellulitis, pelvic
peritonitis, imprisoned cysts, etc. offer prolific sources of error, as
I can aver from the results of my own experience.

PATHOLOGY.--It is a fact, thoroughly proved by physiological
experiment, that blood injected into serous cavities very soon encysts
itself by the enveloping influence of lymph which is poured over it,
forming false membranes, or, as the French term them, néo-membranes.
The clot, once formed, clings to the serous membrane in contact with
it, and soon becomes roofed over by lymph, which, according to Vulpian,
begins to show traces of organization as early as the end of
twenty-four hours. Should the effused blood be poor in fibrin, the
coagulation and encysting do not occur, a rapid absorption taking the
place of these processes.

Pelvic hæmatocele consists, as has been already stated, in the
collection of a mass of blood in the pelvis, either above or below its
roof, without reference to the source of the flow. Such a flow
ordinarily occurs from one of the three following sources: first,
rupture of vessels in the pelvis; second, reflux of blood from the
uterus or tubes; third, transudation of blood in consequence of
dyscrasia or pelvic peritonitis.

From this it becomes evident that hæmatocele is not a disease, but a
symptom which marks a number of different pathological conditions of
quite various significance. As, however, we cannot discover the
original accident or pathological condition, we are forced to
compromise with {241} taking its most prominent sign as the exponent of
a state which is beyond the powers of diagnosis.

Autopsic evidence has revealed the following as the special and most
frequent sources of the hemorrhage:

  1st. Rupture of blood-vessels in the pelvis:
                  Utero-ovarian;
                  Varicose veins of broad ligaments;
                  Vessels of extra-uterine ovisac.
  2d. Rupture of pelvic viscera:
                  Ovaries;
                  Fallopian tubes;
                  Uterus.
  3d. Reflux of blood from the uterus:
                  Menstrual blood.
  4th. Transudation from blood-vessels:
                  Purpura;
                  Scorbutus;
                  Chlorosis;
                  Hemorrhagic peritonitis.

It is then clear that the mere presence of a large clot of blood in the
pelvis, apart from general symptoms, is a matter of very doubtful
significance, since on the one hand it may be the result of a mere
regurgitation of menstrual blood due to imperviousness of the cervical
or tubal canal, or on the other of the rupture of a Fallopian tube
which has become the nidus of an extra-uterine foetus.

Whatever be the source of the blood which escapes, it coagulates,
unless very poor in fibrin, either in the most dependent part of the
peritoneum or in the pelvic areolar tissue beneath it. Here the watery
portions of the mass are gradually absorbed, leaving a hard, small
tumor remaining; or, suppurative action being excited, the hard mass is
softened down and discharged into the rectum, vagina, bladder, or
peritoneum as a grumous material somewhat resembling currant-jelly in
appearance.

CAUSES.--These must be divided into predisposing and exciting, for it
is rare to meet with the disease in a woman who has previously been in
perfect health. The predisposing causes which can be cited with
confidence are--the period of ovarian activity (fifteen to forty-five
years); disordered blood-state, plethora or anæmia; the menstrual
epoch; chronic ovarian or tubal disease; pelvic peritonitis; and the
hemorrhagic diathesis. The exciting causes have been found to be sudden
checking of the menstrual flow; blows or falls; excessive or
intemperate coition; obstruction of cervical canal; obstruction of
Fallopian tubes; violent efforts; and ectopic gestation.

VARIETIES.--The two great classes of the affection are the peritoneal
and the subperitoneal. In the former the blood collects in the
peritoneal cavity and becomes encysted there; in the latter it collects
in the cellular tissue beneath the peritoneum, and there forms a solid
mass.

Some authors have opposed the consideration of these two varieties
under the same head; among them, Aran, Bernutz, and Voisin. But from a
clinical standpoint such a consideration appears to me to be valid. Not
only have distinct instances of subperitoneal hæmatocele been recorded
by such observers as Barnes, Simpson, Olshausen, and Tuckwell, but
{242} cases have been met with in which the subperitoneal variety has
ruptured the peritoneal roof of the pelvis, and thus broken down the
theoretical barrier which pathologists have been inclined to establish
between the two varieties.

Of the two varieties, there can be no doubt that the peritoneal is that
which presents itself the more frequently. In 41 autopsies Tuckwell
found the tumor to be peritoneal in 38.

SYMPTOMS.--As a rule, long before the occurrence of pelvic hemorrhage
the patient will have complained of more or less decided symptoms of
disease, or at least of disorder, of the genital system. The symptoms
which mark blood-dyscrasia or pelvic peritonitis or menstrual
irregularity will probably have attracted attention.

When the accident occurs the gravity of the symptoms will depend in
great degree upon the character of the lesion which has taken place.
Sometimes the blood-accumulation takes place so insidiously that the
existence of the tumor created by coagulation takes the practitioner by
surprise. At other times what Barnes has called a cataclysm occurs, and
in a few hours puts the unfortunate patient beyond the sphere of hope
or the resources of art.

In portraying the symptoms of this affection a writer can therefore
merely approximate the truth, satisfying himself with the description
of a case of ordinary severity, avoiding the description of cases in
either extreme, and guarding the reader against supposing that all
attacks give the same intensity of symptoms.

Most prominent among the immediate symptoms are--severe and sudden
pelvic pain; pallor, faintness, and coldness of the extremities; a
sense of exhaustion; nausea and vomiting; metrorrhagia; uterine
tenesmus; enlargement of the abdomen; interference with the bladder and
rectum; small and rapid pulse; subnormal temperature.

These are the symptoms of invasion, those which may be termed
immediate, and which depend upon loss of blood and a sudden traumatic
influence exerted upon living tissues. Very soon, generally within
forty-eight hours, a reaction occurs which is sometimes slight, and at
other times decided. The secondary symptoms are usually the following:
tendency to chilliness; constipation; suppression of urine; tympanites;
high temperature; rapid pulse; and tenderness over abdomen.

These symptoms are due to a combination of two causes--loss of vital
fluid and the invasion of the peritoneum or pelvic areolar tissue by a
mass of blood which becomes coagulated and irritant, on the one hand,
and inflammatory processes resulting from such invasion on the other.
Half of them might be produced by metrorrhagia, and half by sudden and
complete retroversion; but a union of the whole will point toward
hæmatocele and prompt a physical examination.

PHYSICAL SIGNS.--A tumor will be felt by vaginal touch, usually, though
not always, posterior to the uterus and vagina, and partially occluding
the latter. This will, if the examination be made very early, be found
to be soft and obscurely fluctuating, but it soon becomes a smooth,
dense, and solid body. The uterus is very generally found pressed
upward and forward, so that the body lies against the abdominal wall
and the cervix is on a level with or a little above the symphysis {243}
pubis. In some rare cases the blood-tumor is anterior to or obliquely
to one side of the uterus, but these are very rare.

Abdominal palpation reveals the presence of a tumor of varying size,
and which sometimes extends up to the navel in peritoneal hæmatocele,
but in the subperitoneal variety no tumor whatever may be discoverable
by these explorations, unless conjoined manipulation be added to it for
the sake of deeper and more thorough search.

DIFFERENTIATION.--Hæmatocele may be confounded with pelvic cellulitis
or abscess, retroversion, extra-uterine pregnancy, fibroid tumor, and
dislocated ovarian cyst.

The tumor of cellulitis develops slowly, with great pain; is hard at
first, and then softens; is tender from the first; does not elevate the
uterus or press it forward; and is not often accompanied by
metrorrhagia.

Retroversion will readily be detected by the uterine sound, conjoined
manipulation, and the absence of anæmic symptoms.

The development of extra-uterine pregnancy is slow and gives the signs
of gestation.

Fibrous tumors grow slowly, are painless, and move with the uterus, and
they are hard, irregular, and do not lift the uterus against the
symphysis.

Displaced cysts are painless, non-hemorrhagic, cause no metrorrhagia,
and yield fluctuation readily to palpation.

COMPLICATIONS.--The complications to be feared in this disease are
septicæmia, suppuration and abscess, and peritonitis.

COURSE, DURATION, AND TERMINATION.--The hemorrhage may be so severe as
to destroy life immediately. Five such instances have been recorded by
Voisin; I have met with one; and Ollivier d'Angers mentions two in
which death occurred in half an hour from a varicose utero-ovarian
vein. Such a termination is, however, very rare.

As a rule, absorption takes place unaided by art; in some cases
suppuration occurs, and the mass is discharged as if it were a large
abscess by the vagina, rectum, bladder, or abdominal walls; and at
other times septic absorption, accompanied by septic peritonitis,
destroys the life of the patient.

PROGNOSIS.--The prognosis will depend in great degree upon the severity
of the constitutional symptoms. As a rule, it is decidedly favorable
unless the surgical tendencies of the attending practitioner alter its
natural inclination. The prognosis of the peritoneal form is graver
than that of the subperitoneal, and when the tumor is very large the
danger is greater than when it is small. A large tumor argues great
loss of vital fluid, which may in itself destroy life, and the
necessity for the absorption of a large amount of coagulated material
which may poison the blood.

The usual causes of death are loss of blood, shock from sudden invasion
of the peritoneum, peritonitis, secondary discharge of the encapsulated
mass into the peritoneum, or septicæmia.

TREATMENT.--Should the physician be called in the inception of the
attack, the patient should at once be placed in the recumbent posture,
all excitement around her be quelled, the head be kept low, warmth be
applied to the soles of the feet, and perfect quiet enjoined. An effort
should be made to check the flow by applying bladders of ice or cloths
wrung out of hot water over the hypogastrium, pain and tendency to
{244} shock met by the use of morphia hypodermically, and ammonia and
brandy freely administered by the mouth. This is all that promises
benefit, and further efforts should be avoided as calculated to do
absolute harm.

After reaction has occurred let it be borne in mind that the factors
which tend to the production of death are--1st, peritonitis; 2d,
septicæmia; 3d, suppuration and discharge through some dangerous
outlet; and let all efforts be directed toward the prevention of these
events.

All pain should be quieted by opium or one of its salts, hypodermically
or by mouth or rectum; the patient should be thoroughly nourished by
milk and strong animal broths, given as often as every two hours;
febrile action should be controlled by the coil of running ice-water
and quinine; and strict quietude observed, all unnecessary examinations
being avoided, as belonging to the most pernicious class of perturbing
influences.

Should the case progress favorably, no surgical procedure looking
toward the artificial evacuation of the accumulated blood either by
bistoury or by the aspirator should be thought of, however large the
accumulation be; for experience has proved that cases left to nature,
as a rule, do better than those interfered with.

On the other hand, the great value of surgical interference in those
cases in which suppurative action occurs, or in which septicæmia
develops itself either in acute or chronic form, must not for a moment
be lost sight of. Should the case not progress toward recovery, should
the symptoms of septicæmia develop as a sharp attack or as the
insidious hectic fever, the accumulated blood or pus and blood should
at once be evacuated, and the nidus from which it is discharged be
thoroughly washed out with a 2½ per cent. solution of carbolic acid or
a solution of the bichloride of mercury, 1 to 2000 of water. Should the
accumulation be attainable, tuto, cito, et jucunde, by the vagina, an
exploring-needle should be carried into it, and as soon as the fluid is
seen to flow a sharp-pointed bistoury should be slid along this and a
free opening be made, all the contents of the sac evacuated, and
antiseptic washing be at once practised by means of Davidson's syringe
and a glass tube.

Should the accumulation point toward the abdominal walls, the opening
may with perfect safety be accomplished there. I have operated thus
upon 3 cases, with recovery in all, but the accumulation had at the
time of operation assumed the character rather of an abscess than of an
hæmatocele. A. Martin of Berlin has operated by abdominal section upon
8 cases, with 6 recoveries and 2 deaths, and Baumgärtner of Baden Baden
has done so upon 1 case, with recovery. Zweifel has collected 30 cases
operated upon by free vaginal incision, with a result of 3 deaths,
giving a mortality of 10 per cent. Mere puncture through the vagina he
found followed by a mortality of 15 per cent.

The question of surgical interference in pelvic hæmatocele is still sub
judice. In my judgment, the rule of practice may, with the present
light which we have to guide us, be safely formulated thus: So long as
the symptoms are good and the case progresses toward recovery, avoid
surgical interference of all sorts, however great be the sanguineous
effusion. So soon as symptoms of decided septicæmia or septic
peritonitis develop themselves, evacuate the accumulation by a free
opening practised by the safest outlet which presents itself, and use
antiseptic washings thoroughly.




{245}

FIBROUS TUMORS OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.


RELATIONS AND STRUCTURE.--These tumors grow from the muscular and
connective tissues of the uterus, and consequently partake of the
character of these tissues. Sometimes the substance of the tumor
consists principally of connective, at others of muscular, tissue. The
variations in the relative proportion of these two fibrous substances
constitute the main differences in the characters and appearances of
the tumors, and lead to the different terms applied to them, as
myomata, fibromata, myo-fibromata, etc. The firmer the tumor the more
connective tissue it contains. When we inspect, either ante- or
post-mortem, a uterus with a fibrous tumor attached or contained within
its wall, it will be found to present a much darker hue than natural.
Instead of the normal light rose-color, it is generally dark, sometimes
almost of a purplish tint. The time of menstruation makes some
difference; just before it is darker than soon after the menstrual
flow. The color also varies with the character and size of the tumor.
In large solid tumors the color is darker than in the large
fibro-cystic variety; indeed, in some of the latter the pearly color
strongly reminds one of an ovarian cyst. We cannot therefore depend on
the color or shape of surface for a diagnosis. Even after the abdominal
cavity is opened the contour of the uterus is usually not regular. If
we make an incision into the tumor, we find that it is surrounded by a
distinct capsule, which limits and defines its boundaries and separates
it from the adjacent substance. This envelope is not a cyst or other
form of membrane: it is continuous with, and inseparable from, the
muscular structure of the uterine walls. It, in fact, is a condensed
layer of the fibrous substance of the uterus. In cases of true encysted
tumors the cyst-wall is the generating portion of the growth. In
fibrous tumors of the uterus the growth produces the capsule by
displacing the surrounding substance in every direction, pressing it
strongly against the unaffected fibrous tissue and condensing it into
the smooth capsule. It is thus engendered in, and enveloped by, the
muscular walls of the uterus. These latter of course grow to dimensions
sufficient to keep pace with the increasing tumor. The growth may, as a
consequence of such a connection, be hulled out or enucleated, and will
not be reproduced. Inflammation or other degenerating processes may
occasionally cause adhesion of the capsule and tumor, but this is an
accident of uncommon occurrence. To understand this mode of
encapsulation we must remember that the uterine muscles are irregularly
stratified, {246} and that the tumors are developed between the strata
as between the leaves of a book, separating them sufficiently to gain
lodgment and room.

The appearances of the substance of the tumor are not uniform. In many
cases the color of the interior of the tumor is dark gray; in some it
is dull red; again, sometimes almost livid. The surface of the tumor
after the capsule has been removed is often marked by sulci denoting a
division into lobules. In other cases the tumor is smooth and
symmetrical in shape, and the fibres distinctly visible to the naked
eye. The smooth tumor is apt to be very dense and comparatively
difficult to destroy, while the lobulated variety is less dense and
sometimes easily broken to pieces. But the difference of density does
not correspond altogether with the color or shape of surface.

We seldom find large tumors of uniform structure. In some places they
are of solid fibrous structure; in others there are cavities of greater
or less size, containing a tenacious red serum. These cavities, which
seem to be made by localized disintegration of the fibrous tissue, are
sometimes of great size, containing several pounds of serum (Atlee).
Much more frequently they are small and hold a small amount of fluid. I
have met with several where the substance of the tumor seemed to be
made up of alveoli filled with a tenacious fluid the color of milk.

Besides this effect upon the density of the tumor resulting from what
might be called its usual course, there are numerous modifications in
it and in the other properties of the tumors arising from spontaneous
degeneration.

It may be said, I think, that without adventitious or supplementary
vascular supply the life of a fibrous tumor is self-limited, and it
ceases to grow after it has attained to a certain size, and that then
it either remains stationary or undergoes degeneration. As I shall have
occasion to say farther on, the original supply of blood-vessels cannot
be increased to an indefinite degree, and the tumor that grows
indefinitely derives a supplementary supply of blood by contracting
adhesions to the viscera or abdominal walls. Such adhesions are common
and mischievous.

After a tumor has attained its growth, degeneration into the more
elementary forms of tissue sets in, as the cartilaginous degeneration,
and there is often a deposition of earthy material found in it which
reduces it to a hard, dense, stationary, and indestructible body. In
such cases there is almost a complete loss of vitality in the tumor,
and it becomes a calcified mass.

We may easily demonstrate that the structure of these tumors is
essentially fibrous. By maceration and careful dissection the fibres
are traceable to a greater or less degree in all of them, the
proportion and characters of which, as before said, differ greatly. In
the smooth, symmetrically-developed tumor the fibres are usually long
and distinctly traceable, while in the lobulated light-gray tumor the
fibres are more rudimentary and not so easily followed up by
dissection.

MODE OF DEVELOPMENT.--It has already been stated that the fibrous tumor
of the uterus grows in or on its wall and originates in the fibrous
structure of the organ. The point of beginning is in one or more
fasciculi of the muscular system or the connective tissue of the
uterus. If in one fasciculus, the point of origin is very minute, as
indeed it is generally at first.

The development consists in an hypertrophy of the bundle of fibres
{247} affected and a deposit of material similar in structure to that
first involved. Sometimes there are numerous nuclei, and nearly all the
fibrous structure of the uterus is involved in fibrous degeneration. In
the case where the deposit is defined and occupies a small space, it
should be borne in mind that the future tumor, however large it
becomes, must occupy the same nidus in which it first originated. The
nidus becomes enlarged sufficiently to accommodate the growing tumor.

The nucleus of development is enlarged by the accretion of substance
similar, if not identical, in character to its own proper material. The
nature of the tumor is determined by this fact, and its fibres are
rudimentary in organization, instead of being hypertrophied and highly
developed, as those of the uterine wall by which it is surrounded. As
the tumor grows the fibrous structure surrounding it is pressed aside
in every direction in such a way as to completely embrace the growth
and encapsulate it. The tumor does not incorporate the adjacent fibres
and grow by inducing degeneration in them, but, as before said, it
presses them aside. As it thus moulds and shapes a bed in the solid
substance of the interior wall, it impresses upon the embracing
muscular fibres an increased vitality, and they grow by hypertrophy of
a character similar to that of pregnancy. The fibres become longer, and
apparently, if not really, more numerous. This hypertrophy of the
uterine fibres surrounding the tumor is equal to the capacity demanded
by the increasing size of the growing tumor. In this description of the
method of development and the embracing capacity of the hypertrophied
fibres surrounding it the reader will trace the formation of the
capsule in which the tumor is contained. The inner surface of the
capsule is smooth, and there are many feeble fibres of connective
tissue seen to connect it with the surface of the tumor. There is no
adhesion proper between the surface of the tumor and its capsule.

I must call attention to another point that governs the extent and
limits of the growth of the tumor--viz. the number and distribution of
its vessels. The vessels entering the tumor represent the minute twigs
that supplied the fasciculus in which it originated. They arrive at the
point of morbid deposit from the parts constituting the capsule, and
there are always several of them. The number of these vessels always
remains the same, and their calibre is increased with the hypertrophy
of the surrounding tissues. They cannot grow at the demand of the
trophic energies of the tumor to an unlimited degree, but their size is
limited by the growth of the surrounding parts. As the tumor grows and
its capsule expands, the vessels are separated farther from each other,
until after a while the area becomes so large that the supply of blood
will not admit of further growth and the tumor comes to a standstill.
Thus their growth, from the nature of their supply, is limited; hence
the usual history of the tumor is one of self-limitation. It is
all-important in forming an opinion in reference to the greater or less
vitality of the fibrous tumor, therefore, to remember that it is not
supplied by one large arterial trunk entering at one place and
spreading over its capsule, but that the supply is by a number of small
vessels penetrating the tumor at different points; that their number
cannot be increased and their growth is limited; that as the tumor
grows their capacity to supply it grows gradually less until entirely
exhausted: then the growth stops.

{248} There is another and adventitious source of nutritious supply,
and I think it is essential to very large growths: at least, so far as
I know, it is always present. I mean the adhesion of the uterus or
tumor to the wall of the abdomen, the pelvic or abdominal viscera, or,
what is more common, the omentum. When adhesions occur from whatever
cause, the vessels of the tumor increase in size and supply it with a
vast increase in the amount of blood. All the large tumors I have had
an opportunity of examining were to a greater or less extent covered by
a network of large vessels contained in the omentum. These vessels
penetrate the uterus, carrying a deluge of blood into its substance.
These large vascular adhesions are a source of embarrassment in
operations for their removal. Operators allude to them and give
instructions how to overcome the difficulty presented by them. The
uterine vessels alone would never be sufficient to supply the forty- or
fifty-pound tumors so often mistaken for ovarian tumors.

EFFECTS UPON THE UTERUS.--I have already said that the fibres
immediately surrounding the growth undergo a true hypertrophy,
acquiring dimension, susceptibility, and capacity similar to the
hypertrophy of gestation. All the fibres of the uterus undergo a
similar change, only less in degree; the more remote from the tumor,
the less marked the hypertrophy. This remark must be modified somewhat
by the consideration of the locality of the tumor. A polypoid tumor
growing from the fundus causes universal hypertrophy of the uterine
fibres. A submucous tumor will usually cause a general hypertrophy of
the uterine fibres, but greater on the side of the tumor. A subserous
tumor is attended by a slight hypertrophy, and in a centrally-located
intramural tumor the hypertrophy would be much like that in the
submucous variety, only less in degree. But this augmentation of tissue
is not confined to the fibrous structure: it extends to the vascular
and nervous apparatus and to the serous and mucous membranes. With this
growth of the tissues comes change in the properties and functions of
the uterus itself. It is more sensitive, the secretions are increased,
and almost parturient contractility is acquired.

But probably as remarkable and uniform a symptom as any arising from
the general hypertrophy is hemorrhage. The mucous membrane of the
uterus is hypertrophied in all its constituents and proportions. The
membrane acquires larger superfices and greater thickness, its glands
are enlarged, and its blood-vessels augmented. Its functions, as a
consequence of these changes, are exaggerated. The glands secrete
greater quantities of mucus, and the vessels when ruptured in the
processes of menstruation pour out a superabundance of blood. Indeed, I
know of no other way to account for the hemorrhages so generally
present in cases of fibrous tumors of the uterus, except upon the
ground that the endometrium, a natural hemorrhagic surface, has its
properties and functions enhanced by a general hypertrophy.

LOCATION OF THE TUMOR.--For the purpose of considering the relation of
these tumors to the different regions of the uterus we may call that
part situated above the entrance of the Fallopian tubes the fundal
zone, and that above the internal os uteri the corporal zone; all below
this the cervical zone. Fibrous tumors may and do originate in all of
these zones or regions, but they spring more frequently from the
corporal {249} than either of the others, and less frequently from the
fundal zone. The part of the corporal zone in which these tumors more
frequently grow is the lower or cervical portion. There is another
important view of the relation of the tumors to the uterus. The
muscular fibres of that organ run in every direction with reference to
the latitude and longitude of the uterine circumference--transversely,
longitudinally, obliquely, spirally, etc. There is probably not much
more definiteness in the layers constituting the walls of the uterus.
If they cannot be completely separated into regular strata, there is
sufficient distinctness in the layers to justify us in employing the
term strata in connection with their arrangement, and this term will
enable us to get a more exact understanding of the language used in the
description of tumors. Authorities differ as to the exact number of
strata to be found in the body of the uterus, but for clinical purposes
it is convenient to describe them as follows: By drawing a line through
the middle of the uterine wall longitudinally we will indicate a
central stratum of fibres. A tumor originating in that line or stratum
is what is usually called an intramural tumor. The number of tumors
growing in this stratum is not very great as compared with those
situated nearer the two surfaces.

[Illustration: FIG. 25. Diagram showing Muscular Strata of Uterus, as
divided for clinical purposes.]

If we run one line between the serous and another between the mucous
membrane and the central line, as in the diagram, other strata with
intervening spaces will be indicated. _a_ would represent the centre
stratum of the wall; _b_, the space immediately outside of that; _c_, a
stratum still farther out; _e_, the subserous; and _d_, a deeper one.
When we look at the inner layers of fibres, we find _f_ situated
immediately beneath the mucous membrane; _g_, farther out; and _h_,
next the median line. The nucleus of a tumor may be first manifested in
any of the strata or spaces marked by these lines, and its position
with reference to the central line will, to a great extent, govern the
direction it takes during development. A tumor the nucleus of which is
situated in line _a_ will, as it develops, press the muscular fibres
equally in every direction, and when large, the prominence caused by
pressure of the tumor would be equal in the uterine cavity and on the
peritoneal surface. In marked contrast to this, when the nucleus is at
_f_ the growing tumor presses the mucous membrane before it until it
becomes pendulous, and then the name of polypus is given to it; or if
the origin is at _e_, the serous membrane is pressed before it, and the
tumor is called subserous. When the nucleus is at _d_, the tumor
elevates the serous membrane and becomes a prominent hemispherical
protuberance. It is also called a subserous tumor, although situated
some distance from the membrane. When a tumor takes its origin at _g_
the mucous membrane is crowded before it, and a marked prominence into
the cavity of the uterus is observed. This is the submucous tumor.
These illustrations are intended to call the attention of the student
to the fact that practically these tumors spring {250} from any one or
all the fibrous strata of the uterus instead of only the central,
submucous, and subserous layers, and that it is profitable, on account
of the difference in their effects upon the shape and functions of the
uterus, to study them in this aspect of their growth.

ETIOLOGY.--While we know many of the conditions under which fibrous
tumors exist, we have really very little, if any, definite and reliable
information as to their causes, either remote or proximate. We know
that they occur much more frequently near the time when the uterus
begins to undergo senile degeneration, although they do originate in
earlier years. They very seldom, if ever, are observed in the foetus or
child, nor is it common for them to commence growing after the
menopause. Women belonging to the African race are the most frequent
subjects of these tumors.

The married or single status does not seem to have any effect in
predisposing to these tumors. We do not know what physiological or
pathological states of the uterus or other organs predispose to them.
There is probably no tumor in the body strictly analogous in structure,
mode of origin, supply, or development to the fibroid tumor of the
uterus. There is no other organ in the body that undergoes analogous
normal trophic changes. The vast multiplication of tissue that takes
place in the uterus during gestation, and the more rapid but equally
great changes toward degeneration or atrophy, would naturally suggest
pathological possibilities of a peculiar nature. The rhythmical changes
of menstruation are like no other functional condition. They too
involve the processes of hypertrophy and atrophy. When the menstrual
and generative changes are normal every part of the body of the uterus
is simultaneously and proportionately hypertrophied and atrophied.
Local derangements of these processes of hypertrophy and degeneration
must sometimes occur, probably from defective or excessive innervation
of loculi in the fibrous structure. Congestion or hyperæmia may thus
result, and consequently very great influence be exerted upon the
nutrition of the parts concerned after the deposit has begun; its
presence increases the hyperæmia and thus perpetuates its growth
indefinitely.

CLINICAL HISTORY.--Probably the earliest, most frequent, and constant
symptoms connected with fibrous tumors of the uterus are hemorrhage and
leucorrhoea. They are both the result of active or arterial hyperæmia,
and doubtless come from the endometrium. Polypi, submucous, and
intramural tumors are more likely to give rise to these two symptoms.
The nearer the mucous membrane, and the greater that membrane is
expanded, the greater the amount of hemorrhage and leucorrhoea, and, as
a counter-fact, the nearer the serous membrane, the less the amount of
these two discharges. While this statement in reference to the effects
of the proximity of the tumor to the two membranes is usually true, it
is not always so.

Hemorrhage is sometimes not very great, but at others it is appalling,
and constitutes an imperative reason for the employment of desperate
remedies. The hemorrhage is usually first noticed in connection with
the menstrual flow, and it may even be confined to the periods:
sometimes it extends over the whole of the interval. The leucorrhoea is
generally constant, and sometimes thin and watery, especially after the
hemorrhagic paroxysm has subsided, and at others it is constituted
{251} mainly of mucus with the débris of the mucous membrane and
blood-corpuscles.

Other symptoms are pelvic pressure, vesical and rectal, with tenesmus,
distension, and dysmenorrhoea. The pelvic pressure and tenesmus are
observed early in the development of the growth, and may be relieved as
the tumor becomes large enough to rise out of the pelvic cavity. The
abdominal distension of course comes later. Solid tumors do not often
attain to such a size as to cause great abdominal distension. The
fibro-cystic generally are inconvenient, if not fatal, from this cause.

The above are the more direct and common symptoms. A less frequent yet
important effect and symptom is oedema of the lower extremities from
pressure upon the venous trunk passing through the pelvis. In rare
cases this symptom is aggravated to a degree constituting phlegmasia
alba dolens. As the tumor rises and enlarges the pressure may embarrass
or interrupt the function of any or all the abdominal viscera.

In many cases none of these symptoms present themselves to an
inconvenient degree, and the tumor is discovered by accident. Again, we
meet with cases in which the symptoms are formidable for a time, and
then entirely subside, leaving the patient free from suffering the
balance of her lifetime. While this subsidence may take place at any
time during the growth of the tumor, it is very apt to take place at
the menopause.

The clinical history of the fibrous tumor may be very much modified by
the intervention of various circumstances. As organized bodies they are
subject to those affecting the organs of the body. We must regard them
as adventitious growths acted upon by organs in a state of disease and
reacting in turn upon them. They may become inflamed, undergo
suppuration and gangrene, and produce symptomatic fever, hectic fever,
prostration, gastric, hepatic, and nervous derangement in a degree
sufficient to prove fatal.

When situated near the mucous membrane, nature sometimes turns these
organic changes into a means of cure by destroying the portions of the
capsule near the uterine cavity and permitting the pus or gangrenous
material to escape. They are also subject to pressure from the
development of other tumors, and either disappear, become inflamed and
adherent, or cause great trouble to adjacent organs. Their clinical
history is sometimes modified by complication with pregnancy.

This complication is rare, because the uterus in most cases, on account
of the effects produced upon its circulation, nerve-supply, and mucous
membrane especially, will not retain the ovum, and conception does not
take place. The uterus being more vascular, and subject to congestions
that affect the placental attachment injuriously, miscarriages are
likely to occur. It is also morbidly sensitive to the pressure of the
ovum, while the mucous membrane is rendered incapable of decidual
changes. The retentive power of the uterus is further interfered with
from the irregularity of its growth: the fibres where the tumor exists,
being under a morbid influence, cannot partake of the regular
hypertrophy necessary to normal gestation. There is something of
uniformity in the circumstances under which the coexistence of
pregnancy and fibrous tumor is observed. The nearer the tumor is
situated to the mucous membrane, the less likelihood of pregnancy--the
more remote, the greater the tolerance of pregnancy. Tumors that occupy
the wall of the corporal portion {252} are conducive of sterility.
Those in the cervical portion of the corporal and the cervical zone are
more likely to be accompanied with pregnancy than those situated in
other parts of the organ. While the reader will find these statements
borne out by his experience as general facts, he will also discover
that pregnancy is occasionally compatible with almost any form,
variety, or position of tumor. When this complication occurs, it does
not generally influence the process of gestation or the condition of
the tumor. The main symptoms depending on it are those caused by
pressure. When small this is not very considerable.

Complication with labor generally gives rise to more apprehension than
difficulty. Most of the cases of labor terminate spontaneously and
happily, and the others are generally within reach of the less
destructive modes of delivery. Labor more frequently decidedly affects
the growth of the tumor, in the majority of cases causing its
disappearance during the process of involution. The cervical polypi
affect labor less, and are less affected by labor, than any other
variety of the tumor. If small, they are sometimes merely pressed to
one side or into the hollow of the sacrum, and the head passes by them;
if a polypus is large, the head of the foetus carries it before it
beyond the vulva, where it remains until the child is expelled, when it
may recede into the vagina.

DIAGNOSIS.--The history usually includes hypersecretion, hemorrhage,
pressure, and enlargement. These, while suggestive, are not conclusive,
hence physical examination becomes indispensable to accuracy. The
methods of examination vary with the size of the tumor. It is generally
near the truth to say that the uterus is enlarged, and may be shown to
be so by the introduction of the sound; yet the cavity is not always
enlarged, and it is often so tortuous that the ordinary sound may be
arrested before reaching the fundus. The sound, therefore, should in
such condition be flexible. The fine whalebone or the sound of Jenks
will generally pass obstructions caused by tortuosities. The most
skilled and dexterous use of the inflexible sound is often delusive. We
may generally determine the size by bimanual examination--one finger in
the vagina or rectum while the hand is passed down into the pelvis from
above. The uterus of normal size cannot be felt with any distinctness
from above in this way, while an enlargement of 50 per cent. may be
thus determined. The finger below will sometimes recognize the pressure
from above when the upper hand will not feel the fundus distinctly.
Small tumors of the uterus may be mistaken for many other conditions,
and the converse. If one is situated in the posterior wall, it may be
mistaken for retroflexion. We may make the distinction by means of the
inflexible sound and the finger in the rectum. If the case is one of
retroversion, the finger in the rectum will pass behind it and overlap
it above. If a retro-uterine tumor is in the cul-de-sac, the finger
will not reach above the uterus. If the case is one of retroflexion, a
strongly bent sound may be made to enter it, especially if the fundus
is slightly raised by the finger in the rectum. If there is a tumor in
the posterior wall, the sound with slight flexion will pass above it;
which is clearly ascertained by the finger in the rectum. When the
sound is introduced in the case of retroflexion, the fundus may be
elevated to its proper position by turning the sound upon its axis. In
making these examinations with the sound the finger should be made to
co-operate with it by being kept in {253} the rectum. A small tumor in
the anterior wall may be distinguished from anteflexion by the sound
passing upward instead of forward, or into the part lying on the
bladder. When a small tumor is intra-uterine, the uterus will occupy
its natural position, with the mouth directed slightly backward; and if
the polypus is large, the cervix can be moved forward with considerable
difficulty. A flexible sound, especially the thin whalebone, may
sometimes be made to partially or wholly surround it, and its size or
connections be determined. But the diagnosis may be more definitely
made out by dilating the cervical cavity and introducing the finger.
The difference between a polypus and an intramural submucous tumor may
be determined in this way. In the case of a polypus the finger will
pass around it, while if the tumor is intramural or submucous the
finger will be arrested at the point of attachment. A polypus or
intramural submucous tumor presenting at the os externum may sometimes
be mistaken for a partial inversion. Such a mistake may be prevented by
using the sound. In the case of a tumor the flexible sound will pass to
more than the normal depth. In one of inversion the sound will pass
very much less or not at all. When a polypus has escaped from the mouth
of the uterus and occupies the vagina, the sound will pass beyond it
into the enlarged uterus, whereas in complete inversion it cannot be
passed into the uterus in any direction. We cannot rely upon
consistence or shape as marks of distinction in these two conditions.
When the tumor rises above the pelvic brim and is not very large it
generally displaces the os from its normal position. If in the front
wall, the os will be too far back; if in the posterior, it will be
displaced forward. In the former, when a sound is introduced, it will
pass backward and upward; in the latter, the sound will pass forward
and upward. In both cases the bimanual examination will enable us to
determine that the tumor above the pelvis is continuous with or
attached to the uterus. With the hands in this position, if we move the
uterus the tumor will move with it, and vice versâ. Tumors of this size
are usually more or less uneven in their outline, and of greater
consistence than the uterus when enlarged from other causes. Tumors of
this size may be generally distinguished from the pregnant uterus by
the history of pregnancy, by the consistence, and by the size of the
cervix. When pregnancy and a tumor are associated, this may be
determined by a part of the enlargement being very hard and other parts
quite elastic, and by auscultation. I need not caution the reader
against the use of the sound where there is any suspicion of pregnancy.
When a doubt exists, we should await the progress of the case until
pregnancy becomes obvious. We may generally determine whether a tumor
is uninuclear by the fact that a single tumor is nearly round, when if
there are several points of origin it will be irregular and nodular.

When the tumor is large enough to nearly or quite fill up the abdominal
cavity, the flexible sound may be made to pass a great distance into
it. It is not often that a solid tumor grows large enough to fill the
abdominal cavity. Before it grows to such dimensions it generally
undergoes cystic degeneration. When the tumor is solid, generally its
very great hardness, and often its irregular shape, will distinguish it
from other abdominal tumors. The condition with which I have seen these
tumors most frequently confounded is enlargement of the liver or
spleen. {254} In the South and West an enormously enlarged spleen is
not infrequently met with. It sometimes spreads over the whole anterior
part of the abdomen, completely covering the intestines. Less
frequently the liver is found similarly enlarged. In this condition the
organ becomes greatly indurated, and sometimes nodular. The
distinguishing features of these enlargements are--first, that the
abdomen does not present the prominent rotundity it does when filled by
a growth; second, that somewhere in the extent of abdominal surface by
careful manipulation the edge may be discovered and the fingers be made
to sink beneath and grasp it; third, percussion will elicit general
deep resonance, in some parts quite obvious, and in others less so. In
the case of tumor none of these signs will be present. Again, the
enlarged liver or spleen, while it may reach to the brim of the pelvis,
does not reach into that cavity far enough to be recognized by the
finger in the vagina, while the tumor does.

Sometimes inflammatory effusions form indurated masses in the abdomen
that are mistaken for fibrous tumors. These of course have the history
of inflammation, are generally if not always tender, and yield obvious
intestinal resonance upon percussion. The large fibro-cystic tumor may
be mistaken for pregnancy, ovarian tumor, cystic degeneration of the
kidney, and omental tumors. Pregnancy can generally be established by
absence of the menses, by the shape, size, consistency, and position of
the cervix, together with auscultation. It may be said that in case of
fibro-cystic tumor the cervix is greatly displaced in some direction,
indurated, and not enlarged. In pregnancy none of these conditions
prevail.

The fluctuation of the fibro-cystic tumor is more obscure than that of
the ovarian tumor, and, although sometimes noticeable over a large
space, it is usually more constricted in extent. There is also usually
less regularity in the shape of it. In large ovarian tumors the uterine
cervix is not changed in shape and size. The whole organ generally lies
beneath the tumor, and the elastic sound will not pass very deeply into
the cavity. If the uterus is attached to the anterior part of the
tumor, which sometimes happens, the elastic sound will pass into it and
the depth will not be very great. The fibro-cystic tumor may be
distinguished from the enlarged encysted kidney by the facts that the
kidney is traceable to one side more than the other, and it cannot be
reached by the finger through the vagina or rectum. Still, if we cannot
make the differentiation clear in any other way, we can generally do so
by aspiration. In most cases we cannot draw the fluid from the
fibro-cystic uterine tumor; in almost all cases the quantity removable
in that way is small. When fluid is drawn, it usually coagulates,
contains hæmatin, and none of the cells so generally found in ovarian
tumors.

The fluid drawn from the kidneys presents epithelial cells, is not
coagulable, certainly does not coagulate spontaneously. The abdominal
cavity is sometimes more or less filled with peritoneal serum. After
this is withdrawn from the peritoneal cavity the uterine attachment of
the tumor may be made out by bimanual examination, as above directed,
if undertaken immediately after the evacuation.

PROGNOSIS.--Less than twenty years ago the general prognosis to be made
upon the discovery of a tumor of the uterus was very grave. The
profession knew so little about the clinical history and diagnosis of
these {255} tumors that they were invested with many of the bad
qualities of other tumors, with which they were so often confounded;
and we had so little knowledge of their nature and the measures which
would influence their growth that we felt an entire helplessness in the
treatment of them. Fortunately, there have been many favorable changes
in these respects. We understand their clinical history better, and can
make a pretty clear diagnosis. We know that relatively few of them
prove fatal even when left wholly to nature. Compared to all other
uterine and ovarian growths, they are innocuous. Most of them are
self-limited in consequence of the mode of blood-supply. A goodly
number not only stop growing, but disappear without the application of
any remedial measures. Then, as I shall have occasion to show, they may
be often cured by the judicious administration of medicines, and the
surgery for their extirpation has become a reliable resort in extreme
cases. These considerations render the general prognosis of the true
fibrous tumor quite hopeful. The menopause generally starves them out,
and thus removes all the bad qualities they may possess.

When they lead to fatal results, they generally do so through three
different conditions--viz. hemorrhage, pressure, and complicating
inflammations--and probably in the order mentioned. Hemorrhage is by
far the most fatal symptom. The kind of fibrous tumor accompanied with
severe hemorrhage is usually the submucous variety. The submucous tumor
with a broad base is the most mischievous, because it induces great
hypertrophy in the vascular system of the mucous membrane especially,
and also the vessels of the whole organ. A sessile submucous tumor
arising from one nucleus is worse than one in the same situation with
several nuclei of origin. The intracorporal polypus or pendulous tumor
is almost as bad in this respect as the sessile submucous, especially
if it originates at or near the fundus. Fortunately, these forms of the
tumor are more amenable to the effects of medicine and more accessible
to surgical treatment. The tumors located in the central stratum of
fibres are next to these in mischievous qualities. The more remote the
tumor is located from the mucous membrane, the less hemorrhage will
attend its development.

When the tumor becomes cystic the danger from pressure is very much
greater; yet the solid form becomes sometimes so large as to do much
mischief from pressure upon the abdominal organs; and any of these,
except perhaps the polypoid variety, may be so situated as to cause
mischievous if not fatal pressure upon the pelvic organs.

It is rare, however, that the pressure in either of these cavities
proves fatal, especially when the case is under intelligent management.
The supervention of inflammation in the tumor, even to a moderate
degree, is very apt to lead to gangrene and death from peritonitis,
shock, or septicæmia. Sometimes subacute inflammation of the peritoneal
surface of the tumor gives rise to serous effusion or dropsy in the
abdominal cavity that proves fatal; and, as before stated, peritonitis
sometimes causes adhesions which result in augmented vascularity and
consequent increase of blood-supply. This condition, I believe, often
changes a solid to a fibro-cystic growth, a more highly vitalized
tumor, and consequently a more mischievous one.

Do these tumors ever become sarcomatous or malignant? I do not {256}
believe they have any innate tendency of that kind. Where they are
found complicated with malignant growths I believe the malignancy is an
independent quality, and is an invasion resulting from some cause
extraneous to its organization, and in that respect is analogous to an
attack on the cervix or other portions of the uterus.

The prognosis when complicated with pregnancy is of course more grave,
but experience has demonstrated the practicability of complete and
normal gestation. Conception will not often occur where these growths
have attained any great size, but may sometimes. Of the nine cases
which I have met and had an opportunity to follow, not one has been
attended with abortion or premature labor. In one the pregnancy seems
to have been protracted at least four weeks. The foetus was in a state
of decomposition, and had probably been dead four or five weeks before
labor began. What is not less remarkable also is that labor did not
seem to be seriously affected in but one case, and in that the
difficulty was easily overcome by turning.

Until lately there were several supposititious sources of danger at the
time of confinement--viz. inefficient uterine contractions, and
consequent tedious or impracticable labor, and after expulsion or
artificial removal of the foetus dangerous hemorrhages from the same
cause; also, the possibility of the placental connection being made at
the site of the tumor, with the imperfect closure of the sinuses that
was supposed to follow.

Reports of cases occurring within the last few years, while they have
not completely swept away the grounds for such apprehensions, prove
that the accidents so greatly feared do not in fact occur. Chadwick
reports a case where the placenta was attached to the mucous membrane
over the tumor, yet the placenta was spontaneously expelled and there
was no considerable hemorrhage. The efficiency of the expulsive efforts
were not materially affected in any of the cases I have attended. And
this is what we might expect, because conception and gestation would
not be perfect where there is not a sufficiency of healthy mucous
membrane, upon which a normal decidua could be formed, and of fibrous
structure to permit the hypertrophy of gestation.

The apprehension of obstruction from the tumor lying in such a position
as to intercept the expulsion of the foetus is not often realized; for
those in the cervix, either pendulous or otherwise, are pressed out of
the external parts in advance of the head, while those in the body and
fundus are lifted up into the abdominal cavity, where there is plenty
of room. It must indeed be rare that the tumor becomes impacted in the
pelvis so as to interfere with the passage of the foetus.

Neither does the puerperal condition seem to be rendered materially
more dangerous in consequence of the presence of these tumors.

What effect does pregnancy have upon the growth of these tumors? It
might be supposed, from the plentiful supply of blood afforded them by
the growth of the vascular system of the uterus, and from the fact of
their being situated in and surrounded by tissues in a state of active
hypertrophy, that the tumors would grow in a corresponding degree with
the uterus itself; but this is not generally, if it is ever, the case.
I have not witnessed a decided increase in the size of the tumor in any
of my cases. Pregnancy usually produces the opposite effect; and this
can be easily understood when we remember that the tumor is subjected
to great {257} and uniform pressure, which prevents its own circulation
from becoming as great as it otherwise would be; and I think this
pressure often inaugurates a retromorphosis that results in the final
disappearance of the tumor. Whether degeneration begins during
pregnancy or not, the tumor is very apt to disappear after pregnancy
and labor. In six of my own cases the tumor disappeared by a slow
process of some kind after labor. Speculating as to what might be,
another apprehension of danger arises out of the tumultuous excitement
and terrible pressure to which it is subjected during the throes of
parturition. But this apprehension is rarely if ever realized.

TREATMENT.--The treatment of fibrous tumors of the uterus consists
largely of the means calculated to relieve such symptoms as endanger
the life of the patient or materially affect her general health. When
these are unavailing resort is had to measures calculated to get rid of
the tumor. Some remedies necessary to the relief of symptoms act as
very powerful curative agents; hence, while it is convenient to speak
of the treatment of symptoms under one division of the subject, and the
methods employed for radical cure under another, we cannot, in fact,
completely separate these two branches.

Hemorrhage is by far the most important of the symptoms connected with
these growths, because it is at the same time the most frequent and
hazardous. It is also the symptom that leads to most suffering in
consequence of depriving important organs of the blood necessary to
support them in their functions. Every reasonable means should be made
use of, not only to prevent fatal losses, but also to prevent moderate
hemorrhage. In the outset, therefore, I would insist upon watching with
great vigilance to prevent any unusual loss of blood. It is not
advisable to temporize by adopting the milder and less efficient
measures as being sufficient for cases not likely to prove fatal, but
we should treat all hemorrhages arising from this cause with
promptitude and energy. Fortunately, in many cases we can anticipate
the attacks of hemorrhage, because we know when they will occur, and we
are generally able to judge of their probable severity. To discharge
our duty in this respect effectually, our patient should be properly
provided with remedies and fully instructed how to use them. She should
be made to understand that unusual hemorrhage at the menstrual period
may be checked without endangering her general health. Among the
remedies are--dorsal recumbency with the hips elevated, cold to the
hypogastric region and cold to the dorsal spine and sacrum, ergot, and
some form of tampon. The best fluid extract of ergot in drachm doses,
if the stomach will bear it, is probably the most efficacious, but the
fresh drug in the form of infusion is also very efficient. Full doses
should be given every half hour when there is much loss, until some
effect is produced upon the hemorrhage, and then continued every four
hours as long as necessary. Compressed sponges saturated with the
solution of sulphate of alum make the best tampons for the patient to
make use of. These may be made and kept in readiness, so that they can
be introduced as soon as they are found necessary. The patient or nurse
can make them by taking a fine sponge, large enough to fill the vagina,
passing a piece of string through the centre to aid in its removal, and
then, after dipping it in the solution, winding it with twine from one
end to the other, compressing it into as small {258} a space as
possible. The twine should so compress the sponge as to make it assume
an elongated form. It should then be laid aside and permitted to dry.
Several sponges should be thus prepared. When necessary the twine may
be unwound and the sponge introduced. Its size when in the dry
condition will allow of an easy passage into the vagina, where the
moisture will cause it to expand, and fill up and seal the vagina so as
to absolutely check the discharges. If the attending physician is
present, he may tampon the vagina with pellets of cotton secured by
thread and moistened with a solution of alum. The inconvenience
experienced from this plug will be more than counterbalanced by the
saving of blood. This form of tampon has the additional advantage of
being antiseptic. I have allowed it to remain for three days, and upon
removing it satisfied myself that there was no decomposition of the
blood or the vaginal secretions. When the tampon is removed it will not
be found difficult to wash out all the granular clots caused by its
presence. It may be repeated as often as necessary, but usually, if
allowed to remain forty-eight hours, the hemorrhage will not return. It
may be said that for small losses this is unnecessary, but it is
convenient and harmless, and will answer the purpose. In dangerous
cases no one will question the propriety of its employment.

Another very important means of arresting hemorrhage which can be used
by the physician when necessary is the introduction of a compressed
sponge into the cervix uteri. This will temporarily act as a tampon and
stimulate the uterine fibres to contraction. The free incision of the
cervix, as directed by I. Baker Brown, may be tried between the times
of the paroxysms of hemorrhage.

The pressure of the tumor upon the pelvic viscera is another
inconvenience which calls for attention. This takes place usually at a
time when the tumor has acquired a size sufficient to fill the pelvic
cavity. Consequently, the elevation of the tumor above the pelvis is
the remedy. This may be done sometimes by placing the patient in the
knee-elbow position and pressing the growth upward. The powerful
influence of atmospheric pressure called to our aid by the position and
opening of the vagina is a very material auxiliary in the process of
elevation. If this is not sufficient, we may pass the fingers into the
rectum and elevate the tumor. I once succeeded in this operation by
using an ivory-headed cane in the rectum when the fingers failed to
reach high enough. If we cannot elevate the tumor by any of these
means, we may introduce into the vagina or rectum a gum-elastic bag,
and by means of a powerful syringe fill it with water to as great
distension as the patient will bear, permit it to remain, and thus do
the work more gradually.

Dysmenorrhoea is another symptom of fibrous tumors, and sometimes a
very distressing one. It depends, no doubt, on the imprisonment of
blood in the uterine cavity in consequence of the tortuosity of the
canal causing the closure of some part of it. The remedy consists in
dilating these narrow places. I know of nothing so well calculated to
effect this object as the slippery-elm tent. One or more of these
tents, long enough to reach the fundus uteri and of sufficient size,
moistened so as to render them very flexible, may be passed up through
the tortuous places with great facility. If introduced as soon as the
symptom begins to manifest itself, and allowed to remain an hour or
two, the relief will be pretty {259} certain. If used once a day for
four or five days before the attack, and three or four hours at a time,
dysmenorrhoea may be generally avoided.

Curative Treatment.--When we broach the question of the permanent cure
of these affections, we find that great difference of opinion exists
among the members of the profession as to the value of medicines. One
party, perhaps a majority of the profession, believe that no medicine
has any direct effect upon them, and these ignore any means of
permanent relief but surgical. There is, however, a respectable number
of medical men who place great reliance upon the administration of
certain medicines, and, if I am not greatly mistaken, recent
observation has added greatly to their number. They do not, however,
wholly agree as to the therapeutic processes that should be instituted,
and consequently do not employ the same kind of medicines. Some
gentlemen have more confidence in what I will term the sorbefacient
medicines and processes of treatment. They endeavor to institute
measures that will cause the absorbents to attack and remove the
neoplasm in the same way that tumefactions caused by effusions are
removed. This they do by friction, pressure, and the administration of
the old-fashioned sorbefacient medicines. The most popular among these
are the iodides, chlorides, and bromides of mercury, potassium, sodium,
calcium, and ammonium. Reports may be found in books and periodical
medical literature of cures by several if not all of these articles and
their combinations. The late W. L. Atlee, whose experience was very
extensive, had great confidence in the action of hydrochlorate of
ammonia. He administered it internally, applied it externally, and used
it as vaginal injections. The iodide of potassium has long enjoyed a
great reputation in causing the absorption of these and other forms of
tumors. There is no professional fairness in assuming that the faith in
these remedies derived from the observation of their effects or the
promulgation of cures from the use of sorbefacient measures are
fallacious. Some of the men arrayed in favor of the opinion that cures
may be effected by a patient and long-continued administration of some
one of the articles I have mentioned stand high as men of honesty,
accuracy of observation, and faithfulness in their records; and
therefore I give full confidence to their statements. Yet I must also
say that I have not witnessed the good results which I unhesitatingly
believe others have seen from the sorbefacient treatment alone.

Others who expect much from medicinal treatment look to that class of
medicines which cause contraction of the unstriped muscular fibres as
the most promising. With these medicines they expect to diminish the
supply of blood to the tumor by causing contraction of the arterioles
traversing their substance, and thus disturbing their nutrition to such
a degree as to stop their growth, lessen or destroy their vitality, and
so render them subject to the influence of the absorbents, whereby they
may be removed. Some of the more energetic of these medicines--as ergot
and belladonna, for instance--often affect these growths very promptly.
Ergot not only lessens the calibre of the small blood-vessels, and thus
causes a diminution of their nutrition and disappearance, but it causes
strong contractions in the muscular fibres of the uterine walls, which
lessen more decidedly their supply of blood. It sometimes squeezes and
chafes the tumor until it is disintegrated and rendered a foreign
substance. {260} The capsule finally becomes ruptured, and the tumor is
expelled either piecemeal or en masse.

When properly administered, ergot frequently greatly ameliorates some
of the troublesome and even dangerous symptoms of fibrous tumors of the
uterus--_e.g._ hemorrhage and copious leucorrhoea; it often arrests
their growth; in many instances it causes the absorption of the tumor,
occasionally without giving the patient any inconvenience: at other
times the removal of the tumor by absorption is attended by painful
contractions and tenderness of the uterus; by inducing uterine
contraction it causes the expulsion of the polypoid variety of the
submucous tumor; in the same way it causes the disruption and discharge
of the intramural tumor. There are many cases on record to substantiate
every one of these propositions.

From what I consider well-authenticated sources, including the cases
under my own observation and in the practice of my friends and
neighbors, I have collected 136 cases of fibrous tumors treated by
ergot. Of these, 25 cases were cured without giving the patients any
inconvenience from painful contractions. In 46 cases the tumors were
diminished in size and the hemorrhage was cured. In 27 others the
hemorrhagic symptom was relieved, while the size of the tumor was not
affected. In 8 other instances the tumors were broken to pieces and
expelled piecemeal.

For examples of cases in which the first conditions obtained, I would
refer to those cured by Hildebrandt; of the other examples, 4 were
reported to me by the late J. P. White of Buffalo, N. Y., 1 each by the
late Hodder of Canada and Jukes, and 11 that occurred among my
immediate acquaintance and in my own practice.

Among those in which the hemorrhage was cured and a diminution of the
tumor took place, 11 occurred to Hildebrandt, 2 to Chrobak, 5 to White
of Buffalo, and the remainder to gentlemen upon whose veracity I have
implicit reliance. The most remarkable case of which I have any
knowledge was reported to me by the late G. C. Goodrich of Minneapolis,
in which absorption of a large tumor took place under the
administration of ergot and belladonna. I subjoin his description: "The
treatment was commenced in 1870, and continued two years. The uterus
filled the whole space between the ilia, and measured in the transverse
diameter twelve inches and in the vertical nineteen inches--extended up
under the ensiform cartilage and close up to the margin of the
cartilages of the ribs. The treatment was followed by cramps in the
uterus, which produced a wild enthusiasm in the mind of the patient and
inspired her with strong hopes of recovery. Without consulting me she
doubled the dose of medicine, which was administered internally, and as
a consequence she was attacked with very strong uterine contractions
and symptoms of metritis. This caused me to abandon treatment for about
one month, and had it not been for the urgent determination of the
patient I would not have resumed it. She insisted that as this was the
first medicine which had ever affected the enlarged organ, she believed
it would cure her, and promised to obey my directions if I would
proceed. She so promptly and rapidly improved that I doubted if it were
not a coincidence with, rather than a consequence of, the treatment.
Prompted by this doubt, I abandoned the use of the ergot and belladonna
and continued alterative {261} treatment. The patient soon assured me
that she no longer felt the griping pains caused by the remedy, and
that the tumor was softer and larger than when she took the ergot
prescription. The ergot and belladonna were again resumed, and in four
months she was able to make a trip to Boston alone. While absent she
continued to take the medicine. From this time she continued rapidly
convalescing, and is now in the enjoyment of fine health."[1]

[Footnote 1: The author's address before the American Medical
Association at its meeting in 1875.]

I subjoin two cases in which the tumors were expelled piecemeal under
the administration of ergot, which came under my own observation:

A woman of Sterling, Illinois, called on me December 13, 1875. She was
thirty-five years old, married, and had never been pregnant. On the
first of the preceding June she noticed a circumscribed hard lump two
inches below and to the left of the umbilicus. She was the subject of
serious uterine and sympathetic symptoms, for which she had at
different times had treatment. She had profuse menorrhagia,
leucorrhoea, and great sense of weight in the pelvis. Upon examination
I found a hard, round, movable tumor extending up to within two inches
of the umbilicus, filling up the whole of the right iliac, the
hypogastric, lower half of the umbilical, and more than half of the
left iliac regions. The contour of the tumor was somewhat uneven,
though not distinctly nodular. The cervix was long, pointed, and thrown
backward and to the left. The sound entered the small uterine mouth and
passed upward, backward, and to the left five and a half inches. The
diagnosis was a fibrous tumor of the right anterior wall of the uterus.
I prescribed thirty drops of Squibb's fluid extract of ergot, to be
taken three times a day. She went home, but did not commence taking the
medicine until the 20th of December. On the 26th of December J. B.
Crandall was called to see her, and describes her condition as follows:
"The patient was in a state of great nervous prostration and worn out
by severe pain and loss of sleep. The pains commenced soon after taking
the second dose of ergot, and were excruciatingly severe for about
three hours, after which they continued less severely for two days and
nights. She had more or less hemorrhage from the uterus after taking
the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin was
hot and dry, and she complained of great pain and tenderness over the
uterus and lower bowels. The feet were drawn up, and the face wore a
pinched and peculiar expression." Under these circumstances the doctor
administered anodynes, tonics, and nourishment, to the great relief of
the patient. On January 11, 1876, the patient began to pass from the
vagina small masses of fibrous substance, from the size of a chestnut
to that of an English walnut. The substances thus discharged were firm
and gray in color, and were exceedingly fetid. This discharge continued
up to the 21st of January, when the uterus was very much diminished in
size, the tenderness had subsided, and the patient appeared
comparatively comfortable. Up to that time she had taken but three
doses of ergot--on the 20th of the preceding month--and the doctor
ordered it to be resumed again. This time the ergot produced no pain,
and after three or four days was discontinued. From the 21st of January
there were no more pieces discharged, but up to February 1st a
yellowish, thin, offensive fluid passed from the vagina in considerable
{262} quantities. On the first day of February the ergot was again
ordered and continued two weeks, when, as no results ensued, it was
finally dropped. Crandall states that on the 14th of February the
uterus was reduced to its normal size, and on the 26th the patient was
up and about her work, completely cured. He remarked, in this
connection, that the first three doses of ergot taken by the patient
was the cause of her recovery.[2]

[Footnote 2: This case is published in the August (1875) number of the
_Chicago Medical Journal and Examiner_, as reported by Crandall.]

Mrs. L. D. M., aged forty-seven years, had a fibroid tumor in the
anterior wall of the uterus, which, with the enlarged uterus, arose to
within two inches of the umbilicus. She commenced taking thirty drops
of the fluid extract of ergot on the 22d of September, 1876, and was to
increase gradually the dose with the object in view of causing the
disruption and expulsion of the tumor. The ergot at first produced no
perceptible effect until she had taken it ten days, when she began to
experience the pain of contraction. The pain became so severe and
continuous that it was necessary to omit it for two or three days at a
time. The patient was intelligent and understood the object and mode of
action of the ergot, and when the pain entirely subsided she
courageously resumed it in the smaller doses, and increased again until
the pains became intolerable. On the 13th of January, 1877, small
pieces of the tumor showed themselves in the vaginal discharges, and by
the 26th of the same month the whole of it had been discharged
piecemeal. She wrote me on the 30th of January, saying, "I think I
wrote one week ago to-day. At that time the tumor was passing. It
continued to pass until the 26th, when, I think, the last was expelled.
To-day I send you by express a portion of the last that came. I think
the whole of it, including the portion I send you, would have weighed
one and a half pounds. I do not believe a quart can would hold it if
the whole had been preserved. It commenced to come on Saturday, and
from Saturday evening to Sunday morning there was a pint or more. After
that the stench was so disagreeable that we could not cleanse it;
consequently we threw it away. Wednesday and Thursday it seemed to be
in one continuous mass. I cannot better describe it than to say that it
came like sausage-meat from a stuffer. I would cut off about four
inches a day--that is, on Wednesday and Thursday. On Friday morning the
last of it came away." During and for some days after the expulsion she
suffered slight symptoms of septicæmia, but recovered from them, and in
the course of a month afterward she visited me, when I found the uterus
measured two inches and a half in depth. She then had some leucorrhoea,
but was fast regaining her health. She is now perfectly well, and has
passed in safety the menopause.[3]

[Footnote 3: This case--the abstract of which I have here given--was in
the May (1877) number of the _Archives of Clinical Surgery, N. Y._]

I have known 9 cases in which the tumors were expelled piecemeal by
ergot, with but 1 death. The death occurred in a patient who rode one
hundred and fifty miles on a railroad train to see me with pieces of
the tumor hanging from the vagina, which she would not allow her
physician to remove. When she arrived I passed my fingers up into the
contracted capsule and scooped out the remaining portion of the tumor.
She was so exhausted, however, by the journey and the sepsis that she
died three {263} days afterward. I cannot help believing that if she
had remained at home and submitted to the treatment of her physician,
her life need not have been sacrificed.

The influence of ergot over the uterus has been a familiar fact to the
profession for a long time. It is not long, however, since we were
aware of its effects upon the muscular fibres entering into the
formation of other organs. We now know that this medicine acts upon the
unstriped muscular fibre wherever found, whether in the viscera or in
the vessels of the body.

The fibres of the uterine walls, and the arteries supplying them with
blood, both belong to this class; this fact in the formation of the
uterus renders it particularly susceptible to the action of ergot. The
drug acts upon the uterus[4] in a threefold manner, and causes a
diminished flow of blood to the morbid as well as healthy tissues in
the uterine structure.

[Footnote 4: From the author's address before the American Medical
Association, 1875.]

First: the calibre of the arterial tubes is diminished by the
contraction of the muscular fibres which enter into their composition.
Second: the arterioles are diminished in size by compression from the
contraction of the uterine muscular fibres which surround them. Third:
these vessels are distorted and drawn in diverse directions by both the
contraction and compression, and hence are rendered less fit for
sanguineous conduits.

Another consideration of prime importance is that, under the influence
of these medicines, the nutrition of fibrous tumors is interfered with,
not only from diminution of blood in their tissues, but also from
compression of their substance by the proper fibres of the uterus, and
are therefore made more susceptible in the process of disintegration
and absorption.

The great influence exerted by ergot over the circulation of the uterus
is rendered more efficacious in the removal of fibrous tumors of that
organ, because of the peculiar organization of the growths. It is now
pretty well understood that this neoplasm is not very generously
supplied with arterial blood, and that its supply is derived from
numerous minute vessels instead of one or two of large calibre. From
these circumstances it results that its vitality is very low, its
circulation easily disturbed, and consequently its nutrition impaired.

I think we are justified from observation in assuming that the action
of ergot may be graded from an almost imperceptible to a very intense
degree. Probably the first degree affects the vascular supply; the
second, in addition to this, causes so much contraction as to merely
render the fibres tense without causing pain; and the third prompts the
uterine fibres to vigorous and painful contraction.

This inference is plainly deducible, I think, from the several modes by
which tumors are made to disappear under its action, as well as from
direct observation of the uterine fibres.

I will now venture to call attention especially to the manner of
expulsion of the polypoid and submucous intramural varieties. It will
be seen that when the uterus contracts all the fibres unite in pressing
the polypus through the cervical canal, which is usually already
shortened, and rendered dilatable in consequence of its increased
vascularity. The cervical canal dilates, and after more or less painful
efforts the polypus is expelled entire, covered by the mucous membrane.
This membrane is often in a {264} state of gangrene, but so far as I
have observed these cases the tumor is not broken to pieces.

A submucous intramural tumor has a thin layer of fibres separating it
from the mucous membrane, and a thick and heavy layer spread over its
external hemisphere. A greater part of the muscular wall is therefore
applied to the outer side of the tumor. If in this position all the
fibres of the uterus vigorously contract, the fibres near the mucous
membrane must be overcome by the heavy layer outside. But the opposite
wall plays an important part by supporting the weaker layer at the
fundus of the tumor, and adding its own force in overcoming the
capsule, where it usually gives way. The position of the tumor makes
its escape from the concentric action of all the fibres of the uterus
impossible, and every one knows that when the resistance is partially
overcome the uterus is stimulated to more vigorous action, and the
pains will not abate until the mass is expelled. If not too large, it
is driven out without undergoing great laceration, but if its size and
attachments are such as to make this impracticable, it will be broken
into fragments and expelled piecemeal.

In subperitoneal tumors there is, next the uterine cavity, a thick and
strong stratum of fibres, while immediately under the peritoneum the
layer is very thin and comparatively weak. When the uterus is acting
with vigor the former contract forcibly, and the mass becomes
pedunculated; but that is all, for the tumor lies outside the field of
concentric action and escapes the crushing influence to which the
submucous variety is subjected. The amount of force exerted upon it is
that exercised by the weaker layer of fibres in a state of conquered
antagonism, and the rupture of the capsule is impossible.

In the case of a fibroid tumor situated in the central stratum of
fibres the antagonism is equal at all points, and it is evident that
there is no tendency to rupture of the capsule, and much less crushing
influence exerted upon it than if it were situated slightly nearer the
mucous membrane. This variety of the tumor, therefore, yields to ergot
only as it may be starved out by diminution of its blood-supply and as
the effect of pressure, which we all know are the two conditions most
favorable to absorption.

Now I think we have arrived at a point in this investigation where we
can draw inferences as to the forms of tumors likely to be effected by
ergot in different ways, as well as those that will not be effected by
it. We do not expect ergot to cause painful and efficient contractions
in the healthy unimpregnated uterus; its fibres are not capable of such
contraction, and it is not until the fibres have become greatly
developed that they are susceptible to the impressions of ergot. In
cases of early abortion its action is very unreliable, but after the
fourth month of pregnancy it acts quite efficiently.

In tumors of the uterus the development of the fibrous structure is
sometimes so slight that it is incapable of contraction; there may be
so many nuclei of degeneration that there are not enough sound fibres
left for efficient contraction. Then, where there are many small tumors
developed in the uterine walls, the circulation is cut off to such a
degree that they degenerate into a cartilaginoid substance, and
sometimes they are infiltrated with calcareous material. In none of
these cases will ergot cause any appreciable results. When, however,
there are {265} but one, two, or three nuclei of morbid growths, as
they increase in size the fibres undergo the development necessary to
enable them to contract with great efficiency and render them
susceptible to the influence of ergot.

Another condition which influences the hypertrophic growth of the
fibres is the situation of the tumor. Subperitoneal tumors do not cause
as great growth in the fibres of their neighborhood as the intramural
or submucous varieties. A single intramural tumor causes great
development of the whole uterine tissues, but the development of the
wall in which it is situated decidedly predominates. The submucous
neoplasm so soon gains the uterine cavity that the development is
nearly the same in the whole organ. When, therefore, we administer
ergot for the cure of fibrous tumors of the uterus, the beneficial
action of the drug will depend upon the degree of development of the
fibres of the uterus and the position of the tumor with reference to
the serous or mucous surface. The nearer the mucous surface, the better
the effects. If the tumor is very near the lining membrane, we may hope
for its expulsion en masse or by disintegration.

We can often select the cases in which good results may be expected.
There are four conditions which are usually reliable for this purpose:
they are--smoothness of contour, hemorrhage, lengthened uterine cavity,
and elasticity. A smooth, round tumor denotes, for the most part,
uniform textural development, hemorrhage, a certain proximity to the
mucous membrane, a lengthened cavity, great increase in the length and
strength of the fibres; and elasticity assures us of the fact that
cartilaginoid or calcareous degeneration has not begun in the tumor.

An even, nodulated tumor may be composed of many separate solid masses.
These displace and prevent the growth of the fibres to such an extent
as to render contractions inefficient. When hemorrhage is not present
the tumor is probably near the serous surface, and consequently not
surrounded by fibres. A short cavity denotes short, undeveloped fibres,
while hardness is indicative of unimpressible induration.

Although I have no experience in the use of ergot in such cases, I
should expect large fibro-cystic tumors to resist the action of ergot.

From this view of the subject it will be seen that I freely admit that
there is a large number of cases in which ergot cannot produce any good
results, in consequence of the nature of the cases; but there is
another reason of equal moment why ergot may fail to act upon such
cases as would seem to be favorable--by the worthlessness of the drug
and its preparations. Squibb of New York, a high authority, says in
reference to this subject: "The molecular constitution of the active
portion of the drug seems, however, in its natural condition to be
loose, and, like a slow fermentation, to be undergoing slow molecular
changes, so that by age its peculiar activity is slowly diminished
until finally lost." And again: "The ergot in the grain, however well
kept, is known to become inactive without any known change in
appearance, though the sensible properties, such as odor and taste, may
and probably do not change. Ergot in powder is known to diminish in
activity much more rapidly than when in grain, and probably soon
becomes inert. The tincture and wine of ergot are believed to change,
though more slowly than the ergot in substance, whilst the extracts and
so-called ergotins are all supposed to change more rapidly."

When all these causes of failure are considered, the variety of {266}
experience met with in the reports upon its trial in the treatment of
these tumors is not surprising. It should not, however, be
discouraging, but should prompt us to more care in selecting the cases
and securing reliable preparations of ergot. I have implicit faith in
the action of ergot when all the conditions I have pointed out are
present. I do not believe it to be uncertain in its action.

In addition to the above conditions, I believe perseverance an
indispensable condition to success, as it often requires several months
to get the best results.

The mode of administration should be governed by the objects to be
attained. If we desire to cause the painless absorption of the tumor,
the doses ought to be moderate in size and not too frequently
administered. Hildebrandt administered by hypodermic injection a
preparation containing from fifteen to twenty grains of the crude drug
to the dose once daily or once every other day; and once a week will
often be sufficient, as proven by cases cited in my address, quoted
above. If we desire to have the tumor expelled, we should administer
full and increasing doses often repeated, and continued until the
object is attained. It will sometimes be necessary to vary the quantity
and times of giving it to suit the susceptibility of the patient--less
or more according to the amount of pain caused by it.

It is not essential to give it hypodermically, although when it does
not produce much inconvenience this is a very efficacious method; it
may be given by the mouth, in suppositories, per rectum, etc.

In conclusion, I desire to disclaim any expectation that ergot will
supplant other modes of treatment. The expert surgeon will, as he
always has done, use his instruments to the neglect of remedies less
summary in their effects, and in his hands the maximum of safety will
obtain; but there are very few general practitioners who ought or would
be willing to undertake enucleation of fibrous tumors of the uterus.

Surgical Treatment.--The surgical processes resorted to for the cure of
fibrous tumors of the uterus vary in their nature and gravity with the
relations of the growth to the different strata of the uterine fibres.
The nearer the mucous membrane, the simpler, safer, and more successful
the operation for their removal; the more remote from it, the greater
the difficulty and danger. Proximity to the cervix is another element
of facility and safety. The removal of the cervical polypus is scarcely
ever followed by serious consequences. While a polypus situated at the
fundus requires greater complexity in the operation for its removal,
and must be regarded as a serious one, the difficulty of removing the
submucous tumor more remote from the mucous membrane is increased the
higher up in the organ it is situated.

Polypi may be removed by torsion, excision, and écrassement; any one of
these operations may be successfully and safely employed. No
preparation of the patient is usually necessary for the removal of the
cervical polypus, because it is accessible under ordinary
circumstances. In very rare instances in the virgin or senile condition
the vagina may require dilatation. The polypus attached at the body or
fundus is not accessible to any of these operations until the mouth of
the uterus is sufficiently dilated to permit the introduction of the
instruments in the uterine cavity, or until the tumor is in part or
wholly expelled.

{267} It will therefore generally be necessary to completely dilate the
cervix with sponge, tupelo, or laminaria tents or the fingers. The
fingers, when the object can be accomplished by them, are much the
better instruments for dilatation. I have several times accomplished
the dilatation of the cervical cavity and removed an intra-uterine
polypus in the course of half an hour by the fingers.

I prefer torsion, and believe that when properly performed it is the
most simple, expeditious, and safe plan of removing a polypus. The
tissues entering into the formation of the neck of a polypus are an
extremely thin layer of fibres and mucous membrane. We cannot always be
sure of placing the écrasseur or applying the knife or scissors exactly
at the point of junction between the substance of the polypus and
uterine wall; but, as that is the weakest point, it invariably yields
to the force applied in the operation of torsion. The tumor is thus
completely removed, and without protracted manipulation. No hemorrhage
results, for two reasons: (1) there are no large vessels entering the
tumor, and the small ones are torn instead of being cut, as in
amputations; (2) septicæmia does not occur, for no portion of the tumor
is left to slough. In performing this operation the operator must guide
a vulsellum with his fingers high enough on the tumor to enable him to
fasten the instrument upon or near the central part of the polypus. In
two instances, when the tumor was too large to be firmly held by any
forceps at my command, I introduced the hand inside the uterus and
detached the tumors by rotating them, afterward making traction with
the forceps. I brought them into the vagina and delivered them with the
obstetrical forceps. One of these weighed forty-six ounces.

To perform torsion for the removal of a polypus, the surgeon, after
fixing the instrument firmly in the desired position, should be careful
to twist it enough to be sure of its detachment before commencing
traction. Not less than from four to six complete revolutions should be
effected. This procedure will prevent the danger of lacerating the
tissues of the uterus.

The greatest objection urged against the operation of torsion is the
likelihood of lacerating the wall of the uterus at the point of
attachment. If we call to mind what was said about the relative
thickness of the muscular strata upon each side of the different kinds
of fibrous tumors, we will at once perceive the groundlessness of this
objection. In the pendulous variety the whole wall of the uterus is
outside the point of attachment, and is strong enough to resist the
very few fibres that are carried down with it. Indeed, the polypus has
almost no substantial attachment except that formed by the investing
mucous membrane. If, therefore, the torsion is performed with
sufficient thoroughness before traction is begun, laceration of more
than the superficial tissues surrounding the neck of the tumor is next
to impossible; consequently the operation is perfectly safe.

Hemorrhage is not so likely to occur after torsion as when the tumor is
amputated by the knife or scissors, or even by the écrasseur. The
danger of hemorrhage, then, is an objection that cannot with any show
of reason be urged against torsion. I have never seen hemorrhage
succeed torsion. The contractions of the uterus which take place after
removing the polypoid growth from the cavity of the uterus in the great
{268} majority of cases is as effective in the prevention of hemorrhage
as it is when its contents are expelled at the time of labor. I trust
that it is not necessary to dilate further upon this part of the
subject. However, hemorrhage, although improbable, is yet possible, and
we should therefore be prepared for it. After what has been said under
palliative treatment about the management of this complication, it will
not be necessary to enlarge upon that point. I would therefore refer
the reader to the remarks there made.

After an operation of this kind the only treatment necessary is perfect
quietude for a few days, cleanliness by injections if needful, and the
administration of anodynes to quiet pain. When a tumor has been removed
from high up in the uterus, the patient of course should be carefully
watched, and if symptoms of inflammation or septicæmia arise they
should be treated by suitable remedies.

I will commence what I have to say on extirpation of deeper tumors by
assuring the inexperienced that the formidable operations required for
their removal are very seldom necessary, and should not be resorted to
until all other and less hazardous efforts have been made.

The operation of enucleation is applicable only to cases of sessile
submucous tumors, such growths as are nearer the mucous than the serous
membrane. If enucleation is practicable in tumors which have their
origin in the central stratum of the wall of the uterus, the operation
must be regarded as equally hazardous, if not more so, than
laparo-hysterectomy. I am aware that such operations have been
recorded, but it is so easy to be at fault with reference to the exact
point of origin that I must be permitted to doubt--not the honesty of
the operators, but the accuracy of their observations. In many cases of
submucous tumors the cervix is dilated so much that immediate
dilatation with the fingers or hard-rubber olive-shaped dilators will
be practicable. When that is not the case, the cervix must be
thoroughly opened by sponge, sea-tangle, or tupelo tents or bilateral
incision: the more patent the mouth of the uterus can be made the
better. The operation is so serious in its nature that the competent
surgeon will study his preparations so carefully as to avail himself of
every means that will enable him to perform it in the most expeditious
and complete manner. Expedition, rendered possible by thorough
preparation, is a most important item; for it must be understood that
every superfluous moment spent in enucleation increases the peril of
the patient. I would not counsel haste, but the earnest and careful
despatch acquired by reflection and experience. When the patency of the
mouth of the uterus is secured, the uterus should be drawn to or near
the vulva by a strong vulsellum and firmly held by an assistant. The
operator may then make an incision with scissors entirely across the
most dependent part of the tumor, completely through the capsule. After
this is done, another incision is to be made from the centre of this
cross-cut upward upon the most prominent part of the tumor, as high as
the instrument can be guarded by the fingers. The fingers should then
be inserted between the tumor and the capsule, and the latter separated
as extensively as possible from the former. In some cases a large part
of the tumor may be thus detached from its envelope. When the whole of
it cannot be detached by the fingers, Sims's enucleator may be made to
finish that task. It can be passed up and around the upper and less
{269} accessible portion. The detachment should, when possible, be
complete before traction is begun. The traction is affected by a strong
vulsellum. By that instrument the tumor, after being firmly seized, can
often be rotated upon its longitudinal axis to assure the operator that
it is loosened at every point. Simple, firm, but slow traction, aided
by pressure of the hand on the upper part, will assist the uterus in
expelling the growth. Should the tumor be too large to pass the mouth
of the uterus and vagina, it may be divided by well-directed efforts
with the scissors or knife and removed in pieces. When the tumor is
semi-pedunculated the capsule may be separated by Thomas's serrated
spoon in a much more expeditious manner. As the tumor is drawn out of
its cavity the uterus usually contracts, and thus prevents the
hemorrhage that might otherwise occur. The surgeon, however, must
always be prepared with plenty of cotton saturated with the subsulphate
of iron with which to plug the uterine cavity. It will very seldom be
necessary to use the ironized cotton, and it should not be employed
until its necessity is apparent. The after-treatment consists locally
in detergent and disinfectant injections, and in such general measures
as will aid in reaction where there are symptoms of shock and
counteract the tendency to inflammation. For both these purposes a
liberal amount of opium will be very useful.

When the symptoms in connection with a tumor situated in or slightly
outside the centre of the wall of the uterus are so urgent as to demand
surgical interference, the choice of operations lies between
laparo-hysterectomy and öophorectomy. In the light of recent
observation I have no hesitancy in recommending the former for large
tumors and the latter for small ones. As before stated, I regard
enucleation in such cases as hardly practicable, and when successful I
believe it is attended with as much danger as the entire extirpation of
the uterus.

Without entering into details of this operation, I will state that it
is so like ovariotomy as to be governed by the same principles and
require to a great extent the same methods. The incision should be
sufficiently free to permit the removal of uterus and tumor without the
necessity of cutting away the tumor in pieces, as thus mutilating it
gives rise to great and dangerous hemorrhages and of necessity soils
the abdominal cavity. I have always used silk ligatures with which to
secure the pedicle. In most instances we will be obliged to ligate the
uterus near its junction with the vagina. Extra-peritoneal treatment is
probably safer.

Where a small intramural tumor is attended with exhausting hemorrhage,
menacing the patient with a probable fatal loss, and other remedies
have been found inadequate, öophorectomy may with great propriety be
resorted to.

I would refer the reader to the description of this operation as given
elsewhere. There is no other surgical operation by which a large
fibro-cystic tumor can be gotten rid of than laparotomy or
laparo-hysterectomy. Recently I have removed a large fibro-cystic tumor
that grew from the anterior surface of the fundus and body of that
organ without removing the uterus. The tumor was detached by a sort of
enucleation, and the detachment left a large bleeding surface.
Hemorrhage from that surface was profuse, and seemed to issue from
numerous cavernous openings instead of veins and arteries. The
hemorrhage was checked by {270} passing silk ligatures one-eighth of an
inch beneath the surface from one side to the other of the bleeding
surface in several places. When these ligatures were tightened the
tissues were so condensed as to entirely control the bleeding.

This was my fourth laparotomy for fibro-cystic tumor of the uterus, and
the only one that recovered. In all the other three I ligated the
uterus and removed it at the internal os.

Large subserous, fibrous, or fibro-cystic tumors are almost always
covered with a network of great vessels, generally furnished by
adhesions to the omentum. These vessels should be ligated in bundles by
two ligatures around each bundle at least two inches distant from the
uterus. If the two ligatures are not thus widely separated from each
other, when the division between them is made the collapse and
retraction of the vessels will be so great that they will not hold. If
in detaching adhesions a bleeding surface is left on the tumor or
abdominal wall, the bleeding should be arrested by ligatures applied
before the tumor is lifted from its bed. When it is necessary to remove
the uterus, a double ligature around its substance should be applied;
also, when practicable, before the tumor is lifted out. In this method
of securing the vessels we will avoid the terrible hemorrhage that
would otherwise follow the removal of the tumor. The pedicle should
then be brought out and secured by pins in the wound. The cleansing of
the peritoneal cavity and closure of the wound should be done as in
ovariotomy. The after-treatment is also the same as in bad cases of
ovariotomy.

I have not thus far mentioned the treatment of fibrous tumors by
electrolysis; and as the profession has not generally consented to the
adoption of this measure as safe and efficacious, I will refer the
reader to an account given of that process and its results in my work
and other standard works on gynecology.




{271}

SARCOMA OF THE UTERUS.

BY W. H. BYFORD, M.D.


This disease is as much entitled to the clinical definition given to
cancer as any of the varieties of that malignant affection. Miller, as
quoted by West, says: "Those growths may be termed cancerous which
destroy the natural structure of all the tissues; which are
constitutional from their very commencement or become so in the natural
process of their development; and which, when once they have infected
the constitution, if extirpated, invariably return and conduct the
person who is affected by them to inevitable destruction." If we
substitute the word malignant for cancerous in the above quotation, the
definition would include sarcoma as well as carcinoma. It will be found
upon comparing sarcoma with fibrous and cancerous tumors that it
possesses clinical and histological features common to both. If it is
not indeed the result of a transition of fibrous tumors into a
malignant form of disease, it is a connecting link between fibromatous
and carcinomatous affections, and illustrates in a remarkable manner a
relationship of these two forms of growths--viz. the morbid
proliferation of the tissue resembling those of the structure in which
they originate. Sarcoma has its origin in the fibrous portion of the
connective tissue, as do many of the fibrous tumors. It consists of a
redundant proliferation of the cells of that tissue, while the fibrous
tumor is constituted of a morbid proliferation of the fibrous element
of the connective and muscular tissues. Cancer now is admitted to be an
excessive production of the cells of the epithelium; this excessive
growth of the cells inhabiting these structures, sarcomatous and
epithelial, seems to give to them respectively the feature of
malignancy. The fibrous tumor is contained in a capsule; both forms of
these malignant growths invade the tissues without any such limitation.
In this respect the two latter resemble each other and differ from the
former. In sarcoma the cells are mingled intimately with the fibres,
and are not generally contained in alveoli, or nests, as they are
sometimes called. Cancerous cells are always surrounded by alveoli.
Sarcoma in many instances resembles very closely the fibrous tumor. In
malignancy it is very much like the cancerous tumor.

CLINICAL HISTORY.--The early symptoms of sarcoma are leucorrhoea,
hemorrhage, and tumefaction. The discharge from the genital organs
resembles that of fibrous tumors. This does not generally possess an
offensive odor, but as the disease advances necrosis of the tumor
occurs to a greater or less extent, and then the smell of the discharge
comes to {272} resemble that of cancer. The necrosis does not take
place at the expense of the uterine tissues, but is a process of
disintegration going on in the growth. The ulcer resulting does not
corrode the uterus, but it eats away the tumor. It in this respect
resembles epithelial fungus. The tumor formed by the sarcomatous
deposit is sometimes polypoid, and presents the appearance of the
fibrous polypus. In other instances it resembles to the touch a
submucous fibrous tumor, and again in others it is diffusely
disseminated into the whole structure of the uterus. When thus
diffused, like cancer it invades the neighboring organs. When the tumor
projects from the inner surface of the womb, and has attained a
considerable growth, limited necrosis occurs, and sloughs of varying
size take place, and offensive sanious discharges occur very similar to
the flow observed in cancer.

The general symptoms at first are slight, consisting of obscure pelvic
pains and pressure and increased discharge. Gradually septicæmia is
developed, and this is the condition in which the patient usually dies.

DIAGNOSIS.--There is nothing in the symptoms by which we can arrive at
a correct diagnosis, as in the early periods they resemble those of
fibrous tumors so closely as to be undistinguishable from them, and in
the latter cancer neither manual nor ocular examination will give us
any more definite information. Their qualities in this respect also are
in the early stages of development those of fibrous tumors, and in the
latter of some forms of cancer. We are therefore reduced to the
evidence afforded by microscopical examination.

When the tumor is in such a position and of such a consistence that we
can remove a fragment from it, we can study its histology. There are
two varieties, as distinguished by the shape and size of the cells. One
variety is called the small-celled sarcoma, from the size of the cells;
they are round, or nearly so, in shape. The other is called the
spindle-celled sarcoma. In some specimens of this variety the cells are
much larger than others; and hence there is the large and small
spindle-celled sarcoma. The cells are different among the fibres of the
tissues affected, and in rare instances some of the cells are contained
in imperfectly-formed alveoli, in this respect showing a further
analogy to the growth in cancer.

PROGNOSIS.--The malignancy of sarcoma is now universally recognized in
the known facts of its persistency in returning when removed, and its
simultaneous existence in many organs of the body. This acquired or
innate constitutional dissemination is not constant--no more than in
cancer, perhaps less so. Hence when the size of the tumor is small and
apparently isolated there is some encouragement to attempt a cure.

The comparative prognosis is also probably better than cancer, as it
pursues a less rapid course of development, and hence the patient may
survive for a longer time.

The local dissemination of the cells cannot always be measured, and
that their dissemination into the surrounding tissues may reach much
beyond the boundaries of the apparent tumor must be regarded as an
important element in considering the subject of prognosis in connection
with treatment by ablation or cauterization. The widespread local
dissemination of the cells of this growth is doubtless an explanation
of the term at first applied to it--viz. recurrent fibroid.

{273} TREATMENT.--It will not be necessary to consume the time of the
reader by giving the treatment of sarcoma in detail, as most of it is
identical with that of Cancer, and may be found under that head. I will
only call attention to the excellent palliative effects of ergot: this
drug will often arrest, and generally modify, the hemorrhage so often
one of the most annoying symptoms. When the tumor is in a state of
progressive necrosis, protrudes like a submucous fibrous tumor, or is
pendulous, resembling the fibrous polypus, it may, by inducing
contraction of the uterus, be expelled, partially if not completely,
and thus for the time being do away with the source of sepsis. I have
in several instances been highly gratified with its effects in this
way. In one case, when the patient was so overwhelmed with symptoms of
septic fever as to cause apprehension of immediate dissolution, the
administration of ergot expelled large masses of sloughing tissue, and
so cleansed the uterus that the symptoms subsided, the patient rallied,
and lived several months in comfort. Not less than four times this
process of expulsion was successful in relieving the same patient for
long intervals: each time the medicine was administered relief was so
marked that both she and her friends anticipated recovery.




{274}

CARCINOMA OR CANCER OF THE UTERUS.

BY WILLIAM H. BYFORD, M.D.


While it is possible that in very rare instances the scirrhous or
colloid form of cancer may attack the uterus, the practitioner will
seldom meet with either. I will therefore describe but two
varieties--the soft or medullary, and the epithelial. Although there is
much difference histologically and microscopically, they are so nearly
allied in their clinical history that I feel justified in placing them
together. In the clinical description of carcinoma I shall be governed
more by what I have seen at the bedside than by the observation of
others.


Medullary or Soft Cancer.

I use this term in a comparative sense. By it I mean a tumor caused by
a carcinomatous deposit that infiltrates, enlarges, and renders more
fragile than natural the parts attacked, which after a greater or less
time undergo necrotic ulceration, death, or solution of the morbid
growth, giving rise to extensive ulceration. I have never seen this
variety convert the uterus into a tumor of encephaloid consistence. The
deposit usually begins in the extremity of the cervix and extends up to
the body, and without reference to the boundaries of different tissues
attacks and involves the fibrous, mucous, and serous tissues, extending
to any organ or substance that may be contiguous, thus infiltrating the
bladder, rectum, connective tissues in the broad ligaments, and
ovaries. The necrotic ulcerations of the part where the disease began,
and the extension of the deposit in the more distant parts, progress
simultaneously, the one diminishing while the other is increasing the
bulk of the parts involved. This kind of progressive local
dissemination and necrosis of cancerous matter often results in the
more or less complete destruction of the uterus, bladder, and rectum.

Accompanying these morbid processes in the pelvis, cancerous cells
migrate to other and distant portions of the body, creating new centres
of carcinomatous disease. These multiple centres of disease are
probably in all instances caused by the errant products of the pelvic
disease. This view of the subject makes the general carcinomatous
disease a constitutional infection, the same as the wandering cells of
the chancre give rise to constitutional syphilis.

ETIOLOGY.--No one circumstance seems so intimately connected with {275}
the origin of cancer of the uterus as age, more than half the cases
occurring between the fortieth and fiftieth years, 33 per cent. between
the thirtieth and fortieth; this leaves only 20 per cent. for all other
ages. It very seldom attacks the young under twenty-five years or the
old over fifty. So far as I have been able to examine statistics, I am
not sure that cancer occurs any more frequently among multipara than
nullipara. The fact that the number of childbearing women far exceeds
those who are not married nor fruitful is likely to mislead us in this
respect. Race does not seem to afford even comparative exception. The
negro and North American Indians seem to be subjects of cancer as
frequently as the European races.

If there is anything in the idea of heredity as a causative influence,
it must be rather through physiological similitude of children to
parents than the transference of taint from the former to the latter.
If cancer is a degeneration of tissues, as the effect of a law that
organs in certain individuals undergo dissolution at a particular age,
we can understand that the child may inherit such physiological effect
from the mother. The cell-formation of the organs of the child will be
capable of reaching the same period at which the disease was developed
in the mother, when the normal histological changes will be interrupted
and dissolution begins. In this view of the subject the child would by
virtue of its organization inherit the mode of dying evinced in the
mother.

Old writers, assuming that cancer was the result of a peculiar
dyscrasia, described the state of general health as a causing
condition. It does not seem, however, that the majority of people in
whom cancer is developed exhibit any signs of ill-health until the
local disease has made sufficient advance to account for their
symptoms. Indeed, many present the appearance of a faultless condition
of general health until the disease is discovered to have made hopeless
progress. The same may be said of the local condition. It so often
happens that we are assured by a patient that she had been
congratulated by her friends as one especially favored by exemption
from female weaknesses. I have yet to witness any evidence that chronic
inflammation, congestion, or laceration of the uterus predisposes to
malignant disease of any kind.

I do not mean by this to say that patients having chronic uterine
ailments may not become the subjects of cancer of the uterus. There is
nothing in the gross anatomy or the histological construction of cancer
to indicate an analogy to inflammation. The allegation that the
long-continued irritation of laceration invites a malignant deposit in
the tissues involved is mere assumption, and should rank as an unproved
hypothesis.

The location of the primary lesions is usually in the cervix, but
occasionally it attacks other parts of the uterus, the body next in
frequency to the cervix, and less commonly the fundus.

CLINICAL HISTORY.--The early stage of cancerous development is not
marked by obvious symptoms. Judging from my own observation, a bloody
discharge more frequently attracts the attention of the patient than
any other symptom, and this does not appear until the deposit is
somewhat extensive, and it indicates necrosis. The loss of blood is
sometimes copious, but generally moderate in quantity. It may be
intermittent or continuous. Not infrequently in menstruating women
{276} it assumes the form of menorrhagia. The next symptom generally is
a discharge of ichor, usually colored, sometimes entirely clear. With
the appearance of the serous discharge the cancerous odor becomes
apparent and continues. These two exhausting and disgusting symptoms
continue alternating with each other with the persistence of fate.

Another symptom of cancer of the uterus is pain. It is not, however,
generally an early symptom. Often it is entirely absent until the
disease has made great progress. When noticed early, the pain is sharp
and lancinating, consisting of recurring twinges rather than of
continuous pain. When it does not occur until later in the progress of
the case, it is such as arises from the accompanying congestions and
inflammations.

GENERAL SYMPTOMS.--No general symptoms are manifest until the disease
has made considerable advance, and often not until there begin to be
degenerations in the tumor. It would seem, indeed, that the growth of
cancer was not a morbifacient process, and that constitutional
disturbance results from the septic influence exerted by the necrosis
of the tumor.

The absorption and circulation of the products of decomposition at the
extremities of the tumor through the nervous centres and secreting
organs soon induce nervous ailments and derange the functions of all
the important vital organs. A continuance of the derangement thus
inaugurated, and kept up, eventuates in fully-developed septic fever,
by which the energies of the patient are exhausted. The uniformity with
which septicæmia terminates the existence of these unfortunate patients
renders the exceptions to the above description very rare indeed. While
patients think they are being eaten up by cancer of the womb, they are
really dying from slow poison caused by absorption of dead tissues.

DIAGNOSIS.--In the great majority of cases the diagnosis of cancer is
easily arrived at. For reasons already stated the disease is not
suspected until the deposit is extensive and obvious changes in the
shape and consistence of the cervix occur. It is enlarged, very hard,
and generally irregular in shape. In most instances it is very much
enlarged, measuring from one to ten times its natural diameter; the
tissues are devoid of elasticity; and nodosities, projections, and
sulci deform the cervix in a manner and to a degree that change the
shape of the organ as nothing else does. Add to this the stinking
sero-sauguinolent discharge, and the diagnosis is complete. By the time
these physical changes become diagnostic features of the case the
uterus becomes fixed, the immobility being obviously dependent upon the
extension of the deposit to the vagina, bladder, and contents of the
broad ligament. The invaded tissues become as hard and unimpressible as
the uterus. We could hardly mistake cancer in this stage of development
for any other disease, and as the general practitioner will seldom see
it before the most of these changes have occurred, the diagnosis will
generally be easy. When the tissues break down to a considerable extent
the ulcers, if they can be so called, are very irregular in shape,
greatly excavated, have a hard, rough, granular bottom, and are not
tender to the touch. Generally they bleed upon being handled. The
hardness, enlargement, irregularity of shape, and fixedness are as
conspicuous features during the process of destruction as they are in
the stage of deposit.

{277} The demonstrative portion of the diagnosis, however, is derived
from the histology of the deposit. "Histological examination of the
changed uterine tissues shows, as in every carcinoma, a stroma of small
alveoli filled with polymorphous cells, generally arranged without
order; sometimes those of the periphery are implanted regularly on the
wall of the alveolus. The stroma composed of connective tissues
frequently contain also smooth, muscular fibres."[1]

[Footnote 1: Cornil and Ranvier, translated by Shakespeare and Simes,
p. 696.]

PROGNOSIS.--This form of carcinoma uteri will bear no other than a
desperate prognosis. I doubt whether it is ever discovered until the
deposit has reached an extent locally that renders complete ablation
impracticable. In addition to this consideration the malignant cells
are disseminated, if not degenerated, in distant parts.

Nature in an infinitesimal number of cases institutes curative
processes. These processes consist of extensive sloughing and a species
of atrophy in the morbid growth. The growth ceases to enlarge, becomes
smaller, and finally disappears. Very few men are lucky enough to
witness the fortunate results of these processes. Art is powerless to
cure, but may do much to palliate the suffering connected with the
fatal march of carcinoma.

The duration of uterine cancer is greater in the old than in the young.
In the former it may last several years; in the latter it often
terminates fatally in a few months.

TREATMENT.--Taking the above history of the disease as true, it will
not be necessary to say much about curative treatment. If we should
find a case of cancer in which the cervix is not enlarged as high up as
the junction of the cervix and vagina, I would advise amputation of the
cervix and excavation of the uterine tissues as extensively as
possible. The amputation and excavation may be performed by means of
hooks and scissors, as in epithelioma. Taking the statistics of
Freund's operation, as practised and modified by himself and others, as
my guide, I am not disposed to sanction or advise the complete
extirpation of the uterus for this form of cancer.

The subject of palliative treatment of cancer for the relief of local
symptoms, and the amelioration of the general suffering caused by the
septic fever, with which the patient usually dies, is more hopeful. The
local symptoms requiring palliation are the sometimes disastrous
hemorrhages, fetor, acridity of the sanious discharges, and pain.

The tampon made of cotton saturated with the solution of the
subsulphate of iron is generally a very effectual means of treating the
hemorrhages, while it also temporarily removes the fetor and acridity
of the discharges. The tampon saturated with a strong solution of alum
is also very effective. Frequent injections and ablutions with a weak
solution of carbolic acid or permanganate of potassium will also be
very useful in keeping the discharges free from odor. Much comfort may
also be derived from small pellets of absorbent cotton introduced just
within the vulva to absorb the discharge. Their frequent removal will
of course be necessary, but they will be found to protect the external
parts from excoriations that would otherwise occur. Applications of
tincture of the chloride of iron or solution of hydrate of chloral
carefully made to the raw surface upon the cervix very materially
correct the foulness {278} of the discharges and lessen the process of
necrosis which is continually taking place.

The local and general use of anodynes is about our only means of
relieving pain. They may be used locally in suppositories introduced
into the rectum or vagina, or hypodermically or by the stomach in such
quantities as may be required. Further detail is unnecessary in
reference to the use of anodynes, as the quantity, quality, and mode of
administering them will depend so much upon the urgency of the pain and
the character of accompanying symptoms.

The treatment of the septicæmia is both general and local.

The general treatment consists of such measures as will sustain the
vital powers. Tonics of quinine and iron are the remedies that will be
of most service, and judiciously used will greatly ameliorate the
symptoms of exhaustion. A very important item in the treatment of these
prolonged cases of septic fever is a well-selected diet--the more
nutritious and easy of digestion the better. It should consist largely
of fresh mutton, beef, poultry, game, milk, and butter. The bowels will
be generally troublesome in the early part of the time by constipation,
and in the later by diarrhoea. For the former a diet containing fruit
and coarse flour bread will often enable us to dispense with
cathartics, which are generally both exhausting and annoying. For the
diarrhoea opiates can be used freely, as also bismuth, pulverized
charcoal, etc. etc.

But the most important as well as the most effective measure with which
to combat this destructive fever is to keep the raw surface of the
tumor as free as possible of necrosed material. This is done most
effectively by the sharp curette or Simon's spoon. The whole of the
ulcerated surface should be thoroughly scraped off with one of these
instruments. The parts completely exposed by Simon's retractors should
be scraped energetically until the solid tissue is reached. It should
be remembered that the tissues exposed are not sound, but are cancerous
deposit. The sacrifice of it, therefore, is not a matter of importance,
so that the excavation if not fearlessly should be thoroughly done. An
operation of this kind is attended with two dangers. One is the
removing so much substance as to open the peritoneal cavity, bladder,
or rectum; and the other is hemorrhage. Care will enable us to avoid
the former; and, when formidable, the latter may be staunched by the
astringent tampon already mentioned.

This operation is only intended as a palliative measure, and it
sometimes proves remarkably beneficial. After it the patient will
occasionally rally so much and become so comfortable as to indulge in
the belief that she is on the road to recovery. The amelioration lasts
sometimes months. It will often be profitable to repeat the scraping
several times, especially if the case is advancing slowly. It will
usually not only make the patient more comfortable, but greatly
protract her existence.


Epithelioma of the Uterus.

This malignant disease differs in several respects from the cancer
already described. The morbid cell-growth in that form of cancer takes
place in the lymph-spaces of the connective tissues of the cervix {279}
and uterine body. The lymph-spaces are converted into alveoli or nests
in which the cells are developed until they become greatly distended
and changed in shape. The lymph-spaces thus occupied freely communicate
with each other, and of course with the lymphatic vessels. Hence, the
rapid dissemination of the cells locally and the ease with which they
find their way to distant parts of the system.

The cells in epithelioma are developed on the free surface of the
mucous membrane. From this surface the cells seldom travel to any great
distance, and consequently the disease often does not become general.
Epithelioma is cancer of the mucous membrane of the uterus, while the
other form is interstitial cancer of the uterus. The dense mucous
membrane serves as a barrier to the passage of the cells into the
surrounding tissues. After the disease has existed for a long time, the
surface of the mucous membrane is impaired, and it does not resist the
dissemination of the cells. Then the process of cell-dissemination is a
result of partial destruction of the membrane. In cancer of the uterus
they are disseminated early, and possibly from the beginning, because
they are generated within the lymph-spaces, with which the lymphatic
vessels are continuous.

Epithelioma of the uterus very rarely assumes the form of an ulcer;
generally it is a deposit upon, or growth from, the surface of the
mucous membrane. The growth assumes shapes that vary with the different
localities. If the extremity or external surface of the cervix is the
seat of the disease, it usually projects into the vagina as a fungus
which may grow large enough to fill up that cavity. Much more
frequently the cervix is enlarged and is covered with a stratum of
epithelial deposit very frail in texture that bleeds freely when rudely
touched. This fungous growth or deposit does not affect the mobility of
the uterus, even when the cervix is considerably enlarged. When the
morbid deposit takes place in the cavity of the uterus, it often does
not project from the os uteri to any extent, but is confined to the
cavity. When the cavity is filled up by an epitheliomatous growth
emanating from the entire surface of its lining membrane, we seldom see
anything more than an ashy-looking substance filling up the external os
uteri. Sometimes the growth covers the whole of the mucous membrane of
the body and neck, including the external covering of the latter part.

CLINICAL HISTORY.--The clinical history of epithelioma is essentially
the same as that of the other form of cancer, and consequently need not
be given in detail. The main symptom is hemorrhage, with an abundant
and stinking sanious discharge.

DIAGNOSIS.--In examining with the finger and with both hands it will be
found that the uterus is movable and not much, if any, enlarged. If the
case is of the ulcerated variety, the finger may not detect the lesion;
if, on the contrary, there is a fungus, it will at once detect it.
Should the deposit not project from the os externum, the finger may not
recognize its presence. Upon exposing the cervix to view in the
ulcerative variety an ulcer of a light ash-color will be seen,
presenting an irregular outline slightly excavated, and if the probe is
applied to it the bottom and sides of the ulcer will be found of the
same firmness and consistence as the uterine tissues. It is not
indurated. If a fungus exists, it can be seen and examined. When not
bleeding it is also ash-colored. The {280} consistency of the
projecting mass is sometimes tolerably firm, but more frequently it is
quite frail and gives way under moderate pressure. Should the deposit
be inside of the uterus, the os will be slightly dilated and filled
with a gray substance.

The probe will readily pass through this frail material and enter the
uterine cavity. In cases presenting such an appearance the cavity is
generally enlarged and filled with this fungous deposit. These facts
may be ascertained by the use of the probe while the parts are exposed
to view.

The microscope will verify and correct our diagnosis. For microscopic
examination some substance from the surface of the ulcer or fungoid
projection may be collected and submitted for inspection. The
appearances are nests or spaces of greater or less size filled with
epithelioid cells.

PROGNOSIS.--Without judicious treatment practised at an early period
epithelioma may be said to be invariably fatal. There is, however, much
promise of great amelioration in this form of disease with the present
improved methods of treatment, and in some cases we may succeed in
effecting a permanent cure.

TREATMENT.--The general palliative treatment is the same as that
described in the other form of cancer, and need not be repeated. While
I have failed to see any other than palliative effects result from
amputation of the cervix and excavation of the body of the uterus in
the first form of cancer described, I have seen cures of epithelioma
effected by thorough extirpation of the diseased mass. One of these
cures was in a case where the disease was confined to the posterior lip
of the cervix; another, where the deposit apparently occupied the whole
surface of the mucous membrane of the body and cavity of the cervix. In
other cases I am sure the life of the patient was prolonged and her
comfort greatly enhanced. I am persuaded, from a good deal of
observation, that the younger the patient the more promising the result
of operations. The worst and most rapidly fatal cases of epithelioma I
have seen have been in patients beyond the menopause. This is contrary
to what I have witnessed in the other form of cancer, as in it the
younger the patient the more rapid the progress of the disease and the
least beneficial the operations were.

After a trial of the several methods pursued in the removal of
epithelioma, and the different instruments used for the purpose, I
prefer using the scissors, aided by hooks and vulsellum, to cut away as
much of the diseased tissue and the sound structure upon which it is
implanted as possible, and then burn the surface with the cautery in
some of its forms or the strong caustics. When the disease is confined
to the cervix, the whole of the intravaginal portion should be cut away
and the excising process carried as high up as possible, carefully
avoiding the peritoneal cavity on the one hand and the bladder on the
other. With the cervix exposed and fixed by a vulsellum, the
sharp-pointed curved scissors may be insinuated beneath the external
covering, and the tissues removed by pieces until the operation is
completed. When the utmost attainable portion is thus removed, I prefer
applying to the whole of the cut surface pellets of absorbent cotton
thoroughly moistened with the solution of the pernitrate of mercury
(the acid nitrate, as it was formally called), and then filling the
upper part of the vagina with dry absorbent cotton, {281} tightly
packing it so as to absorb any of the free acid. This last is necessary
to defend the sound parts from the superfluous cauterization which
would otherwise follow. The dressing may be removed in twenty-four
hours, and the whole of the surgical cavity as well as vagina washed
out with pure warm water twice a day afterward. If the cavity thus
formed does not fill up, and the surface assumes a malignant aspect, it
should be scraped out with a view to remove its entire surface and
treated again with the acid. This last operation may be repeated again
and again. It will sometimes be found that the cavity will grow less
after each scraping with the sharp curette, and finally fill up.

If the disease is developed in the cavity of the uterus, Simon's sharp
curette should be used to scrape out and destroy the whole mucous
membrane. When this is done the cavity should be carefully filled with
the cotton pellets saturated with pernitrate of mercury, as recommended
for the cervical operation. And this operation should be repeated also
with the same thoroughness as at first as soon as evidence of a return
is manifested. When the scraping and cauterizing have been beneficial
the uterine cavity will become smaller, and when the discharges
indicate a reproduction of the morbid deposit the surface to be
operated upon will be sensibly diminished, until finally it will be
apparently almost closed. I say almost, because one of my patients,
while she seems to have been cured, still menstruates.

While I do not pretend that many of these cases can be thus cured, I am
sure some of them can be. Hence I do not hesitate to recommend an
effort to be made in all cases in which the disease has not spread to
the adjoining organs or tissues. When a cure is not thus effected, such
great amelioration will so often occur as to make an operation
justifiable.

The hemorrhages encountered in these operations are generally
unimportant, but occasionally so much blood will be lost as to require
hæmostatic measures. The practitioner should therefore be supplied with
an astringent tampon and use it if necessary.

If an operation for the complete extirpation of the uterus is ever
justifiable for malignant disease, I think it is in this form. The
operation which I think the simplest and easiest to accomplish is that
performed first in this country, so far as I know, by S. C. Lane of the
Medical College of the Pacific, and in Germany by Langenbeck.




{282}

DISEASES OF THE OVARIES AND OVIDUCTS.

BY WM. GOODELL, M.D.


The ovaries are two almond-shaped glands attached to either side of the
womb by a ligament of contractile tissue called the ovarian ligament,
and they are enclosed between the two layers of the peritoneum known as
the broad ligament. It has recently been contended that this
envelopment in the broad ligament is not a complete one, but that the
peritoneum is absent from the posterior surface of the ovary. This has
been denied, but even if it be so, the fact does not seem thus far to
have any physiological or any pathological bearing.

The ovarian nerves and blood-vessels run between the two layers of the
broad ligament, the former coming chiefly from the renal plexuses of
the sympathetic, the latter from the spermatic arteries. The ovaries
being themselves movable bodies and attached to a movable organ, the
exact position of which remains yet a moot question, their own natural
situation has not yet been authoritatively determined. His,[1] from an
examination of three suicides, holds that the ovary in the adult virgin
hangs with its long diameter almost vertical, and with one side against
the wall of the pelvis, but below the brim, the free border being
behind and the attached end below. Each oviduct is looped over the
ovary, rising along the front and falling over behind it. Hence the
ovary lies on the fimbriæ which turn back and spread over the summit of
the ovary. The ovaries are generally situated on a level with the inlet
of the true pelvis, the left one being in front of the rectum, the
right one surrounded by a coil of small intestines. When healthy they
keep so high up as to be beyond the reach of the examining finger, and
consequently they are not impinged upon during coition.

[Footnote 1: _British Medical Journal_, Dec. 10, 1881, from _Archiv f.
Anat. u. Entwick._, 1881, Nos. 4 and 5.]

The important and special function of the ovaries--that of secreting
and excreting the Graäfian follicles or ovisacs--and their monthly
engorgements are the causes of many of the diseases to which they are
subject. Hence it is that affections of the ovary, being due most
commonly to perverted function, rarely occur before puberty.


Malformations.

Absence of the ovaries is a congenital condition very rarely met with.
It is usually associated either with the absence also of the womb or
{283} with an imperfect development of the other portions of the sexual
apparatus. The breasts will be flat, the vagina generally imperforate,
the vulva small, the pubic hair absent, and sexual feeling wanting.
Menstruation never takes place. Very commonly the growth of the body is
arrested, and the stature is dwarfed to that of a child. Occasionally,
however, there is an approach to the masculine type in the size, the
figure, the voice, and in the growth of hair on the face and on the
body.

An arrested development or a rudimentary condition of the ovaries is a
more common malformation than the preceding one. The womb is then
infantile in size, and the vulva and vagina are small and the pelvis is
narrow. Puberty either fails to take place or it is postponed. When
menstruation is present it is scant and appears at long intervals.
General development is impaired, and the figure and mental
characteristics may be those of advanced childhood. Sexual feeling is
either wholly absent or very imperfect.

DIAGNOSIS.--Whenever the ovaries are wanting, their absence cannot be
positively made out by a digital examination of the parts, for even
fully-formed ovaries often elude the finger. The diagnosis depends
mainly on the symptoms previously given. If the ovaries are
rudimentary, the finger passed high up the rectum while the woman is
anæsthetized will sometimes recognize them. But the diagnosis rests
usually on some manifestation of puberty, and the greater these
manifestations the greater the curability.

TREATMENT.--For the complete absence of the ovaries all treatment is of
course useless. Whenever these organs are in a rudimentary condition
more can be done for the woman, but success is by no means assured.
Every treatment that tones up the body is of service. The rest-cure,
with its accessories of massage, general faradization, and
over-feeding, promises much. Electricity has done good when one pole is
applied directly over an ovary and the other pole placed either on the
sacrum or on the cervix uteri. It is still more efficacious when the
reophore in the form of a properly insulated sound is passed into the
uterine cavity. Should the interrupted current fail to do good, the
galvanic current may cautiously be tried.

From the vascular and nervous kinship between the ovaries and the womb
all stimulants to the latter tend to invite blood to the former, and
from this flux may come growth. It is therefore good practice to
irritate the womb by tents, by applications of iodine and of silver to
its cavity, and especially by the use of galvanic stems. The marriage
relations sometimes quicken dormant ovaries into life, and development,
followed by pregnancy, has been the result. But the remedy is a
hazardous one, for if the sexual sense be not awakened, as often it
will not, the union leads to much unhappiness.


Inflammation of the Ovary; Ovaritis.

Acute inflammation of the ovary rarely exists per se, but it is by no
means an infrequent accompaniment of pelvic peritonitis and pelvic
cellulitis, the causes of each being the same. It is then so masked by
the {284} greater inflammation that its symptoms are lost in the
general ones. Following the same course as that of pelvic
inflammations, it begins with fibrinous exudation and ends either in
resolution or in suppuration, or in chronic hypertrophy.

The TREATMENT of this inflammation is the same as that of pelvic
inflammation--viz. rest, poultices, vaginal injections of hot water,
and morphia and quinia in large doses. Sometimes the local abstraction
of blood will be useful. Should pus form, it must be evacuated by the
aspirator, and preferably per vaginam. After such an inflammation, and
especially if caused by gonorrhoea, the ovary usually remains
permanently injured, its functions being crippled by fibrous bands,
adhesions, hardening of its stroma, and thickening of its investing
peritoneum. If both ovaries be thus affected, sterility inevitably
ensues.


Chronic Ovaritis.

By chronic ovaritis is meant either persistent congestion of the
ovaries, or such tissue-changes in the stroma or in the follicles of
the ovary, or in both conjointly, as are brought about from a previous
attack of acute inflammation or from persistent hyperæmia. In its early
stages it appears to be characterized by passive congestion, followed
by infiltration of sero-sanguinolent fluid and by increase in bulk.
Later on, if the congestion be not dispersed or it passes the
health-limit, it becomes formative, or nutritive; the capsule thickens,
the follicles enlarge, and a general hypertrophy takes place. According
as the brunt of these changes falls on the stroma or on the follicles,
the degeneration is termed either interstitial or follicular. When the
stroma is chiefly attacked, the ovary becomes hard and rugous; when the
follicles are diseased, they increase in size, and one or two of them
are usually found to be distended into miniature cysts. There are
indeed good reasons for the opinion that an ovarian cyst is a dropsy of
many ovisacs, and is caused by ovaritis. The left ovary is the one more
commonly affected--a fact accounted for by the pressure of the
distended rectum and by the emptying of the left ovarian vein into the
renal vein instead of into the vena cava, which is the course of the
ovarian vein on the right side. It is a very common form of disease,
very rarely coming from an acute attack, but starting subacutely with
all the symptoms of chronicity.

CAUSATION.--Whatever induces a lasting congestion of the reproductive
apparatus tends to create ovaritis--a torn cervix, a lacerated
perineum, an arrest of involution after labor, dysmenorrhoea, and
uterine tumors, flexions, and displacements. Barren women are very
liable to this disease, and so especially are women who shirk maternity
by preventive methods; for in both the menstrual congestions continue
without that much-needed break which gestation and lactation bring, and
in the latter the sexual congestions arising from incomplete
intercourse are not relieved. So repeated erectility from self-abuse,
by ending in a passive congestion of the womb and of the ovaries, will
tend to produce this lesion. The prevalence of this habit in unmarried
women is, I think, very much overrated, and yet I have seen from this
cause several cases of ovaritis accompanied with prolapse of the
ovaries. In one the ectropion {285} of the cervical mucosa was so
marked that it leads me to think that this is the cause of the
occasional inversion of the womb in virgins. My notebook shows also
cases of ovaritis from such imperfect sexual relations as come from the
ill-health or the advanced age of the husband, and not a few from
immoderate sexual intercourse. Some of the most common causes of
chronic ovaritis are emotional in character, such as long engagements,
disappointments in love, single life, the reading of corrupt
literature, unhappy marriages, nerve-exhaustion, and hysteria. These
causes operate by producing circulatory disturbances which keep up a
constant congestion of such exacting organs as the ovaries.

SYMPTOMS.--Pain in one or in both ovarian regions, especially in the
left one, is a prominent symptom. It is increased by walking or by
standing, and is lessened by the recumbent posture. Starting usually
from the ovary, it radiates to the small of the back or down the inner
side of the thigh. It often begins from a week to ten days before the
monthly period, and goes on increasing until the flow appears, when it
commonly abates. Menorrhagia may usher in the disease, and may continue
during the remainder of menstrual life, which then is usually
prolonged. Ordinarily, however, menstruation becomes scant and
irregular, postponing rather than anticipating. Sometimes amenorrhoea
takes place. Sterility is usually present, and so almost always is
nerve-exhaustion with all its emotional manifestations. Pressure over
each ovarian region elicits pain and causes a contraction of the rectus
muscle on the affected side. The finger per vaginam or per rectum will
often discover behind the cervix uteri or to one side of it the very
tender ovary, of the form and size of an almond. Pressure on it gives a
sickening pain, very unnerving in its character. Reflex nervous
symptoms are very common, especially those of hysteria. In the form of
pain they show themselves in backache, spine-ache, nape-ache, and
headache; in pain under the left breast, in the scalp on the top of the
head, and in the stomach, bowels, womb, and coccyx. Nervous dyspepsia
is common, accompanied by costiveness, nausea, vomiting, flatulent
distension, and noisy eructation. Wakefulness and bad dreams are not
infrequent. Other reflex neuroses may appear, such as paralysis or
spasm of the sphincter muscles, the latter producing asthma,
dysmenorrhoea, irritable bladder, and painful defecation. Then, again,
there may be nervous disturbances, taking the form of low spirits,
violent hysterical attacks, epilepsy, hystero-epilepsy, and of positive
mental aberration.

PROGNOSIS.--This disease is rarely fatal, but it is always very
stubborn, and often incurable. The patient grows anæmic and she tires
on the slightest exertion. Very soon nerve-exhaustion with its protean
symptoms sets in. She takes to her back and becomes a sofa-ridden
invalid. If the patient has contracted the habit of taking stimulants
or anodynes, her chances for recovery will be greatly lessened.

TREATMENT.--The pelvic organs should be carefully examined, and any
discoverable lesion of the womb and of its annexes be remedied. Pelvic
engorgement must be met by keeping the bowels soluble, by scarification
of the cervix, by large vaginal injections of water as hot as can be
borne, and by vaginal suppositories of belladonna and by rectal ones of
iodoform. Tenderness and hardness in either broad ligament is first
treated by applications of a strong tincture of iodine both to the roof
of {286} the vagina and to the skin overlying the ovarian regions.
Flying blisters may also be placed there with benefit. Sexual
intercourse should not be indulged in unless the desire for it be
strong or there is a possibility of conception, for, by the prolonged
rest which it gives to the ovaries, pregnancy usually brings about a
cure. The patient should keep on her back during her menstrual period;
but, while rest in the recumbent posture should be taken morning and
afternoon, she should be encouraged to move about and exert herself in
some light household work, yet not to over-fatigue herself.

As far as medicines are concerned, those should be chosen which lessen
the engorgement of the reproductive organs. Thirty grains of potassium
bromide and ten drops of tincture of digitalis, given in compound
infusion of gentian before each meal, will tend to quench all
erectility of these organs. After the patient has been kept for some
time on these anaphrodisiacs, alteratives will come into play: very
good ones are ammonium chloride and mercuric bichloride, which can be
advantageously administered after the following formula:

  Rx. Hydrargyri chloridi corrosivi, gr. j-ij;
      Ammonii chloridi,              drachm ij-iv;
      Misturæ glycyrrhizæ comp.      fluidounce vj.  M.

S. One dessertspoonful in a wine-glassful of water after each meal.

The paregoric in this mixture helps to control the aches; the antimony
adds its quota to the needed alterative action; and the licorice
disguises the harsh taste of the ammonium chloride.

Another very excellent alterative and nervine is the chloride of gold
and of sodium. It is best given in pill and after each meal in doses of
from one-eighth to one-quarter of a grain.

As there is in this disease a craving after stimulants and anodynes,
which often degenerates into intemperance and into the opium-habit, the
physician should be very careful how he prescribes such remedies,
reserving their use wholly for emergencies.

In plethoric cases marked with menorrhagia iron is hurtful, but in
anæmic cases with scant menstruation it rarely fails to do good,
especially when given conjointly with arsenic. An excellent combination
is one part of Fowler's solution of arsenic to nine of the syrup of the
ferrous iodide. Beginning with ten drops after each meal, the patient
increases the dose daily by one drop until thirty drops are reached.
She then continues this last dose as long as it does good or it can be
borne. In stubborn cases a sea-voyage may prove of lasting benefit.

The best of all treatments, however, and by far the best, is that
devised for nerve-exhaustion by S. Weir Mitchell, which goes by the
name of the rest-cure. It consists of prolonged rest in bed, seclusion
from friends, massage, electricity, muscular movements, and a diet
consisting largely of milk. By this treatment the circulation of the
blood is made equable and the ovaries and other pelvic organs are thus
relieved of their turgescence. I have had wonderful cures from this
treatment, and can recommend it with the utmost confidence. Bed-ridden
patients have been restored to health and chronic invalids returned to
society.

Once in a while, lasting tissue-changes take place in the ovaries which
medication cannot reach. The question then comes up, whether the woman
shall be doomed to drag out the rest of her menstrual life {287}
burdened with distressing ovaralgia, with crippled locomotion, and with
pelvic aches and pains and throbs, or whether the source of all these
mischiefs, the ovaries themselves, shall be extirpated. This is a very
important question, and the removal of these organs should not be
decided upon without careful deliberation and without the conviction
that the disease is otherwise incurable.


Prolapse of the Ovary.

This displacement of the ovary is almost always one of the lesions of
chronic ovaritis, and as such might have been discussed under that
general heading. But as it displays certain symptoms peculiar to
itself, and needs a special treatment aside from the general one, it
seems to me best to describe it by itself.

At every monthly period the ovaries become turgid with blood, and from
their weight sink low down. They can then be often felt, and even
outlined, in Douglas's pouch. When this congestive period is over they
discharge their over-freight of blood and again float up out of reach.
Unfortunately, however, they sometimes keep turgid--blood-logged, so to
speak--and consequently become permanently displaced. Accompanying this
dislocation there will generally be some uterine lesion which will
stand in the relation either of cause or of effect.

Nor could it very well be otherwise, for very close is the vascular and
nervous kinship between the two--so close, indeed, that turgidity in
the one means erectility in the other. Hence it is not always easy to
decide which lesion was primary and which is secondary. When one ovary
is displaced, it is usually the left one, because the left ovary, as
explained under the heading of Ovaritis, is the one more liable to
disease. When both ovaries are displaced, the left one will be the
lower and the more easily reached, because the left round ligament is
the longer and the left side of Douglas's pouch the deeper.

CAUSATION.--Any condition tending to a lasting congestion of the
reproductive apparatus is very likely to lead to a descent of the
ovaries. The causes, therefore, are the same as those of chronic
ovaritis, to which subject the reader is referred.

SYMPTOMS.--First and foremost is pain in locomotion. Since the ovary
now lies between the womb and the sacrum, it is liable at every step to
be pinched between them. This pain is referred to the inguinal and
sacral regions, and is of a sickening and an unnerving character. It
often occurs suddenly, and then runs down the corresponding thigh along
the track of the genito-crural nerve. One of my patients would, while
walking, be unexpectedly seized with such a pain, which would either
momentarily cripple her or else last so long as to compel her to call a
carriage. Her left ovary, until cured by treatment, behaved like a
loose cartilage in the knee-joint, and slipped down so low as to get
pinched.

A second symptom is a throbbing pain while the rectum is loaded, and an
agonizing pain during defecation. This arises from the grating of the
hardened feces over these tender glands. In one of my cases[2] rectal
enemata or the presence of hardened feces kindled up sexual throbs of
the {288} most painful and exhausting character, which thrilled through
the whole body for hours at a time.

[Footnote 2: _Lessons in Gynæcology_, by W. Goodell, M.D., ed. 1880, p.
332.]

A third symptom is painful coition, for the ovaries are now so low down
as to be bruised by the male organ. A fourth is gusts of pain radiating
from either groin. Lastly, there is usually present a morbid state of
the mind, accompanied by low spirits. I have seen suicidal tendencies
evoked by dislocation of the ovaries and relieved by their replacement.

DIAGNOSIS.--A digital examination will discover in Douglas's pouch a
very tender almond-shaped body on one side of the womb. If both ovaries
are dislocated, two such bodies will be found; but the left one, for
reasons previously given, will be lower down and more easily defined.
Pressure upon one of them produces a sickening pain, like that when the
testicle is squeezed. If the pressure be increased, and be so made that
one of these bodies slips abruptly away from under the finger, such a
thrill of indescribable pain darts through the groin and down the side
of the corresponding thigh that the woman screams out and grows pale or
becomes nauseated.

A dislocated ovary is sometimes mistaken for a pedunculated fibroid
tumor of the womb or for the fundus of a retroflexed womb. But the
uterine growth is not sensitive to the touch, and the flexion of the
womb can always be told by the sound.

TREATMENT.--Whenever the dislocated ovaries are congested or they
display signs of chronic inflammation, the same remedies will of course
be useful as those for ovaritis. In addition, pessaries are important
adjuvants, and especially in those cases in which the womb has a
backward displacement. In the simple, uncomplicated cases of ovarian
dislocation, in which the womb is in its proper position, a pessary
often does more harm than good. To be of service it must be long enough
to obliterate Douglas's pouch, and the pressure on the rectum or on the
sacral nerves then becomes unbearable. If, on the other hand, it be too
short, the ovary slips down behind it and gets badly pinched. These
requirements practically exclude the resort to Hodge's pessary or to
any of its modifications, with the exception, perhaps, of Fowler's. In
the long run, a thick elastic and soft ring-pessary will do the most
good, by offering a broad shelf on which the ovaries will sometimes,
but not always, lodge. The air-cushion pessary and Gariel's air-bag
will often answer the purpose better than any other, but, being of soft
rubber, they soon become fetid and soon collapse.

A very excellent way of keeping up the ovaries is the knee-chest
posture devised by H. F. Campbell of Georgia. Two or three times a day,
or more frequently if needful, the woman unbuttons her dress, unhooks
her corset, and loosens her underclothing. She then kneels on her bed
with her body bent forward until her chest is brought down to the
surface of the bed, while her head is turned to one side and the lower
cheek supported in the palm of the corresponding hand. Her knees should
be about ten inches apart and the thighs perpendicular to the bed. The
trunk of the woman's body is now supported, like a tripod, by her two
knees and the upper portion of her thorax. If she now refrains from
straining and breathes naturally, a reversal of gravity will be
established. With the fingers of her free hand she next opens the
vulva. Air will {289} rush in, distending the vagina, and the contents
of the abdomen will at once sink toward the diaphragm. This will, of
course, draw the womb and the displaced ovaries out of the pelvic
basin. As it is rather awkward for a woman while in this posture to
free one hand to reach the vulva, Campbell advises that previously to
taking this attitude she should insert into the vagina a small glass
tube open at each end and long enough to project externally. This will
leave an air-way and dispense with the use of the fingers. After
staying in this posture for a few minutes, the woman removes the tube
and slowly turns over on her side, where she is to lie as long as she
can. Such constant replacements are of great service, for they lessen
the throbbing and they give the limp ligaments a chance of shrinking
and of keeping the truant ovaries at home.

In this intractable disorder an abdominal brace will sometimes do good.
It may not cure, but it often blunts the edge of the aches, and thereby
gives much comfort. By pressing the abdominal wall upward and inward
the brace forms a shelf on which the viscera rest, and thus it takes
off a portion of the load from the womb and from its ovaries. By
virtually narrowing the pelvic inlet it lessens the space into which
the bowels tend to crowd, and to that extent protects the pelvic
organs. By swinging the pelvis backward it makes the axis of the
superior strait lie more obliquely to the axis of the trunk, and the
sum of the visceral pressure now converges, not in the pelvic basin,
but on the portion of the abdominal wall lying between the symphysis
pubis and the umbilicus.

There is yet another treatment which, combined with the knee-chest
posture, I deem the best of all. It is Mitchell's rest-cure, to which I
have before referred. After the patient begins to improve and to
fatten, as she usually does under this treatment, she is taught how to
replace the ovaries by atmospheric pressure, and the result is that in
my experience they finally stay up. The explanation is as follows: By
this treatment the circulation of nerve-fluid and of blood is
equalized, and the ovaries, relieved of their turgescence, grow
lighter. Then the increased deposit of fat in the abdominal walls, in
the omental apron, and around the viscera, to say nothing of the
needful fat-padding in all the pelvic nooks and crannies, increases the
retentive power of the abdomen. Finally, by its gravity the now
fat-laden and overhanging wall of the abdomen tends to draw toward
itself--that is to say, upward--the movable floor of the pelvis. The
behavior is like that of a rubber ball half filled with air, in which
bulging at one pole causes a corresponding cupping at the other. This
explains the ascent of the womb in women who get fat after the
climacteric.

In exceptional cases the hypertrophied glands keep heavy and refuse
either to go up or to stay up under any treatment whatever. The only
known remedy will then be their extirpation--an operation which will be
discussed under its appropriate heading.


Hernia of the Ovary.

This is usually a congenital displacement, and, according to
Englisch,[3] is, when double, almost always so. The ovary is then found
either in {290} the inguinal canal or outside of this canal in the
corresponding labium majus. The oviduct then accompanies it. When the
hernia is acquired, the ovary, with or without the oviduct, makes one
of the contents of the sac of an inguinal, a crural, a ventral, or an
ischiatic hernia. Of these, the inguinal is by far the most common.
Thus, out of 67 cases observed in 9 years by Langlon at the Truss
Society, all were inguinal with 1 doubtful exception. Of these 67, 42
were congenital, 25 acquired.

[Footnote 3: _New Sydenham Soc.'s Biennial Retrospect_, 1871-72, p.
291.]

The character of the lesion is told by the peculiar tenderness and
nausea following pressure, and by the swelling of the tumor just before
the menstrual flux. In one case mentioned by Routh[4] pressure on the
tumor produced distressing sexual excitement; but this is an unusual
symptom, although I have seen it produced by the pressure of hardened
feces.[5] It is not always easy to decide whether the displaced glands
are ovaries or testicles; and repeated mistakes in regard to sex have
thus been made.[6] So difficult, indeed, is it sometimes that the
microscope can alone settle the question.

[Footnote 4: _Trans. Royal Medical and Chir. Soc., Lancet_, Jan. 28,
1882.]

[Footnote 5: Goodell, _Lessons in Gynæcology_, 2d ed., chap. xxvi. p.
332.]

[Footnote 6:  Chambers, _Trans. London Obstet. Soc._, 1881.]

TREATMENT.--In a reducible hernia, taxis and an appropriate truss
comprise the treatment. If irreducible, a truss with a concave pad may
be used to protect the ovary from injury. If the ovary be fixed by
adhesions and it give much discomfort, it should be removed by
operation.


Öophorectomy; Battey's Operation.

There are certain forms of diseases of women peculiar to the menstrual
period of life. The attendant lesions are found either in the
reproductive organs themselves or outside of them in remote organs, but
with such monthly exacerbations as show their participation in the
catamenial excitement. They are always very hard to cure, and often
prove to be wholly unmanageable until the climacteric has been
established.

In this category may be classed fibroid tumors of the womb, chronic
pelvic peritonitis and cellulitis, chronic ovaritis and ovaralgia,
ovarian insanity, ovarian epilepsy, and, in short, all those phenomena
or those lesions which are embraced under the term of pernicious
menstruation.

Fibroid tumors of the womb are, fortunately, pretty manageable.
Usually, the womb, like a generous host, hospitably entertains them;
but once in a while an unwelcome one presents itself which arouses all
the resentment of that organ. If, then, it stubbornly resists all
treatment, it slowly but surely destroys life by the pain which it
evokes and by the loss of blood it gives rise to. In such a case the
woman is virtually bed-ridden from her floodings and sufferings, and
she looks forward to the climacteric as her only hope. But the change
of life is then always postponed for several years beyond the natural
term--oftentimes so many years as to be overtaken by the death of the
patient.

Then, again, there are those cases in which, despite all treatment, the
ovaries remain turgid with blood, acutely neuralgic, and to the last
degree sensitive. They become dislocated and lie in Douglas's pouch, or
irremediable tissue-changes take place, attended by follicular or by
{291} interstitial degeneration. A woman with such a lesion is usually
a helpless invalid, racked with atrocious pains, weakened by exhausting
menorrhagia, and wholly unable to fulfil her duties as wife or as
mother. Usually she seeks relief in anodynes and becomes a confirmed
opium-eater.

There are also many distressing cases of salpingitis or of pelvic
peritonitis and pelvic cellulitis which cripple a woman past all hope
by monthly exacerbations. Such cases are by no means rare, and the
woman, reduced to skin and bone, finally dies, because in spite of all
treatment the inflammation is rekindled at every monthly period.

Further, there are cases of epilepsy which seem to come wholly from the
sexual organs--cases with an ovarian aura, so to speak. The fits begin
at puberty, very generally last through life, and end in impairment of
the mind. Often the first convulsion is ushered in by the first
menstruation, and ever after it is around ovulation as a storm-centre
that future eclamptic attacks revolve. Such an epileptic is the terror
of her family and a valueless member of society. Generally she dies
insane or with enfeebled mind, and if she marries she is very likely to
transmit her infirmities to her children, either in the same form as
her own or in kind.

Finally, what insane asylum does not hold incurable women whose mental
infirmities seem to depend wholly upon the act of ovulation? Some there
are who, indeed, never exhibit symptoms of insanity excepting during
the monthly flux.

For these menstrual affections there is a remedy which, while yet in
its infancy, promises much--one first proposed and performed by R.
Battey of Rome, Georgia. This able surgeon reasoned that, since these
disorders are kept up by the monthly afflux of blood to the sexual
apparatus, and therefore incurable during menstrual life, the only
chance of immediate relief lies in the establishment of an artificial
menopause. To bring about this change of life he advocated the
extirpation of both the ovaries, and labeled the operation normal
ovariotomy. With this name fault has been found, because it does not
cover the whole ground, for often the ovaries themselves, together with
the oviducts, are found diseased. Now, since it is important to
distinguish this operation from that of ovariotomy proper, and since
the term spaying, which technically defines the character of the
operation, is obnoxious from its association with the lower animals,
the terms öophorectomy, or Battey's operation, have been adopted.

In well-selected cases this operation has been followed by wonderful
results; but it has been greatly abused. By it I have restored to
perfect health cases of otherwise incurable fibroid tumors of the womb,
cases of dysmenorrhoea and of menorrhagia, and cases of pernicious
menstruation in which the sufferers were reduced to the last degree of
emaciation and feebleness. Out of 5 cases of ovarian insanity I have
also cured 4; the fifth, while not wholly restored, is yet very much
better.

This operation has been performed both by the vaginal and the abdominal
section. For some years I was a warm advocate of the vaginal method,
but I have wholly given it up, because by this method of operation
adherent ovaries cannot be safely dislodged, the ovaries cannot always
be reached, the vaginal wound cannot be dressed antiseptically, {292}
and because the abdominal mode is more simple and less dangerous. Only
when the ovaries are dislocated and low down in Douglas's pouch would I
possibly resort to the vaginal incision.

If the abdominal operation be performed, the incision should be made
between the navel and the pubes in the median line, and not over each
ovary, as advised by some authors. One great caution must, however, be
observed, and that is not to wound the intestines. In ovariotomy the
cyst is in front of the intestines, and there is very little danger of
injuring the latter. But in cases of öophorectomy, no tumor being
present, the bowels lie in contact with the wall of the abdomen, and
are very likely to be wounded by the knife when the peritoneum is
incised. The incision should be long enough to admit two fingers.
These, being passed behind the womb, are conducted to the ovary by
gliding along the oviduct as a guide. Each ovary, together with its
oviduct, is in turn brought up to the opening. It is then seized by a
fenestrated polypus-forceps and its stalk transfixed, tied on either
side with fine silk, cut off, and dropped back into the abdominal
cavity. Should the stalk be so short that ovarian tissue is left behind
in the button of the stump, it should be destroyed by Paquelin's
cautery, for it is astonishing how small an amount of this tissue will
keep up not only menstruation, but even menorrhagia. On the other hand,
it will not answer merely to ligate the pedicles without removing the
ovaries. This has been tried, and not only did menstruation continue,
but in one instance pregnancy took place.[7]

[Footnote 7: Murphy, _British Medical Journal_, April 18, 1885, p.
787.]

The dressing is precisely the same as in ovariotomy, and, like it, the
operation should be performed with every detail of antiseptic surgery.

In the vaginal operation the vagina first should be thoroughly cleansed
with a solution of carbolic acid, and the patient placed on her back
and not on her side. I am convinced from experience that the usual
left-lateral position is a dangerous one, for as soon as the peritoneum
is opened the air rushes out and in during every inspiration and
expiration--an untoward circumstance which cannot happen in the dorsal
position. A duckbill speculum is introduced, and the perineum pulled
downward. The cervix uteri is transfixed by a strong thread, by which
the womb is drawn downward and forward. The post-cervical mucous
membrane is next caught up by a uterine tenaculum and snipped open for
about an inch. The index finger of the left hand is then passed in, and
each ovary brought down to the incision by the finger-tip hooked into
the sling made by the oviduct. The ovary is seized by a fenestrated
forceps and brought into the vagina, where its stalk is transfixed by
passing a needle armed with a double thread between the ovarian
ligament and the oviduct, and each half is securely tied. The ovary and
the fimbriated end of the oviduct are then removed, the ligatures cut
off at the knot, and the stumps returned into the pelvic cavity. To
close the vaginal opening one or two stitches will be needed, and
finally the wound is covered with iodoform and the vagina gently packed
with pads of carbolated or salicylated cotton.

It is a fact worthy of note that during the week following the ablation
of the uterine appendages a sanguineous discharge from the womb usually
takes place. This is in no wise a menstruation, but a metrostaxis {293}
set up by the irritation of the ovarian nerves, caused by the means
adopted to secure the pedicles. Candor, however, compels me to say that
for some inexplicable reason the removal of the uterine
appendages--viz. ovaries and oviducts--does not always bring about the
change of life. These cases are exceptional, and they are supposed to
be due to either the presence of a third ovary or to some small portion
of ovarian stroma left behind.

This operation in no wise unsexes a woman or changes her appearance or
character. It simply brings on the change of life with its attendant
phenomena. Her instincts and affections remain the same, her sexual
organs continue excitable, her breasts do not wither up, and she is no
less a mother or a wife.[8]

[Footnote 8: _Lessons in Gynæcology_, by Wm. Goodell, M.D., chap.
xxvi.]


Extra-Ovarian Cysts.

There is a class of tumors which, while not ovarian, lie so near to the
ovary as often to involve it, and usually need precisely the same
treatment as cysts of that organ. In their extirpation the ovary is
almost always also involved. This close anatomical relationship makes
it needful to describe them in conjunction with ovarian tumors. They
comprise Cysts of the Parovarium, Cysts of the Oviducts, or Fallopian
Dropsy, and Cysts of the Terminal Vesicle of the Oviduct, often called
the Hydatid or Vesicle of Morgagni.


Cysts of the Parovarium.

These are formed from the dropsical distension of one of the tubules of
the parovarium, or organ of Rosenmüller, which lies between the folds
of the broad ligament and between the ovary and the oviduct. Usually,
one tubule alone is affected, and the cyst is then unilocular; but
exceptional cases have been met with in which several of the tubules
have become dilated, and the cyst is then bilocular or even
multilocular.[9] These cysts are often called cysts of the broad
ligament.

[Footnote 9: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans.
American Gynæc. Soc._, 1881, p. 231.]

By examining cysts in their early stage Albert Doran has demonstrated
that "the vertical tubes of the parovarium are lined with epithelium,
sometimes ciliated, but oftener cubical, the original, primitive form
of the tubes of the Wolffian body. From these tubes and from the hilum
of the ovary, full of Wolffian relics, spring the multilocular
papillary cysts which give so much trouble to the operator. At the
outer end of the horizontal tube of the parovarium is a cystic
dilatation which is lined with a structure resembling endothelium.
Apart from the parovarium, between the folds of the broad ligament,
minute cysts are frequent. It is from these and from the terminal cyst
of the parovarium that the simple unilocular so-called parovarian cyst
arises. The terminal cyst of the Fallopian tube never attains a large
size, and no true cysts of the broad ligament appear, when young and
minute, to arise from that tube."[10]

[Footnote 10: _British Med. Journal_, Oct. 21, 1882, p. 792.]

{294} These cysts are more commonly found in young women. From the
thinness of their walls and the limpid character of their fluid, they
yield very marked waves of fluctuation which are equally distinct at
every point. They can usually be distinguished from ovarian cysts
either by a lack of that tenseness so characteristic of the latter or
by varying conditions of tenseness and flaccidity, as if the fluid were
sometimes absorbed more quickly than at other times. They also grow
more slowly than the ovarian cyst, and do not exert the same profound
constitutional impression. The facies ovariana is absent, and the
health of the woman may in no wise be disturbed. They, indeed, in the
majority of cases, seem to do no harm, and are merely annoying from
their bulk. The fluid they contain is with rare exceptions as limpid
and clear as spring-water, but with refractive powers so high as to
magnify the fibres of the wooden pail into which it has been drawn off.

Owing to their very thin walls and delicate structure these cysts on
very slight provocation are liable to burst. On account of the
blandness of the contained fluid this accident is rarely followed by
collapse or by peritonitis. The rent heals up and the cyst usually
refills; but in a large proportion of cases it does not, and the woman
remains permanently healed.[11] Sometimes they are pedunculated, but
often they lie between the two folds of the broad ligament, having no
proper stalk.

[Footnote 11: "Bursting Cysts of the Abdomen," by Wm. Goodell, _Trans.
American Gynæcological Society_, 1881, p. 226.]

Cysts of the broad ligament must not be confounded with those ovarian
cysts which, instead of growing free in the peritoneal cavity, develop
between the two layers of the peritoneum--intra-ligamentous ovarian
cysts, as Garrigues very aptly calls them in his paper on the
"Diagnosis of Ovarian Cysts."[12] In this excellent paper, from which I
have gleaned much, he says that sometimes the anatomical relations are
so lost that nothing short of a microscopic examination of the outer
epithelium can determine the character of the cyst. Thus, "a tumor
covered with columnar epithelium is ovarian, and cannot be anything
else; while the cyst of the broad ligament, being covered with
peritoneum, has flat peritoneal endothelium. In cases of
intra-ligamentous development of an ovarian cyst the lower portion is
covered by peritoneum, but the upper part has the columnar epithelium
characteristic of the ovary." There are, however, certain macroscopic
characteristics which will generally tell the nature of the cyst. For
instance: usually by a careful examination the corresponding ovary will
be found either stretched out and spread out in the wall of the sac,
or, what in my experience is more common, elongated and forming a part
of the stalk. These cysts are in the vast majority of cases monocysts,
while unilocular ovarian cysts are very rarely if ever met with. Their
walls are thin, of a conjunctival blue, and fretted with a delicate
network of blood-vessels. The oviduct is usually imbedded in the cyst,
and by transmitted light its fimbriæ can be traced out in the
cyst-walls in long fronds as delicate as those of dried and pressed
seaweed. Then, again, the peritoneal coat is readily stripped off. On
the other hand, in an ovarian tumor the oviduct is not ordinarily
incorporated in the cyst-wall; in fact, a meso-salpinx usually exists;
and, further, the peritoneal coat, being nailed down to the cyst-wall
proper by the cicatrices of ovulation, is not capable of being stripped
off.

[Footnote 12: _Am. Journ. of Obstetrics_, April, 1882, p. 394.]

{295} TREATMENT.--Since these cysts do not ordinarily affect the
general health or grow to a very large size, they should, as a rule, be
let alone. Whenever grounds for interference arise the cyst should be
aspirated, for sometimes after being wholly emptied it does not refill.
Should, however, the fluid return, the cyst must be extirpated in
precisely the same way as an ovarian tumor. When it is without a
pedicle it will have to be carefully enucleated from between the folds
of the broad ligament, which then cover it. If this cannot be done, all
of the cyst possible should be removed, the edges stitched to the
abdominal wound, and a drainage-tube put in. This is the advice
ordinarily given, but I have not yet met with a cyst of this variety
which could not be removed. Were such a one to occur in my practice I
should be tempted to remove all of the cyst possible, and to close up
the adherent portion in the cavity of the abdomen without resorting to
a drainage-tube. The fluid secreted by a parovarian cyst is so bland
that I believe no mischief would arise. The late Washington L. Atlee
was accustomed to make merely a large circular opening in the cyst,
without attempting to remove it.


Cysts of the Oviducts, or Fallopian Dropsy.

These tumors may contain either fluid or pus. In the former case the
cyst is called hydro-salpinx; in the latter, pyo-salpinx. They are
caused by salpingitis, or inflammation of the oviduct, which exists
rarely per se, unless of gonorrhoeal origin, but is one of the sequels
of pelvic peritonitis. The distension of the tube is due to the
occlusion of each of its ends. Thus by pelvic inflammation the fimbriæ
become glued to the ovary, sealing up the ovarian end, while an
endometritis closes the uterine opening. In addition to the dropsy of
the tube, I have repeatedly met with small cysts, or bladder-like
bodies outside of the tube proper, very analogous to those found on the
umbilical cord.

This affection is by no means an uncommon one, every age being liable
to it, and it is often the unrecognized cause of ill-health. Since Tait
first called the attention of the profession to the frequency of the
disease and the means for its cure, many cases have been reported in
which obscure pelvic symptoms were cured by the removal of the ovaries
and of the oviducts--the uterine appendages, as they are called.

DIAGNOSIS.--This is difficult, because the symptoms are those of pelvic
peritonitis or of pelvic cellulitis, the disease of the oviduct being
usually associated with that of the broad ligament. In some cases the
womb will be found movable, with a sausage-like tumor behind it; the
diagnosis is then easy. Usually, the symptoms are negative, and the
diagnosis is based upon constant groin-pains and recurring attacks of
pelvic inflammation.

TREATMENT.--Like hydrocele of Nuck's canal, hydro-salpinx occasionally
heals spontaneously, but more frequently it will need aspiration,
together with injections of iodine or of carbolic acid. When pus is
present, absorption probably never takes place, and an operation will
be needed. If the symptoms are grave enough to warrant an exploratory
incision, and dropsy of the tubes be discovered, both the tube and its
ovary should be extirpated, for in the great majority of cases the
{296} corresponding ovary will have undergone follicular or
interstitial degeneration. Unless there are very good reasons for
adopting a different course, both ovaries and tubes should be removed,
because the sound ovary, together with its tube, is liable to become
diseased. The incision should always be abdominal, and not larger than
to admit two fingers. The broad ligament is transfixed between the tube
and the ovarian ligament by a double ligature and tied on either side.
The operation is, in fact, analogous to that of öophorectomy. When the
tubes contain pus, they are liable to become adherent to the sigmoid
flexure, to the rectum, or to the small intestines, making their
removal very difficult--sometimes, indeed, impossible. The separation
of such adhesions requires the greatest care and delicacy.


Cysts of the Terminal Vesicle of the Oviduct.

A little bladder-like body, not larger than a pea, is often found
hanging by a thread-like stalk from one of the fimbriæ of the oviduct.
It is a relic of foetal life, being probably the remains of the
Wolffian body, and sometimes goes by the name of the hydatid or vesicle
of Morgagni. The walls are very thin and covered by peritoneum. What
rôle these vesicles play in the economy is uncertain, but they have
been found to undergo cystic degeneration. They rarely attain to a size
larger than that of an orange, and then either remain stationary or
else burst. I have met with several examples of cysts which, after
reaching the above size, did not grow any larger. I have also met with
one case in which, after attaining the bulk of a small apple, the cyst
burst, and immediately refilled, to burst again and again at intervals
of from four to six weeks.[13] The collapse of the sac was attended
each time by colicky pains, but of no great severity.

[Footnote 13: "Bursting Cysts of the Abdominal Cavity," by Wm. Goodell,
_Trans. Amer. Gynæcol. Soc._, 1881, p. 228.]

Other small cysts I have met with which either burst under the pressure
of the examining finger or were designedly burst by bimanual pressure.
These, I am disposed to think, were cysts of the terminal vesicle of
the oviduct. These cysts are of but little surgical importance, as they
rarely need operative interference. If such should arise, they are to
be treated by aspiration, and if this fails by extirpation.


Solid Tumors of the Round Ligament.

These are occasionally met with, and usually on the right side. They
belong to the connective-tissue group, being either myoma, fibroma, or
sarcoma. They form at any point of the round ligament, and may
therefore be either intra-peritoneal, intra-canalicular--that is, in
the inguinal canal--or extra-peritoneal. The symptoms are those arising
from pressure, and are not at all diagnostic. The only treatment of
these tumors is removal, but, as their growth is very slow, they are
not to be touched unless the symptoms become exacting.[14]

[Footnote 14: _Medical Times and Gazette_, Dec. 1, 1883.]


{297} OVARIAN TUMORS.

The morbid growths of the ovary are conveniently divided into the solid
and the cystic.

The solid ones are either benign, under the form of fibroma, or
malignant, being then either carcinoma or sarcoma.


Fibroid Tumor of the Ovary.

Fibroid degeneration of the ovary is so rare a form of disease as to be
denied by excellent authorities, who contend that all the cases
reported under that term were pedunculated uterine fibroids, which had
so grown around and so involved the corresponding ovary as to be
mistaken for an ovarian fibroid. Yet while such mistakes have
undoubtedly been made, there can be no question that ovarian fibroid
does occasionally present itself as a rare form of disease.[15] Out of
155 cases of ovariotomy thus far performed by myself, I have met with 4
undoubted cases of ovarian fibroid. The tumors weighed respectively 2,
3, 4, and 15 pounds, and in each, with the exception of the first,
abdominal dropsy was the prominent symptom. All but one of these cases
promptly recovered.

[Footnote 15: _Brit. Med. Journ._, March 18, 1882, p. 384.]

According to Francis Delafield,[16] "The structure of a fibroid of the
ovary resembles that of the ordinary fibroid tumors of the uterus. That
is, they are composed of connective tissue and smooth muscular fibre.
The tumor, therefore, is a myo-fibroma. There has been some question
whether ovarian tumors ever contain smooth muscle, but the best
authorities now admit that it does sometimes exist in such tumors."

[Footnote 16: _Boston Med. and Surg. Journ._, Nov. 17, 1881, p. 461.]

Occasionally these tumors arise not from a general hypertrophy of the
whole ovary, but from a nodule or a tumor growing in and from the
stroma of the ovary. Solid ovarian fibroids are of slow growth and
rarely attain a large size. When, however, they are of the geode
variety, with numerous cystic cavities, they grow rapidly and may reach
enormous proportions.

DIAGNOSIS.--The only other abdominal tumor for which it is very likely
to be mistaken is a pedunculated fibroid tumor on the peritoneal
surface of the womb, and with our present knowledge it seems impossible
to tell them apart.

When they float about in ascitic fluid they often give the sign of
ballottement in a very perfect manner. From carcinoma of the ovary they
can generally be told by their smooth surface.

PROGNOSIS.--Fibroid tumors of the ovary grow so slowly that, like
pedunculated fibroid tumors of the womb, they ordinarily do not attain
a very bulky size. When the climacteric is reached they tend, like the
latter, to stop growing and to undergo a calcareous degeneration. More
often, however, they cause by their presence a dropsical effusion of
the abdominal cavity, which has to be repeatedly drawn off; and it is
for this reason that they usually have to be extirpated. They are
removed precisely in the same way as an ovarian cyst, and the prognosis
is equally {298} good, but they are liable to have short and broad
pedicles which need to be tied very carefully in sections.


Malignant Diseases of the Ovary.

These affections are either primary or secondary. When secondary, they
follow analogous diseases of the womb or of the pelvic structures. When
primary, they appear under different forms, as in other portions of the
body, being either encephaloid, scirrhous, melanotic, or papillary.
Colloid cancer of the ovary may be practically excluded, because it is
of extreme rareness. The term colloid when applied to ovarian cysts
refers more to the gluey consistency of the contained fluid than to the
question of malignancy. In my experience the most common form is that
of papilloma, which, however, like villous growths elsewhere, is not
always malignant. I have removed papillary cysts and villous growths of
the ovary, yet the subsequent history of the cases proved that the
tumors were benign. The only macroscopic distinction between the benign
and the malignant form which I have hitherto attempted to make is, that
in the malignant form papillary growths will be found in patches upon
adjacent structures, or else the womb and the broad ligaments are also
involved in one cauliflower-like tumor. But Tait observes that he has
had two cases of ovariotomy in which he left large masses of papilloma,
fixing the womb, yet in each case these masses wholly disappeared, and
the patients are both in perfect health.[17]

[Footnote 17: _Diseases of the Ovaries_, 4th Am. ed., p. 147.]

There is, however, no question that malignancy lurks in many ovarian
cystomata which present to the naked eye an innocent appearance.

The patient recovers promptly from the operation for their removal, but
dies a few months later from cancer of the peritoneum or of other
organs. Every ovariotomist has met with such examples. In one of my own
cases, in which not the slightest sign of malignancy was apparent, the
patient wholly recovered from the operation. Shortly after her
convalescence an effusion took place in the right pleural cavity. The
chest was tapped three times before her death, which was due to cancer
of the liver and of the broad ligament at the site of the ablated
ovary. In my first case of ovariotomy, one in which the clamp was used,
menstruation took place regularly for several months from the cicatrix,
which within a year became affected with cancer.

Both ovaries are usually involved in cysto-carcinoma, and this fact
should be borne in mind in making a diagnosis. From the marvellous
changes often produced progressively in the epithelial linings of
ovarian cysts, by which they are transformed into tufts of villous
cancer, Tait inclines to the opinion that their growth is associated
with a tendency toward malignancy. He believes that tapping hastens on
this degeneration, and that after an accidental rupture of such a cyst
the peritoneum will be found studded with patches of papillary cancer.
Hence he argues that ovarian cysts should never be tapped, and that
they should be removed in the earlier stages of their existence, before
these malignant transformations have taken place.[18]

[Footnote 18: _Op. cit._, p. 148.]

DIAGNOSIS.--Since, as has been shown, this cannot always be made {299}
out, even by the eye, after the removal of the cysts, it follows that
in a large proportion of cases the malignant character of the
degeneration cannot be recognized. There are, however, certain symptoms
pointing to malignancy which will often throw much light. These, in the
order of their frequency, are--

  (_a_) The presence of ascitic fluid or of oedema of the lower
          extremities when the tumor is too small to produce such
          pressure symptoms.

  (_b_) General cachexia, rapid emaciation, and grave constitutional
          disturbance out of all proportion to the size of the tumor.

  (_c_) The hardness and solidity of the tumor, together with its
          nodulous and irregular surface.

  (_d_) The concurrent development of two ovarian growths.

  (_e_) The retraction and burying of the cervix in the vaginal vault.

  (_f_) Pain in stabs, starting from the groin and running down the
          inside of the thigh. But pain is not a trustworthy symptom,
          as it is often absent, especially in cysto-carcinoma, and may
          be caused by benign growths as well.

TREATMENT.--Whenever no doubt exists as to the malignancy of an ovarian
growth, an operation looking to its removal should not be urged by the
physician. On the other hand, since a positive diagnosis on this point
is rarely attained, and since cancer of the ovary tends for a long time
to remain localized, whenever a suspicion of malignancy exists
ovariotomy should be performed early, before adhesions have been
contracted with neighboring structures. In such a case I should incline
to burn off the pedicle in preference to using the ligature.

In those cases in which, on account of adhesions, no operation is
justifiable, palliative treatment can alone be resorted to. This
comprises the removal of the ascitic fluid or the contents of the cyst
by the aspirator whenever the pressure becomes uncomfortable. Symptoms
should be treated, and, that of pain being the most urgent, opium will
be needed up to the last in increasing doses.


Dermoid Cyst, or Piliferous Cyst of the Ovary.

A dermoid cyst is a congenital tumor having a wall composed of elements
like true skin, with its appendages of hairs, sebaceous glands, etc.,
and contains teeth, hair, bone, cartilage, muscle, and a cheesy
material very like vernix caseosa. These cysts are solitary, two never
being found in the same person, and, further, they are always
unilocular. They are either external or internal--that is, they affect
either the surface of the body or else the cavities of the body, as
"under the tongue, in the pharynx, oesophagus, cranial cavity,
peritoneal cavity, lung, ovary, testis, bladder, and kidney."[19] No
tumors are more curious, and none are more puzzling to explain. The
theories accounting for their origin are very remarkable, and are as
follows: Excess of formative nisus. Parthenogenesis, or virgin birth;
that is to say, imperfect imitation of transmitted fertility--a
property peculiar to many insects, by which, without any renewal of
fertilization, successive generations of procreating individuals start
from a single ovum. Inclusion of abnormal structures, {300} where there
is a dipping in of the epiblast to meet the hypoblast during foetal
life, and the pinching off of the same. Foetus in foetu--viz. the
inclusion of an imperfectly developed ovum within another which matures
perfectly. Hypererchesis; which means that "the ovum has in it the
origin-buds of certain tissues, which under exceptional hypererchetic
action may go on to the rudimental formation of these tissues without a
fusion with the male germ."[20] According to Elsner, who has written
last on this subject, and to whom I am indebted for much information,
"dermoids occur externally and internally in places where the epiblast
dips down to meet the hypoblast, and where by processes of grooved
involution new bodies are formed, such being, first in order, the
testicle and ovary, and that they are therefore all (without exception)
embryonal in their first structure."

[Footnote 19: Elsner, _Dublin Journal Medical Sciences_, May, 1882, p.
380.]

[Footnote 20: _Diseases of Ovaries_, by L. Tait, 4th ed., p. 177.]

SYMPTOMS.--These congenital tumors begin early in life, and usually
remain dormant until puberty. Then the periodic congestions of
menstruation usually stimulate them into growth. Sometimes they need
the increased vascularization of pregnancy. They are more liable than
ovarian cysts to inflammation and suppuration, but they grow much more
slowly, and very rarely reach the large size of the latter. They are
also very liable to contract adhesions to every structure they touch,
making their extirpation very difficult and sometimes impossible. Often
they create pain out of all proportion to their size. Occasionally,
they break and empty their contents through fistulous communications
with the intestines, bladder, or the abdominal wall. But collapse of
the usually thick walls of the cyst does not take place, and a cure
results far less frequently than in pelvic abscesses, which empty
themselves through analogous channels. The cyst ordinarily does not
lessen in size; suppuration goes on with hectic fever and exhaustion,
which finally carry off the patient.

DIAGNOSIS.--Quiescent or slow-growing pelvic tumors, semi-solid to the
feel, and first discovered at the age of puberty, are usually dermoid
cysts. Their small size is also an aid to diagnosis, for they very
rarely reach the bulk of the adult head. On several occasions I have
found them in Douglas's pouch, fig-shaped and flattened in their
antero-posterior diameter. From its attachments to neighboring
structures a dermoid cyst is very liable to be mistaken for the cyst of
an extra-uterine foetation. But the exclusion of the history of
pregnancy and the slow growth of a dermoid cyst, unless suppuration has
taken place, ought to distinguish the one from the other.

TREATMENT.--While quiescent the cyst should not be touched, as it is
very vulnerable and liable to resent the slightest injury, even from
the slender trocar of the aspirator. If suppuration takes place and the
tumor points to the surface, it should be treated, like any other
abscess, by a free incision, by the evacuation of its contents, by the
introduction of a drainage-tube, and by the injection of antiseptic
solutions. Small cysts lying in Douglas's pouch can sometimes be cured
by aspiration; at least I have twice succeeded in obliterating them in
this way. The operation was, however, followed by suppuration of the
cyst, the abscess bursting into the vagina. If after an exploratory
incision an abdominal cyst turns out to be dermoid, it should be
extirpated. But if extensive adhesions {301} preclude such an
operation, the cyst should be opened, evacuated, and thoroughly
cleansed. The edges of the opening should then be stitched to those of
the abdominal wound and a drainage-tube put in. The after-treatment of
such a case will be analogous to that of an ovarian cyst under like
conditions, to which the reader is referred.


Cystic Tumors of the Ovary.

These represent by far the most frequent variety of ovarian tumors, and
as such demand our best attention. They consist, in probably the
majority of cases, in a dropsical enlargement of one ovisac or of
more--viz. in a follicular dropsy. Indeed, as Cazeaux has aptly said,
the ovisacs, or Graäfian follicles, are ovarian cysts in miniature.
These cysts are divided into three classes, which depend wholly upon
the number of ovisacs involved. Thus, a single, or barren, cyst,
containing merely fluid, is called a monocyst or unilocular cyst. Such
a cyst would be due to the dropsical enlargement of but one ovisac. It
is extremely rare--so much so that its existence is denied. The
probability is that a one-chambered sac does not begin as such, but it
becomes so through the breaking of the walls of other contained cysts.
A multiple cyst is caused by the simultaneous growth of two or more
ovisacs, one of which usually takes the lead in growth and keeps the
others dwarfed. This form of cyst is by far the most common. It grows
with great rapidity, and may reach a weight of over one hundred pounds.
I have successfully removed one weighing one hundred and twelve pounds.
A proliferous cyst is a mother-cyst packed with innumerable child-cysts
of varying size. These endogenous cysts multiply by exogenous and
endogenous growth. The proliferous cyst rarely attains to the size of
the multiple cyst, but surgically it is a solid tumor, because it
cannot be emptied by tapping, and therefore often needs a long incision
for its removal. It also usually possesses a very thin wall, which is
liable to be torn during the needful manipulation for its removal.
Racemose cysts are occasionally met with. They consist of a number of
isolated cysts of varying size attached to one common stalk like a
bunch of grapes. I have met with two such examples. Tait thinks that
they are "produced by the retention of the ova in the Graäfian
follicles, and the distension of their cavities by a continuous
secretion of the liquor folliculi."

The pedicle or stalk by which an ovarian cyst is attached to the womb
consists of the corresponding broad ligament, oviduct, ovarian
ligament, and vessels. The pedicle is sometimes long and slender, at
other times short and broad. There is one form of ovarian cyst which
has no proper pedicle. It grows between the two layers of the broad
ligament, and tends to develop downward into Douglas's pouch. It is
called the intra-ligamentous cyst, and needs careful and tedious
enucleation for its removal. Sometimes, indeed, extirpation is out of
the question, and the cyst has to be treated by the drainage-tube, as
will hereafter be shown.

The contents of ovarian cysts vary very greatly in color and in
consistency. In monocysts the fluid is often limpid and colorless. In
multiple cysts the contents are usually syrupy, thick, and turbid.
Sometimes the {302} color is quite dark, as much so as weak coffee. The
surface of the fluid, after standing, will be covered with a pellicle
of cholesterin crystals, which sparkle in the sunlight. In proliferous
cysts the contents are usually viscid, sometimes as much so as jelly,
and to this the term colloid is applied. Foulis, who is an authority on
this subject, states that he has "never found that an ovarian fluid,
however long kept, ever deposited a precipitate spontaneously. Whereas
very frequently in the case of an ascitic fluid such a spontaneous
precipitate appeared within a period varying from a few hours to a few
days."[21] Again he observes: "After ten years of observation made on
fluids withdrawn by the aspirator, I found that ovarian fluids never
throw down a precipitate of a fibrinous character. An ovarian fluid was
always a pure cellular secretion. An ascitic fluid was always the
result of obstruction to the circulation or of inflammatory action in
the peritoneum, and ascitic fluids allowed to stand for a short time
nearly always showed a precipitate with the character of felted
material under the microscope. If they tapped the patient and subjected
the fluid to this test, two or three days would suffice to tell in
cases in which there was doubt. The deposit in ovarian fluids showed
cellular, not fibrinous, elements under the microscope."[22]

[Footnote 21: _Edinburgh Medical Journal_, July, 1885, p. 76.]

[Footnote 22: _Ibid._, June, 1885, p. 1131.]

Chemically, the contents are mucous and albuminous, the albumen being
readily detected by the tests of heat and nitric acid. Microscopically,
ovarian fluid is found to contain fat-globules, epithelial, granular,
and pus-cells, crystals of cholesterin, blood-corpuscles, and compound
granular cells, also called the inflammatory globules of Gluge.

Whether ovarian fluid contains a cell or corpuscle peculiar to itself
is yet a moot question. Drysdale contends that it has a characteristic
cell. He describes it as "an albuminoid body containing little fatty
particles which give it a granular appearance. It resembles in some
particulars many other granular cells, but can be distinguished from
all other cells found in the abdominal cavity.... The principal test I
employ is acetic acid. If the cell is ovarian, the acid changes it but
little, perhaps rendering it only a little more transparent. But if it
be a white blood-cell, a lymph-corpuscle, or any of those granular
cells which resemble them, it will nearly always take on a different
appearance, the cells almost vanishing perhaps, and multiple (2-5)
nuclei appearing, as in the pus-cell. Then, if the cell be suspected to
be fatty, degenerated, or Gluge's cell, ether may be added, by which
the fatty materials will be dissolved and disappear. If no fatty
degeneration be present, it is sufficient to add acetic acid."[23]
Garrigues, on the other hand, contends that the ovarian fluid does not
contain a characteristic cell.[24]

[Footnote 23: _Trans. Amer. Gynæcol. Soc._, vol. i. p. 195.]

[Footnote 24: _Ibid._, vol. vi. p. 54.]

If I am not mistaken, the opinion of the best microscopists of
Philadelphia is that the Drysdale cell, while not characteristic of
ovarian fluids, is not found in any other fluid in such large numbers,
and to that extent it is of diagnostic value.

CAUSATION.--In probably the very great majority of cases an ovarian
cyst is a dropsy of several ovisacs, but the cause of such growths has
never yet been ascertained. In the majority of cases it seems to depend
upon some sexual disturbance.

Very recently the relation of the sexual condition to disease has been
{303} made the subject of scientific inquiry. From a careful
examination of the registrar's tables for France, M. Bertillon shows
that marriage, by giving a comparative immunity from diseases of the
sexual organs, prolongs life in both sexes. This statement is confirmed
by the statistics of ovarian tumor. Of Lee's 136 cases, 88 were
married, 37 were unmarried, and 11 were widows. Of Sir Spencer Wells's
first 500 cases, 260 were married, 221 were unmarried, and 19 were
widows. Out of 155 completed cases of ovariotomy performed by myself,
91 were married, 48 were single, 16 were widows. Of the married, 24
were sterile, 10 had one child, and 26 had but two children, and
several confessed to using preventive measures. Out of a total of 791
cases of ovarian tumor, there are, then, 352 without husbands to 439
with husbands. Now, when one considers how small the proportion of
single women and of widows is to married women whose husbands are
living, the significance of these figures goes to show that
childbearing women, and especially the prolific ones, are less liable
to cystic degeneration of the ovaries, and that, unless the cycle of
reproduction is completed in a woman, she is plainly violating some law
of her being.

SYMPTOMS.--There are no symptoms pathognomonic of this affection, for
they are mainly those of pressure, and therefore belong in common to
all fluid collections in the abdominal cavity. But in proportion as the
abdomen swells there is a marked emaciation of the extremities. The
limbs waste away, the face becomes pinched, the eyes are hollow and
staring, deep wrinkles and furrows appear on the forehead and around
the mouth, and the nostrils are wide open. This facial expression is
termed the facies ovariana. Sometimes, when both ovaries are
simultaneously affected, hair will grow on the chin and on the upper
lip.

THE NATURAL HISTORY.--The natural course of an ovarian cyst is to grow
rapidly, and in about two years from the time of its discovery to
destroy life by exhaustion through the embarrassing pressure which it
makes upon the organs of respiration, circulation, and nutrition.
Malignant cysts grow more rapidly than the benign, while the latter
will, on the other hand, occasionally remain for years in a state of
quiescence. I have kept stationary cysts under observation for ten
years, and others have been reported which lasted twenty years without
change.

As a cyst develops it is very likely to contract adhesions to the
organs with which it lies in contact. The most common adhesion is that
of the omentum. Next to this is adhesion to the abdominal walls. Then
will happen more rarely adhesions to the bowels, womb, bladder, pelvis,
liver, and stomach. A loop of intestine will sometimes be found
fastened to the front wall of the cyst, but usually the bowels lie
packed behind the tumor.

Rupture of the cyst sometimes takes place, either spontaneously,
through over-distension, or through violence, as a kick, a rude fall,
or from being run over by a carriage. This accident, if the fluid
happens to be bland, may be followed by a cure; but more often a
violent peritonitis sets in, which carries the patient off in a few
hours. From a study of 257 cases, Aronson[25] rates the fatality at 41
per cent.; but without question the very great majority of cases of
bursting cysts of the abdomen in which this accident was followed by a
cure were cysts of the parovarium, which being {304} thin-walled are
likely to burst, and which contain a bland, unirritating fluid.
Bursting of the sac can be recognized by more or by less collapse and
pain, by the disappearance of the cyst, and by the lessened size of the
abdomen. If the patient does not at once succumb, excessive diuresis
usually occurs.

[Footnote 25: _American Journal of Obstetrics_, Nov., 1883, p. 1210.]

It happens occasionally that the inner cyst-wall inflames, either
spontaneously or in consequence of being tapped or from other injury.
Suppuration then takes place, the contained fluid becomes fetid, and
offensive gases are generated which give a tympanitic sound on
percussion. There will be creeping chills, a red tongue, night-sweats,
a frequent pulse, a general rise in the temperature with evening
exacerbations: in one word, all the well-known symptoms of
blood-poisoning will be present in a greater or less degree. Unless the
cyst be at once removed the woman will speedily die.

Ulceration of the cyst, with perforation of its wall, may also occur.
The decomposing contents will then be discharged, either into the
peritoneal cavity or into any viscus to which the cyst may have
contracted adhesions. In this way the purulent contents of an ovarian
cyst have been discharged through the bowels, the bladder, the vagina,
and even into the womb through the oviducts.

Hemorrhage within the sac is an occasional accident. When it takes
place the tumor rapidly enlarges, great abdominal pain is caused by
this sudden stretching, the complexion grows pale, the features become
pinched; there will be collapse and all the symptoms of internal
hemorrhage. If the bleeding does not stop, the patient will die in a
few hours. On the other hand, if she survives the immediate danger, she
is liable to succumb later to septicæmia, which arises from the
decomposition of the now bloody fluid. The immediate removal of the
cyst gives the woman, then, her sole chance of life.

Twisting of the pedicle of an ovarian tumor by axial rotation is
another serious complication, which leads to its strangulation and
gangrene, with consequent fatal peritonitis. The chief factors of this
accident are, probably, the filling and emptying of the bladder and
rectum, which may rotate an unadherent cyst with a long stalk. The
symptoms of axial rotation, as carefully noted by Tait[26] and
Aronson,[27] are sudden accession of severe abdominal pain and
tenderness, a rapid increase in size, and incessant vomiting, the
matter thrown up soon becoming green. The pulse rises, but the
temperature is not always affected, and rigors are absent. Such a train
of symptoms should lead at once to the abdominal section.

[Footnote 26: _London Obstet. Trans._, vol. xxii. p. 97.]

[Footnote 27: _American Journal of Obstet._, Nov., 1883, p. 1211.]

DIAGNOSIS.--The diagnosis of ovarian cysts is often beset with so many
difficulties that very humiliating blunders have been made by the best
surgeons of the day. Lizars of Edinburgh performed laparotomy on a
woman in order to remove a suspected ovarian cyst, and found nothing
but fat. Others have done the same thing, and to their dismay have
discovered merely an accumulation of wind in the intestines. The great
Dieffenbach once opened the belly of a woman for supposed extra-uterine
pregnancy, and found neither fat nor wind--not even, indeed, a trace of
a tumor. Once an enormously distended bag of waters {305} broke just as
a deservedly eminent British surgeon had rolled up his sleeves and was
about to wheel his patient into an amphitheatre crowded with spectators
to witness an ovariotomy. A surgeon of whom Great Britain can well be
proud once drove his trocar into the shoulder of a foetus under the
idea that he was tapping one of these cysts. These facts show the
importance of knowing how to make an examination for a suspected
ovarian cyst, and how to distinguish such a cyst from other tumors and
other fluid collections in the abdominal cavity.

The usual history of an ovarian cyst is--a tumor first discovered in
one groin, rapidly enlarging, without tenderness or soreness, giving no
inconvenience save from its bulk. The general health remains good until
the tumor begins to distend the abdomen; then emaciation takes place,
the strength becomes impaired, and the features begin to assume that
pinched expression described on a preceding page as the facies
ovariana. By inspection and palpation there will be found an elastic
but somewhat irregular tumor, yielding the sense of fluctuation. By
percussion a dull sound will be elicited at every point, except in the
flanks, which are more or less resonant. If the contents of the tumor
are colloid or the tumor is thick-walled or very tense, the sense of
fluctuation may be either obscure or wanting. Sometimes a feeling like
that of fluctuation is conveyed by a fat-laden wall of the abdomen. To
muffle this fat-thrill the ulnar edge of the hand of an assistant is
laid along the linea alba while the surgeon percusses the abdomen. The
pressure thus exerted acts precisely like the damper-wedge of the
piano-tuner, which muffles the sound of one string while its fellow is
being tuned. By these means fluctuation can be detected and the
diagnosis of a collection of fluid unhesitatingly made out.

By the amount of solid and fluid portions of a cyst correct diagnosis
can often be made out, whether it is simple or multiple, compound or
proliferous; but this is a matter of comparatively little practical
importance, because when once a growing tumor has been ascertained to
be ovarian, its removal must follow as a matter of course.

There are, however, certain enlargements or tumors of the abdomen which
are very liable to be mistaken for an ovarian cyst, and to these, in
the order of their frequency, we shall call attention.

Ascites.--When the fluid is not encysted, but free, as in ascites, it
is at liberty to go to the most dependent portions of the body. Hence
changes in the posture of the woman will make corresponding changes in
the level of the fluid. These level-changes are made evident by
percussion. When the woman lies on her back the intestines float up to
the surface, and the fluid gravitates to the flanks, making them bulge.
In other words, percussion in the dorsal position elicits a clear note
in the umbilical region and a dull note in each flank. In this posture
the front surface of the abdomen is symmetrical and somewhat flattened.
But when the woman sits up the belly becomes convex. Further, ascitic
fluid is displaceable by pressure on the abdomen. But even these signs
are not always trustworthy, because the intestines, glued down by
adhesions, may not float up, and there will be dulness over the front
of the abdomen, or a distended colon may make each flank resonant. For
instance, I have known a papillary cancer of the omentum attended with
dropsy of the abdominal cavity to give such signs of ovarian cyst as
dulness in front and resonance {306} in the flanks. When the fluid is
ascitic the floating or false ribs are not pushed outward. The womb is
usually low down and movable; there will also be more or less of
bulging in Douglas's pouch.

On the other hand, in an ovarian cyst the womb is usually not very
movable, and it is displaced to one side, generally behind the cyst.
While the woman lies on her back the front surface of the abdomen is
convex and unchanged in form. The floating ribs bulge out, making the
chest conical. There will also be dulness in the front wall over the
tumor, but usually more or less resonance in the flanks and over the
region of the stomach: this clearness on percussion has been aptly
termed coronal resonance. These areas of dulness and of resonance
remain constant whatever the posture of the woman. Yet in suppurating
cysts or after a careless tapping, or in cysts communicating with the
intestine, the sac may contain gas, which will give a tympanitic sound
over all the elevated portions of the abdominal surface.

It must, however, be borne in mind that ascites may exist concurrently
with an ovarian cyst, and especially if the tumor be malignant in
character. This can usually be detected by deep palpation, when the
cyst will be reached and recognized by the fingers; or by pressing
lightly, and then more firmly during percussion, an upper and a lower
stratum of fluctuation will be detected.

Pregnancy.--The question of pregnancy is a very serious one, for it is
sometimes a most difficult one to decide, especially when dropsy of the
amnion (hydramnios) exists. In making a diagnosis nothing must be taken
for granted, not even the woman's statement. She may be mistaken, or,
indeed, she may be wilfully deceiving in the hope of having a cheap
abortion induced by the examination. She may be pregnant and yet
menstruate. On the other hand, an ovarian tumor will sometimes arrest
menstruation. A healthy, ruddy complexion coexistent with abdominal
enlargement should always excite a suspicion of pregnancy. There is
sometimes a jaded look in pregnancy--the facies uterina--but never the
facies ovariana.

The various signs of pregnancy should be searched for, especially
ballottement and the foetal heart-sounds. The cervical region should be
most carefully examined per vaginam. A good broad rule to remember is,
that when the womb is gravid the cervix is as soft as one's lips; when
it is empty the cervix is as hard as the tip of one's nose. In all
doubtful cases any operation should be postponed until time has
revealed the true condition of things. Of course the introduction of
the sound will settle the question of pregnancy, but this procedure is
not to be thought of when any doubt exists, and it is therefore useless
as a diagnostic agent. An ovarian tumor may coexist with pregnancy, and
may have to be tapped or be extirpated before the delivery of the
woman. The history of the case, the unusual size of the abdomen, the
sulcus between the two tumors, will generally reveal the condition.

Fibroid Tumors of the Womb.--These tumors often reach a very large
size, and if of the soft variety give an obscure sense of fluctuation
which so closely resembles that of a colloid ovarian cyst or of a tense
thick-walled cyst as to make the differential diagnosis very puzzling.
The hard myoma gives no sense of fluctuation, but, on the other hand,
if pedunculated it can be very readily taken for a solid ovarian tumor.
A {307} fibroid tumor of the womb can very generally be told by the
history of menorrhagia, by its slow growth, by the uterine souffles and
colics, by the effacement of the cervix, and by the tumor being felt to
be continuous with the cervix and inseparable from the womb. Then,
again, women burdened with a fibroid tumor so far from losing flesh
usually become more fat, and their complexion, like that of many
pregnant women, is mottled with patches of brown pigment. Further, the
uterine cavity is usually much longer than natural, and when the tumor
is moved from side to side the motion is communicated to the sound
passed within the cavity. But every rule has its exceptions, for when
an ovarian cyst has a close attachment to the womb the latter may
become elongated and also follow the movements communicated to the
tumor.

The positive diagnosis between an ovarian cyst and a fibro-cystic tumor
of the womb is impossible, but, fortunately, the latter disease is
exceedingly rare. The existence of the latter may be inferred if the
woman's face has a jaded appearance and is disfigured by brown
patches--the facies uterina--if the growth of the tumor has been very
slow, and if the womb is implicated with it. After tapping there will
be a partial collapse of the tumor, and the fluid withdrawn is usually
bloody and it coagulates on being cooled. After an exploratory incision
the tumor presents to the eye a dark-blue and vascular capsule covered
with interlacing fibrous bands.

Renal Cysts.--Cysts of the kidney are very commonly mistaken for
ovarian cysts. I have made this mistake, and it was not until after
breaking up adhesions and emptying the cyst that I discovered the
character of the tumor. It was successfully removed. Renal cysts start
from below the floating ribs and extend downward and forward, while an
ovarian cyst begins from below and grows upward. The former, being
generally caused by impaction of a calculus in the ureter, are usually
associated with urinary disturbances. They also push the intestines
before them, which give a resonant sound on percussion, while the
contrary holds good with an ovarian cyst. Since the transverse colon
lies between the cyst and the liver, the line of resonance caused by it
will show that the cyst is not hepatic. The fluid withdrawn from a
renal cyst contains urea and the other constituents of urine, but the
urinous odor will be either very faint, or, as in my case, wholly
absent. It may as well be stated here that when renal cysts present
great difficulties in the way of their removal, they had better be
treated by a large drainage-tube.

A floating kidney may be mistaken for a small ovarian tumor. But the
latter has a pelvic attachment and can readily be pushed down into the
basin, while the former is kept from being pushed very low downward by
an upper attachment. Again, the floating kidney usually keeps its
peculiar shape, and it is frequently lost by slipping from under the
fingers into its natural bed in the flank.

Spina Bifida.--Strange as it may seem, this spinal cyst, when internal
on account of a deficiency in the anterior parietes of the lower
vertebræ, has been mistaken for an ovarian or a parovarian cyst. I am
cognizant of two such errors of diagnosis made by two distinguished
gynecologists. In each the sac was emptied by the aspirator, and the
patient perished shortly afterward with the same kind of cerebral
symptoms which follow the sudden withdrawal of the fluid from the
cavity of an external spina bifida.

{308} Phantom Tumors.--In the diagnosis of an ovarian cyst one must be
on guard not to mistake for it a phantom tumor. In this imaginary kind
of tumor, which hysterical women have the knack of creating, the whole
belly will be uniformly distended to the size of the gravid womb at
term. This is caused partly by flatus and fat, and partly by the
arching forward of the spinal column, with the recti muscles drawn so
tense that they cannot be indented. I have frequently had patients with
this kind of abdominal enlargement sent to me from a distance, under
the impression that it was due to some kind of tumor. But the diagnosis
is easily made from the uniform resonance all over the belly; if,
moreover, the patient's attention be engaged by conversation, the
rigidity of the recti muscles disappears, the abdomen becomes flaccid,
and the hand can be made to sink in so as to feel the spine. In very
nervous women it may be needful to administer an anæsthetic, when all
the tokens of a tumor will promptly disappear.

Obesity.--A large accumulation of fat on the abdominal wall and in the
omentum has frequently given rise to the suspicion of the existence of
an ovarian cyst. This condition occurs, usually, at the climacteric,
and on percussion the vibratile thrill of the fat-laden wall of the
abdomen conveys a very misleading impression of fluctuation. Further,
to add to the difficulty, if the layer of fat be a very thick one, the
abdomen, instead of being resonant on percussion, yields a dull note.
But in obesity the fat is not limited to the abdomen, for the breasts,
face, and limbs partake of the general enlargement. The abdominal wall
hangs in folds when the sitting posture is assumed, and the umbilicus
is indented and not protuberant. My own method of making the diagnosis
is to grasp the abdominal wall with both hands and ascertain the amount
of fat. When this amount is excluded, there will not be found room
enough behind it for a tumor of any size, and the enlargement will thus
be satisfactorily accounted for.

A dilated stomach, cystic tumors of the omentum, and encysted abscesses
of the peritoneal cavity, and, indeed, of the abdominal wall, have been
mistaken for ovarian tumors; but these are very exceptional cases. In
all doubtful cases an exploratory incision should be resorted to.

SURGICAL TREATMENT OF OVARIAN CYSTS.--In the consideration of this
subject it may be divided into the palliative treatment and the radical
treatment.

Palliative Treatment.--Tapping either by the trocar or by the aspirator
comprises the only palliative treatment of ovarian cysts; yet, as a
broad rule with but few exceptions, an ovarian cyst should not be
tapped. The objections to this operation are--that, slight as it may
seem, it is by no means devoid of danger. Even when the smallest hollow
needle of the aspirator has been used inflammation of the cyst may
follow, which will compel the immediate resort to ovariotomy and very
greatly compromise the success of this radical operation.[28] This has
repeatedly happened--once in one of my own cases, in which, however,
the removal of the cyst saved my patient's life. Further, the fluid of
a polycyst is usually acrid--so much so sometimes as to irritate the
hands of the operator--and the escape of a few drops into the cavity of
the peritoneum may set {309} up a violent and rapidly fatal
peritonitis. Then, again, a fatal hemorrhage may take place from some
wounded vessel, either in the cyst-wall, or in the adherent omentum, or
in the vascular pedicle which may lie spread out in front of the
cyst-wall, or, indeed in the abdominal wall itself, for the vessels
here are often varicose from impeded circulation. In the fourth place,
adhesions are very likely to form after tapping. Fifthly, innumerable
child-cysts, which were very small before the tapping, being now
relieved from pressure are liable to take on rapid growth and make the
tumor more solid; and the more solid the cyst the longer the incision
needed for its removal. Sixthly, in polycysts not only are the dangers
attending the operation enhanced, but the cyst rapidly refills, and the
woman becomes exhausted by the drain on her system. At the very best, 2
per cent. of cases of tapping in polycysts are fatal, even when
performed by the most skilled specialists. Seventhly, a cyst once
tapped rapidly refills, and soon needs repetitions of the operation.
This drain on the system quickly tells upon the woman, and she is
sometimes left too weak to have the radical operation performed. The
first tapping, indeed, greatly hastens on this crisis, and it should
therefore be put off as long as possible. Eighthly, a cyst emptied by
tapping tends to rotate on its axis, and torsion of the pedicle may
result, ending in gangrene and peritonitis. Ninthly, repeated tappings
tend to convert benign papillary growths into malignant. Finally,
Lawson Tait[29] draws attention to the fact that "repeated tappings
deprive the blood of some element or elements included in the infinite
variety of albuminous substances found in ovarian cysts, the deficiency
of which predisposes to coagulation of blood." Hence after the removal
of the cyst deaths have been "due to the formation of a firm white clot
which started from the point of ligature of the pedicle, and slowly
traversed the venous system until it reached the heart, death ensuing
in from thirty to forty hours after the operation. The symptoms which
precede death are swelling of the legs, rapid rise of the pulse, and
its disappearance from the extremities some time before death, and
breathlessness, ending in suffocation and slight delirium." He has met
with several such cases of venous thrombosis starting from the pedicle,
and they all occurred in patients who had been previously tapped. There
are, however, cases in which tapping cannot be dispensed with; for
instance--

1. Many women with ovarian tumors, having heard of cases of abdominal
effusion or of cyst in which tapping was followed by a cure, will not
submit to the radical operation until repeated tappings have proved to
them the futility of the trocar.

2. Cysts of the parovarium and of the broad ligament being often cured
by the use of the trocar, it is proper to try the effect of one tapping
in slow-growing, unilocular, thinned-walled, and flaccid cysts, which
thus exhibit the chief characteristics of these extra-ovarian cysts.

3. When an ovarian cyst develops during the later months of pregnancy,
it will often be best to resort to tapping in order to relieve the
woman from the pressure of two growing organs and enable her to go to
full term. Sometimes labor is made impossible by the presence of a
cyst, which will then have to be emptied.

4. In very large tumors which by pressure interfere with the functions
of the kidneys, heart, and lungs, thereby causing albuminuria, oedema,
or {310} dyspnoea, tapping is a useful prelude to ovariotomy. By the
relief from pressure afforded to these organs not only will the
liability to shock be lessened, but also to hemorrhage, for vessels
previously varicose will now contract to their natural calibre.

5. In cases of doubtful diagnosis or in those in which from malignancy,
from formidable adhesions, or from other circumstances the radical
operation is deemed impracticable, tapping in the first case may clear
up the diagnosis, and in the latter ones will prolong the patient's
life. But it must always be borne in mind that in a few weeks the fluid
will reaccumulate, and the operation will have to be repeated, rapidly
exhausting the patient by the drain on her system. It is well,
therefore, to put off the first tapping as long as possible.

[Footnote 28: _American Journal of Obstetrics_, Nov., 1883, pp. 1169
and 1189; also _Transactions American Gynæcological Society_, vol. ii.,
1877, p. 270.]

[Footnote 29: _Midland Medical Society, Lancet_, Feb. 18, 1882.]

Tapping may be performed through the abdominal wall, through the
vagina, or through the rectum, but, for reasons which will presently be
given, the first mode is decidedly the best.

Tapping through the Abdominal Wall.--For this operation either the
aspirator may be used or else Wells's trocar with a long rubber tube
attachment. Of the two, I much prefer the former. In aspiration, after
the bladder has been emptied, the woman lies on her back close to the
side of the bedstead with her abdomen exposed. The preferable site of
puncture is in the linea alba midway between the navel and the
symphysis pubis; that is to say, at a point where the tissues, being
tendinous, are most free from blood-vessels, and where the omentum is
most out of the way. But if at this point the tumor feels solid, or an
underlying knuckle of intestine is discovered by percussion, or the
vessels look varicose, any other place in the abdominal wall may be
selected where fluctuation is most manifest, provided it lies below the
level of the navel. The reason for choosing a low site for the puncture
is, that if the hollow needle be plunged in at any point above the
navel it will slip out of the cyst as the latter collapses and before
it is wholly emptied. The skin is now thoroughly cleansed with soap and
water and washed with a 5 per cent. solution of carbolic acid. The
painful part of the operation being the penetration of the skin, the
selected place for puncture should either be frozen with the ether
spray or be benumbed by a lump of ice dipped into some table-salt.
After the aspirator-jar has been exhausted of air the hollow needle or
canula, armed with its stilette, is lubricated with carbolated oil or
vaseline, and rapidly plunged deeply into the cyst. Should the cyst not
wholly collapse, the canula has probably become obstructed, and it
should be cleared out by one of the blunt stilettes which are made of
different sizes to fit the different canulas. Sometimes the flaccid
walls of the sac as it becomes empty are sucked up into the end of the
canula, and the flow of fluid is suddenly arrested. This accident is
recognized by a peculiar valve-like vibration communicated to the
instrument, and is overcome by raising up the end of the canula or by
directing it to another part of the cyst. Should, on the other hand,
other cysts present themselves, they can be emptied without withdrawing
the canula by reintroducing the stilette, and by directing its point to
each cyst in succession. When the fluid ceases to flow the fore finger
and thumb firmly compress the fold of the abdominal wall behind the
canula as it is withdrawn, so as to avoid the entrance of air, and the
small puncture is covered by a piece of adhesive plaster. A pad of
cotton wool is now laid over the {311} scaphoid abdomen and a flannel
binder applied. These afford a grateful feeling of support and take
away that sense of goneness which is likely to occur. To avoid all
risks of inflammation the patient must keep her bed for three or four
days and eat sparingly.

When Wells's or any other large trocar is used, the operation should be
performed under the spray and with every antiseptic precaution. The
skin should be previously incised with a lancet, and, lest air should
be sucked up into the sac, the free end of the rubber tubing should
touch the bottom of the bucket, so as to be always immersed in the
escaping fluid. This rubber tubing acts as a syphon with great suction
power, and the cyst is more rapidly emptied by Wells's trocar than by
the aspirator. Yet I cannot help believing that the latter by its small
size is by far the safer instrument, and I always use it when a simple
tapping is aimed at. Should any stubborn bleeding follow the removal of
the canula, a harelip pin may be passed across the wound deeply enough
to get below the wounded vessel, and compression made by a turn or two
of silk ligature around the pin. The same means are to be adopted to
stop the oozing of fluid which sometimes takes place when a cyst with
colloid contents cannot be wholly emptied by the trocar. For it is
highly prudent under such circumstances to stop the oozing, as some of
the fluid is sure to get into the cavity of the peritoneum, with very
generally fatal effects. In such a case the pin ought to include the
lips of the wound in the cyst. To avoid as much as possible the escape
of irritating ovarian fluid into the cavity of the abdomen, the cyst
when tapped should always, if possible, be wholly emptied. This is a
rule without an exception. It is therefore very bad practice to remove
even with the hypodermic syringe a few drops of the fluid for
microscopic examination. Several cases of death from this cause have
been reported.[30] I lay stress on this point because in my _Lessons in
Gynæcology_ I advocate the practice.

[Footnote 30: _American Journal of Obstetrics_, April, 1876, p. 146.]

Tapping through the Vagina.--This operation is sometimes a very
tempting one to perform when one of the cysts of a polycyst is pressing
downward behind the bladder and causing dysuria. But it is by no means
so safe as the supra-pubic mode of tapping. The reasons for this
are--(_a_) The vessels are larger and lie closer together in the lower
wall of the cyst near the stalk; (_b_) in a polycyst the larger cysts,
growing where they have most room, usually develop in the abdominal
cavity, while the more solid portion remains below in the pelvic
region; (_c_) other organs, such as the bladder, womb, and rectum, are
liable to become dislocated and lie in the track of the trocar; (_d_)
the roof of the vagina responds to every respiratory movement of the
diaphragm, and a cyst low down is not, from pelvic adhesions, so likely
to collapse when tapped as one higher up: hence the cyst is liable to
act as a pair of bellows, sucking in air and forcing it out. This
inevitably causes suppurative inflammation with all its attendant
evils. For these reasons this mode of tapping is never resorted to,
except in cases of pelvic adhesion or in those in which the cyst starts
from the lower side of the broad ligament and grows downward. Even then
it is done only to relieve the distress caused by the double pressure
upon bladder and rectum. In such cases the aspirator should be used, as
it lessens all the risks. Should suppurative inflammation set in, the
sac must be again emptied, the wound kept open by a {312}
drainage-tube, and the cavity thoroughly cleansed by daily injections
of antiseptic fluids.

Tapping through the rectum has long ago been abandoned by the
profession, as it ought to be, except in some very rare cases of
atresia vaginæ. It was at one time supposed to possess advantages over
the vaginal method, because the subsequent offensive discharges could
be retained at will like the other contents of the bowel. But the
cavity of the sac always became distended with fecal gas, and fatal
septicæmia was pretty sure to set in.

Radical Treatment.--Tapping, followed by the injection of iodine into
these cysts, has sometimes been rewarded with a cure, and at one time
this mode of treatment had very warm advocates. After the cyst is
wholly emptied by aspiration the action of the instrument is reversed,
and from two to ten ounces of the officinal tincture of iodine are
thrown in. The tincture is used of full strength, because the residual
fluid in the cyst will be enough to dilute it. The cyst-wall is next
kneaded, and the patient made to turn from side to side and from back
to chest, so that the tincture may come in contact with every portion
of the secreting surface of the cyst. The fluid is then pumped out, but
all cannot be brought away; enough usually remains behind to produce
some slight constitutional disturbance. While the canula is being
withdrawn, in order to prevent the escape of any of the irritating
injection into the abdominal cavity the thumb and fore finger are made
to grasp the fold of abdominal wall at the puncture-site and to press
it firmly down on to the collapsed cyst-wall. Good and lasting cures
have followed such a treatment; but since they can happen only in
monocysts, which are almost always parovarian, and not ovarian, it is
probable that the mere emptying of the cyst would have done as much. In
polycysts such a treatment is not to be thought of, for it would be
attended with far more hazard than even the operation of ovariotomy. At
the present day injections of iodine are practised only by physicians
who do not operate; ovariotomists never resort to them.

Tapping, followed by enlarging the wound in the cyst, stitching its
edges to those of the abdominal wound, and permanently keeping it open
by tents or by a large drainage-tube, has frequently been attended with
success. But since extensive and prolonged suppuration must inevitably
ensue, this operation has proved to be a far more dangerous one than
that of ovariotomy. It should, therefore, not be resorted to excepting
in cases of cysts which are too adherent to be removed. The
after-treatment consists in treating the case precisely as if it were
an abscess. The cyst is kept empty by draining, and sweet by such
deodorizing agents as solutions of iodine, carbolic acid, potassium
permanganate, and the liquor sodæ chloratæ. Early this year I had one
such case, a patient of C. A. Currie, in which the cyst was wholly
adherent to all the pelvic organs and structures, and had besides a
communication with the bladder. Not daring, under such circumstances,
to remove it, I treated it successfully by incision, drainage, and
disinfecting injections; but it was a long time before the
drainage-tube could be removed and the woman be released from her bed.
Cases, indeed, have occurred in which six months elapsed before the
drainage-tube could be taken out and the woman pronounced well.

Another exception in favor of this operation may be made in the case of
small cysts growing downward and bulging out the hind wall of the {313}
vagina. It may then be advisable to follow Noeggerath's plan. He snips
open the vagina transversely behind the cervix to the length of one
inch, and makes a corresponding incision in the cyst-wall. The edges of
the two incisions are then stitched together and a drainage-tube put
in. Thus, the cyst is left with a free and permanent opening into the
vagina, through which such antiseptic solutions as have been noted
above are thrown up. In time the collapsed cyst-walls adhere to one
another and cease to secrete.

Electrolysis has of late also been lauded as a sure and harmless remedy
for these cysts. But a careful examination of the subject made by Mundé
shows that this agent has been greatly overrated as a specific, and
that it "can in no wise supplant ovariotomy."[31]

[Footnote 31: _Transactions American Gynæcological Society_, vol. ii.
p. 435.]

Rupture of ovarian cysts has occasionally taken place, either through
over-distension or through such violence as a rude fall or an upset
from a carriage. This accident, if the tumor were a monocyst or if the
fluid happened to be bland, sometimes ended in a lasting cure. The hint
was not thrown away, and several surgeons cut circular openings into
the cyst to establish a permanent communication with it and the
abdominal cavity. But this practice was soon given up, because it was
found that the intrusion of ovarian fluid into the serous cavity
usually set up a violent and rapidly fatal peritonitis. For such an
accident, when followed by inflammation, there is but one remedy--the
immediate removal of the cyst by ovariotomy. Desperate as this remedy
seems, it has repeatedly been followed by success. The only cyst in
which it might be held warrantable to establish a communication with
the abdominal cavity is that of a cyst of the parovarium recurring
after repeated tappings, and so bound down by adhesions or so covered
by the broad ligament as to be irremovable. The fluid it contains is so
limpid and bland as not ordinarily to inflame the peritoneum.

OVARIOTOMY.--The term ovariotomy comes from [Greek: ôarion], ovary, and
[Greek: tomê], an incision. It is a barbarous compound of Latin and
Greek, which is forced into meaning the operation for the extirpation
of an ovary on account of some disease of its own structures which
causes it to increase in bulk. A fibroid or a sarcomatous degeneration
of this organ, as has been shown, will sometimes happen, but cystic
degeneration is by far the most common form of disease to which the
ovary is liable. When both ovaries are enlarged and removed the
operation is called double ovariotomy. The terms ovariotomy and
öophorectomy ([Greek: ôophoron] and [Greek: echtemnô], to cut out the
ovary) really mean the same thing, the latter word, indeed, being the
more appropriate. But by modern usage the former is limited to the
operation for the removal of an ovary greatly enlarged by some
intrinsic disorder. By öophorectomy is now meant the operation for the
removal of both ovaries for the purpose of bringing on the menopause,
and thus curing diseases kept up or caused by the functional existence
of those organs, while they themselves may or may not be diseased.

Before the eighteenth century the operation of ovariotomy as a radical
cure had been suggested by a number of physicians, but had never been
put into practice. Later, John Hunter and John Bell both advocated the
operation, but neither ventured to perform it. This honor was {314}
reserved for Ephraim McDowell, a Virginian practising in Kentucky, who
had attended Bell's course of lectures delivered in Edinburgh in 1794,
and had imbibed the opinions of his teacher. He returned to Kentucky in
1795, and began at once to practise his profession, but it was not
until 1809 that he first met with the opportunity for performing
ovariotomy. The operation was successful, his patient having lived
thirty-two years longer and having died at the end of her
seventy-eighth year. Before his own death, which occurred June 25,
1830, in the fifty-ninth year of his age, McDowell had performed 13
ovariotomies, with 8 recoveries.

In spite of McDowell's success, and in spite of a large and growing
percentage of recoveries reported by Atlee, Clay, and Spencer Wells,
this operation was condemned so violently by the profession that its
advocates were fairly ostracised, and fifteen years have hardly elapsed
since it has been put upon as firm a basis as any other capital
operation in surgery. "In 1843, Dieffenbach, the boldest of all
surgeons then living, wrote that ovariotomy was murder, and that every
one who performed it should be put into the dock. Now," writes
Nussbaum, "we save lives with it by the hundred, and the omission of
its performance in a proper case would in these days be looked upon as
culpable negligence."[32]

[Footnote 32: _British Medical Journal_, Oct. 26, 1878, p. 617.]

The most common causes of death after ovariotomy are septicæmia or
septic peritonitis, traumatic or frank peritonitis, shock, exhaustion,
and hemorrhage; and it is against these foes that the operator must
from the first aim all his efforts. In no other operation does the
issue depend so largely on the experience of the surgeon. Every
ovariotomist finds that his success grows with the number of his cases.
Of 1000 successive ovariotomies, Wells lost 34 out of the first group
of 100 cases, and but 11 out of the last group of 100. Out of his first
50 ovariotomies, Lawson Tait had 19 deaths.[33] The mortality of his
last 313 cases was as low as 4.76 per cent.[34] Keith, who began with a
mortality of about 20 per cent., lately had a series of 100 cases with
97 recoveries; 70 of these were successive. Schroeder had in the first
100 of his Berlin cases 17 deaths; in the second 100, 18; and in his
third 100, 8 deaths.[35] Of my own first cases, I lost about 1 in every
3. Out of my last 22 cases there was but 1 death, and that occurred in
a lady operated on at her home, too distant for me to see her again. In
July, 1884, Peruzzi collected statistics up to date of Italian
ovariotomists. Out of the first series of 100 cases, they lost 61. In
the second 100 there were 36 deaths, but in the third series only 26
died.[36]

[Footnote 33: _Medical Record_, Jan. 3, 1885, No. 2, and _British
Medical Journal_, April 15, 1882, p. 544.]

[Footnote 34: _Medical Record_, Jan. 3, 1885, p. 2, and _American
Journal of Obstetrics_, July, 1882, p. 547.]

[Footnote 35: _Maryland Medical Journal_, July 1, 1882, p. 110.]

[Footnote 36: _British Medical Journal_, Sept. 16, 1882, p. 528.]

The statistics of the leading ovariotomists up to January, 1883, are as
follows:[37]

                     Cases.  Recovered.  Died.  Mortality,
                                                per cent.
  Clay                 93        64        29     31.11
  Sir Spencer Wells  1088       847       241     22.15
  Keith               381       340        41     10.76
  Knowsley Thornton   328       293        35     10.67
  Lawson Tait         226       199        27     11.94

[Footnote 37: _Medical News_, Jan. 27, 1883, p. 117.]

{315} The statistics of general hospitals are by no means so good. In
the Vienna General Hospital during the year 1881 "ovariotomy was
performed 64 times, with 38 complete recoveries, 25 deaths, and 1 woman
was discharged with marasmus."[38] Taking the profession at large, out
of 5153 cases of ovariotomy collected by Baum, there was a mortality of
29.13 per cent.[39] Out of 2023 cases collected by Younkin, the
mortality was 27 per cent.[40] By operative skill, by cleanliness, by
wise hygienic measures, and probably by the use of antiseptic
precautions, the fatality may be said to have been reduced by skilled
specialists to about 10 per cent.; which, considering the size of the
wound, the importance of the parts involved, and the delicacy of the
exposed structures, is a remarkably low average. The average is indeed
better than that of amputations. Before 1869, Sir James Y. Simpson
stated that the average mortality of amputations of the extremities was
39.1 per cent. In the Glasgow Royal Infirmary the average mortality has
been 25.5 per cent.--viz. of thigh cases there were 380 cases, with 113
deaths = 29.7 per cent.; of the leg, 182 cases, with 54 deaths = 29.6
per cent.; of arm cases, 167, with 33 deaths = 19.7 per cent.; of
forearm cases, 93, with 12 deaths: mortality = 12.9 per cent.[41]

[Footnote 38: _Medical News_, Dec. 30, 1882, p. 745.]

[Footnote 39: _Agnew's Surgery_, vol. ii. p. 811.]

[Footnote 40: _The New York Medical Record_, Nov. 11, 1882, p. 560.]

[Footnote 41: _Lancet_, Sept., 1882.]

This brings up the question of simple or of aseptic ovariotomy--a very
important question and one not yet fully settled. The objections to
Listerism are--that it is very troublesome; that it is liable to poison
the patient fatally, as well as to injure the health of the operator;
that it is useless, indeed merely a surgical craze; and that it is not
the carbolic acid which does good, but the cleanliness enforced by this
system. But there is no doubt that since the introduction of antiseptic
surgery the mortality has been much lessened in every land. For
instance, "in Germany, where the success of ovariotomy has not been so
good as in other countries, the mortality by means of the antiseptic
treatment has been reduced from 90 to 20 per cent."[42] From an
analysis of all the cases of ovariotomies performed by American
surgeons, "the percentage of recoveries is overwhelmingly in favor of
Listerism."[43] During the year 1881 in the Samaritan Hospital two of
the surgeons used the carbolated spray of a strength of 1 in 40, and
followed out every detail of antiseptic surgery. They had a mortality
of 7 per cent. A third surgeon of that institution, after gradually
lessening the strength of the spray until water was alone used, finally
gave even it up altogether. He, however, for purposes of cleanliness
always covered the instruments in the tray with water. The mortality of
his operations showed the high rate of 30 per cent. The house
committee, a body of laymen, thereupon "expressed a strong opinion
against the performance of ovariotomy for the future without full
antiseptic precautions."[44]

[Footnote 42: _Agnew's Surgery_, vol. ii. p. 800.]

[Footnote 43: H. C. Bigelow, _American Journal of Obstetrics_, July,
1882, p. 651.]

[Footnote 44: _British Medical Journal_, May 20, 1882, p. 747.]

On the other hand, Tait of Birmingham and Keith of Edinburgh, with a
recent mortality each of only 3 per cent., have abandoned the spray.
The latter claims now "to get as good results without it, and better
results than any one has yet got with it."[45] My own practice is to
adhere {316} to the spray and to every detail of antiseptic surgery;
and I fully agree with Bigelow that "it would be a grave error to
abandon a practice which has achieved brilliant results until something
shall be brought forth which shall be as thoroughly protective, and in
the use of which there may be no possible dangers. Time alone can
demonstrate satisfactorily the relative values of Listerism and of
perfect cleanliness without Listerism. The results of a large number of
cases in which cleanliness and attention to detail have alone been used
are the only criteria upon which we can strike a judicial balance."[46]

[Footnote 45: _Brit. Med. Journ._, May 27, p. 796.]

[Footnote 46: _Am. Journ. of Obstetrics_, July, 1882, p. 651.]

Contraindications for Ovariotomy.--An operation should be declined in
far-advanced tuberculosis, in cancer of the ovary or of any other part
of the body, in grave structural lesions of any of the vital organs, in
ascites if caused by disease of the heart, the liver, or the kidney, in
gastric ulcer, or in any serious disease of the alimentary canal.
Extensive adhesions should not count as a contraindication, nor should
age, since young girls and very old women have been successfully
operated on. Albuminuria is often due to the pressure of the tumor on
the kidneys, and, unless it existed before the appearance of the tumor
or is positively known to be caused by Bright's disease, should not
preclude the operation. Extreme debility dependent upon the ovarian
disease makes the prognosis grave, but it should not prevent a resort
to ovariotomy. I have indeed had several recoveries when the patient
was so reduced in strength as to make it a very anxious and difficult
task to keep her from dying on the table.

Indications for Ovariotomy.--This operation should not, as a rule, be
performed when the cyst has first been discovered, but when it has
grown so large as to distend the belly, and when the woman has become
thin and her health has begun to fail. The reasons for waiting
are--that the woman will have lived longer should the operation turn
out to be a fatal one; that, the abdominal wall having become thinner
both by being overstretched and by the absorption of fat, the incision
will be proportionately shorter and shallower; that, the patient being
now less full-blooded, both hemorrhage and inflammation will not be so
likely to occur; that the bowels are crowded away from the line of
incision; and that the pressure and rubbing to which the peritoneum has
been for some time subjected will make it less vulnerable, and
therefore less likely to take on inflammatory action. When, however, a
woman broods over her condition and is anxious to have the tumor
removed, the operation should be performed much earlier, especially if
the surgeon be experienced.

Again, when an ovarian cyst is complicated with pregnancy it is best to
perform the operation in the first half of the period of gestation; for
in the last half the broad ligaments receive a large supply of blood,
and all the pelvic vessels become varicose. Pregnancy is indeed no bar
to the operation, the prognosis being favorable both to the mother and
to the child. Schroeder and Olshausen performed 21 ovariotomies in
pregnant women, with only 2 deaths.[47]

[Footnote 47: _Brit. Med. Journ._, Dec., 1880, p. 1027.]

When septic peritonitis sets in; when the contents of the sac become
purulent, as they sometimes do either spontaneously or after an
unprotected tapping; when the cyst bursts and serious symptoms arise;
when torsion of the pedicle occurs or when a free hemorrhage into the
sac takes {317} place,--the radical operation should unhesitatingly be
performed, and that without any delay.

Preparation of the Patient for the Operation.--The operation having
been decided upon, every precaution must be taken to ensure a favorable
result. The patient should avoid all exposure to contagious or to
zymotic diseases, and she should be put in the very best condition of
health possible under the circumstances. If the kidneys be inactive and
the urine highly concentrated, depositing mixed urates in abundance, it
will be well for the patient to make use of warm baths and to take
saline cathartics in quantities sufficient to secure a daily action of
the bowels. The alkaline carbonates, largely diluted, will also prove
beneficial, and so will also the effervescent citrate of lithia.
Sometimes, and especially when anasarca and oedema of the legs occur,
it will be advisable to relieve the pressure-congestion of the kidneys
by a preliminary tapping. Other organs will also be relieved, and
valuable time for the action of medicines is often gained by emptying
the cyst. Tonics, iron in the form of Basham's mixture, a generous
diet, and fresh air may be needed. A trip to the seashore or to the
country will often do much good in preparing a broken-down patient for
the operation. If the patient comes from a malarial district, from
twenty to thirty grains of quinia should be given during the
twenty-four hours for two or three days before the operation, and ten
grains a few hours before the time of the operation. If this be not
done, a severe explosion of malarial fever after the operation may put
the patient's life in jeopardy.

An operation of election should not be undertaken during a monthly
period. It should be performed either about ten days before one or
about a week after one. The very best time is midway between two
fluxes. When, however, through some lesion or some accident, immediate
relief is demanded, no regard whatever should be paid to the factor of
menstruation. Some surgeons operate, indeed, in any case whether the
woman is menstruating or not, and profess to find no difference in the
result.[48]

[Footnote 48: T. Savage, _Brit. Med. Journ._, April 14, 1883, p. 712.]

For several days before the operation the bowels should be kept open,
and the diet should consist largely of milk, eggs, rice, and of
wholesome and easily-digested food. On the day preceding that of the
operation the upper portion of the pubic hair should be cut off and the
abdomen, if hairy, shaved. In the evening the patient takes a warm
soap-bath, and is washed perfectly clean by her nurse, who must be an
experienced woman, able to pass the catheter and take the temperature.
She then puts on clean clothing and goes to bed, where she stays until
the hour fixed upon for the operation. To ensure sleep, I am in the
habit of giving at bedtime thirty grains of potassium bromide, combined
sometimes with opium. Early next morning a dose of castor oil is
administered, and it is much more easily swallowed if disguised in some
vehicle and brought to the patient without any previous warning. When
oil cannot be taken, I give, at bedtime of the previous evening and in
one dose, two compound cathartic and two Lady Webster pills. To avoid
ether-vomiting, breakfast should consist merely of one piece of dry
toast and a cup of tea, or of a cup of beef-tea or of a goblet of milk,
and afterward she must eat nothing more. To calm the nerves another
thirty-grain dose of {318} potassium bromide may be given, with or
without opium as the case may be, and especially if the woman be at all
agitated.

A very good time for operating is from noon to two o'clock in the
afternoon, for by that time the oil will have acted and the light
breakfast will have been digested. Some surgeons operate as early as
nine and ten o'clock in the morning, in which case the cathartic will
have to be administered in the afternoon of the previous day. At the
hour fixed upon for the operation the woman puts on a flannel sacque,
warm stockings, and drawers, and her nurse then passes the catheter.

The bedstead on which the woman is to lie after the operation should
have a horse-hair mattress, and should be wide enough to permit her
attendants to move her on a draw-sheet from one side of it to the
other. I formerly placed my patients on narrow single bedsteads, so
that they could be reached and be waited upon equally well from either
side; but I found that an unchangeable position on the back soon became
intolerably irksome. Next, indeed, to the thirst following the
operation, my patients complain mostly of the supine posture which they
are compelled to assume.

The room in which the operation is to take place ought to be a separate
one, so that the lady can be etherized in her sleeping-room, and may
not be unnerved by witnessing the needful preparations. Several days
beforehand the carpet of the operating-room should be taken up and the
curtains taken down. Every useless piece of furniture should be
removed, the closets and bureau-drawers emptied, and the whole room
thoroughly cleansed and ventilated. Several hours before the time of
the operation this room ought to be heated to a temperature of 75°, and
the air disinfected and made moist by a solution of carbolic acid kept
boiling in a dish on the stove or over an alcohol lamp. Let me here say
that, if possible, this operation should not be performed within the
walls of a crowded general hospital nor in unhealthy localities, but,
as statistics well show, in private houses or, far preferably, in small
special hospitals.

Articles Needed for the Operation.--The following articles should be
provided by some member of the patient's family. Following the example
of the late Washington L. Atlee, I have a printed list of them, which
is sent to the family physician some days before the operation:

One yard of rubber plaster; two rolls of raw cotton, made aseptic by
being baked in the range-oven just before the operation; two yards and
a half of fine white flannel, for two binders; six one-grain rectal
suppositories of the watery extract of opium; two pounds of the best
ether; two gallons of a 5 per cent. solution of the best carbolic acid,
made at least two days beforehand; four ounces of Monsel's solution of
iron; twelve ounces of undiluted alcohol for the spray-producer; some
old whiskey, with cup, spoon, and sugar; a nail-brush, basin, and soap;
a pin-cushion, with large pins; two kitchen tables, or two
dressing-tables; one small stand for the spray-producer; one small
table for the basins and sponges; one chair without a back for a bucket
of hot water; two new tin basins and one tin cup; a new bucket and a
jug of hot water; a kettle of boiling water, ready on the range; a
small tub and an empty bucket; six bottles filled with hot water and
tightly corked; an empty wine-bottle for the aspirator; a rubber
ice-cap or two pig's bladders for holding ice; a rubber-cloth one yard
and a quarter square, with an oval hole in the centre six inches wide
and eight long; one kitchen apron for the operator; one {319} clean
blanket for the patient's lower extremities; two large platters or two
meat-dishes, to be used as trays for the instruments;[49] clean towels,
clean sheets, clean blankets, clean comfortables, and clean pillows.

[Footnote 49: These platters are usually too shallow to hold a solution
of carbolic acid deep enough to cover the bulkier instruments. It would
therefore be well to have a tin tray made especially for the purpose,
measuring nineteen inches long, twelve wide, and three deep; or a nest
of smaller trays can be carried in the operator's bag.]

Instruments.--In simple cases very few instruments are needed; but as
one never knows beforehand what complications may be met with, it is
best to be always prepared for every emergency. One must therefore have
on hand every instrument likely to be wanted in the most formidable
operation. The following list comprises all the instruments and other
articles that I carry with me in my operating-bag, but it will not suit
every surgeon, who will after a few operations choose his own favorite
instruments:

One steam spray-producer, which will work two hours; assorted silk
ligatures on spools; Lister's antiseptic gauze or salicylated cotton;
two dozen straight surgeon's needles; assorted needles with varying
curves; two large needles for transfixing pedicles; an aneurismal
needle; one needle-holder; one hypodermic syringe; two dozen assorted
pressure-forceps; one uterine tenaculum; assorted hair-lip pins and
acupressure needles; one grooved director; two scalpels; Baker-Brown's
cautery clamp; ten fine surgeon's sponges of different sizes; two long
and flat sponges; one wire écraseur; one wire clamp or Koeberle's
serre-noeud; Paquelin's cautery or three cautery-irons; one Wells's
trocar with rubber tubing; one aspirator; two Nélaton's cyst-forceps;
one straight pair of scissors; one pair of scissors curved on the flat;
one right-angled pair of scissors; Allis's improved ether-inhaler; one
flexible male catheter; three glass drainage-tubes of different sizes
and lengths, together with the rubber sheeting and the sponge used with
them.

The twenty-four needles should be threaded, two on one thread of fine
silk eighteen inches long--viz. No. 1 or 2, of an excellent quality
furnished by Messrs. J. H. Gemrig & Son of Philadelphia. To keep these
threads from becoming snarled they are rolled up in a strip of muslin
gauze, each pair of two needles with their thread being covered up by
one fold of the gauze. The two pedicle-needles should also be threaded,
but with stouter thread (No. 4), fully two feet long. All these armed
needles should be put into a 5 per cent. solution of carbolic acid for
several hours before the operation. Assorted needles of varying curves
come occasionally into use, and it is always well to have several very
fine needles on hand, together with the finest Chinese silk, in order
to close a wounded viscus, such as the bladder or the bowels.

As an aid to the memory it is well to have invariably at every
operation the same number of sponges and the same number of
pressure-forceps, for these are the only articles likely to be left
behind and closed up in the abdominal cavity. The cautery-irons should
be wedge-shaped; the iron spreader used by apothecaries in making
plasters forms an excellent substitute. In my hands the best
pressure-forceps is Koeberle's. Its pointed beak catches the tissues
far better than that of Wells's forceps, which looks like a crocodile's
muzzle. The ordinary hæmostatic bulldog clips, or the serres-fines,
must on no account be used, because if {320} they should lose their
hold and drop into the abdominal cavity they would be too small to be
readily discovered, and might indeed be hopelessly lost in the coils of
the bowels. Long strings attached to each one would, however, overcome
this objection.

The ten sponges must be of the best quality and about the size of one's
fist. Two of them should be flat, long, and thin, such as are called by
the trade potter's sponges. When first bought, sponges almost always
contain sand. To rid them of this they are beaten, then soaked for
twenty-four hours in a 3 per cent. solution of muriatic acid, and
afterward washed out in clear running water. Sponges should never be
put into boiling water, which destroys their elasticity, shrivels them
up, and spoils them. After every operation the sponges should be
thoroughly cleansed in cold water and immersed for forty-eight hours in
a solution of washing soda (sodii carbonas) containing four ounces to
the gallon of water. They are then rinsed out in running water, and
placed in a 5 per cent. solution of carbolic acid. At the end of a week
they are to be taken out and hung up in a bag. Instead of a solution of
soda, some prefer an 8 per cent. solution of sulphurous acid, in which
the sponges are soaked for from two to four hours. This bleaches the
sponges, but does not cleanse them so well as the alkaline solution.

Only three assistants are needed--two are enough if they are
experienced--and they and the surgeon should take a soap-bath, and not
see on that morning any patient ill from a zymotic or a contagious
disease. Their clothes should also be scrupulously clean. To ensure
still further protection, each one takes off his coat, waistcoat, and
neck-tie if they are of a material which cannot be washed. The nurse
must also wear clean clothing which can be washed. A few bystanders may
be permitted, but they should wear clean clothing and take off their
overcoats. They should also be cautioned not to visit before the
operation any case of contagious disease.

Upon arriving at the patient's house the surgeon, together with his
assistants and the nurse, proceeds at once to get everything in
readiness. The two tables may be arranged in the form of a T, covered
with several thicknesses of quilts, and with a pillow on the
cross-table. When the tables are thus arranged a third one will be
needed for the instruments and the spray-producer. In order to
economize room and furniture, I am in the habit of putting one table at
right angles to the other--viz. with its short arm to the left instead
of to the right, thus: _|. The woman lies on the long arm of the _|,
with her feet directed to the short arm, and on the projecting and free
portion of the table forming the short arm are placed the tray of
instruments and the spray-producer. As it takes time to get up steam in
the necessarily large spray-producer, hot water should be poured into
the boiler, and it should be one of the first things attended to. In
order not to chill the patient, the spray solution of carbolic acid
should also be heated before it is used. The edges of the oval hole in
the rubber cloth are next smeared with some adhesive preparation, but a
plaster suitable for all seasons of the year is not easy to devise.
Keith's formula is the following, but it will not always stick:

  Rx. Emplastri saponis, ounce iv;
      Emplastri resinæ,  ounce iij;
      Olei olivæ opt.,   ounce i.   M.

{321} After many trials, W. D. Robinson of Philadelphia has succeeded
in making for me a very good plaster according to the following
formula:

  Rx. Emplastri saponis, ounce ij;
      Resinæ,            drachm vi;
      Terebinthinæ albæ, drachm ij.  M.

I must, however, add that I now very rarely use this rubber cloth.

Not all the instruments in one's bag, but only those likely to be
needed, are now placed in the tray or in the platters, and covered over
with boiling water, to which in a few minutes is added the same
quantity of a 5 per cent. solution of carbolic acid. The best plan
would perhaps be to pour into the tray a boiling 2.5 per cent. solution
of carbolic acid. Into the same tray is also laid the roll of gauze
containing the threaded needles. By its side on the table, and within
easy reach, is placed a small bottle filled with a 5 per cent.
carbolated solution in which are kept two small spools of Nos. 1 and 2
silk. The adhesive or rubber plaster is cut into strips of appropriate
length, and the antiseptic dressing put in readiness. The trocar with
tubing attached is hung on a nail near by. The sponges are carefully
counted and placed in one of two basins arranged side by side on a
table to the left of the patient. The other basin is one-third filled
with a 5 per cent. solution of carbolic acid, which later on is reduced
by the addition of pure hot water to a strength of 2.5 per cent. On a
chair is placed a bucket of clean warm water.

Let me here say, once for all, that throughout the operation the
assistant who looks after the sponges attends to them in the following
way: Every soiled sponge returned to him is first cleaned in the bucket
of warm water, next rinsed in the carbolated solution, then squeezed
out and placed in the empty basin. This sequence must be rigidly
observed, because, if the soiled sponge be plunged first in the
carbolated water, the blood and serum which it contains will at once
coagulate in its meshes, and become liable to be dislodged in the
abdominal cavity as foreign bodies.

Meantime, the woman, in another room, has been inhaling the
anæsthetic--the best being, in my opinion, the ether fortior of our
leading manufacturing druggists. It should be administered by Allis's
inhaler, which largely dilutes it with air. Wells and Thornton employ
the bichloride of methylene; Keith uses pure ether; Bantock resorts to
chloroform, and Tait to a mixture of two parts of ether and one of
chloroform, given by means of Clover's apparatus.[50] When the patient
is wholly unconscious her water is drawn off, and she is carried into
the operating-room and laid on the table. To this table she is strapped
down by a belt over her thighs, and her hands are also secured to the
same belt. Her legs are wrapped in warm blankets, and her clothes are
drawn up out of the way. Her chest and body are then covered by the
rubber sheet, but the edges of its oval opening are made to adhere to
the skin from just above the navel to the pubic hair, thus exposing
only a limited portion of the abdomen. After this the spray is turned
on, and the 5 per cent. solution of carbolic acid in the tray and in
the basins is diluted with hot water down to 2.5 per cent. The operator
and his assistants now take off their rings and cleanse their hands
very carefully with carbolated soap and a nail-brush. They may clean
and pare their nails with a penknife {322} before the use of the
nail-brush, but not after, because the knife not only does not remove
all dirt, but it loosens up that which remains. Arranging themselves in
their places, the operator stands to the right of the woman, his chief
assistant to her left, the one who gives the ether at her head, while
the other, who attends to the sponges, takes his place near the basins
at the side of the chief assistant. The nurse holds herself in
readiness to hand towels when called for, and especially to see that a
third basin always contains warm water, so that at any stage of the
operation the surgeon can wash his hands without delay.

[Footnote 50: _The Medical Record_, Jan. 3, 1885, p. 2.]

When everything is ready the door is locked, and the exposed portion of
the abdomen washed with the solution of carbolic acid. An incision
about three inches in length is made with a free hand, and not by
nicks, in the median line below the navel, where the blood-vessels are
few in number. It should end about one inch and a half above the pubes;
that is to say, low enough for the pedicle to be easily reached, but
high enough to avoid cutting the fold of peritoneum reflected from the
bladder to the abdominal wall. The brown line running below the navel
is the surface guide, but after cutting through the skin and fat one
cannot always hit the linea alba beneath. When the cyst is large the
recti muscles have become separated from one another, and there is no
difficulty in keeping within the wide tendinous interspace. But when
the cyst is small the linea alba is, as its name indicates, a mere
line, and the knife will often go astray into the anterior sheath of
one of the recti muscles. The red muscular fibres pouting out of the
opening will be the danger-signal of one's having got off the track
into more vascular regions. To recover it a probe is passed in across
the muscle to the right and to the left, and the nearest point of
arrest will note the linea alba. The disadvantages arising from the
wandering from the linea alba are--that the sheath of the rectus muscle
being cut open, or the muscle itself being wounded, there results
hemorrhage; that the wound is more jagged, and therefore less easily
coaptated; that suppuration in the suture-tracts is more liable to take
place; and, finally, that in cases of small cysts with but little
abdominal enlargement a spasmodic contraction of the wounded muscle is
very likely to embarrass the operator both in removing the cyst and in
introducing the sutures.

Again, one cannot on a grooved director cut canonically through the
different layers of tissue described with so much precision in the
textbooks. On the contrary, all that one needs is to know when the
knife is approaching the peritoneum. An excellent landmark is the thin
layer of fat overlying the peritoneum. So, after pinching up the
abdominal wall to estimate its thickness, the surgeon can boldly cut
down through the skin and its underlying fat, but somewhat cautiously
through the aponeurotic structures until the second layer of fat is
reached. Practically, therefore, he need regard but the following
layers: skin with its underlying fat, the intermediate tendinous or
muscular structures, the supra-peritoneal fat, and the peritoneum.

Before the abdominal cavity is opened all bleeding is stopped by the
use of pressure-forceps, of which one dozen will sometimes dangle from
the wound. When the hemorrhage has been wholly stayed, and not until
then, the peritoneum is hooked up by a delicate uterine tenaculum and
nicked open. On a broad grooved director or on the finger this opening
is slit up for a distance of about two inches, either by a {323}
right-angled pair of scissors or by a probe-pointed bistoury. A little
serum usually escapes and the nacreous wall of the cyst comes into
view. This is called an exploratory incision, for by it the diagnosis
is confirmed, the presence of adhesions ascertained, and the
possibility of completing the operation determined. When it has been
decided to go on with the operation, more working room will be needed,
and the wound is therefore enlarged by the scissors, the finger being
used as a guide to prevent injury to the omentum or to any chance
knuckle of bowel that may lie in the way. The size of the incision will
depend upon the character of the cyst and on the number of its
adhesions. Hence it may range from a length of three inches to the
distance from ensiform cartilage to symphysis pubis. An incision
contained between the umbilicus and symphysis pubis is technically
called a short incision, and one extended above the umbilicus a long
incision. Should it be found needful to prolong the wound to a point
above the umbilicus, the incision is usually carried to the left of the
navel and brought back in a curved line to the linea alba. This is done
to avoid the round ligament of the liver and its vessels, which come in
there from the right side. Keith, however, cuts directly through the
navel; and I find this straight incision to be superior in every
respect to the curved one. Other things being equal, the short incision
is safer than the long one; but it is a good rule to have an opening
large enough for easy manipulation and for the easy withdrawal of the
cyst. For instance, a large monocyst without adhesions after being
emptied can, like a wet rag, be pulled out, hand over hand, through a
very small opening, whereas a much smaller polycyst, which cannot be
wholly emptied, and which is more or less adherent, will need a long
incision. I once removed an oligo-cyst weighing one hundred and twelve
pounds through an incision barely admitting my hand; while I had to
open the abdominal cavity from ensiform cartilage to symphysis pubis in
order to remove a solid ovarian fibroid tumor weighing but eighteen
pounds. Both patients recovered, but the chances were, of course, more
against the woman with the long incision. To avoid the escape into the
abdominal cavity of any blood from the wound, and to prevent the
soiling of the operator's hands, a clean napkin wetted with the
carbolated water is doubled over each edge of the incision.

Whenever the cyst-wall in the line of the incision is glued by
adhesions to the parietal peritoneum, the latter is liable to be
mistaken for the former, and accordingly to be stripped off from the
abdominal wall. To avoid this very serious error, either proceed with
the cutting until the cyst-wall unmistakably comes into view or is
opened, or else extend the incision upward until a point is reached
where the cyst is free from adhesions. Adhesions binding the cyst to
the abdominal wall are of importance only from the troublesome oozing
their rupture often gives rise to. To lessen this risk, they are to be
sundered by the finger whenever possible. Should the scissors be used,
the adhesion bands must be snipped close to the surface of the cyst,
and not to that of the abdominal wall. Thus, a free end is gained,
which may, if needful, be subsequently tied or in which the dangling
blood-vessels may the more readily constringe. All thick and long bands
of adhesion should be tied in two places and be divided between the
ligatures. These ligatures should consist either of very fine silk or
of gut. For isolated vessels the latter {324} are the better ones, but
the silk is more suitable for tying en masse a group of bleeding
vessels or for pursing up an oozing surface by an in-and-out stitch. A
very important rule, on the observance of which one's success greatly
depends, is, never to let a bleeding point or an oozing surface get out
of sight. It must either be ligatured at once, or else caught by
pressure-forceps and tied later if needful. If the delicate omental
apron be found glued to the cyst, it should be carefully detached with
as little tearing and splitting as possible, for each shred will bleed,
and so will the fork of the split. It should then be turned out of the
abdominal cavity on a clean napkin wetted with the carbolated solution.
If its bleeding vessels be few, each one may be tied with gut; but if
they are many, the torn portion of the omentum should be tied en masse
or in sections, and the ligatures cut off close to the knot. All shreds
and ragged ends of omentum must be trimmed off, and it is then returned
to the peritoneal cavity.

When all the adhesions within reach, and those that do not demand great
force, have been severed, it will be time to tap the cyst. This should
be done with a large-sized trocar, such as Wells's, which is furnished
with spring teeth to prevent it from slipping out of the cyst. Any
trocar will do, provided it has a large bore, so that the vent may be
free and that none of the acrid fluid can escape along its side into
the abdominal cavity. In order to save time, neither Schroeder nor
Martin use a trocar. They incise the cyst, and try by pressure and the
lateral position to direct the contents externally. Frequently,
however, some of the fluid escapes into the abdominal cavity, but they
contend that if antiseptic precautions be taken no harm accrues.[51]
Although dissenting from this opinion, I must confess to having had the
contents of the cyst escape repeatedly into the abdominal cavity
without doing any harm whatever. Always tap at the upper angle of the
wound, because as the cyst collapses the trocar is drawn downward
toward the lower angle. Hence, were the trocar entered low down it
could not travel with the collapsing cyst, which would therefore slip
off. While the fluid is flowing flat sponges should be packed in
between the abdominal wall and the cyst, and the edges of the incision
should be pressed firmly against them, so that the peritoneal cavity
may not receive a single drop of that which frequently escapes along
the side of the trocar. To avoid this accident--which, without being a
very serious one, is yet not to be invited--some ovariotomists before
tapping turn the woman well over on her belly and over the edge of the
table; but this is liable to cause a protrusion of the bowels; which
is, in fact, a more dangerous accident than the entrance of some of the
fluid into the abdomen. Rosenbach, indeed, reports that during the
extraction of biliary calculi through an abdominal incision a cure
resulted, although several calculi were lost in the peritoneal
cavity.[52] Should the mother-cyst not collapse on account of its
containing a few other large cysts, the point of the trocar, without
being withdrawn, can be made to enter each one. But if the child-cysts
are many and small, the trocar is withdrawn, the opening enlarged, its
edge seized by several pressure-forceps, and the hand introduced to
break up these cysts.

[Footnote 51: _Berlin. klin. Wochenschrift_, 1883, No. 10.]

[Footnote 52: _Medical News_, Feb. 3, 1883, p. 130.]

Before this hand can again be used for separating adhesions it must be
{325} carefully cleansed with soap, and dipped into the carbolated
solution in the tray of instruments.

The empty cyst is next gently pulled out through the abdominal wound.
It is, however, so slippery that this cannot ordinarily be done with
the hands alone. A strong forceps with a firm grip is needed, and one
of the best is Nélaton's. While the cyst is being withdrawn the bowels
are sheltered from the air and the spray by one large flat sponge, and
the abdominal cavity must also be packed with smaller ones at every
exposed point; and one of them should always be placed between the womb
and the bladder.

In the majority of cases there is not much difficulty in freeing the
cyst from its ordinary attachments and in reaching its pedicle. But
should adhesions bind the cyst to the adjacent viscera, matters will
not go on so smoothly. Such adhesions to bladder, liver, bowels, or to
other important organs sometimes present difficulties which are
insurmountable. The problem here is to sever these bands of adhesion
without injuring the viscera to which they are attached. When these
adhesions are numerous or very firm, much advantage will be gained by
having the assistant put his hand within the cyst and stretch its wall
while the operator severs the adhesions over it. By this means the
adhesions can be better broken off close to the cyst, which is the
all-important course to pursue in visceral attachments. Sometimes it
will be needful to peel off the outer and non-secreting layers of the
cyst and leave them behind--sometimes to cut off the adherent portion
of the cyst and scrape off or strip off the secreting surface. Whenever
the stalk of the tumor can be reached before all the adhesions are
severed, it will be well to catch it with one or two pressure-forceps,
or even to tie it and cut it off between two ligatures, like the
umbilical cord. This will prevent bleeding from the torn surfaces of
the cyst. When the cyst is closely adherent to the edges of the
abdominal incision, either extend the wound upward until a free point
is reached, and work downward on the adhesions, or else cut into the
cyst, empty it, and seize with strong forceps its inner surface just
beyond where the adhesions begin. The sac is then inverted by traction,
which will break up its adhesions to the abdominal wall, the last
portions to be freed being those attached to the edges of the incision.
This prevents the stripping up of the peritoneum. Should the appendix
vermiformis be so adherent to the cyst as not to be detached, it must
be ligated in two places, between which it is to be cut, in order that
its contents may not escape into the abdominal cavity. The fecal plug
in each distal end should also be carefully squeezed out. Double
ovarian cysts sometimes fuse together, and, rupturing at the point of
fusion, form apparently one cyst. Such a cyst will have two pedicles,
and will be very puzzling to the inexperienced operator.

When the cyst has been freed from its attachments and turned out of the
wound, the very important question comes up of the treatment of the
stalk or pedicle. Shall it be secured by a clamp? shall it be burned
off by the actual cautery? or shall it be tied, cut off, and dropped
back? The first is called the extra-peritoneal method; the others, the
intra-peritoneal. For many years the clamp claimed the most advocates,
but it has lost ground on account of possessing the following
disadvantages: By keeping the wound open it prevents a strictly
antiseptic treatment; {326} the stalk sometimes sloughs below the line
of constriction and conveys putrilage into the abdominal cavity; the
stalk always becomes united to the abdominal wall, hence when it is
short the womb is dislocated or it is too much dragged upon. Then,
again, in one-third of the cases the oviduct has a trick of remaining
open, and the woman will menstruate indefinitely from the abdominal
cicatrix. This is owing to the fact that the clamped portion sloughs
off too early for a firm plug of cicatricial tissue to be formed, and
the oviduct is therefore liable to stay open. In my first case of
ovariotomy this happened, and one year later the cicatrix degenerated
into a malignant growth which destroyed the life of my patient. It is,
however, probable that in this instance the cystic disease of the ovary
was malignant, although the sac did not look so at the time of its
removal. Another disadvantage arising from the use of the clamp is the
subsequent weakness of the cicatrix at its site, and the liability of
ventral hernia to form there. These are the objections to the clamp,
and they are so valid that at the present time all distinguished
ovariotomists have abandoned its use.

The actual cautery, performed by Paquelin's instrument or by
platinum-tipped irons, which do not scale off or discolor the tissues,
is theoretically the very best way of dealing with the stalk. No
foreign body besides the charred portion of the stalk is left within
the abdominal cavity; but, on the other hand, it cannot always be
trusted to close the vessels. On this account it is looked upon with
disfavor by all ovariotomists with the exception of Keith. His method
is as follows: The pedicle is spread out evenly within Baker-Brown's
clamp, so as to get equable compression. The cyst is cut off, leaving a
stump about an inch in height above the clamp. To protect the parts
from heat a folded napkin wetted in the carbolated solution is tucked
under the clamp. The stump is next carefully dried, and then burned
slowly down to the level of the clamp by wedge-shaped cautery-irons at
a brown heat. They give off a whistling sound during the process. The
thick end of the stump can be more quickly burned down, but the thin
end should be burned very slowly, and the blades of the clamp by
prolonged contact with the cautery-iron must also be made hot enough to
dry up and shrivel that portion of tissue which they compress. In order
not to disturb the stump after it has been cauterized, it is best to
clean out the peritoneal cavity first, and to leave this treatment of
the pedicle for the last thing. Before removing the clamp, which is to
be unscrewed very slowly and carefully, one side of the pedicle is
seized by a pressure-forceps, by which it is kept in sight and out of
harm's way if the peritoneal cavity needs further cleansing.

The plan of treating the pedicle most in vogue, and the one which I
adopt, is that of the ligature--one of fine carbolated silk, the finest
compatible with safety. The ends are cut off close to the knot, and the
stump is dropped into the peritoneal cavity, where the silk, being
animal tissue, will in time become disintegrated and absorbed. Now,
when I say silk, I mean silk, and not silver or gut ligature. Silver,
being inelastic, cannot bind a shrinking stalk, while the gut is a
treacherous ligature, and will sooner or later bring one to grief. It
slips in the tying, it is liable to untie, it gives instead of
shrinking, and it is too short-lived for the obliteration of large
vessels.

{327} The reasonable objection has been urged that since the abdominal
cicatrix left by the use of the clamp is liable to reopen every month
to give vent to menstrual fluid, the same phenomenon will by this
intra-peritoneal method happen within the abdominal cavity and expose
the woman to all the risks of a hæmatocele. But fact is here opposed to
theory, for it has been found that either the oviduct in the stump
atrophies into an impervious cord of fibrous tissue, or that its raw
end, by contracting adhesions with the surrounding tissues, becomes
hermetically sealed. It might also be supposed that the distal end of
the ligatured stalk would slough and expose the woman to septic
peritonitis. But such sloughing rarely happens, and for the following
reasons: From shrinkage of the stump the constriction is lessened, and
the capillary circulation is re-established; or the peritoneal surfaces
on each side of the narrow and deep gutter made by the fine silk will
bulge over and touch one another. Adhesion then takes place between the
two, and the blood-vessels which shoot over from the proximal or
uterine side of the ligatured stump will carry life into the distal
end; or lymph exuded by the irritation of the ligature will throw a
living bridge across the gutter in the stalk; or, what is the least
desirable, the raw end of a long stalk glues itself to any peritoneal
surface with which it may come in contact. I say least desirable,
because sometimes such an adhesion makes a kink in the bowel, and may
so constrict it as to give rise to fatal obstruction. To prevent this
accident, Thornton stitches with gut the raw end of the stump to the
broad ligament, to which it adheres; while Bantock catches it up out of
harm's way by including it in the lowest abdominal suture, which, being
of silkworm gut, can be left in for a long time. If the stump be short,
it stands upright, and does not then need this treatment.

If the stalk be a thick one, it is transfixed by a blunt needle
threaded with a double ligature, and is tied on either side, each half
by itself, and then the whole is further tied by the free ends of one
of the ligatures, or the Staffordshire knot, recommended by Tait, may
be used. If it be a broad one, it is tied in three or more sections by
cobbler's stitches. In thick or in broad stalks it is a good plan to
catch the stalk in Dawson's clamp, which compresses it circularly, and
to transfix and tie it in the furrow made by the clamp. This lessens
the risk of secondary hemorrhage, which is usually caused either by the
slipping off of the ligature or by its loosening through
tissue-shrinkage. When this clamp is used the pedicle need not be tied
until the wound is ready to be closed. The stalk must be cut off at a
distance from the ligature of not less than three-fourths of an inch,
so as to leave a button of tissue sufficiently large to prevent the
loops from slipping off. In short and broad stalks the outer or broad
ligament portion, which is thin and membranous and sustains most of the
tension strain, is liable to slip out of its ligature and cause a fatal
hemorrhage. To avoid this accident the ends of the corresponding
ligature may, before being tied, be repassed in opposite directions
through the stalk very near its margin to form the cobbler's stitch.
Another way is to pass a fine silk thread through the thin portion of
the stalk about one-third of an inch from its edge, and tie it. In the
notch thus made, and below the knot, is laid and tied the outer
ligature.

In anæmic cases Thornton ties the arterial side of the pedicle first,
but in young and vigorous women he ties the venous side first, so as to
{328} deplete the woman by gorging the tumor with blood. While cutting
off the cysts the abdominal cavity must be so protected by sponges that
not a drop of blood shall fall into it. A dilated oviduct in the
pedicle tends to suppurate; hence in such a case the ligature should be
applied as close to the womb as possible, so as to get below the
expanded portion. Before the cyst is cut away the pedicle should be
seized on one side by a pressure-forceps, and kept more or less in
sight until the wound is ready to be closed up. This will also prevent
the ligatures from being rubbed off by the sponges while the abdominal
cavity is being cleansed.

Sometimes the cyst has no stalk, but lies between two folds of the
broad ligament, or else it is bound to the bladder, womb, and the
pelvic tissues by intimate adhesions which cannot be safely severed.
Formerly, under such circumstances the abdominal wound was hastily
closed up and the case abandoned. Now, thanks to Miner of Buffalo, New
York, we can fall back on enucleation, and need rarely be foiled.[53]
This operation is performed by slitting open the peritoneal capsule of
the sac at points close to its attachments, by introducing one finger
or more into the opening, and by stripping off this serous and vascular
envelope up to where the vessels enter the cyst-wall and become
capillary. The artificial stalk thus made is to be treated precisely
like a natural one--that is to say, by clamp, ligature, and cautery,
or, if it does not bleed, by nothing whatever. This operation I have
repeatedly performed, but it is seldom easy, and is always anxious
work. Should the cyst be so wholly adherent to the viscera as not to be
even enucleated, an incision is made into it. It is then emptied,
thoroughly cleansed, and the child-cysts are also crushed by the hand.
The edges of the opening thus made in the sac are now included in the
stitches of the abdominal wound, but the latter is kept open either by
a large cloth tent at the lower angle or by two glass drainage-tubes,
one at each angle running down into the sac. Sometimes it may be
needful to tie the adherent portion in sections and to cut the free
portion away. A drainage-tube must then be inserted at the lower angle
of the wound. This expedient has the sanction of Atlee and Olshausen,
who have reported successful cases thus treated.[54] My own practice in
such cases would be, after breaking up the child-cysts, to gather
together the free portion of the cyst and bring it out at the lower
angle of the wound. A short nickel-plated steel drainage-tube of large
bore is inserted, the sac firmly clamped to it by a small wire
écraseur, and the redundant portion cut away. Into this metal tube is
passed a glass drainage-tube long enough to touch the lowest portion of
the sac.

[Footnote 53: _Transactions International Med. Congress_, 1876, p.
801.]

[Footnote 54: _Monthly Abstract_, July, 1877, p. 334.]

In such cases, when feasible, I think it would also be well to adopt
Freund's plan of tying the pedicle and severing it, in order to lessen
the blood-supply to the cyst.[55]

[Footnote 55: _Boston Med. and Surg. Journal_, Aug. 24, 1876, p. 219.]

The sac having been removed, the other ovary should be examined, and,
if diseased, be tied and cut off. From the sundered bands of adhesion
more or less bleeding has been taking place, which must now be attended
to. It can usually be stopped by pressure with a sponge or with a
finger, or with sponges wrung out of very hot carbolated water. For
single vessels torsion will usually succeed, but if it does not, fine
{329} carbolated silk or gut ligatures must be used; and it is
wonderful how many can be applied without materially compromising the
safety of the woman. I once tied over thirty vessels in a lady
sixty-eight years of age, who recovered without any symptoms of
peritonitis. The free ends of the ligatures should always be cut off
close to the knot. Stubborn oozing surfaces can very generally be
stanched by searing them with Paquelin's thermo-cautery, or by passing
a needle armed with fine silk under and ligating any vessel that may be
detected leading up to the seat of the oozing. In some cases nothing
answers so well as the pressure of the finger moistened with alcohol or
with a drop or two of the ferric subsulphate or of the tincture of
iodine. In oozing from inaccessible points in the pelvis a sponge
dipped in the undiluted solution of iodine or in Monsel's solution of
iron, and afterward well squeezed out, may be pressed firmly down for a
few moments into Douglas's pouch. When the oozing comes from a large
surface of the abdominal wall, it may finally be arrested by the
doubling of the raw surface on itself. The fold thus made is then
secured either by a long acupressure needle or by cobbler's stitches
passed through from skin to skin. Forty-eight hours after, this needle
or these stitches should be removed. For this ingenious device we are
indebted to the late Kimball of Lowell, Mass. Should all these measures
fail, put in a drainage-tube, close up the abdomen in the manner about
to be described, and temporarily lay over the dressings some heavy
weights, such as bags of sand or of shot. This plan I have not been
obliged to resort to, but it has the sanction of Nussbaum, who uses two
large bricks, and it is worthy of being borne in mind.[56] In my hands
an elastic flannel binder pinned very tightly over a large roll of
cotton wool has made pressure enough to check the hemorrhage.

[Footnote 56: _British Med. Journal_, Oct. 26, 1878, p. 617.]

The toilet of the peritoneum next comes in order. By this is meant the
peeling off from the peritoneum of plastic deposits, the removal of the
sponges packed into its cavity, and the careful cleansing away of all
fluids and of every blood-clot. In the search for all such foreign
bodies, or, indeed, for obscure oozing-points, the reflector of the
ophthalmoscope or Colin's illuminating lamp will give much aid.
Douglas's pouch and the peritoneal fold between the bladder and the
womb are favorite localities for the collection of blood or of serum,
and should therefore be thoroughly mopped out by small sponges on
holders, otherwise peritonitis or septicæmia may result, which are the
two great factors of death in unsuccessful cases. When this has been
thoroughly done, a clean sponge is placed in Douglas's pouch, another
in the sulcus between the bladder and the womb, and a third, a large
and broad flat one, is laid over the intestines under the wound to
catch the blood that may drop from the needle-tracks. Each needle is
passed from within outward a quarter of an inch away from the
peritoneal edge of the wound, and is made to emerge at the same
distance from its cutaneous edge. If the recti muscles are included in
the sutures, there is said to be a liability to the formation of
abscesses in the suture-tracks. Hence almost every ovariotomist advises
that the peritoneum and skin should be pinched together, and that the
needle should be passed through them alone without perforating the
muscles. Yet I believe that from a too close observance of this rule
come many cases of hernia in the track of the wound, and that were the
recti muscles {330} more closely coaptated they would not recede from
one another and thus aid in the formation of a rupture. My own rule is
to include these muscles in the suture wherever they are exposed to
view. The sutures should lie about one-third of an inch apart. The
needles should be lance-pointed and held by a needle-holder. In fat
women it is not always easy to get the two surfaces of the wound in
exact coaptation; consequently, more or less puckering and eversion of
the edges may take place. To avoid this, it will be well, before
passing the needles, to bring the edges of the wound together, and make
with a fountain-pen transverse lines at proper intervals across the
incision as landmarks for the introduction of the sutures. These
cross-lines are also of advantage whenever the abdominal walls are too
tense for accurate coaptation, as after öophorectomy, after the removal
of a small abdominal tumor, or after an exploratory incision for a
solid tumor which cannot be removed. In these cases, indeed, it would
be well to make the cross-lines the first step of the operation, before
even the abdominal incision has been made.

The reasons why the needle is made to enter the peritoneum first are,
that the stitches are lodged more evenly on that vulnerable surface,
and with less injury to it, such as the stripping of it off from the
abdominal wall; and, further, that a stray knuckle of bowel is not so
likely to be wounded by the upward as by the downward thrust of the
needle. The object of including the peritoneum in the stitches is to
bring in contact two long and narrow ribbon-like surfaces of a
membrane, which will quickly unite--so quickly as to forestall any
formation of pus in the overlying tissues, and to bar the entrance of
this or other septic fluids from the wound in the abdominal wall.
Another advantage is, that this inclusion of the peritoneum by
presenting an uninterrupted surface of parietal peritoneum to the
visceral peritoneum prevents the adhesion of the omentum and of the
intestines to the internal lips of the wound, which otherwise takes
place.

When all the sutures have been passed, their ends on one side are
loosely twisted together into a single strand, which is securely caught
by a pressure-forceps. The same thing is done with the ends on the
other side. A finger of each hand is now passed down into the centre of
the wound, and the middle portion of all the upper sutures and of all
the lower ones are separated from one another by being drawn to
opposite angles of the wound. This permits the removal of the sponges,
and, if they are stained with blood, the further search for some
overlooked bleeding vessel. To guard against twisting of their
convolutions, the bowels, still further disturbed by these final
manipulations, are now restored to their natural position, and the
omentum, after being again examined for some bleeding vessel, is gently
spread out over them. The forceps and sponges are then counted to see
that not one has been left in the abdominal cavity. The importance of
this cannot be too strongly impressed upon the operator, for
distinguished ovariotomists have overlooked these articles, and have
left them behind in the abdominal cavity--a sponge and a bulldog
forceps in one case.[57] Tait has heard of ten such cases.[58] It is
indeed sometimes no easy task to find a missing sponge when lost in the
{331} convolutions of the intestines. The sponges therefore should not
be much smaller than the fist.

[Footnote 57: _Lancet_, May 26, 1877, p. 783; _British Med. Journ._,
Jan. 28, 1882, p. 115; _Ibid._, Dec. 25, 1880; also, _Ovarian and
Uterine Tumors_, by Spencer Wells, London ed., p. 336.]

[Footnote 58: _Diseases of the Ovaries_, by Lawson Tait, 4th ed., p.
261.]

Before closing the wound the operator removes the pressure-forceps and
catches in one hand all the ends of the sutures on his side, his
assistant does the same thing on the other side, and the edges of the
wound are brought together by a firm pressure, which also chases the
air out of the abdominal cavity. To stop the bleeding from the
needle-tracks as soon as possible, each suture is rapidly tied and by
the surgeon's knot. When the whole wound has been closed, and not till
then, the ends of all the sutures are gathered together in one hand,
and they are cut off about two inches from the knot by one snip of the
scissors. This saves precious time, which would be lost were each
suture by itself to be cut after being tied. At gaping points of the
wound intermediate superficial stitches should be put in. In fat women
several such stitches will usually be needed.

Dressing of the Wound.--After the wound has been closed the rubber
apron is removed and the abdomen cleansed and dried. The wound may now
be dressed according to Lister's plan. This consists, first, of a
narrow protective of prepared oiled silk, moistened by a 1:40 solution
of carbolic acid; next, of one broad layer of antiseptic gauze wetted
with the same solution; and over this eight folds more of the dry
gauze, having a piece of mackintosh interposed between the seventh and
the eighth layer. The lamp is now blown out, and the spray-jet being
directed away from the abdomen, the dressing is secured by an elastic
flannel binder, the rucking of which can be prevented by tapes pinned
to it around each thigh. Most of the leading ovariotomists, however,
employ simpler dressings, which have been found equally antiseptic.
Wells covers the wound with a dry dressing of thymol cotton, kept in
place by long strips of adhesive plaster, going two-thirds of the way
around the body. Over all is pinned a flannel binder. The thymol cotton
is prepared by steeping absorbent cotton wool in a solution of one part
of thymol to one thousand of water, and drying it. Keith dresses the
wound with gauze wrung out of a 1:8 glycerole of carbolic acid. On this
are laid several layers of dry carbolated gauze, next some cotton wool,
and over all a flannel binder. Thornton uses Lister's gauze and the
mackintosh, but without the protective. This dressing is secured by
adhesive straps. On these are laid several folded napkins, and over all
a flannel binder is pinned very tightly. Bantock resorts to dry thymol
gauze. Tait uses nothing but ordinary absorbent cotton. Salicylated
cotton I have found to answer so well that for years I used nothing
else. It is made by steeping two parts of absorbent cotton in a
solution of one part of salicylic acid to two of commercial ether, and
afterward drying the cotton by a low heat. Lately I have been resorting
to Keith's dressing, but it probably possesses no greater advantages.

The flannel binder having been pinned on, the night-dress is pulled
down and the patient put to bed. The opium suppository containing one
grain of the watery extract is slipped into the rectum, the six bottles
of hot water are applied to different portions of the body, and she is
covered with warm blankets. The tables, tubs, and other articles used
in the operation are now removed, the room is darkened, and she is left
alone with her nurse, who has positive instructions to admit no one
besides the physician.

{332} Drainage.--When blood in small quantities is effused into the
peritoneal cavity, coagulation usually takes place, the serum is then
absorbed, the clot becomes organized, and no harm results. But when
blood in large quantities collects in Douglas's pouch, it may behave as
a foreign body and cause mischief. When, also, blood is mixed with
serum, coagulation is not so likely to take place; the blood-corpuscles
then are liable to break down, the fluid to become putrid, and
septicæmia to set in. For these reasons the removal of these fluids by
different modes of drainage has long been put in practice. The best
mode is by a glass tube passed down to the bottom of Douglas's pouch
through the abdominal wound, and not, as has been recommended, through
a special opening made for it in the roof of the vagina. Drainage is at
present very rarely resorted to by those operators who use strict
antiseptic precautions, for they contend that septic changes in the
blood do not then take place. Wells and Thornton have virtually given
it up, while Keith, Tait, and Bantock, who have abandoned Listerism,
are warm advocates of it. This question is a very important one,
because a drainage-tube tends to the formation of a ventral hernia,
and, being a foreign body, is in itself hurtful, and therefore should
not be resorted to unless it will do more good than harm.

After a careful consideration of the subject I am forced from
experience to believe that between the two extremes there lies a golden
mean, and that drainage, even when the spray is used, is needed under
the following conditions:

  (_a_) Whenever a purulent or a colloid cyst has burst, and its
          contents have escaped into the cavity of the abdomen, either
          during the operation or some days beforehand.

  (_b_) Whenever the contents of the cyst are putrid or purulent, and
          septic symptoms or those of peritonitis are present.

  (_c_) Whenever a large amount of ascitic fluid is found in the
          abdominal cavity.

  (_d_) Whenever four drachms or more of pure blood, or especially of a
          sero-sanguinolent fluid, can be squeezed out of the sponge in
          Douglas's pouch when removed just before the closure of the
          wound.

  (_e_) Whenever the operator is in doubt what to do.

Should it be deemed needful for some of the above reasons to make use
of drainage, a glass tube, open at both ends and about six inches in
length, is passed through the salicylated cotton or other dressing,
then between the two lowest stitches, down to the bottom of Douglas's
pouch. A wire suture is first introduced between these sutures and left
untwisted, its object being to close firmly the opening left by the
removal of the tube and to hasten its union. Otherwise, a weak cicatrix
results, tending to the subsequent formation of hernia. Keith's
drainage-tube of three sizes is the one that I prefer. Its lower end is
perforated with holes, and its upper end has a shoulder which keeps it
from slipping into the abdominal cavity, and also enables it to hold a
piece of thin rubber sheeting about eighteen inches square. In the
centre of this a small circular hole is made, which, by stretching, is
sprung over the tube. The mouth of the tube is covered by a cup-shaped
sponge wrung out of a 5 per cent. solution of carbolic acid, and over
this the sheeting is folded four times. The flannel binder may either
be pinned over the drainage-tube, or else {333} it may be slit at the
site of the tube and passed on each side of it, leaving the sponge and
rubber sheeting outside of the dressing. They are then best held in
place by a narrow strip of flannel, so as to permit inspection without
interfering with the main dressing. Several times a day the sponge is
removed, squeezed out, cleansed in a 5 per cent. solution of carbolic
acid, and replaced. This in a hospital had better be done under the
spray. Bloody serum collecting in this tube is sucked out either by a
fine rubber tube attached to a syringe, or else by the long nozzle
itself of the ordinary uterine syringe.

To prevent injurious pressure on the rectum, the tube must be lifted up
occasionally about half an inch, and allowed to slip back of its own
accord. It can be removed whenever the discharge has been reduced to
not more than one or two drachms, and this usually happens within the
first forty-eight hours. After its removal the opening left in the
wound is closed by twisting the free ends of the wire suture placed
there for this purpose.

AFTER-TREATMENT.--The subsequent treatment needs the greatest
attention. The first care is to establish reaction. This is best done
by stimulants, such as brandy and whiskey given in iced soda-water.
Enemata of beef-tea and brandy or of milk and brandy will also be of
advantage, while artificial heat is kept up. For the vomiting, which
comes partly from the anæsthetic and partly from shock, repeated deep
inspirations should be tried. They help by getting the blood rid of the
anæsthetic as soon as possible. Chloral may also be given, or small
lumps of ice may be swallowed. Sips of very hot water, or a
tablespoonful every hour of a mixture containing equal parts of
lime-water and of cinnamon-water, may also do good. A hypodermic of
morphia will often allay vomiting, and I have seen it yield to small
doses of atropia, and also to two grains of pure pepsin given every two
hours in a tablespoonful of raw-beef juice. Twenty drops of ether given
by the mouth will sometimes relieve it, and so also will a few drops of
chloroform confined by a watch-glass over the pit of the stomach. In
some cases I have tried, with the best results, the following
effervescent mixture, recommended by Chèron:[59]

  Rx. Potassii bicarb.     |
      Potassii bromidi. aa | gr. xxxij;
      Aquæ,                  fluidounce ij.  M.

  Rx. Acidi citrici, drachm j;
      Syrupi,        fluidounce j;
      Aquæ,          fluidounce iv.  M.

A dessertspoonful of the former is added to a tablespoonful of the
latter, and given every hour. For vomiting, especially of the bilious
variety, Lawson Tait recommends Monson's pepsin wine, given every ten
minutes in drachm doses with a little ice-water.

[Footnote 59: _Archives de Tocologie_, Février, 1883, p. 122.]

Flatus is another annoying symptom, which, however, can very generally
be dispelled by turning the patient over on her side and inserting a
flexible catheter high up in the rectum. If this fails to relieve it,
enemata of turpentine may be tried, or five-drop doses of the tincture
of nux vomica may be given every two hours. Should the abdomen become
painfully bloated, the binder must be loosened and the adhesive straps
{334} nicked in several places. The painful tension on the stitches can
be relieved by drawing the knees up and supporting them over a pillow
doubled on itself. Should the flatus not yield, and symptoms of
obstruction set in, the bowels must be opened at all hazards. Castor
oil and Epsom salts are good cathartics for this purpose. When vomiting
accompanies obstruction, calomel answers best, because it is not so
liable to be rejected.

For the first thirty-six to forty-eight hours after the operation
nothing whatever should be given to the patient excepting cracked ice,
sips of hot tea or of barley-water, and an occasional teaspoonful of
old whiskey. After that time tablespoonful doses of milk, of beef-tea,
of thin oatmeal gruel, or of barley-water can be given every hour or
two. The diet may then be cautiously increased, and especially after
wind begins to escape from the rectum, the patient being enjoined not
to hold it back from motives of delicacy. If the condition of the
patient is such as to demand more nourishment, it had better be taken
by the rectum. For a week the urine should be drawn off by the nurse,
and the bowels kept quiet by a morning and an evening suppository. No
other anodyne need be given unless called for by pain, wakefulness, or
restlessness. Should the body-heat indicate a temperature of 101° or
over, a bladder filled with broken ice, or, what is far better, a
rubber ice-cap, should be kept on the head of the patient as long as it
feels comfortable and does not chill her. If the temperature does not
fall, and peritonitis or other septic symptoms set in, ice should also
be applied to the pit of the stomach. Quinia and morphia must then be
given in very large doses, preferably by the rectum, together with ten
drops of the tincture of digitalis every hour until the pulse-rate is
lessened and the temperature falls.

When a full week has elapsed the bowels should be opened; and, as this
is a matter of importance, and is occasionally attended with symptoms
of obstruction and with a good deal of constitutional disturbance, a
few words will not come amiss. If the hardened feces can be softened
down and dislodged by enemata, this is perhaps the best plan, clysters
of ox-gall and water or of glycerin and water being the most efficient.
But in my experience enemata have so often failed that I rarely resort
to them in the first instance. If the woman's stomach is not irritable,
I prefer to give her an ounce of castor oil. This is disguised in the
compound syrup of sarsaparilla or in some other suitable vehicle, as
warm milk, and is brought to her without any previous warning early on
the morning of the eighth day. Should it be deemed unwise to try the
oil, two Lady Webster pills and two compound cathartic pills can be
given at bedtime of the seventh day, or a pill containing three grains
of the compound extract of colocynth with one grain of the extract of
hyoscyamus may be swallowed every four hours. The compound licorice
powder of the German Pharmacopoeia, to which has been added potassium
bitartrate, also answers well, provided the patient's stomach will bear
teaspoonful doses every four hours. Should these remedies fail to act,
they must be supplemented by enemata.

Fatal obstruction of the bowels from matting or from constricting bands
of organized lymph has been frequently reported. Thus far, I have met
with one fatal case, which, however, passed out of my hands after the
operation. But occasionally I see cases of obstinate {335} constipation
which give me great uneasiness and put me to my wits' ends. In one
case, after the failure of other remedies the obstruction was overcome
by broken doses of calomel combined with sodium bicarbonate, and by the
distension of the lower bowel with very large enemata slowly given.
Another desperate case yielded to repeated doses of tincture of
belladonna. A third case, complicated by obstinate vomiting, was saved
by ten grains of calomel given every two hours until the bowels were
moved. Seventy grains were thus administered before the desired effect
was attained, yet salivation did not occur.

When symptoms of obstruction once present themselves, they are likely
to recur. The contents of the bowel should therefore be kept fluid, and
for this purpose I know nothing better than the German compound
licorice powder, given in teaspoonful doses at bedtime.

Suppression of urine sometimes follows ovariotomy, and in cases of
diseased kidney is an alarming complication for this condition. For
this symptom digitalis and the acetate of potassium should be given.
Thornton treats it by baring the arms and packing them in towels which
are kept wet with ice-water.

Tetanus may destroy the life of a patient while convalescing from the
operation of ovariotomy. J. M. Bennett reports such a case.[60] The
symptoms first showed themselves on the sixteenth day, and the woman
died two days later. Chloral in drachm doses, administered by the bowel
in the yolk of an egg, is perhaps the only remedy from which any good
can be expected.

[Footnote 60: _Lancet_, Dec. 3, 1881.]

Occasionally, a few days after the operation, without any septic
symptoms whatever or without any marked rise in the temperature, the
parotid glands grow tender, swell up, and run through a course
precisely like mumps, ending in resolution. This complication has been
met with so frequently by myself and others that it cannot be a mere
coincidence, but must be due to a reverse sympathy between the ovaries
and these glands. It does not appear to increase the risk of the
patient, for recovery took place in all the reported cases, of which
three occurred in my own practice.[61] Parotid bubo may also take place
after ovariotomy, but this sign of blood-poisoning, being a general
one, happens as well after other grave surgical operations and during
the course of specific fevers. Yet from the sympathetic relation
between the parotid glands and the sexual organs it seems to occur more
frequently in the septicæmia following ovariotomy.

[Footnote 61: Wm. Goodell, _Transactions of American Gynæcological
Society_, 1885.]

Acute mania sometimes follows ovariotomy, especially when both ovaries
have been removed. The attack is usually temporary, but it sometimes
ends in insanity, and even in death, as in one of my own patients.
Keith, Thornton, Tait, and other leading ovariotomists report analogous
cases.[62]

[Footnote 62: _The British Medical Journal_, March 21, 1885, p. 597.]

SURGICAL TREATMENT.--The dressings, being antiseptic, need not, as a
rule, be removed until the day following that on which the bowels are
moved. Every other stitch may then be removed, and especially all that
are loose or are cutting the tissues. The wound is then washed with a
2.5 per cent. solution of carbolic acid, and dressed anew with
salicylated {336} cotton. I usually find the first dressing so sweet
that I am able to reapply the unsoiled portion of it for a second
dressing. A clean binder is now pinned on and the woman's clothing
changed. Three or four days later all the stitches should be removed,
the wound secured by narrow adhesive strips, and dressed as before. For
fear of a weak cicatrix and the formation of a hernia at the site of
the wound, the patient should not get out of bed until fully three
weeks have elapsed, and should for as many months wear some kind of
close-fitting gored binder or abdominal supporter.

If, before the week is over, the dressings become soiled or give out a
bad odor, they should be at once renewed. They should also be removed
whenever a high temperature, without being accompanied by tympanites,
leads to the suspicion of cutaneous abscesses.

THE ACCIDENTS AND COMPLICATIONS OF OVARIOTOMY.--When by the breaking up
of adhesions to it the liver is wounded, the bleeding surface can
usually be stanched, as Koeberle has shown, by the ferric subsulphate
applied to the raw surface by the finger. If this fails the actual
cautery at a dull heat should be used.

If, unfortunately, an adherent portion of the bowel is torn open, the
wound should be carefully closed with very fine silk by the continuous
suture. The sutured portion is then fastened to the lower angle of the
abdominal wound as a safeguard in case of the subsequent formation of
stercoral fistula.[63] Should the intestine be injured to any extent,
the wound must be closed by two sets of fine silk sutures, the first
set uniting the mucous edges of the wound by the continuous suture, the
other set uniting one serous coat to the other at a line about one
quarter of an inch distant from the wound. An ordinary cambric needle
with fine sewing-silk will answer admirably for this purpose. In small
wounds one continuous suture, carried through all the coats but the
mucous, will suffice. A mere puncture can be closed by hooking it up
and surrounding it by a single fine ligature.

[Footnote 63: "Discussion on a Paper by Garrigues," _Am. Gynæcol. Soc.
Trans._, 1881.]

Wounds of the bladder have frequently happened, but they are by no
means necessarily fatal.[64] These accidents are liable to occur when
the bladder, being adherent to the cyst and carried upward by it, lies
directly under the line of incision, or the bladder may be torn open
while adhesions to it are being severed. The wound should at once be
grasped by a pressure-forceps, the bladder emptied by the catheter, and
the operation proceeded with. When the operation has been completed the
wound in the bladder is attended to, and in one of the following ways:
Either the vesical wound is brought up within the lips of the abdominal
incision, and is closed by being included in the abdominal stitches, or
it is closed by the continuous or Glover's suture, without including
the mucous membrane in the stitches. A self-retaining catheter, such as
the Skene-Goodman, must then be kept in the bladder for at least a
week.

[Footnote 64: Eustache, _Archives de Tocologie_, April and May, 1880,
pp. 193, 277; _Boston Med. and Surg. Journal_, Feb. 16, 1882, p. 153;
_British Med. Journ._, Jan. 28, 1882, p. 115; _Am. Journ. Med. Sci._,
Jan., 1883, p. 123.]

One of the ureters will sometimes be torn across while pelvic adhesions
are being broken up. This accident is most likely to happen during the
enucleation of a cyst growing downward because enveloped in the folds
{337} of the broad ligament. It is almost always fatal, and is usually
not discovered during the life of the patient, and, I am disposed to
think, not often discovered after her death. Sometimes, however, urine
will ooze out of the abdominal wound, and in rare cases the patient has
recovered with a urinary fistula. In such a case Simon[65] successfully
removed the corresponding kidney; Nussbaum[66] constructed an
artificial ureter leading from the fistula to the bladder; and
Tauffer[67] inserted the upper end of the divided ureter into the
bladder by an artificial opening. It, however, failed to unite, and he
later made an artificial ureter.

[Footnote 65: _Annales de Gynécologie_, June, 1877.]

[Footnote 66: _Edinburgh Medical Journal_, July, 1876, p. 1.]

[Footnote 67: _Archives de Tocologie_, Avril, 1880, p. 201.]

When an umbilical or a ventral hernia of moderate size is present at
the time of the operation, efforts should be made for its radical cure.
This is done by cutting out the thinned-out sac by two incisions
meeting below and above, and by bringing together the thick edges of
the abdominal wall in the final closure of the wound.

In cases of ascites complicating ovariotomy the ascitic fluid should
not be wholly removed until the cyst has been cut off and the wound is
ready to be closed. By this means any blood oozing from broken
adhesions, or any fluid escaping from the cyst into the abdominal
cavity, being diluted, is less likely to irritate the peritoneum, the
cavity of which can also be more readily cleansed.

When a patient seems in danger of dying on the table from shock or from
exhaustion the anæsthetic should be withheld while hypodermic
injections of ether and enemata of brandy are given. Warmth should also
be applied to the body by bottles of hot water, or, what is better, by
rubber bags of the same. Theoretically, atropia administered
subcutaneously would be the proper remedy, but I have not yet tested
it. In all cases of ovariotomy, especially if prolonged, the woman
should not be kept profoundly under the influence of the anæsthetic for
any length of time, but should be allowed from time to time to come to
at least enough to make her flinch or move about. This caution should
especially be observed in very feeble patients and in those with very
large cysts.


The Removal of Both Ovaries.

Whenever both ovaries are diseased there can be no question about the
extirpation. But when only one has undergone cystic or other
degeneration the question of the removal of the sound one may come up.
There always is a tendency to the subsequent degeneration of the sound
ovary after the diseased one has been removed. More especially is this
tendency observed in sterile women and in those with malignant
affections of the ovary. Many women, therefore, whose lives should have
been imperilled but once, have been compelled to face the dangers of a
second operation. In view of these facts, it seems to me wise to remove
the sound ovary in all cases of sterility, in every case of malignant
degeneration of one ovary, and in all women who have either passed the
climacteric or are approaching it, provided its removal is not attended
with great additional risk. Double extirpation should also be performed
whenever the womb {338} contains a fibroid tumor or whenever it seems
desirable to hasten on the climacteric. In these convictions I am
further strengthened by the disappointment often expressed to me by my
patients that one ovary had been left behind, and by their great fear
afterward lest the remaining organ should also become diseased. On the
other hand, in women who are in the prime of their menstrual life the
sound ovary should be left untouched, unless there exist grave reasons
for its removal.




{339}

DISEASES OF THE URINARY ORGANS IN WOMEN.

BY ALEXANDER J. C. SKENE, M.D.


ORGANIC DISEASES OF THE BLADDER.


Hyperæmia.

This is an acute congestion of the mucous membrane due to a disturbance
in the balance of the circulation. It may be common to both bladder and
urethra, or limited to either; may terminate within a short period of
time (a few hours), or it may go on and end in hemorrhage or
inflammation. If the mucous membrane is seen with the endoscope, it
appears of a bright-red color; the blood-vessels are distended, more
prominent, and apparently more numerous. The arteries are the first to
be affected. If the cause is transient, this is all that is seen, the
membrane returning to its usual color. When the congestion is of a
higher grade, rupture of some of the vessels occurs either on the free
surface or beneath the epithelium. The venous side of the circulation
now becomes more prominent. In a few cases the above order may be
reversed, the veins being the first congested, as in the case of a
sudden interference with the portal circulation.

SYMPTOMS.--The attack occurs suddenly. Frequent but painless urination
is the most prominent feature. There is a sense of heat and heaviness
in the bladder, aggravated by standing. When the urethra is involved
the patient complains of scalding during urination. The pulse and
temperature are practically normal. The composition of the urine is but
little changed; there may be excess of mucus and a few
blood-corpuscles.

DIAGNOSIS.--This has to be made by exclusion. It is apt to be
confounded with a neurosis of the bladder or a displacement.

ETIOLOGY.--The most frequent cause is exposure to cold, especially
during menstruation; over-taxation in walking or using the
sewing-machine; excessive venereal indulgence; disorders of the portal
circulation; and the use of improper articles of food.

TREATMENT.--Every means should be employed to equalize the circulation.
The most important element is rest in the recumbent position.
Diaphoretics and warm applications to the feet and epigastrium, and, as
a rule, a saline laxative. Where there is frequent urination and
vesical tenesmus and pain, Dover's powder and camphor should be given,
or a suppository of morphia and belladonna by the vagina.


{340} Hemorrhage.

This is a symptom rather than a disease itself. It is usually due to
acute congestion or ulceration occurring in advanced inflammations, new
growths, or the lacerations caused by foreign bodies and instruments.
Hemorrhoids of the bladder due to obstructed circulation is not
infrequently the source of the bleeding. The amount of blood transuded
varies very greatly, though it is seldom so great as to prostrate the
patient. In all cases when it is considerable it is of great importance
to localize the bleeding point. The urethra can be excluded if there is
no bleeding between the acts of micturition. The differential diagnosis
between hemorrhage from the bladder or kidney is less easy. The old
rule, that the blood and urine are more intimately mixed in renal
hemorrhage than in cystic, is of little service. Sir Henry Thompson's
method of detecting the source of pus in the urine may be employed in
cases of hemorrhage. He introduces a soft catheter, and then washes out
the bladder gently with warm water; if after a time the water comes out
clear, the inference is that the bleeding point is higher up. To make
sure, he corks the catheter until a drachm of urine has collected; if
this is bloody, the diagnosis of its being extra-cystic is tolerably
certain. With the endoscope it is occasionally possible, and always
desirable, to locate the bleeding point.

The symptoms in hemorrhage from the bladder, besides the actual
appearance of blood in the urine, are much the same as those in
hyperæmia. Other symptoms liable to arise are from blood-clots forming
and either being passed by the urethra, causing its distension and
impeding micturition, or else such clots may be retained and accumulate
in the bladder, giving rise to still greater functional disturbance,
until they are either broken into small pieces by the surgeon and
extracted, or else by the slower agency of decomposition they break
down and come away.

TREATMENT.--The first thing is to obtain the advantages, both
mechanical and physiological, of the recumbent position. A large number
of hæmostatics have been used--tannic and gallic acids, ergot, and
aromatic sulphuric acid. These are doubtless of some value, but we
prefer giving opium in sufficient doses to allay the desire of too
frequent micturition, and at the same time to render the urine more
bland by alkaline diluent drinks. When the bleeding points can be
discovered with the endoscope, they may be touched with caustic acid,
nitrate of silver, or persulphate of iron. But such applications must
be made with the greatest care, lest inflammation and ulceration
result. Ice in the vagina and at the hypogastrium may be tried when
other means fail. When the hemorrhage is hemorrhoidal, due to impeded
venous return owing to pressure of the gravid uterus, the treatment
will have to be purely palliative in the mean time, as the pathological
condition of the veins usually rights itself after delivery. When a
large blood-clot forms in the bladder, experience has abundantly shown
that it is better not to meddle with it, but to let it break down
itself and come away, the patient being kept easy--if necessary by
opium and alkaline diluents.


{341} Cystitis.

Inflammation may be limited to the bladder alone, in which case we call
it cystitis, or to the urethra alone, when it is termed urethritis.
But, practically, the pathological processes and the causes of cystitis
and urethritis are so closely allied that it will be convenient in our
limited space to consider them together. Like inflammation of other
mucous membranes, various forms or degrees of cystitis and urethritis
are described: these classifications are useful clinically, but it
should not be forgotten that the pathological conditions presented are
only different stages of the same process. Inflammations of the bladder
are divided according to the cause of the disease and the character of
structural lesions into--the acute, including the catarrhal and the
suppurative; and the chronic, including the ulcerative, interstitial
(and peri-cystitis); and the specific, embracing the gangrenous,
croupous or diphtheritic, and gonorrhoeal, in which the inflammation is
the result of a special poison.

ETIOLOGY.--The causes of cystitis may be classed under four heads: (1)
Direct injuries, such as blows in the vesical region, falls, fracture
of the pelvic bones, violent copulation, sudden uterine displacements
causing pressure, foreign bodies, rough catheterization,
over-distension from retention of urine, and, above all, contusions and
injuries during labor. (2) Abnormal urine, from improper food or
malnutrition and certain irritating drugs (cantharides) and irritating
deposits of urine salts. (3) Certain constitutional diseases (eruptive
fevers, gout, ague). (4) Inflammation of adjacent organs, hyperæmia due
to cold.

PATHOLOGY.--The acute forms always begin with hyperæmia, then follow
swelling, perverted or hyper-secretion, then exfoliation of epithelium,
giving rise to a roughened and denuded state of the mucous membrane,
particularly on the top of the rugæ, the products of inflammation
accumulating within the sulci, and finally the formation of pus. A
description of these, the ordinary phenomena of inflammation of mucous
membranes, it is quite unnecessary to give here, but there are one or
two modifying conditions in cystitis that are of great importance and
need consideration. The first of these is the effect which the function
of the bladder as a reservoir of urine has on the inflammation. Normal
urine is irritating to an inflamed mucous membrane, and in cystitis it
soon undergoes decomposition, becomes alkaline, and hence more
irritating. The main agent in producing this decomposition is mucus,
which is secreted abnormally both in quantity and quality. It acts
injuriously in two ways, its fixed alkali tending to neutralize the
acid of the urine, which in the early stages of cystitis is often
hyper-acid, and in promoting the decomposition of the urea and thereby
liberating the volatile carbonate of ammonia. As the urine becomes more
alkaline the precipitation of the phosphates of lime and magnesia
occurs, and the formation of the triple or ammonio-magnesian phosphate.

The irritant effect of these salts, really deposits of foreign bodies,
on the inflamed mucous membrane completes the vicious circle, the
effect now aiding the original cause.

Another most important point in the pathology of cystitis is the effect
of over-distension of the bladder. This is itself sometimes the primary
cause of the trouble, as in certain neuroses, but more frequently it is
the {342} effect of certain injuries during delivery. The mechanism of
its production is not very clearly made out. It usually follows long,
tedious deliveries, during which either the child's head or sometimes
the forceps crushes the urethra against the unyielding pubic bones,
giving rise to an acute urethritis, with swelling of the membrane and
blocking up of the canal, causing retention. The primary injury is not
done, as a rule, to the bladder in these cases, for if it were we
should find the vesical neck the seat of sloughing of the mucous
membrane; but, as a fact, this is the part (owing to its more loose
connections with the underlying connective tissue) that most frequently
escapes. This danger of over-distension is so clearly recognized that
the catheter is nearly always used both before and after delivery if
there should be retention. But a condition more apt to mislead both the
doctor and the nurse is the urine dribbling away either constantly or
intermittently. This is too often ascribed to an irritable bladder
causing frequent micturition, when it is a sign of over-distension, the
dribbling always occurring as soon as the mechanical pressure of the
urine is sufficient to overcome the resistance of the swollen parts.

We have already referred to this condition of over-distension as a
cause of inflammation; it will suffice to say that it may, if
unrelieved, produce a partial or even total slough of the mucous
membrane of the bladder; but, fortunately, this is rare.

Thus far we have spoken of the common forms of acute and subacute
cystitis; it only remains to say a word with regard to its rarer
manifestations. The inflammation may extend to the submucous coats,
becoming interstitial cystitis. Again, this may limit itself here, or
it may extend still deeper to the serous coat, in which case it is
known as peri- or epi-cystitis. Peri-cystitis is almost always a
secondary disease, arising sometimes from deep ulcerations of the inner
coats of the bladder, such as occur in chronic cystitis. More
frequently it is but a part of a pelvic peritonitis which originated
outside of the bladder itself. The final result of peri-cystitis is to
form adhesions between the bladder and the neighboring organs, and
thereby prevent distension of the bladder.

A very rare form of gangrenous inflammation has been described, but it
is more than doubtful if this ever occurs in women except as the result
of mechanical violence or pressure, already described. The specific
lesion of croupous or diphtheritic inflammation has occasionally been
diagnosticated, either from shreds of false membrane passed by the
urethra or by means of the endoscope. Gonorrhoeal inflammation of the
bladder has been less carefully observed in women than in men. Still,
it is known that this specific inflammation extends to the bladder in
some cases, but it does not differ essentially in its pathology,
history, or treatment from that arising from other causes; hence it is
unnecessary to dwell upon it here.

The pathology of chronic cystitis is characterized by ulceration and
sloughing of the tissues involved. They do not differ materially from
the same processes elsewhere, except that the salts of the urine are
apt to be deposited upon the shreds of dead tissue the products of
destructive inflammation. The hard masses thus formed are passed with
great pain. They block up the urethra, and are only expelled by extra
strong efforts which cause intense suffering.

{343} Lastly, the ulceration may extend through the bladder into the
peritoneal cavity and give rise to septic peritonitis and death, or the
perforation may take place into the cellular tissue of the roof of the
pelvis, and cause a fatal cellulitis.

SYMPTOMS.--The various forms of cystitis being but different stages and
degrees of the same disease, their symptoms may be discussed all
together. For convenience we shall consider them under three heads: (1)
Referable to the organs themselves; (2) Symptoms referable to the
neighboring organs; (3) General symptoms.

(1) In all forms of cystitis there is more or less derangement of
function, as shown by pain, tenesmus, and frequent micturition. In the
mildest form of the trouble there is a frequent desire to pass water,
which often comes with unusual force. Micturition is followed by a
desire to strain, as if the organ was not fully emptied. This sensation
may pass off in a few moments, and not arise again till the next
micturition, but in the severer cases it may last continuously. When
urethritis is also present there is the additional and characteristic
symptom of painful scalding as the urine passes over the inflamed
track.

In urethritis alone there is often a desire to urinate frequently, but
if the desire is resisted it passes off, and the patient can retain the
urine for a long time. This symptom should not be mistaken for the
tenesmus of cystitis. In the more advanced stages of the disease,
especially as ulcerative changes occur, the tenesmus becomes more
violent. The pains also are more diffused, often shooting to the
umbilical region. There is often a dull, aching pain in the perineum,
and in nearly all cases there is continuous backache, or, more
correctly, sacral pain.

The composition of the urine is of great importance. The specific
gravity in cystitis does not present any constant change, except that
in the chronic forms it is often a little below the normal. The
reaction in acute cystitis, at first, at least, is usually acid,
whereas in the chronic forms it is almost invariably alkaline. The
color at first is not particularly altered; later, unless discolored by
blood, it is a pale, dirty yellow. The odor is normal in the acute
type, unless where retention has been followed by decomposition, but in
the chronic form it is not only ammoniacal, but has a characteristic
fleshy or organic smell. The sediment in the acute varieties is mainly
light and yellowish, composed of mucus, with some pus generally; in
addition there may be blood, epithelium, and the amorphous and triple
phosphates. In the chronic forms the sediment is usually heavier and of
a darker brownish color. Flakes of pus, shreds of tissue, blood, and
epithelium in all stages of growth are more or less present, and in the
intensely alkaline conditions of the urine the pus and mucus form a
jelly-like, ropy, opaque mass.

Albumen will be found if there is pus in the urine without there being
any kidney disease. As the result of a careful analysis of a number of
cases of chronic cystitis, the amount of albumen varied from
one-sixteenth to one-fifth of the volume of urine. Microscopically, in
addition to the pus, mucus, organic shreds, phosphatic and other
crystals already spoken of, the most interesting appearances are the
various kinds of epithelium. In the advanced stages of chronic cystitis
epithelial elements of any kind are very rarely found. It is only in
the earlier stages that normal and transitional forms of vesical
epithelium are present, and again they {344} reappear on the subsidence
of the inflammation. This fact is of great importance, because the
transitional forms of bladder-epithelium are often indistinguishable
from the permanent forms of the urinary tract higher up. It is thus
often impossible to make a differential diagnosis between pyelitis and
cystitis from this symptom alone. When renal disease is superadded to
cystitis, the characteristic casts will be found and albumen will
likely be increased in amount.

(2) The symptoms accompanying cystitis in women referable to the
neighboring organs are of some importance, but they very often arise
from some coexisting disease of other pelvic organs. It is therefore
needless to give a list of all the pelvic pains coincident with
cystitis which have been enumerated in the literature of this subject.

(3) The general symptoms are of two classes, toxic and nervous. While
all agree that there is no doubt of direct blood-poisoning in cystitis,
there has been a great deal of difference of opinion as to how this is
effected. I think that there are various agencies at work in this.
First, there may be organic renal disease or sympathetic renal
hyperæmia leading to imperfect elimination. In cystitis caused by
over-distension from long retention the kidneys simultaneously take on
acute inflammation, which usually passes off when the bladder is
emptied, but it may continue and give rise to all the constitutional
symptoms of renal disease. Again, in chronic cystitis the thickening of
the bladder-walls obstructs the ureters, so that the urine is dammed
back upon the kidneys. This arrests their function, and in time leads
to organic disease with all the consequent derangements of the
nutritive and nervous systems. Secondly, absorption of the products of
decomposed urine, or of pus and other septic materials the result of
decomposing shreds of tissue, may take place.

Anæmia is another of the blood-changes which occur in chronic cystitis.
In its origin and continuance it probably is much like anæmia due to
long-continued inflammation elsewhere. The only peculiar symptom in
this connection is the appearance of urohæmatin in the urine.

With this slow deterioration and poisoning of the blood various
symptoms are developed. There is an effort made to eliminate urea by
the mucous membrane of the alimentary canal. This is manifested by
attacks of vomiting or diarrhoea. But when it does not come to these
explosions, there is apt to be lack of appetite, especially at the
morning meal, or there are perverted taste and constipation,
interrupted by occasional attacks of diarrhoea. The skin in the chronic
cases is at times sallow and clammy, and at times there is a distinct
urinous odor about the body. Various more or less marked nervous
symptoms are apt to be present. One set is characterized by the
sluggishness of the patients, an inclination to sleep, despondent
spirits, and occasionally dizziness and fainting. There can be little
doubt that these and allied symptoms are referable to cerebral anæmia,
for they are much aggravated by bromide of potassium, whilst digitalis
and out-door life improves them. A second set of nervous symptoms are
fairly attributable to blood-poisoning of one kind or another, and in
the most severe cases are often promptly relieved by diarrhoea.
Finally, a number of the irregular, wandering neuralgic pains and the
headache are due to the general depression produced by bladder-pain and
loss of sleep.

DIAGNOSIS.--Cystitis is easily made out, except in certain mild cases.
{345} Similar symptoms, especially frequent urination, occur in
prolapsus uteri, often in anteversion and in cases of pelvic adhesions
and pregnancy and abdominal tumors, and lastly in certain neuroses. In
most of these the recumbent position lessens the desire for frequent
urination much more than when cystitis is present. Again, in the
neurosis the attacks are irregular. Tenesmus is usually only present in
cystitis, and lastly the examination of the urine and exploration of
the parts should settle the question. We have spoken above of the
method of differential diagnosis of blood coming from the bladder or
the kidneys: the same method applies to localizing the source of pus.
Urethritis with fissure at the neck of the bladder simulates cystitis
in clinical history, and in the fact that pus in small quantity is
found in the urine. To differentiate, the urine examined should be
taken directly from the bladder with the catheter, when it will be
found free from the products of inflammation. In addition to this, in
some cases it will be necessary to make use of the endoscope, by which
a good view can be obtained of the whole urethra and a portion of the
mucous membrane of the bladder sufficient for diagnostic purposes.

TREATMENT.--The female bladder is so accessible, owing to the shortness
of the urethra, that it is peculiarly amenable to local treatment. This
is by no means, however, all that is required, for in all forms of
cystitis, irrespective of the cause, the urine plays a very important
part in keeping up the irritation. There are, therefore, always three
indications to be met: (1) Removal of the cause; (2) constitutional
treatment (diminishing the irritating character of the urine); (3) the
cure of the local lesion.

(1) In many cases, of course, the cause is transient. The injury is
done, and the inflammation resulting runs its course, longer or shorter
according to the modifying influence of treatment. In a smaller number
of cases, again, the cause is not removable, as in certain
constitutional diseases or permanent pelvic adhesions, tumors, and the
like. In such cases of course the treatment is but palliative, and,
while relieving the immediate symptoms, aids the organs till a certain
amount of toleration of the abnormal conditions is established. But in
a large class of cases the cause, though more or less persistent, is
removable. This includes the numerous cases of uterine displacement.
Lastly, there is a certain number of uncomplicated cases which tend to
recovery without treatment.

(2) The constitutional treatment should be first directed to reducing
the amount of work the bladder has to do. For this purpose the bowels
should be kept rather freely open, saline laxatives being the most
valuable for this purpose. The skin too should be kept healthy and
active. Next, the character of the urine should be as bland as
possible. Food and drugs which are known to cause or keep up cystitis
should be carefully avoided. Milk diet has proved successful in the
hands of George Johnson. In all cases the diet should be carefully
attended to, and should consist largely of fluid foods--milk, yolk of
eggs, soups, etc. Lean meat in small amounts and easily-digested solids
are allowable. Articles such as asparagus, alcohol, beer, and wine
generally are to be avoided. Fruits, such as lemons and oranges, are
usually grateful and at least harmless. The alkaline diluents, such as
citrate of potassium or the alkaline mineral waters (Vichy), answer an
admirable purpose. An infusion of buchu is an excellent agent, and may
be combined with nearly {346} all other drugs employed in treating
cystitis. Where pain is an urgent symptom in acute cases, it should be
relieved by hot applications and by anodynes. Dover's powder is an
excellent form in which to give opium. To relieve tenesmus vaginal
suppositories of morphia, with or without belladonna, may be given. But
in certain cases twenty-grain doses of potassium bromide every four
hours relieve pain where opium fails. Benzoic acid or benzoate of
ammonium in ten-grain doses in infusion of buchu, three times a day, is
a most valuable remedy. The usual remedies, such as balsam of Peru or
copaiba, oil of turpentine, etc., which are given in gonorrhoeal
inflammation, are very useful in the chronic catarrhal forms of
cystitis. To prevent or lessen the decomposition of the urine a vast
number of remedies have been employed, all of the astringents and most
of the antiseptics, but as a rule these remedies are much better
administered locally than constitutionally. In various acute and
transitory cases the constitutional remedies above described will be
all that is necessary, but in the greater number local treatment is
absolutely required.

(3) In local treatment the first point is not to do harm to the parts
by the use of instruments. Dirty catheters and rough catheterization so
often cause cystitis that it is easy to see that the same causes often
perpetuate the mischief. Great care, then, should be used in selecting
instruments for injecting. The ordinary metallic catheter with one or
two large openings is much more liable to wound the sensitive mucous
membrane than one with a number of small holes made either of hard or
soft rubber. It should have a stopcock or something similar at the
outer end, the better to regulate both the injections and the escape of
the solution injected. In ordinary injections only about an ounce at a
time should be in the bladder; this can be repeated four or five times,
and the injection should be as slow as possible. To meet these
indications I use a double perforated catheter made as follows: A small
tube runs from one of the bifurcations to the extreme point. This is
the supply-tube, and the catheter acts as the exhaust. The central tube
can be removed for the purpose of cleaning the instrument. A piece of
rubber tubing attaches the supply-tube to a fountain syringe, and this
completes the whole apparatus. The calibre of the supply-tube being
small and that of the exhaust large, a great quantity of fluid can pass
through the bladder without distending it. The fingers can pinch the
rubber tube and act as a stopcock to regulate the entrance and escape
of the fluid used.

An injection of borax and water is often highly beneficial, and is
alone sufficient in many cases. It should be frequently employed. It
should always precede any topical application or medicated injection.
Lukewarm water alone is employed, but the addition of a little salt
(drachm j to pint j) or chlorate of potassium renders it more bland.
Very often hot water is a most useful application. Of the medicated
injections a vast number might be described, but they are referable to
two classes, anodyne and astringent. The painful nature of cystitis
suggests the use of opium preparations and chloral hydrate for
injections, and they do give some relief. They should be well diluted
to prevent their causing irritation.

Of the astringents, acetate of lead, sulphate of zinc, tannic acid,
nitrate of silver are the most valuable. Many others--perchloride of
iron, chlorate of potassium, hydrastis canadensis, salicylic acid and
its preparations, carbolic acid, etc.--have been commended. In all
cases the strength of {347} the injection should be short of causing
the patient much pain. It is always best to begin with a mild solution
and gradually feel the way up to stronger ones. Of all the astringents,
I prefer nitrate of silver, which I use in strengths varying from one
grain to twenty to the fluidounce. The general rule to be observed, if
a strong solution is used, is to employ only a few drops; if a large
injection is made, the solution should be weak.

Various antiseptics--iodoform, salicylate of sodium, etc.--have been
used to prevent the decomposition which so complicates obstinate
cystitis; but, as a rule, I think frequent washings out and astringent
applications act much better. One of the most distressing obstacles
encountered in making any such injections is where there is a tender or
inflamed urethra. It is well then to carry the catheter only up to the
sphincter of the bladder (as advised by Braxton Hicks), overcoming its
resistance by the pressure of the injection. As a rule, the urethritis
will not long survive the cystitis, but in some cases it exists as an
independent affection; it is then usually gonorrhoeal, and should be
treated as in the male. But when not, the same principles apply as in
the local treatment of the bladder. Great care is needed, as the female
urethra will only hold ten or fifteen drops at a time, and if a large
injection is used it is almost sure to enter the bladder. To meet this
difficulty I devised a reflux catheter for douching the urethra. It is
grooved on the outside, and at the point there is an opening in each
groove which lets a jet of the fluid used flow outward, bringing the
injection in contact with all parts of the urethra.

In cases of ulceration, such as occur in bad cases of cystitis,
applications should be made, if possible, to the part affected only.
This can be accomplished by means of the endoscope when the ulceration
is seated where it can be reached. Having located the point exactly by
means of the endoscope, the inner or glass tube is withdrawn, and the
application made directly to the required spot through the rubber tube.
A glass pipette properly curved or any ordinary insufflator will answer
perfectly, and when a solid is used a delicate long curved forceps will
answer.

In chronic cases of cystitis in which all the above methods of
treatment fail, it becomes necessary to give the parts complete rest by
securing continuous drainage of the urine and products of inflammation.
There are two ways of doing this--the one, to use a self-retaining
catheter which may keep the bladder empty: this method answers very
well when the inflammation is confined to the upper portions of the
bladder, but when the neck of the bladder is involved the presence of
the catheter gives rise to pain and irritation and cannot be tolerated.
The other plan is to establish an artificial vesico-vaginal fistula,
and keep it open for some months, until the bladder-walls have become
normal again. This secures efficient rest to the inflamed parts;
complete drainage is established, the patient wearing a cup, as she
would a pessary, to catch the urine. If the inflammation is limited to
the upper portion of the bladder, the drainage by the fistulous opening
is all that is required; but if the neck of the organ is involved,
frequent and continued medication will be required. This can be done by
injecting through the urethra and letting the fluid escape through the
opening in the bladder. This is not the place to discuss the steps of
the operation or the indications when and how to close the artificial
fistula. For these the reader is referred to works on this department
of surgery.

{348} Suffice it to say, in conclusion, that this by no means easy
operation should be only undertaken as a last resort, but that if
properly done in well-selected cases it will cure where all other known
methods of treatment have failed even to relieve.


Hypertrophy of the Bladder.

This lesion may be partial or total, involving any or all three coats
of the viscus. But the term usually refers more particularly to
increase of the muscular walls. As a rule, the hypertrophic changes are
not confined to one portion of the viscus, all being more or less
affected. The affection is much less frequent in the female than the
male.

ETIOLOGY.--There are two varieties of this affection--one, concentric
hypertrophy, in which the bladder is contracted as well as having its
walls thickened; the other eccentric, in which there is dilatation. Its
principal causes are--obstruction to the outflow of urine from
stricture of the urethra, tumors, or foreign bodies; cystocele,
preventing complete evacuation; cystitis, causing too frequent or too
forcible contraction; and irritable bladder in certain of the neuroses.
Accompanying such dilatation diverticulæ are sometimes formed, though
rarely in the female.

SYMPTOMS.--There is sometimes present vesical spasm, some pain, and
forcible ejection of urine. A certain amount of cystitis is almost
always present, aggravating the original disorder. In the eccentric
form there are sometimes superadded symptoms of over-distension.

DIAGNOSIS.--This is readily made by measuring the thickness of the
bladder-wall between the finger in the vagina and the sound in the
bladder. The capacity of the bladder is easily noted by measuring the
urine passed at each micturition or by injecting a bland solution of
salt and lukewarm water.

TREATMENT.--The treatment should be directed to the removal of the
cause. When this is not possible, palliatives may be sought for in the
use of the catheter, at regular intervals, to prevent over-distension.
Cold baths, astringent injections, and electricity are often of use. By
these means the evil results of the disease may be overcome, but the
hypertrophy is usually permanent.


Atrophy.

Atrophy of the bladder is a rare disease in early life. In women, in
addition to the ordinary decay of age, there is a special
predisposition to degenerative changes in the pelvic viscera, the
bladder-walls included, after the menopause. Extreme distension of the
bladder is usually the exciting cause, giving rise to temporary or even
permanent paralysis, and eventually causing either inflammation or
atrophy and fatty degeneration. Interrupted nutrition, due to impaired
circulation, is the immediate cause, but such altered nutrition may be
purely nervous and due to atrophy of certain ganglion-cells in the
spinal cord.

SYMPTOMS AND DIAGNOSIS.--Patients complain of difficulty in emptying
their bladders, the urine coming away in interrupted jets. They are
{349} apt to be irregular in their times of urinating, and are liable
in consequence at times to have retention and over-distension. Pain and
sometimes a slight cystitis are present. Finally, they completely lose
the power of urinating and a catheter has to be used. The diagnosis is
to be made as in hypertrophy, by a finger in the vagina and a sound in
the bladder.

TREATMENT.--Regular catheterization, strychnia in full doses,
electricity, and tonics, combined with washing out the viscus. Where
the atrophy is due to nerve-degeneration these measures are purely
palliative, in other cases they are of more avail.


FUNCTIONAL DISEASES OF THE BLADDER.

Under the name of functional diseases of the bladder are included a
large number of varied affections of which the pathology is as yet very
obscure. Where there are marked symptoms of vesical disorder, while no
organic lesions are found in the tissues of the bladder, the affections
must be classed under the name of functional derangements. As our
knowledge increases the number of these is constantly diminished, and a
still further and more rapid diminution will occur as the physiology
and pathology of the nervous system innervating this viscus become
better known. These diseases are much more common in children and women
than in men--in children, because the controlling power of habit is
only in process of formation; and in women, mainly because of the more
complex organization of the genito-urinary organs, which are the more
easily exhausted and deranged, especially by the functions of
maternity. True, neuralgia of the bladder has been described under a
variety of names, irritable bladder, cysto-spasm, etc., but it is
rather a rare affection. The most prominent symptom is the painful
micturition, and attendant on this a desire to pass water too
frequently.

There is no particular change in the character of the urine, and no
appreciable visible alteration in the appearance of the parts, though
they are more sensitive than normal to the touch. This condition is
best met by warm fomentations locally and sedatives either locally or
generally, while nutrition is improved by appropriate tonics, nervines,
and by the use of the galvanic current.

A much more common class of affections of the bladder accompany
hysteria, sometimes grouped under the name of hysterical bladder. A
great number of pathological conditions are grouped under this vague
term, but they are held together by all having, as a more or less
prominent symptom, varying degrees of incoördination. The disturbing
effect of strong sudden emotion, as fear, upon the bladder is familiar
to all, and in various organic diseases of the spinal cord and brain,
such as myelitis and locomotor ataxia, a disturbance in the functional
action of the bladder is among the first symptoms. It then becomes a
matter of great difficulty, and yet of great importance, to make a
differential diagnosis.

In hysteria the urine usually diminishes in specific gravity; it is apt
to be increased in quantity, and, though clear in appearance, is
irritating {350} to the mucous membrane. In such cases frequent
urination, sometimes almost continuous, sets in; but it is an important
point that during sleep the patient retains her urine the normal time.
In others we get, on the contrary, retention, and this may be due to
various causes. In some it is doubtless involuntary, as they say they
cannot urinate, but in others it is assuredly will not. Many of these
latter derive a morbid pleasure from catheterization. These are the
patients who are given to the introduction of hair-pins, slate pencils,
etc. etc. into the urethra.

Some authors claim that in the intense sexual excitement of hysteria
the chronic erection of the clitoris makes pressure on the urethra, and
so prevents the escape of urine, but this seems somewhat apocryphal.

Another class of cases resembling the hysterical in the frequency of
urination are those addicted to masturbation; these are, fortunately,
not very common.

In all of these cases the frequency and irregularity of urination is a
much more prominent symptom than the pain. This latter is usually a
slight scalding from the urine passing over the chafed and irritable
urethra, especially at the meatus. (These symptoms sometimes occur in
the miasmatic affections.) A number of neuroses of the bladder are
reflex and dependent on peripheral irritation elsewhere. A typical
example of this class of affections is what has been described under
the title of ovarian irritation. In this condition there is very much
heightened reflex irritability accompanying the increased tenderness
and vascular engorgement of the affected ovary. It is difficult to
explain the bladder symptoms which sometimes accompany the recurring
crises of this disease, except as due to a nervous excitation spreading
from the ovarian centres in the spinal cord to the adjacent bladder
centres.

The diagnosis of this group of affections must be made by exclusion. We
have some of the same symptoms--increased frequency of micturition,
pain during and after the evacuation, tenesmus and shooting pains in
the pelvis--as in organic disease. The most important guide is a
careful examination of the urine, which shows the absence of abnormal
constituents, thereby excluding organic disease. This diagnosis will be
much strengthened by a digital examination, by the vagina, of the neck
of the bladder, and the passage of a urethral sound, neither causing
pain, as they would do in cystitis.

The PROGNOSIS is usually good, but it depends upon the length of time
the affection has lasted.

The TREATMENT is mainly tonic and nutritive. The diet should be
nutritious and simple, and the bowels regulated by mild purgatives.
Constitutionally, small doses of strychnine are most valuable in
improving the nerve tone; so also the constant electric current is of
service. Locally, sedative suppositories in the vagina or enemata are
advantageous, conium combined with belladonna or hyoscyamus seeming to
act best. The liberal use of the bromides gives good results in some
hysterical cases.


Paralysis of the Bladder.

This is the most grave of the functional affections, and, like
paralysis elsewhere, it may be either peripheral or central. When the
latter, as in {351} certain injuries of the brain or in certain
well-marked lesions of the spinal cord, it hardly calls for more than
mention here. Often, however, the cause is not recognizable in any
organic lesion either of the bladder-walls or the central nervous
system, and is to be sought for in more temporary and transient
influences; thus as a result of over-distension most frequently, of
impaired or lost nerve-conduction in fevers involving serious
derangements of nutrition, all of which may be described as functional
or temporary paralysis.

The invasion is usually gradual, except in apoplexy or traumatism. The
patients, who are usually advanced in years, first observe that the
urine is expelled from the bladder with less force than usual; the
stream is smaller and comes slower, and straining takes place, the aid
of the abdominal muscles being invoked. After a while the stream
intermits, and finally partial or complete retention occurs. Then, if
this condition continues, the sphincteric resistance gives way and
constant dribbling occurs. In rare instances dilatation of the
bladder-walls takes place, and finally cystitis. Dilatation of the
ureters and hydro-nephrosis are not uncommon under these conditions.

Where the condition of retention obtains the DIAGNOSIS ought never to
be difficult; the introduction of a catheter will conclusively settle
it.

The PROGNOSIS in uncomplicated paralysis is usually good. When
accompanying fevers, dysentery, peritonitis, etc. it usually disappears
with the original disease. When due to centric lesions the outlook is
about hopeless.

In all cases the bladder should be emptied at stated intervals. If the
patient cannot do this herself, the surgeon should resort to the
systematic use of the clean soft Jacques catheter. A most important
point, too often overlooked, is the method of emptying an
over-distended bladder. It is not safe to empty the bladder at once:
the patient ought to be tapped at intervals, an abdominal binder being
gradually tightened meanwhile. The too sudden removal of pressure from
the vesicle walls which have been rendered anæmic allows of intense
congestion, and in a condition of paralysis is the sure prelude to
cystitis. The diet in these cases should be generous and stimulants are
not contraindicated.

I cannot agree with those authors who recommend washing out the bladder
with medicated solutions and forcibly distending the urethra, nor with
those who use tincture of cantharides as a vesical excitant. Both plans
are apt to produce cystitis. A far more rational though somewhat
impracticable treatment is the use of electricity as recommended by
Winckel--one pole (thoroughly insulated up to the point) in the
bladder, the other on the symphysis or loins. The sitting should last
about five minutes. But by far the most valuable therapeutic agent is
strychnia, which should be exhibited in full doses, many of the
reported failures with this drug being due to too small doses. In
urinating the upright position is generally preferable to lying down,
as the pressure of the abdominal organs to some extent compensates for
the lack of tonicity in the bladder-walls.

Lastly, in these hopeless cases of complete paralysis an artificial
vesico-vaginal fistula and the adaptation of an apparatus to catch the
urine may be of service.

Functional disorders of the bladder are frequently met with, due to
{352} abnormal constituents in the urine. As was mentioned above, these
may be so grave or their irritant action continued so long as to give
rise to cystitis. In the slighter forms, due to transient cause, the
local trouble will speedily right itself, but in other cases, such as
those dependent on functional derangements of other organs, as
dyspepsia, the irritation is apt to return at varying intervals. In
almost all these cases the immediate mechanism of the trouble is the
presence of some urinary deposits. To this may be added the
constitutional impairment, as in oxaluria, when the minute octahedral
crystals are probably not more to blame for the local difficulty than
the impairment of the nervous tone. Similarly, the poison of malaria
and of certain of the exanthemata, and of many diseases marked by
faults of assimilation and elimination, causes functional disturbance.

The prime indication in treating these cases is to render the urine
more bland by dilution. For this purpose water, aided by the salts of
potash and the alkaline mineral waters, is the best. This should always
be given on an empty stomach, and the addition of infusion of buchu is
excellent. In the condition known as oxaluria the alkaline salts are
not called for, but instead thereof acids. Nitro-muriatic diluted and
tincture nucis vomicæ tend to correct the faults of nutrition, and they
should be largely diluted to relieve the local condition.

The last class of functional diseases are caused by lesions of position
either of the bladder or of some of the neighboring organs. Here,
again, we have conditions which if sufficiently prolonged may lead to
organic vesical changes or may simply be temporary or intermittent. By
far the greater number of these are dependent on malpositions of the
uterus, which either drags or presses on the bladder. Either of these
classes may be complicated with adhesions arising from a former
cellulitis or pelvic peritonitis, the adhesions resulting therefrom
maintaining a fixation of the pelvic organs which impairs the functions
of the bladder.

Other causes of displacements are uterine and ovarian tumors, pelvic
deformities, and fecal impactions of the rectum. Of the various
displacements of the bladder it is needless to speak in much detail.
The most important is the downward one. Various degrees of this are
found up to complete cystocele, most commonly associated with prolapsus
uteri. The bladder naturally sags inferiorly as age advances, and by
far the most potent agent in causing this to become pathological is
repeated pregnancy and injuries during labor.

It is a well-known fact that the first stage of vesicle prolapsus is
apt to be marked by as great discomfort as the third, for after a while
the organ seems to become accustomed to its altered relations. The
treatment of this condition is difficult. The bladder should be
replaced and kept there. As this usually necessitates the reposition
and maintenance of the displaced uterus, it is extremely difficult, and
in case of existing adhesions it is impossible. A great variety of
mechanical means have been tried to furnish an artificial support to
keep the parts in position. If the bladder alone is prolapsed, the
pessary used for anteversion of the uterus will sometimes answer. The
instruments devised by Thomas, Grailly Hewett, and myself are most
commonly used.


{353} Acute Urethritis; Inflammation of the Urethra.

This affection may be simple or gonorrhoeal, and it is often difficult
to tell the one from the other. There is a difference in history when
we can get correct testimony from the patient. Simple urethritis
usually comes on gradually, and is often preceded by symptoms of
uterine or vesical disease, while gonorrhoea comes on rather abruptly,
and is preceded or attended by acute vaginitis and vulvitis. The chief
symptom is painful urination. Sharp scalding is produced by the urine
passing over the tender surface. There is often a frequent desire to
urinate, but not so urgent as in cystitis. In some cases the urine is
retained for a long time, evidently from a dread of the pain caused in
passing it. In quite a number of cases I have noticed hemorrhage, the
source of blood being evidenced from the fact that it was not
intimately mixed with the urine, and after micturition it oozed from
the meatus urinarius.

An examination of the parts will show signs of inflammation about the
meatus, with or without the same condition of the vulva. Occasionally
there is a discharge seen coming from the urethra, but if the parts
have been recently bathed this may not be apparent. Introducing the
finger into the vagina and pressing upon the urethra from above
downward will cause a discharge, unless the patient has passed water
immediately before. The appearance of the discharge corresponds to that
of gonorrhoea in its various stages.

Cystitis, which is liable to be confounded with urethritis, may be
excluded by using the catheter, and, after letting urine flow for a
time, collecting the remainder for examination. The mucous membrane, as
seen through the endoscope, is of a deep red, with pus or mucus lodged
in its folds. The instrument cannot be used in all cases, owing to the
acute tenderness of the parts. Bleeding is very likely to occur in the
examination, simply from the contact of the endoscope.

The TREATMENT of acute urethritis, whether specific or not, may be
conducted on the same principles as that of gonorrhoea in the male,
using the same constitutional remedies, local baths, etc. This will
suffice in most cases of acute disease, but when it assumes the
subacute form from the beginning, then the use of injections becomes
necessary. I have seen much benefit derived from douching the urethra
with water as hot as the patient could bear it. For this purpose I use
a catheter made like the fluted roller of a crimping-machine. The
catheter conveys the water to the rounded point of the instrument.
Behind the point of the catheter, where the grooves terminate, there is
a perforation in each groove through which the water returns. By this
arrangement the water, as it flows back through the grooves, is brought
in contact with every portion of the mucous membrane. The instrument is
passed up to the neck of the bladder, and a fountain syringe attached
to it, and the water as it flows away is caught in a cup.

The injection of solutions of nitrate of silver and sulphate of zinc
will often prove useful. It must be borne in mind that the female
urethra will not hold more than ten or fifteen drops, and if more is
used it will enter the bladder, even where very slight force is
employed while injecting. I use a large syringe, placing the nozzle
over (not in) the meatus, and inject slowly and without force a small
quantity. When the case is {354} of long standing, and the neck of the
bladder appears to be involved also, I use a weak injection of one or
two grains of nitrate of silver to the fluidounce, and inject it
through the urethra with force enough to enter the bladder, and let it
remain there, to be passed off when the patient urinates. In old cases
which began by a severe acute attack, and where the walls of the
urethra are very much thickened and the canal contracted, dilatation
with bougies does much good. While the bougie is passed once or twice a
week, I apply to the vaginal portion of the urethra oleate of mercury
or the unguentum hydrargyri. This will often suffice to stop the gleety
discharge, as well as remove the thickening of the urethral walls.


Inflammation of the Urethral Glands.

These glands rarely, if ever, take on inflammation primarily, but
vulvitis and vaginitis, especially if gonorrhoeal, often extend into
them. When they do become inflamed, the disease usually remains without
any tendency to subside. More than that, when a gonorrhoea affects
these glands the inflammation will remain there after all traces of the
disease have left the vagina, vulva, and urethra, and in time the
discharge from these glands will light up the original vaginitis and
vulvitis again. The symptoms of this inflammation are not diagnostic.
The physical signs are the swelling and redness around the mouths of
ducts which are located just within the labiæ of the meatus urinarius.
This give a general redness to the meatus. By pressure made upon the
urethra from above downward a purulent discharge from the ducts will be
produced and can be seen escaping. The only effective treatment is to
lay open the glands their whole length. They run upward in the
posterior wall of the urethra, so that by passing a fine probe-pointed
scissors they can be laid open on the vaginal surface. Care should be
taken to prevent the incision from reuniting, and if the inflammation
does not promptly subside applications should be made, as in the
ordinary treatment of inflammation.

Another very troublesome affection of the urethra which usually results
from urethritis is granular erosion, as it is called. The mucous
membrane is covered with young, imperfectly-developed epithelium; the
papillæ are hypertrophied and extremely sensitive. This gives rise to
the most excruciating pain during micturition, and generally keeps up a
distressing tenesmus. This disease is rarely seen except among old
people. The diagnosis is made from the history and appearance of the
urethra. The treatment is cauterization of the whole surface. The
milder washes and injections do not accomplish much. Pure carbolic acid
may be tried first, brushing it over the surface and repeating it in
eight or ten days. This is the least painful application, and generally
answers very well. When it fails a solution of nitrate of silver (one
drachm to the fluidounce) should be used. In obstinate cases it is
desirable, before using strong caustics, to dilate the urethra, and
then touch it with a 50 per cent. solution of carbolic acid.


{355} Circumscribed and Subacute Urethritis.

Among the inflammatory affections of the female urethra there are mild
forms which fall short of well-marked urethritis. Indeed, some of these
attacks amount to little more than congestion or slight catarrh. In
others circumscribed patches of the urethra become inflamed, the rest
of the canal remaining normal.

The cause of this affection is generally some inflammation of other
pelvic organs, such as cellulitis. In one case it occurred in a
saleswoman who had been upon her feet many days from early morning
until late at night. I found several small ecchymoses on several parts
of the mucous membrane with zones of inflammation around them. The
long-continued passive congestion had caused some of the small vessels
to rupture, and the small blood-clots started the inflammatory process.

These cases tend to recovery if the patient is placed under favorable
conditions. If there is much pain, and if the trouble appears to be
tending to become chronic, mild injections may be employed.


Dilatation of the Urethra.

Dilatation of the whole urethra is not so common as dilatation of a
portion of it. Even when the whole canal is larger than it should be,
it is not, as a rule, uniformly so. In general, the urethral walls and
the urethro-vaginal septum are usually enlarged, relaxed, and flabby.
After a considerable time they may become indurated by infiltration or
hyperplasia of the connective tissue. The mucous membrane is usually
soft and loosely adherent to the subjacent tissues. Beneath the
membrane there are sometimes masses of enlarged veins which give a dark
bluish appearance to the parts. If the meatus be distended like the
rest of the urethra, the mucous membrane with the large veins beneath
it may protrude and form a tumor or tumors, which have quite the
appearance of rectal hemorrhoids. This is especially so when the veins
are large and numerous and the mucous membrane thin, so that the color
of the veins can be seen through it. On the other hand, if the meatus
remains normal in size, nothing will be seen by the examiner until the
catheter or sound is passed into the urethra, when the distended or
distensible condition of the canal will be detected. The dilatation can
be easily detected, even when the meatus is normal in size, by
observing that the sound can be moved about in the urethra, conveying
the same impression obtained when the sound passes into the bladder. By
making a digital examination of the vagina the enlarged urethra can be
felt, and it is usually elastic and compressible. Through Sims's
speculum the abnormal fulness or bulging of the anterior vaginal wall
can be plainly seen and distinguished from displacement of the urethra.
The points of difference between dilatation and displacement will be
brought out more in detail farther on.

When the dilatation has existed for any length of time, the mucous
membrane is usually hyperæmic, and sometimes catarrhal, secreting a
muco-purulent material, which may be seen escaping from the meatus or
lodged in the folds of the membrane, where it can be seen through the
{356} endoscope. When the mucous membrane is prolapsed and forms a
tumor outside of the meatus, it soon becomes fissured and ulcerated,
and consequently very tender and painful. This condition is produced by
the retarded circulation, chafing, and the irritation from exposure to
the air and the urine passing over it.

Dilatation of the anterior or lower third is the rarest of all forms of
urethral dilatation, and occurs usually as a consequence of some
enlargement or swelling of the mucous membrane, neoplasm of the
urethra, or mechanical dilatation. The dilatation may or may not
include the meatus. In rare cases it does not at first, but in time the
enlarged mucous membrane slowly, sometimes rapidly, dilates the
orifice. The general appearances of the parts are the same as those of
which I have spoken under the head of dilatation of the whole urethra.
When the dilatation is due to any new growth in the urethra, the tumor
can be seen on inspecting the parts.

I have only seen one case where the lower end of the urethra was
dilated without any recognizable cause for it. This was a single lady,
thirty-five years of age, a school-teacher. She had displacement of the
uterus and catarrh of the cervical canal, for which she consulted me.
She had no trouble with her urinary organs. While examining the uterus
I noticed that the meatus urinarius was peculiarly formed. In place of
the concentric corrugations of the mucous membrane which form the
closed meatus, the orifice was funnel-shaped and lay open when the
labia minora were separated. About half an inch of the lower end of the
urethra admitted a No. 21 (Eng.) sound. The remainder of the urethra
was normal, and there were no signs of disease about the mucous
membrane of the dilated portion. I could obtain no history which
pointed to the origin of the trouble, and it caused no discomfort to
the patient.

Dilatation of the posterior or upper third occurs in connection with
other pathological conditions, such as prolapsus of the bladder and
urethra. On this account we will defer what is to be said on this
subject until we come to dislocations of the urethra.

Dilatation of the middle third of the urethra is more common than that
of any other portion of the canal. In this form the anterior wall of
the urethra maintains its normal position, but the central position,
being distended, settles down, so that in time the urethra, in place of
being a straight or slightly curved canal, becomes triangular, the
upper wall being the base, and the central portion of the wall (that
is, midway between the neck of the bladder and the meatus) the apex. A
sac or cavity is thus formed in the central portion of the urethra.

In the earlier stages of this affection the urethra in front and behind
the pouch is really or apparently contracted; but as the disease
progresses the upper part of the canal and the neck of the bladder
become dislocated downward, and finally the upper portion of the
urethra becomes also dilated to some extent.

There is in this as in the other forms of urethral dilatation frequent
urination, usually more marked, but, unlike the others, there is
difficulty in passing water. This frequency of urinating, and the
straining efforts necessary to do so, affect the bladder, producing
irritation, and in time hypertrophy of its walls. Cystitis also follows
in the order of morbid developments; but whether that comes from the
frequent and difficult {357} urination, or from extension of the
inflammation from the urethra to the bladder, is a question.

ETIOLOGY.--The hyperæmia of the urethra which occurs in pregnancy, and
which tends to produce over-distension of the veins, favors dilatation
of the whole urethra. There is an apparent increase of tissue in the
walls of the urethra during utero-gestation, and the dilatability of
the canal is often increased also. Now, this condition of the parts
disappears during the involution which takes place after delivery; but
when from any cause the process of involution is interrupted, the
enlarged vessels and relaxed condition of the urethral walls remain and
sometimes increase. When to this state of the parts a catarrh of the
mucous membrane is added, the enlargement of the membrane by swelling
still further increases the calibre of the canal.

The dilatation caused by the passage of calculi may remain permanently,
and the same may be said of the use of large sounds. Neoplasms
obstructing the meatus or stricture at that point may so obstruct the
escape of the urine as to cause dilatation at all points above. This is
no doubt one of the most important and frequent causes of dilatation.

I have already stated that dilatation of the lower third of the urethra
is rare, and is usually due to inflammation of the mucous membrane at
that point or to abnormal growths, the distension remaining after the
causes that produced it have been removed. This and mechanical
dilatation from any cause cover the etiology of this form of the
trouble. Baker-Brown says that the meatus is always dilated when there
is stone in the bladder.

Regarding dilatation of the upper third of the urethra, I am inclined
to believe that it occurs in consequence of a partial prolapsus of the
bladder and the upper end of the urethra. The displacement of these
parts implies a relaxation of the tissues, caused originally, it may
be, by injuries during confinement, and the prolapsus permits an
unusual pressure of the urine upon the upper end of the urethra, and
dilatation is the result. On the other hand, the prolapsus and
accompanying relaxation of the urethral walls may be sufficient to
cause the dilatation. In all the cases that I have critically examined
there has been displacement as well as dilatation, and the whole
trouble could invariably be traced to childbearing or anteversion of
the uterus.

One cause of dilatation of the middle third of the urethra
(urethrocele) has been sufficiently dwelt upon in Bozeman's description
of the pathology of that affection--that is, narrowing of the lower end
of the urethra. This does not explain the etiology of all cases,
however, for I have seen this form of dilatation where there was no
stricture or hypertrophy of the lower end of the urethra. In such cases
I have traced the cause to childbirth, during which the posterior wall
of the urethra had been pushed downward and contused, while the upper
remained in its normal position. The relaxation caused by this
over-stretching of the urethral wall formed a small pocket in the
central portion, which gradually dilated more and more by the pressure
of the urine until the urethrocele was fully developed. This
explanation of the cause may be rather hypothetical, but, so far as my
observations go, it agrees with the facts found in those cases which
cannot be accounted for by Bozeman's views on the pathology of this
affection.

{358} SYMPTOMATOLOGY.--The symptoms vary according to the extent of the
dilatation, the portion of the urethra involved, and the condition of
the mucous membrane. When the whole urethra is dilated the only symptom
present may be frequent urination. When there is inflammation or
prolapsus of the mucous membrane, then pain will be caused by passing
water, and the desire to do so will be more urgent and frequent. The
patient may also be annoyed by a slight loss of control of the water,
under the pressure of lifting heavy weights, coughing, or the like.

Dilatation of the lower third of the urethra does not cause any
derangement of function, unless accompanied with inflammation or
ulceration; then there will be frequent urination possibly, and painful
urination certainly. The symptoms in this form of dilatation are less
marked than in the other varieties.

When the trouble is located in the upper third of the urethra, the
symptoms are sometimes very distressing. In addition to the
frequent--it may be constant--desire to pass water, the patient is
tormented with partial incontinence. Coughing, laughing, sneezing,
stooping to lift anything, a jar on stepping from the curbstone in
crossing the street, causes an escape of urine. This distresses the
patient very greatly. From the constant wetting of the external parts
they become inflamed, unless very great care is taken to keep them dry
and clean. In some of these cases the mortification of mind is
sometimes more distressing than the physical suffering.

The symptoms occuring in dilatation of the middle portion of the
urethra are the same as those already given, with the addition of a
slight mechanical obstruction which causes difficult urination; that
is, more voluntary effort is necessary on the part of the patient to
empty the bladder. The forcing, straining efforts made by some of these
patients while urinating are even greater than the mechanical
obstruction appears to account for. This may be due to the accumulation
of urine in the urethra, which excites extra reflex action in the
bladder and urethra out of proportion to the obstruction. This is the
only way that we can account for the difficult urination and muscular
hypertrophy found in those cases in which there is no great obstruction
from stricture.

The constitutional symptoms arising from these urethral troubles are
the same as those produced by urethritis, and are not peculiar to this
class of affections. In fact, the symptoms here given may all be
produced by other pathological conditions, and consequently cannot
alone guide to a correct diagnosis. The true character of the trouble
can only be discovered by physical exploration.

DIAGNOSIS.--A digital examination by the vagina will detect the
increased space occupied by the urethra. The canal encroaches upon the
anterior vaginal wall, and feels like a ridge extending from the meatus
to the neck of the bladder. This elevation or thickening of the urethra
is elastic and compressible in recent cases; in those of long standing
the tissues are firm to the touch, but still the canal is compressible.
The extent of the dilatation, if general or located in the lower parts,
can be measured by the size of the sound that can be easily passed. If
at the middle or upper portions, an ordinary female catheter or sound
may be used to explore it. By introducing that instrument and pressing
it first against the anterior wall and then upon the posterior, the
distance between {359} the two can be approximately made out. While the
catheter or sound is in the urethra the finger should be introduced
into the vagina to ascertain the thickness of the urethral wall. This
will differentiate between dilatation and hypertrophy.

When the meatus is dilated and the mucous membrane and enlarged vessels
are prolapsed, care is necessary to distinguish that condition from
urethral neoplasm. This can be done by observing that in prolapsus the
opening is situated either at the upper side or in the centre of the
protruding mass, whereas in abnormal growths of the urethra the meatus
surrounds the tumor or its pedicle. More than that, by making pressure
the distended vessels can be reduced in size and the prolapsed membrane
pushed up into the canal. This cannot usually be accomplished with
tumors.

PROGNOSIS.--There is no natural tendency to recovery in these
affections. If left alone they generally get worse. Recovery under
treatment depends upon the location of the dilatation and the duration
of the trouble. The conditions upon which an unfavorable prognosis is
to be based are--bladder complications, inflammation or ulceration near
the neck of the bladder, great varicosity of the veins, and fatty
degeneration of the muscular tissue. In the absence of all these
complications a complete recovery may be expected. In all cases great
relief can be secured by treatment and the patient guarded from getting
worse.

TREATMENT.--In the management of all forms of urethral dilatation
attention should be given to any inflammation of the mucous membrane
that may exist, employing the usual treatment. When there is a relaxed
and prolapsed condition of the mucous membrane, astringents should be
used. Tannic acid or alum will answer well. When these fail, the
redundant membrane should be retrenched, either by touching it with the
thermo-cautery or excising a portion with the scissors. In employing
the cautery for this purpose the long pointed tip of the instrument
should be used, and, having protected one side of the urethra with the
speculum, cauterize a narrow strip of the membrane parallel to the axis
of the canal. Two or more of these cauterizations may be made at points
equidistant on the circumference of the urethra. By operating in this
way pieces of normal membrane are left between the portions cauterized,
which prevents stricture from occurring after healing--a misfortune
which is sure to follow if the mucous membrane is destroyed by
cauterization all around.

In excising the prolapsed portion I prefer to remove one or more
V-shaped portions on opposite sides and bring the edges together by
sutures. This is preferable to clipping off the whole of the protruding
mass, because the cicatrices left are less likely to give after
trouble.

When the dilatation is caused by varicose veins it may be well to
follow the example of Gustave Simon. He exposed the vessels by cutting
through the vaginal wall, ligated the largest, and arrested the
hemorrhage from the smaller ones by applying liquor ferri perchloridi.
He repeated this operation several times on the same patient, who
experienced little or no inconvenience from the proceeding and made a
good recovery.

Dilatation of the lower third of the urethra is usually secondary to
some other trouble, as I have already stated; and all that is necessary
{360} to do for such cases is to remove the cause and treat any
inflammation that may exist. The dilatation will then disappear; and if
it does not, but little if any trouble will be caused by it.

The treatment of dilatation of the upper third consists simply in
supporting the parts. This can be effectually done by using the pessary
already recommended for the relief of prolapsus of the bladder. It may
be necessary to have the instrument so formed as to bring the pressure
where it is required. This is done by placing the pessary in position
and observing what change of form, if any, is necessary, and then
directing the instrument-maker to make the alteration. If the parts are
well supported in this way, recovery will follow unless atrophy of the
muscular wall has previously taken place. Even then the patient can be
kept comfortable by wearing the pessary. If there is urethritis
present, it may be necessary to remove that before using the pessary;
otherwise the pressure of the instrument may cause pain and aggravate
the inflammation.

In dilatation of the middle third Bozeman has proposed to make an
opening into the most dependent part of the urethra through the vaginal
wall, and maintaining it until all inflammation has been relieved, and
then closing the opening by the usual plastic operation. By this means
the urethra is perfectly drained of urine and the products of
inflammation which accumulated there before. This, with appropriate
cleansing and topical applications, soon restores the mucous membrane
to its normal condition, and the removal of the redundant tissue during
the operation of closing the opening effectually cures the whole
trouble. This treatment is admirably adapted to marked cases of long
standing, and should be employed. By using the thermo-cautery to make
the opening the operation is easily performed. In recent cases of less
magnitude I have obtained satisfactory results by dilating the lower
part of the urethra and supporting the dilated portion either with a
pessary or a tampon of marine lint. This permits the urethra to keep
itself empty, and then, by frequently washing it out and applying such
remedies as will cure the urethritis, recovery will sometimes follow.


Dislocations of the Urethra.

This is one of the affections most frequently met with in practice. I
have found very few cases recorded in medical literature. This neglect
of the subject by authors is perhaps due to the fact that in many cases
of displacement of the urethra the bladder is also dislocated, and the
whole trouble is described under the head of vesicocele or cystocele.
Now, it is true that displacement of the two occurs together, but
either may take place alone.

The extent of displacement varies exceedingly, but I shall describe
only the partial and the complete. A clear comprehension of these two
degrees will cover all intermediate forms. In partial displacement
downward the upper two-thirds of the urethra are prolapsed, so that the
direction of that portion of the canal is backward, instead of curving
upward, as in the normal condition. In complete prolapsus the urethra
runs from the meatus (which is in its normal position) backward, and
rests upon the {361} perineum, or in extreme cases, accompanied with
prolapsus of the bladder and uterus, its direction is backward and
downward, the position of the vesical end of the urethra being below
the level of the meatus. In this degree of displacement the urethra and
bladder can be seen presenting at the vulva or lying between the labia
minora. The urethra is usually shortened considerably when the
prolapsus is marked.

ETIOLOGY.--Utero-gestation and delivery are the most important causes
of this affection. In the advanced months of pregnancy I have observed
that while the bladder rose above the pubes the urethra was pushed
slightly downward by the settling of the enlarged uterus into the
pelvis. In such cases when labor occurs the head of the child
dislocates the urethra still more by pushing it still farther down.
This process I have often watched in forceps delivery. When there is a
partial prolapsus of the urethra existing before labor, the urethra and
anterior vaginal wall are forced down before the advancing head, and
that, too, while the attendant is making counter-pressure to prevent
it. The displacement produced in this way is often restored during
convalescence if proper care be taken to push the parts back into place
and the patient is kept at rest until the tissues regain their
tonicity. But in many cases the trouble is overlooked, and by
permitting the patient to get up and be on her feet while there is
still prolapsus it will slowly increase until the dislocation is
complete. This will surely be the case if there is any loss of
perineum. Indeed, rupture of the perineum is an accident which permits
the urethra to descend from its place. The perineum supports the
vaginal walls, which in turn support the urethra; and if it be lost,
even in part, the vaginal walls become relaxed, or perhaps never regain
their tonicity after delivery, and, settling down more and more, carry
the urethra with them.

SYMPTOMATOLOGY.--The symptoms arising from displacement of the urethra
are much the same as those found in dilatation and other urethral
diseases. I need not, therefore, repeat them in detail. Suffice it to
say that in dislocation of the upper portion of the canal there is, in
addition to frequent urination, a partial loss of control of the
bladder. Under the extra pressure of coughing, for example, the urine
will escape. This loss of control does not exist, as a rule, in
complete displacement. On the contrary, there is usually difficult
urination, which requires increased voluntary efforts to empty the
bladder. In all degrees of displacement the symptoms are increased in
the erect position, and are markedly relieved on the patient's lying
down.

DIAGNOSIS.--An examination of the vagina, either by touch or speculum,
will reveal the downward projection of part or all of the urethra,
which will show that there is either dilatation or prolapsus. The
change in the direction of the canal will be shown by passing the
sound, and dilatation can be excluded by observing that the urethra
grasps the instrument firmly at all points. In dislocation of the upper
two-thirds of the urethra the sound passes in the normal direction, but
is arrested at a half or three-quarters of an inch from the meatus; but
by pushing up the vaginal wall and the urethra the sound will then pass
into the bladder. When the prolapsus is complete the instrument passes
in easily, but takes a downward and backward direction.

PROGNOSIS.--Uncomplicated displacement of the urethra can be remedied
in the great majority of cases. By placing the parts in proper {362}
position, and holding them there, the relaxed tissues will usually
contract sufficiently to support themselves. Should they fail to do so,
the patient can at least be made comfortable by wearing some supporter.

TREATMENT.--When the displacement of the urethra is caused by any other
trouble, such as defective perineum or prolapsus uteri, then these
things should first be attended to. Should there be urethritis, that
also should receive appropriate treatment. But the chief indication is
to retain the urethra in place; and this can be easily accomplished by
using the pessary which has been recommended for supporting the
prolapsed bladder. Prolapsus of the upper part of the urethra can be
relieved in this way quite satisfactorily. When the whole urethra is
displaced, this pessary, while it supports the upper part, will still
permit the middle portion of the urethra to settle down. This
difficulty may be overcome by making the anterior portion of the
pessary long enough to engage in the introitus vulvæ, and in that way
keep the whole canal where it should be. Should this cause the patient
much discomfort, a tampon of marine lint should be used to keep the
parts in position until some restoration of the parts is obtained, and
then the pessary will complete the treatment.


Prolapsus or Inversion of the Urethral Mucous Membrane.

The prolapse may be limited to one side or extend all around the canal.
The size and extent of the protrusion vary considerably. If the meatus
is of full size, the prolapsed portion will usually preserve its
natural color for a time; but after a little, from chafing when wet
with urine, and especially if not kept clean, it will become red and
oedematous. When the meatus is small these changes occur sooner and in
a more marked degree, because the prolapsed portion is partially
strangulated. The longer the membrane remains exposed the more
sensitive it becomes, and the frequency of urination and pain attending
it increase. It also becomes very tender and painful to the touch. In
marked cases the ordinary movements of the body irritate the parts, and
in that way render walking painful.

These are symptoms that closely resemble those of irritable growths at
the meatus urinarius, and, so far as history is concerned, it is not
easy to make a differential diagnosis. To do this it is necessary to
make a local examination. The physical signs and the points in the
diagnosis between this affection and other diseases have been given
briefly but sufficiently under the head of Dilatations of the Urethra,
and need not be repeated here.

The causes of prolapsus of the urethral mucous membrane are numerous,
but those that are best known are long-continued congestion of the
membrane, urethral and cystic irritation causing frequent urination and
vesical tenesmus. Chlorotic and greatly debilitated women are said to
be predisposed to it, as also old prostitutes. The few cases that I
have seen were in women over fifty years of age, and all of them were
weak, nervous patients who had suffered from some organic disease or
functional derangement of the urinary organs.

PROGNOSIS.--This disease does not yield promptly to mild treatment,
{363} unless it is seen early in its progress; and if it does yield to
mild, soothing, and astringent applications, it is liable to return.
But in case there is no other disease present that tends to keep it up,
it can usually be cured by surgical means.

TREATMENT.--When a case is first seen it is well to remove any
inflammation or other complicating conditions. The prolapsed membrane
should be replaced, and the patient kept quiet in bed to favor the
retention of the parts in situ. Astringents, such as tannic acid, alum,
or persulphate of iron in a weak solution, should also be used. Should
these fail, the prolapsed portion of the membrane should be removed.
The methods of doing this (by excision and the thermo-cautery) have
already been described.


Stricture of the Urethra.

PATHOLOGY.--Obstruction of the urethra by narrowing of its calibre is a
much less common affection in the female than in the male. Still, it
occurs sufficiently often to demand attention. There are some facts in
the pathology of urethral stricture peculiar to women which we will
first notice. Passing over congenital narrowing of the urethra by
simply saying that such a malformation has been known, we find that
stricture is developed in the female, as in the male, by the deposit of
inflammatory products beneath the mucous membrane, which by gradual
contraction constricts the canal. Ulceration of the membrane in a
marked degree produces the same results. The inflammation and
ulceration which end in the formation of stricture are usually specific
in character, but the same may follow from the too free use of caustics
and injuries during childbirth. Stricture may also be produced by bands
of scar-tissue formed in the anterior vaginal wall and stretching
across the urethra. Contraction of the whole canal occasionally occurs
in cases of vesico-vaginal fistula of long standing. There the
narrowing is simply the result of disuse. The form of stricture that
most frequently comes under observation is a contraction of the meatus
urinarius, produced in many cases by the too liberal use of caustics in
the treatment of abnormal growths at the lower end of the urethra, or
from vulvitis. This form of stricture is the least troublesome and is
easily relieved. When due to the results of former urethritis or
peri-urethritis, the walls of the urethra are thickened and indurated
at the point of the stricture, and there is usually subacute
urethritis, sometimes ulceration. In those cases where the calibre of
the canal is diminished by cicatrices of the vaginal walls, and in
general contraction of the urethra in vesico-vaginal fistula of long
standing, the mucous membrane may be perfectly normal.

SYMPTOMATOLOGY.--Frequent and difficult urination are the chief
troubles caused by stricture of the urethra. The stream becomes
smaller, and may be twisted or flat, but this is rarely observed.
Patients, as a rule, only notice that they require to urinate more
frequently, and that they have to make more voluntary efforts to empty
the bladder than were necessary before. In almost all cases of
stricture the subject has at some previous time suffered an injury at
childbirth, urethritis, or something to which the origin of the
stricture can be traced. The previous {364} history of cases in which
stricture is suspected will aid in settling the diagnosis and etiology.

DIAGNOSIS.--A digital examination by the vagina will reveal thickening
and induration if the stricture is due to that cause. Cicatrices of the
vaginal wall compressing the urethra can be detected in the same way.
The use of the sound will determine the location of the stricture and
the extent to which the canal is contracted. When the stricture is at
the meatus it can be found with facility; but when it is located higher
up the largest sound that can be introduced without force should be
passed up to the point of stricture. This will localize it; then by
using a sound that will pass through it the extent of the constriction
will thus be ascertained.

The affections which are liable to be mistaken for stricture are
retention of urine or difficult urination from pressure on the urethra
by the displaced gravid uterus, pelvic tumors, and dislocations of the
urethra. The former can be excluded by a vaginal examination, and the
latter can also be detected by the sound, used as directed while
discussing the diagnosis of the dilatations.

PROGNOSIS.--Stricture of the urethra usually yields very promptly to
treatment, so that the prognosis is good. The only exceptions are where
the stricture has existed in a marked degree long enough to cause
dilatation of the ureters and disease of the kidneys. Chronic cystitis
or urethritis, occurring as a result of the stricture or coincident
with it, may so complicate matters as to make recovery slow or even
impossible. In cases where the whole urethra is contracted because of
the existence of a vesico-vaginal fistula of long standing, it is
extremely difficult to restore the tissues of the urethral walls to
their normal state.

TREATMENT.--The treatment of stricture will depend upon its location
and cause. If it is situated at the meatus, it can be divided by the
urethrotome or forcibly stretched with the dilator. When due to bands
of scar-tissue in the vagina, they should be divided at several points
and the urethra dilated by repeatedly passing the sound. When it is
owing to deposition of the products of inflammation in the submucous
tissue, forcible and rapid dilatation, as practised on the male
subject, will answer well if the proper cases are selected for this
form of treatment. Dilatation should be made carefully, with a view to
breaking up the constricting tissue without lacerating the mucous
membrane. To do this it is not necessary to dilate the urethra to any
great extent. As soon as the stricture has given way dilatation should
be suspended.

Incising the stricture from within outward, according to the method
commended by surgeons for the cure of stricture in the male, will no
doubt answer a good purpose. In fact, I am inclined to believe that
this plan of treating this affection is the best, but my own experience
with this operation on the female urethra is not sufficient to warrant
my speaking positively.

In contraction of the whole urethra arising from disuse in cases of
vesico-vaginal fistula gradual dilatation with graduated sounds answers
very well. This should be attended to before closing the opening in the
bladder. In all cases attention should be given to any inflammation
that may accompany the stricture or follow the treatment. It is well
also to keep such patients under observation, and pass the sound from
time to {365} time to see if there is any tendency of the stricture to
return. The brilliant results obtained in the treatment of stricture in
the male with electrolysis by Robert Newman should warrant a more
extended trial of this method.


Stricture at the Junction of the Urethra and Bladder.

This form or location of stricture is, so far as I know, peculiar to
women, and its influence on the function of the bladder has not been
clearly pointed out. In fact, no distinction has been made between the
pathology or clinical history of stricture at the upper end of the
urethra and elsewhere in the canal. At least, I am not aware that
writers on this subject have mentioned this form of stricture. My own
observations have been limited, but sufficient, I think, to warrant me
in saying that stricture does occur at the junction of the bladder and
urethra, and that it behaves differently from ordinary stricture at
other parts of the canal.

The causes are the same which give rise to stricture elsewhere; hence
nothing requires to be said on this point. The point of most importance
is the fact that stricture at this part of the urethra will cause
difficult urination out of proportion to the extent of the narrowing of
the canal. Contraction of the canal in a slight degree will cause great
difficulty in urination, and frequently retention. This is contrary to
the history of stricture of the urethra at other points. In such cases
there is no retention of urine until the stricture closes the canal, or
very nearly so; but I have seen retention in cases of stricture at the
neck of the bladder while a medium-sized catheter could be passed with
ease, thus showing that the narrowing of the canal was not alone the
cause of the deranged function. It is possible that the original
stricture causes spasmodic contraction, or in some way disturbs the
normal action of that portion of the canal which performs the function
of a sphincter vesicæ.

The symptoms presented in this form of stricture are difficult
urination and in some cases complete retention. I have also noticed, in
one case, that there was a frequent desire to urinate, but that was
accounted for by a slight catarrh of the bladder. These symptoms are
such as occur in other conditions, such as atrophy and paralysis of the
bladder, obstruction of the urethra from tumors, calculi, the pressure
of the displaced uterus, and prolapsus of the bladder.

In this form of stricture there are thickening and induration of the
neck of the bladder, which may be detected by digital examination of
the vagina. The sound will also reveal a narrowing of the canal at the
vesical neck, but the contraction may not be marked. Our main reliance
must be placed upon the exclusion of all other conditions which can
produce the same symptoms. Pressure upon the urethra and prolapsus of
the bladder can be excluded by an examination of the pelvic organs, and
the use of the sound will show anything like complete obstruction of
the canal.

Having excluded the possible existence of either of these conditions,
the only two affections which are to be confounded with this form of
stricture are atrophy and paralysis of the bladder. To distinguish
these from the stricture, the catheter should be passed when the
bladder is well {366} distended, and the character of the flow of urine
watched, when it will be observed that in stricture the urine comes
away with the usual force. The bladder contracts normally and with its
natural vigor, and sends the urine out in a well-sustained stream
through the catheter, if there is only stricture. On the other hand, in
paralysis and atrophy the stream is slow and without force--so much so
that voluntary effort or the pressure of the hand on the abdomen is
sometimes necessary to empty the bladder. This is especially so when
the catheter is used while the patient is in the recumbent position.
Finally, the diagnosis may be confirmed by testing the dilatability of
the urethra. This can be done by passing a dilator along the urethra
and gently testing the resistance of the walls of the canal. There is a
slight yielding at all points except at the stricture, where a decided
resistance is met.

Regarding the management of stricture at the junction of the urethra
and bladder, I am obliged to say that my experience has not yet been
sufficient to enable me to speak definitely. Rapid and free dilatation
is not sufficient to effect a cure; at least it has failed in one case.
Division of the stricture by incision suggests itself, but I am
confident that that operation would be unsatisfactory, because of the
great irritation which always occurs when there is a solution of
continuity at this point. My practice, therefore, has been to produce
slow and gradual dilatation by the use of graduated sounds, and the
application of oleate of mercury or iodine to the anterior vaginal wall
at the site of the stricture. More extended observation may develop
other and better methods of treatment, but for the present that is all
that I have to offer on this subject.




{367}

DISEASES OF THE VAGINA AND VULVA.

BY EDWARD W. JENKS, M.D., LL.D.


DISEASES OF THE VAGINA.

The subject will be considered in the following order: Anatomy,
Vaginitis, Atresia, Prolapsus Vaginæ, Cicatrices, Double Vagina,
Growths, and Vaginismus.


Anatomy.

The vagina is a musculo-membranous canal extending from the neck of the
uterus--which it embraces--to the vulva. It is usually attached to the
uterine neck at a point midway between the os internum and the os
externum. This canal is composed of three layers or coats: the outer
one is of fibrous and elastic tissue; the middle, of unstriped muscular
fibre and fibre-cell; the inner coat or lining is mucous membrane,
composed of connective tissue and elastic fibre and covered with
squamous epithelium. The outer and middle coats spread out at the upper
portion of the perineum, making the perineal septum, and attach
themselves to the ischio-pubic rami. One of the peculiarities of the
middle coat is that during utero-gestation it becomes much
hypertrophied like the same structure in the uterus, and following
labor undergoes a similar process of involution. The inner or lining
coat extends to the fourchette.

Savage[1] has described the general form of the vagina as similar to
that which would be assumed by a flexible tube if shortened to nearly
half its length by a cord passed from end to end through one of its
sides. The ridge thus formed is called the anterior column of the
vagina, and marks the vesico-vaginal septum; it is about two inches
long, while the posterior wall or posterior column is twice that
length. The anterior column or cord causes the investing mucous
membrane to be puckered and thrown into folds or rugæ which run
transversely toward the posterior column. "This mucous membrane is
studded with papillæ which are covered with pavement epithelium. The
papillæ of the vagina, which were first fully described by Franz
Kilian, were regarded by him as having for their function the
transmission of sensation. He represents them as being thread-like and
filiform."[2]

[Footnote 1: _Anatomy of the Female Pelvic Organs_, London, 1870.]

[Footnote 2: Thomas on _Diseases of Women_, Philada., 1880.]

Anatomists have differed regarding the existence of muciparous glands
{368} in the folds of the vaginal mucous membrane, some asserting that
they are present, and others being equally positive that there are
none. Notwithstanding this lack of uniformity, the fact that some have
discovered muciparous follicles, while others have failed, enables
recent writers to state that there is no doubt of their existence.

The vagina is lined with mucous membrane and covered with pavement
epithelium, studded with projecting filiform papillæ. This membrane
lies in folds, between which are numerous muciparous follicles.


Vaginitis.

DEFINITION.--Vaginitis is a term used to designate inflammation of the
mucous membrane of the vagina.

SYNONYMS.--Colpitis, Elythritis.

VARIETIES.--Three distinct varieties of vaginitis are met with--viz.
simple, specific, and granular.

ETIOLOGY.--Predisposing Causes.--Young girls are not unfrequently the
subjects of vaginitis in consequence of want of cleanliness, exposure
to cold, ascarides migrating from the rectum into the vagina, or the
introduction of foreign substances. It also frequently appears in
consequence of smallpox, measles, and scarlatina. In adults it may be
caused by exposure to cold or wet, more particularly at or near a
menstrual period. The insertion of a sponge into the vagina, as is not
uncommon for the purpose of topical medication or uterine support, acts
as an irritant if allowed to remain a few days, which may cause severe
inflammation. Pessaries, irritating vaginal injections, gonorrhoeal
infection, certain conditions of the urine, as in diabetes, acrid
uterine discharges, childbirth--more particularly if there has been
retention of putrefying secretions--and chemical agents used in
treatment of uterine diseases, are sometimes causes. Uterine discharges
which cause vaginitis are not generally irritating until they reach the
vulva, where by exposure to the air they become changed, first causing
vulvitis, and next inflammation of the vaginal mucous membrane.

Some women have slight attacks of vaginitis after each menstrual
period, but they are generally slight and soon subside; others will
have attacks after each coition or after great physical exertion, but
with such patients the disease is not severe, and usually passes off
without any signs remaining. It is quite common among prostitutes,
independent of specific causes, in consequence of excessive coition.
Chronic vaginitis or vaginal leucorrhoea is not uncommon with
newly-married women in consequence of excess or awkwardness in coition.

Granular vaginitis is generally caused by pregnancy, but occasionally
it seems to be produced by simple or specific vaginal inflammation. A
strumous diathesis or a disordered state of the blood, as in phthisis
or other constitutional disorders, are predisposing causes.

Mention has been made by some writers of diphtheritic and senile
vaginitis. Diphtheritic inflammation of the vagina is sometimes seen
during epidemics of the disease or among puerperal women in crowded
lying-in hospitals. Senile vaginitis is occasionally met with in women
after the climacteric period. Its cause is wholly in consequence of the
physiological retrogressive processes incident to the change of life.
The {369} epithelium is shed in patches, and, according to Hildebrandt,
the raw surfaces adhere, causing contraction of the vagina.

SYMPTOMATOLOGY, COURSE, DURATION, PATHOLOGY, TERMINATION, AND
COMPLICATIONS.--The subjective symptoms of the three varieties of
vaginitis which have been mentioned are nearly identical, but in their
physical signs a marked difference is perceptible. In the outset there
is a sense of heat and burning in the vagina, a feeling of pain and
weight in the perineum, and a frequent desire to urinate. The passage
of urine causes pain and a feeling of scalding in the urethra. It is
believed by many authorities that the sense of scalding is more
pronounced in the specific variety. Not unfrequently there are backache
and pain radiating down the thighs into the hips, along the spine, and
into the head. Sometimes, with the other symptoms mentioned, there will
be a decided febrile disturbance, chilliness alternating with heat, a
rapid pulse, and a foul tongue. With such symptoms the thermometer will
show an elevated temperature. Coincident with the beginning of pain and
irritation the patient has an itching sensation, which sometimes
becomes intolerable, and is generally worse at night when she is warm
in bed. Emmet states that some cases are so severe as to require
anæsthetics before relief can be obtained. After the lapse of from
twenty-four to seventy-two hours these symptoms subside, and there is a
profuse purulent discharge, yellowish or greenish in appearance and of
an offensive odor. In many cases the discharge is of so acrid a
character that it excoriates the vulva and surrounding parts. Walking,
or even standing, is often painful, particularly the former, owing to
the attrition of the inflamed or excoriated surfaces.

A physical examination causes pain, and if the inflammation has
extended to the vulva, urethra, or the vulvo-vaginal glands, it will
often produce intense suffering. When the vaginitis is acute, the labia
are swollen, the vagina assumes a more or less intense red color in
place of the light or pale rose-color of health; it will also be
swollen, and at the beginning seem unnaturally dry, but very soon,
although still red, it will be covered with a yellowish or
greenish-yellow, muco-purulent discharge of an offensive odor. By
careful examination with the speculum the vaginal canal will be seen to
have a congested appearance, with abraded points, and sometimes
follicular ulceration will be found. Generally, the appearance of thick
mucus within the os uteri indicates an extension of the inflammatory
process into the cervical canal.

Sometimes in gonorrhoeal vaginitis the full force of the disease seems
to be chiefly expended in the urethra; when this is the case, and
patients complain of intense scalding in passing urine, a finger
pressed against the anterior vaginal wall will usually cause pus to
exude from the urethral canal.

The duration of vaginitis depends largely upon the treatment. If
appropriate treatment is begun early in the course of the disease, a
cure can be effected in two or three weeks. On the other hand, it may
continue an indefinite length of time or assume a chronic form,
constituting a catarrhal condition of the vaginal mucous membrane, or
vaginal leucorrhoea.

Sometimes inflammation of the lining of the vagina, more especially
specific vaginitis, extends beyond the cervix into the cavity of the
uterus, {370} along the Fallopian tubes to the ovaries and to the
pelvic peritoneum, or it may travel along the mucous membrane until it
reaches the lining of the bladder, causing a cystitis, or in a similar
manner involve the vulvo-vaginal glands.

It is not unusual after all the signs of a vaginitis have entirely
disappeared that the inflammation recurs without any apparent exciting
cause, but wholly in consequence of a diseased condition of the mucous
lining of the cervix uteri, designated cervical endometritis, chronic
inflammation, or uterine catarrh. In consequence of this there is an
increased and changed secretion, which acts as an irritant and causes
vaginitis. These recurrent attacks of vaginitis can be prevented only
by a successful treatment of the cervical disease.

Chronic vaginitis or vaginal catarrh occurs after repeated attacks of
the acute form in persons of a strumous diathesis, and from uterine
disorders, such as catarrh, displacements, or polypi of the uterus.

Vaginal catarrh from any cause may lead to other difficulties; thus, if
it is the primary affection it may lead to catarrh of the uterus and of
the Fallopian tubes. Its long continuance with or without the
co-existence of uterine disorders may lead to relaxation and subsequent
prolapsus of the vaginal walls.

In the beginning of vaginitis, as in inflammations of mucous membranes
elsewhere, the vaginal lining becomes first very vascular, presenting a
congested and swollen appearance, with a diminution in the quantity of
normal secretion; but within a few days portions of the epithelium are
cast off, leaving abraded spots which sometimes ulcerate and become
covered with exudation. Occasionally complete casts of the epithelial
lining of the vagina are desquamated. In lieu of the natural
secretions, within thirty-six hours after the inception of the disease
the vagina is filled with an acrid, foul-smelling muco- or
sero-purulent fluid, having the appearance of unhealthy pus. The
discharge consists of serum, numerous epithelium cells, pus-corpuscles,
blood-globules, and infusorial animalculæ designated Trichomanas
vaginalis, and mucus. When an attack is very severe a true phlegmonous
inflammation is often developed in consequence of the submucous
cellular tissue first becoming involved.

In specific vaginitis it not infrequently occurs that the disease is
confined to the vaginal cul-de-sac--a fact which, according to
Guérin,[3] explains how sometimes apparently healthy women communicate
gonorrhoea to the male.

[Footnote 3: _Mal. des Organes génitaux_, Paris, 1864.]

In granular vaginitis the mucous membrane extending throughout the
entire canal and over the neck of the uterus is covered with numerous
minute elevations or granulations of about the size and shape of half a
millet-seed. Thomas says: "This variety of the disease appears to bear
about the same relation to simple vaginitis that follicular vulvitis
does to the purulent form of that affection."[4] The same author
mentions having seen a patient with granular vaginitis so striking in
its features that the family physician believed it to be malignant
disease developing, until convinced to the contrary.

[Footnote 4: Thomas on _Diseases of Women_, 5th ed., p. 219.]

Simple acute vaginitis frequently causes and remains associated with
{371} vulvitis, urethritis, and less frequently endometritis,
salpingitis, and pelvic peritonitis. The chronic form is not
unfrequently complicated with uterine catarrh. Acute specific vaginitis
is often complicated with buboes from inflammation of the femoral and
inguinal glands and inflammation and abscess of the vulvo-vaginal
glands. This variety more frequently than the others is liable to give
rise to violent urethritis, cystitis, salpingitis, ovaritis, and pelvic
peritonitis.

DIAGNOSIS.--If one is familiar with the symptoms which have been
mentioned, the diagnosis of vaginitis is not a difficult task; but it
is sometimes not only difficult, but quite impossible, to determine
whether a case is one of simple inflammation or of gonorrhoeal
contagion.

The symptoms which are most liable to lead one to decide that a case is
specific are their severity, the sudden development of virulency, the
scalding micturition, urethritis with pus in the urethra, the
greenish-yellow discharge of a foul odor, the very irritating quality
of this causing gonorrhoeal ophthalmia if applied to the conjunctiva or
gonorrhea in the male following coition; the occurrence of buboes,
inflammation of the vulvo-vaginal glands, peritonitis, and salpingitis.
We meet with cases where it is extremely difficult to decide as to the
nature of the disease, and especially when we have every reason for
believing that the subject herself is chaste; on the other hand, the
mere fact of a woman infecting her husband and causing him to have a
urethral discharge is not always sufficient proof of her having
gonorrhoea, as it is well established that certain forms of leucorrhoea
will produce such a result. It is not necessary for us always to
express an opinion of the character of the disease, even when convinced
that it is specific, but it is always our duty "to lean to the side of
charity when the question is one of chastity."[5]

[Footnote 5: Edis, _Diseases of Women_, Philada., 1882.]

PROGNOSIS.--If appropriate treatment is instituted, the disease will
usually subside in the course of a few weeks, or it will assume a
chronic form, lasting indefinitely.

Acute vaginitis causes more pain and actual suffering than the chronic
variety, but is less rebellious to means of cure. Simple vaginitis, of
itself, cannot be considered a grave disease, but the consequences may
prove of a most serious character--viz. extension of the inflammation
to the bladder, uterus, Fallopian tubes, ovaries, and peritoneum.

Specific vaginitis is more virulent than the other varieties, and
consequently there is more tendency to the extension of inflammation
than with them. Sterility is not infrequently a sequel of specific
vaginitis in consequence of contiguous parts, more especially the
Fallopian tubes, being implicated in the disease. Such patients, even
long after the acute symptoms have passed, are unfavorable subjects for
surgical operations, even of a trivial character.

TREATMENT.--The treatment of acute vaginitis is the same in the
different varieties. From the commencement of the attack until the
severest symptoms have subsided patients should rest in a recumbent
position, walking and coition being forbidden. If the inflammation is
severe, with febrile symptoms and a furred tongue, saline laxatives,
cooling drinks, and a non-stimulating diet should be prescribed. If
pain exists, anodynes of some kind should be given. The best mode of
administering {372} anodynes is by means of rectal suppositories. Warm
hip-baths every six or eight hours for the first twenty-four hours of
the disease ought to be employed, and at the same time quite warm water
should be thrown into the vagina with a syringe; this is beneficial in
curing the disease and contributing to the patient's comfort.

A much better mode of irrigating the inflamed parts is as follows: The
patient is to be placed on her back with her hips slightly elevated
over a bed-pan, and then by means of a syringe a stream of warm or hot
water should be thrown into the vagina for fifteen to thirty minutes.
It has been advised by Emmet that the temperature of the water should
be raised rapidly from blood-heat to 110° F., or as hot as the patient
can well bear. By elevating the hips venous congestion is considerably
lessened through gravitation of the blood, and, the hot water causing
contraction of the blood-vessels, the mucous membrane will present a
blanched appearance. The vagina becomes distended by the weight of
water, and somewhat with air, by reason of position, so that with the
hips elevated the injection comes in contact with every portion of the
vaginal mucous membrane.

In addition to hot water or after its use, other injections are useful,
as a decoction of flaxseed alone, or one of the following remedies,
either in the decoction of flaxseed or in water: viz. borax,
bicarbonate of sodium, hyposulphite of sodium, chlorate of potassium
(drachm j ad pint j), or permanganate of potassium (gr. viij ad pint
j). Hydrate of chloral and fluid extract of eucalyptus, either alone or
combined, have proved useful quite a number of times in my own
practice.

Mild attacks will usually subside in a few days without further
treatment than has already been mentioned; but in severe cases, when
the disease has got under full headway before treatment is begun, more
heroic measures become necessary, especially in specific or granular
vaginitis, where there is itching and a greenish offensive discharge.
The vagina should be exposed by means of a speculum, the mucous
membrane thoroughly dried by the use of absorbent cotton, and a
solution of nitrate of silver (gr. xl ad fluidounce j) be applied to
every part of the inflamed vagina. Wherever it is applied the mucous
membrane presents a whitened appearance. If the vulva is involved, the
same application should be made to it. After the parts thus treated
become dry a piece of soft linen or a small roll of absorbent cotton
should be thoroughly smeared with vaseline or soaked with carbolized
glycerin, and inserted within the vagina. The pain caused by the
nitrate of silver is usually better borne than the intense itching
which it takes the place of. After the lapse of eighteen to twenty-four
hours the linen or cotton can be removed and an injection of carbolic
acid drachm ss, sulphate of zinc and borax each drachm j, in a quart of
warm water, is to be used three times a day for two or three days; then
a weaker solution of nitrate of silver is applied and the tampon
inserted as before. This is to be followed the next day by the
carbolized injection, and three days later a weaker solution of nitrate
of silver is applied. The alternate use of these remedies is to be
continued until the mucous membrane appears pale, and the discharge
instead of being a greenish-yellow is white, when it should be
discontinued, and borax alone or combined with hyposulphite of sodium
is to be used as an injection; and immediately after the injection the
tampon {373} is inserted, or instead of the injection tannin dissolved
in glycerin is to be painted over the vaginal walls and followed by the
tampon.

The cure of vaginitis in many instances is obtained by securing rest to
the parts. One of the chief objects of the tampon is to give rest to
the inflamed walls by keeping them apart, rather than to make it the
medium of a topical application. Some gynecologists instead of using a
tampon insert one of Sims's glass vaginal dilators to keep the walls
from coming in contact, directing that it shall be worn most of the
time and that the patient shall rest in the recumbent posture.

The treatment of chronic vaginitis or vaginal leucorrhoea, when caused
by acute vaginitis alone, should be essentially the same as in the
latter after the severest symptoms have subsided, as clinically the
distinction between acute and chronic vaginitis is one of degree.

Generally, vaginal leucorrhoea is an accompaniment of other affections,
notably uterine diseases, and hence a consideration of its treatment
and its complications would necessarily include everything pertaining
to the therapeutics of leucorrhoea.


Atresia.

DEFINITION.--The term atresia ([Greek: a] privative, and [Greek:
trêsis], perforation) means, in its literal sense, an imperforate
condition or an entire absence of an orifice or a canal, but custom has
sanctioned a more liberal use of the word; thus, atresia is the term
sometimes made use of to designate a partial obliteration of a canal;
_e.g._ atresia vaginæ, which means literally an absence or obliteration
of the vagina, is also applied to a partial imperforation of the canal;
hence atresia of the vagina, like that of any other portion of the
generative passages, may be either complete or incomplete.

Atresia of the vulva cannot in a strict sense be considered under the
head of vaginal malformations or disease, but it seems quite necessary
in writing of occlusion of the vagina not to omit a consideration of
similar conditions of the vulva. The writer of this article, therefore,
has followed the lead of most medical authors in including vulvar under
the head of vaginal atresia.


Atresia Vulvæ.

The labia majora may be adherent, and for a long time no suspicion
arise of the condition, as such adhesion does not prevent the exit of
menstrual blood; but, on the other hand, it does sometimes interfere
with micturition, and then calculi are formed, which require surgical
interference for their removal. The adhesion of the labia minora, like
the same condition of the greater lips, is usually the result of
accident or disease, giving rise to the same difficulties in voiding
urine. Unlike adhesion of the labia majora, adhesion of the lesser lips
may cause retention and accumulation of the menstrual blood. Atresia of
either the greater or lesser lips may be consequent upon smallpox,
measles, scarlatina, or any constitutional or local disorder that can
cause inflammation of these mucous surfaces. Such occurrences are,
without doubt, more common in infancy and childhood. This affection is
occasionally found to be congenital, and {374} is due to a simple
agglutination of the contiguous mucous surfaces of the labia. The nurse
in washing the child sometimes discovers that the vulvar orifice is
closed, and it is thus brought to the notice of the physician.


Atresia Hymenalis, or Imperforate Hymen.

Although included under the head of Vulvar Atresia, this will be
considered chiefly in connection with atresia of the vagina. This is a
congenital condition of more frequent occurrence than the other forms
of vulvar atresia.

SYMPTOMS.--If the age of puberty has been attained and the subject has
all the symptoms of menstruation excepting the characteristic
sanguineous flow, an imperforate condition of the genital canal is
suspected. Monthly pain of a bearing-down character in the hypogastric
region, and pain in the back and thighs or uterine colic, are among the
symptoms. At such times the abdomen may become tender and tympanitic,
the pulse more frequent, and slight febrile reaction with nausea and
vomiting may occur.

These symptoms closely resemble those of an attack of peritonitis, but
usually, after a few days of great distress, they gradually disappear.
After a lapse of three or four weeks they again return with increased
severity. The girl's general health is impaired, the appetite is poor,
there is constant nausea and sometimes vomiting, the bowels are
constipated, the eyes lose their brilliancy, the skin presents a dirty
appearance and is often covered with an eruption. Headache is almost
constant. The abdomen is often very prominent from intestinal
tympanitis. Later the lower extremities become oedematous, and there
are indications of septicæmia, and great constitutional disturbance.
The gradual accumulation of menstrual fluid, first filling and then
distending the uterus and vagina, causes a gradual enlargement of the
abdomen, often giving rise to a suspicion of pregnancy.

[Illustration: FIG. 26. Hæmatometra.--Imperforate Hymen, causing
distension of uterus and vagina: H. Hymen; V, Vagina; U, Uterus; B,
Bladder; R, Rectum.]

DIAGNOSIS.--If there is an accumulation of menstrual fluid in
consequence of an imperforate hymen; the latter can be observed as an
elastic tumor of a red color protruding outwardly between the labia. A
rectal examination is necessary in order to complete the diagnosis, as
by this means the presence of menstrual fluid is determined, for if it
be present in sufficient quantity to distend the hymen a finger in the
rectum can detect fluctuation in the vagina.

{375} If there is no escape of the menstrual fluid beyond the vulva on
account of an imperforate hymen, the vagina first becomes gradually
distended, then the uterus, and finally the Fallopian tubes. As this
distension increases, fluid may be forced beyond the fimbriæ of the
tubes into the peritoneal cavity, or, instead, one of the tubes may
rupture from the pressure within. In other instances the uterus itself
ruptures from over-distension and thinning of its walls. Cases are on
record where, the accumulation increasing for years, the uterus has
become distended to the size attained in the latter months of
pregnancy; under such circumstances its walls as well as the walls of
the Fallopian tubes become thinned.

PROGNOSIS.--The physician should be careful and guarded in his
prognosis. The health may become much impaired, and sometimes this is
the case prior to the cause being ascertained. The chief dangers are in
connection with the accumulation of menstrual fluid, such as its
discharge at the fimbriated extremity of the tubes, or rupture of the
tubes or uterus, and consequent escape of the fluid into the peritoneal
cavity. There is also great danger in incising the hymen to permit the
exit of the fluid, as will be shown under the head of Treatment.
Therefore the longer has been the retention, the greater is the
liability of rupture and danger in treatment.

TREATMENT.--As this is of necessity surgical, but brief allusion will
be made to it. A simple incision of the hymen will permit the escape of
the fluid, but the admission of air by this means is liable to cause
sudden contraction of the uterus and a reflex escape of the fluid at
the fimbriated extremity of the Fallopian tubes, with all the severe
consequences of an intra-peritoneal hemorrhage.

The admission of air is liable to cause decomposition of retained
fluid, and this in time produces septicæmia. Further, the sudden
admission of air where there has been none before is liable to cause
inflammation of the lining membrane of the uterus and tubes, resulting
in septic peritonitis. To avoid such risks as have been enumerated two
plans are recommended by authors--one being a slow draining away of the
menstrual fluid and the other its rapid evacuation and washing out of
the uterus and vagina. Graily Hewitt makes an opening of a valvular
character in the hymen, permitting only a slow escape of the fluid.
Others use a small trocar and draw off the fluid slowly, and at
different times if there is a large quantity.

The aspirator is to be preferred to the trocar for emptying the vagina,
and of late years has been more generally used; either instrument, but
especially the former, permits of the discharge of the fluid at
different times, and in such quantities as the physician may desire,
without the admission of air. The rapid evacuation is best represented
by Emmet's mode of procedure. He first cuts the protruding membrane
sufficiently to admit the index finger, and tears the tissues enough to
allow the fluid to escape rapidly, and then washes out the vagina and
uterus with warm water, after which he introduces a glass plug for the
purpose of dilatation and to prevent the action of air upon the parts.


{376} Atresia Vaginæ.

Atresia of the vagina may be congenital or accidental, and, like
atresia of any other portion of the genital canal, may be partial or
complete. In complete congenital atresia of the vagina an examination
per rectum with the index finger fails to discover the fluctuation of
menstrual fluid, as in atresia from imperforate hymen, but in its place
can usually be felt what seems like a hard fibrous cord. If, however,
this cannot be discovered, no doubt remains of entire absence of the
vagina. Sometimes the cord can be felt a portion of the distance, which
indicates that there is a corresponding portion of an undilated vagina.

In case of complete congenital atresia of the vagina an operation
should be avoided, unless there is an accumulation of menstrual fluid
or a uterus can be distinctly felt by rectal and vesical examination,
or the patient is suffering from the absence of menstruation. To these
may possibly be added instances, as mentioned by Thomas, where there
exists an imperative necessity for sexual intercourse. Where there is
no menstrual molimen or distension of the uterus cannot be detected,
and there is non-development of the uterus and ovaries, as shown by the
condition of the external organs, surgical interference should be
indefinitely postponed.

Accidental atresia of the vagina may be produced by causes heretofore
mentioned. When the canal, which has previously been pervious, is
entirely obliterated from any cause, an operation becomes, as a rule,
an imperative necessity by reason of the accumulation of menstrual
fluid and consequent distension of the uterus and Fallopian tubes.

In partial or incomplete atresia it frequently happens that a sinuous
canal remains which serves as a guide to the surgeon.

The reader is referred to systematic treatises on surgical diseases of
women for the details of the various modes of operating for these
affections.


Prolapsus Vaginæ.

Displacements of the vagina are usually secondary, either in
consequence of relaxation of the walls or of some form of uterine
displacement. Prolapsus of the vagina is usually associated with
prolapsus of the uterus, yet it may exist independently. It may be
present for some time without prolapse of the uterus, or exceptionally
it may be the exciting cause.

DEFINITION.--When the tonicity of the vaginal walls is from any cause
impaired and they protrude downward in the direction of the vulva, the
condition is called prolapsus.

SYNONYMS AND CLASSIFICATION.--Owing to the anatomical arrangement, it
is impossible, with one exception, for any form of prolapsus of the
vagina to occur without the coincident prolapse of some viscera. The
single exception is the rare occurrence of prolapsus of the posterior
wall without the rectum being similarly displaced. These displacements
of the viscera with prolapsus of the vagina are commonly described by
medical writers as vaginal herniæ, of which there are three different
forms, as follows: cystocele vaginalis, rectocele vaginalis, and
enterocele vaginalis or hernia vaginalis posterior.

{377} ETIOLOGY.--The causes of displacements of the vagina and the
different varieties of vaginal herniæ can very properly be considered
together, as they are identical. Laceration of the perineum, an
enfeebled condition of the vaginal structure, and a retarded involution
of the vagina and uterus in consequence of pregnancy or childbirth are
the most frequent causes. Other occasional causes may be mentioned, as
former distension of the vagina from repeated childbirths or by tumors,
and senile atrophy.

PATHOLOGY.--Following childbirth, the vagina, like the uterus,
undergoes a process of involution, but if this is retarded from any
cause the vagina is rendered more capacious, its tonicity is impaired,
and the uterus, being heavy, crowds down upon it and causes it to be
displaced. If the vaginal sphincters or the posterior wall are torn or
enfeebled or the perineum lacerated, in addition to the presence of a
heavy uterus, prolapsus of the vagina, associated with some form of
vaginal hernia, is quite sure to follow.

There is a condition which acts as a common cause in producing vaginal
and uterine displacements that has failed to receive on the part of
medical authors the notice it deserves--namely, a relaxed condition of
the vaginal walls and the perineum, in which there may be observed, in
many instances, all of the disturbances caused by a laceration, and yet
a careful examination fails to reveal where any tearing has taken
place. The continuance of this excessive relaxation and atony of the
vaginal walls and the perineum for a long time after parturition is,
doubtless, due to subinvolution.

SYMPTOMATOLOGY AND COURSE.--The patient will complain of a bearing-down
sensation in the vagina, with a sense of fulness and heat in that
locality, sometimes extending to the vulva. These symptoms are
aggravated by any muscular exertion, particularly by walking. A
physical examination will show the presence of an elastic, globular
tumor between the labia. In case it protrudes beyond the vulva, it is
not unusual to find scattered over its mucous surface excoriated
patches of various sizes. Sometimes these become ulcerated. In other
instances the tumor has a smooth, shining appearance. Where there is
simply prolapsus of the vagina without the coexistence of a hernia, it
will, as a rule, be found that it is the posterior wall. If there is a
prolapsus of either the anterior or posterior wall with a hernia, there
will be additional symptoms to those above mentioned, which will be
referred to in connection with cystocele and rectocele.


Cystocele Vaginalis, or Cysto-Vaginal Hernia.

This is sometimes designated as prolapsus of the bladder, and consists
of a descent of the bladder and the anterior wall of the vagina, the
two being closely adherent to each other. In consequence of such a
descent a pouch is formed which becomes filled with urine. The pouch is
in the outset quite small, but gradually becomes larger, so that it is
not unusual for one to become of sufficient size to protrude beyond the
vulva. In consequence of the pouching of the bladder only a portion of
the urine is evacuated by the effort of micturition, and, remaining in
the bladder, it decomposes, causing cystitis or vesical catarrh.

The SYMPTOMS are a frequent desire to urinate, with tenesmus and {378}
scalding; there is also a sense of heat and pain in the bladder. There
is usually more or less ropy mucus discharged with the urine. If a
uterine sound or catheter is passed into the bladder with its point
downward, and can be felt protruding into the pouch, there remains no
doubt as to the case being one of cystocele vaginalis.


Rectocele Vaginalis, or Recto-Vaginal Hernia.

This consists in a protrusion inward of the posterior vaginal wall and
a pouch of the rectum, which is carried with it. The tendency to
rectocele is seen in the natural bulging of the rectum caused by its
expansion just above the sphincter ani. This is more readily
perceptible in cases where the perineum has been torn. If from perineal
laceration or any cause the posterior wall of the vagina fails to give
adequate support to the anterior wall of the rectum, the bulging just
mentioned increases, forming a pouch which becomes filled with fecal
matter. The bowel becomes more distended with feces, which usually
accumulate and harden, and, acting as an irritant, produce tenesmus
with mucous discharges. The venous circulation being interfered with,
hemorrhoids are common, adding to the patient's suffering.

On examination a tumor is found, sometimes as large as a man's fist,
which can be felt projecting from the posterior vaginal wall and over
the perineum; sometimes it is soft and compressible, while at other
times it is quite solid, depending on the absence or presence of
hardened feces. To leave no room for doubt in diagnosticating a case of
rectocele, the rectum should be explored with the index finger.


Enterocele Vaginalis, or Entero-Vaginal Hernia.

This consists in a portion of small intestine dilating the cul-de-sac
so that the peritoneum is carried down with the intestine between the
vagina and rectum as far as the perineum, sometimes forming an elastic
tumor at the vulva. The chief dangers arising from this form of vaginal
hernia are from its being strangulated or lacerated during childbirth.

Enterocele vaginalis is not frequently met with, but it is important
for the physician to know that such a condition is possible and
difficult to differentiate from some forms of vaginal tumor. A thorough
and careful rectal examination is requisite for diagnosis. An
enterocele has the peculiar elastic feeling of a tumor distended with
air, a tympanitic resonance on percussion, and a peristaltic movement.
If there remains any room for doubt, aspiration with the smallest
needle will enable the physician to perfect his diagnosis, for if the
needle enter the intestine it is not in any sense a dangerous
procedure.

TREATMENT.--The treatment of prolapsus and hernia of the vagina is
similar to that of prolapsus of the womb.

If a prolapsus of the vagina has existed but a brief period or has come
on suddenly, it should be immediately reduced and proper measures taken
to prevent its recurrence. To accomplish this the patient should assume
the genu-pectoral position, while the physician with well-oiled fingers
{379} restores the parts to their normal position. The patient should
then lie upon her back with the hips elevated; astringent vaginal
injections ought to be used every four or six hours; and quiet secured
or discomfort or pain relieved by opiates. Sudden displacements of the
vagina not being of frequent occurrence, the physician more frequently
meets with cases of long standing which have come on gradually and
slowly.

Attention to the general health is an important requisite: with this in
view tonics should be prescribed in many cases, the bowels regulated by
means of proper diet or if necessary by medicine, and the bladder more
frequently evacuated than in health. Astringent injections are fully as
useful in cases of long-standing displacements of the vagina as in
those of more recent occurrence; among those more generally used are
solutions of tannin, sulphate of zinc, or alum (drachm iv ad pint j).
Sea-bathing and injections of sea-water into the vagina are beneficial.
It is sometimes more convenient to make topical applications with
vaginal suppositories containing one of the astringents just mentioned.

Where cystocele exists it is important that the bladder be completely
emptied when the patient urinates; to accomplish this she may assume
the genu-pectoral position, and at the same time push the tumor up into
the vagina. If after this urine remains in the bladder, a catheter
should be employed.

If in any form of vaginal displacement the means which have been
alluded to fail, then some form of support or some surgical procedure
will be necessary. In very fleshy women considerable benefit is
sometimes obtained by means of an abdominal band with a perineal pad
attached to it. Pessaries, which have been heretofore quite generally
depended upon, are now considered as of secondary importance.
Sometimes, however, when the hernia is not of great size or when
associated with uterine displacement, a pessary proves of service. A
Hodge's pessary with a cross-bar, or the one devised by Skene of
Brooklyn, will often prove of great benefit in cystocele. For either
cystocele or rectocele the most serviceable form of pessary is one like
Cutter's or McIntosh's cup pessary, which is retained within the vagina
and supported in position by external attachments. To effect a radical
cure in either cystocele or rectocele, especially in the latter, some
surgical procedure generally becomes requisite.

Of the different operations which have secured the general approval of
gynecologists, the most common is perineorrhaphy: this is the name
given to the operation for a torn perineum. Another operation sometimes
performed with success is colporrhaphy or elytrorrhaphy, which consists
of lessening the calibre of the vagina by removing a portion of the
mucous membrane and bringing the edges of the wound together by
sutures. This can be performed on either the anterior or posterior
wall, depending on which seems to demand it the most; and if the
operation on one wall is not likely to be sufficient, it should be made
on both. Not unfrequently the most perfect success can be attained by a
surgical procedure designated as colpo-perineorrhaphy, which combines
the two operations that have been mentioned. Full descriptions of these
different operations and the best modes of performing them can be found
in all late standard works on surgical gynecology.


{380} Cicatrices.

Cicatrices of the vagina may occur in consequence of lacerations or
injuries received in childbirth, surgical operations, wounds from
accident, or the use of caustics about the uterus. If any of the causes
named excite inflammation, there may be more or less sloughing of the
parts, and, as healing must take place by granulation, cicatrices of
various dimensions are formed. These cicatrices may be sufficient to
cause partial or complete atresia, or they may be merely in the form of
projections or bands, dragging the uterus out of its normal position or
interfering with its natural mobility, and cause dyspareunia and other
discomforts.

Recently, since attention has been directed to the reflex symptoms
produced by cicatricial tissue in the neck of the uterus, there has
been a growing belief that similar symptoms are often caused by
cicatrices in the vagina. Thus it is the opinion of some who have
investigated this subject that many cases of remote neuralgia and other
nervous disturbances may often be caused in this way.[6]

[Footnote 6: Vide Skene on "Cicatrices of the Cervix Uteri and Vagina,"
_Amer. Gynæc. Soc._, vol. i., 1876.]

TREATMENT.--This is of necessity surgical, although some cases can be
successfully treated without having recourse to cutting operations, but
are treated by pressure. One method is to tampon the vagina with cotton
or marine lint previously saturated with carbolized glycerin. The
tampon can be left in position four or five days, when the vagina may
be washed out and again tamponed. Another method of treating with
pressure is by means of a Sims's dilator, either worn continuously or a
few hours at a time. Generally a quicker and more effectual mode of
treatment is to nick the bands with scissors or a knife in several
places sufficiently for the vagina to assume its natural shape, and
then insert the dilator. In some instances it is advisable to cut away
portions of the adventitious membrane. On account of the tendency to
hemorrhage after operations in the vagina the physician should avoid
cutting more than is requisite, and must use a finger as a guide in
cutting, to inform him when he has cut sufficiently.

If there is considerable hemorrhage it may be necessary to use a
styptic, but usually the glass dilator, by putting the walls on the
stretch and by pressure, will check the bleeding. It is important that
the dilator be worn for several hours each day after the nicking, for
fear that there will again be contraction. After each removal of the
dilator the vagina should be syringed out with warm carbolized water or
a very weak solution of permanganate of potassium (gr. ss ad fluidounce
ij), that no septic matter may be retained and so that healing of the
cuts may be more rapid.


Double Vagina.

Among the congenital deformities occasionally met with is a vagina
divided by a longitudinal septum, constituting a duplex or double
vagina. The septum is not always so situated as to make the passages of
equal size, nor does it invariably divide the canal through its entire
length. It is stated by most writers on the subject that usually with a
double vagina {381} there will also be a double uterus. The author has
met with only two cases of duplex vagina, neither of which was
associated with a double uterus. The treatment is of necessity
surgical, and consists in dividing the partition with scissors, and
inserting a tampon with some styptic or a Sims's dilator for the arrest
of the bleeding which invariably occurs from cutting operations in the
vagina. If there is persistent hemorrhage, a galvano- or thermo-cautery
may be used.


Growths in the Vagina.

New formations of any kind are not of frequent occurrence in this
locality. They consist almost exclusively of cystic tumors, fibroid
tumors, papillary excrescences or vegetations, sarcomata, epithelioma,
and carcinoma.


Cystic Tumors of the Vagina

are sometimes observed, but are by no means common. Their origin and
nature has not seemed to be well understood. Hugier and Guérin are of
the opinion that they are caused by the mucous follicles being
obstructed. In this view they are sustained by Preuschen.[7]

[Footnote 7: "Die Cysten die Vagina," _Centralblatt für Med._, 1871, p.
775.]

Sinéty remarks that there are two varieties of vaginal cysts--one
superficial and the other profound. The superficial are developed in
the mucous membrane, are small in size, and contain fluid which is
watery or clear and glairy. The profound cysts are developed in the
vaginal walls, and are of various dimensions, from the size of a walnut
to an orange, and capable of attaining to much greater dimensions than
is possible for the superficial variety. Their contents vary greatly;
sometimes clear, mucous, and ropy, in other cases they are colored
brownish or chocolate.

Cysts of the vagina are not to be confounded with those of the vulva or
those which develop in the vulvo-vaginal glands, nor are they as
common.

TREATMENT.--Cysts of the vagina can often be cured by laying them
freely open with a bistoury and wiping out the cavity with tincture of
iodine, carbolic acid, or a solution of nitrate of silver. The tincture
of iodine preferred by the author is Churchill's or a saturation
tincture, either being much more effective than the simple tincture.
Nitric acid and the actual cautery are mentioned by Barnes as having
been used for destroying vaginal cysts. Entire removal of these
formations can be effected by cutting into or through the mucous
membrane and dissecting them out in the same manner as they are removed
from other localities.


Fibrous and Sarcomatous Tumors.

Fibrous or fibroid tumors are by no means as common in the vagina as in
the uterus. It has been observed that they are frequently but not
invariably associated with the latter. They are developed in the {382}
muscular or fibrous structure of the vagina in the same manner as
similar formations in the muscular tissue of the uterus.

Some authorities assert that they frequently have the point of
departure from the uterus, and then descend little by little between
the walls of the vagina.

Sarcomatous tumors are developed in the same tissues and similarly to
fibrous growths of the vagina. They are, however, of less frequent
occurrence. They sometimes appear primarily in the vagina, but more
frequently are consecutive to sarcoma of the uterus.

It is a difficult and often impossible task to make out the
differential diagnosis of sarcomatous and fibrous growths in the vagina
except by means of the microscope. The symptoms of each are similar to
those which indicate sarcomatous and fibrous growths of the uterus, it
being accompanied by profuse leucorrhoea, more or less sanious, and
occasional hemorrhage. If tumors acquire much size, they interfere with
the functions of the rectum and bladder, and cause pain and discomfort
by their pressure in the pelvis; sexual intercourse is difficult,
frequently painful, and followed by a flow of blood.

DIAGNOSIS.--If of a large size, diagnosis is easily made. Uterine
tumors and prolapsed uteri have been mistaken for vaginal growths. By
using a uterine probe and inserting a finger in the rectum there need
be no error in these respects. By careful examination there is little
difficulty in diagnosis.

TREATMENT.--This consists of removal by the knife, scissors, écraseur,
or galvano- or thermo-cautery. If there are reasons for believing that
a tumor is sarcomatous, it is important that every particle be removed.
For this purpose scissors or the galvano- or thermo-cautery are
preferable to the ordinary écraseur, which by its action crushes and
bruises tissues, and is liable to draw into the chain or wire and crush
off more than the operator desires. Serious accidents, such as opening
into the peritoneal cavity or the bladder, have occurred in this way in
the practice of distinguished and experienced surgeons.

Papillary growths and vegetations in the vagina will receive merely a
brief allusion, as they are rarely seen even in the practice of
gynecologists. They are not commonly limited to the vagina, but are of
more frequent occurrence about the vulva and on the cervix uteri.
Vegetations of considerable size sometimes develop in consequence of
pregnancy or of granular vaginitis. Sometimes papillary growths within
the vagina assume a cauliflower shape with well-defined stalks, or
about the ostium vaginæ they may take the form of condylomata. These
formations may be confounded with epithelioma.

Treatment consists of removal by scissors or with the thermo- or
galvano-cautery, and to guard against hemorrhage some styptic and a
vaginal tampon will be required.


Cancer of the Vagina.

Carcinoma or epithelioma rarely occurs as a primary affection in the
vagina; it is generally secondary, extending from the neck of the
uterus. The author has met with only three cases which were primary
cancer.

{383} In a recent work Kustner[8] has collected statistics of
twenty-two cases of primitive cancer of the vagina. The result of the
analysis of these observations is, that nearly always the posterior
wall is first affected in primary cancer, while in secondary cancer the
anterior wall is the first to be attacked.

[Footnote 8: "Ueber den Primären Scheidenkrebs," _Arch. f. Gyn._, t.
ix. p. 279.]

The symptoms after the disease is somewhat advanced are similar to
uterine cancer--viz. a sanious, watery discharge of an offensive odor
or sometimes a veritable hemorrhage. There is no pain peculiar to or
pathognomonic of the disease. It is not until infiltration causes
pressure on nerves or there is considerable ulceration that pain is
experienced; in either of these conditions the sufferings are often
excruciating. Occasionally in women of advanced age, in consequence of
cancerous infiltration before ulceration has occurred, the vagina is
found to be contracted and there is roughness and induration of the
walls.

Epithelioma generally occurs in young women. The early symptoms are
pain and hemorrhage following coition. A digital examination will show
the friable nature of the formation and an indurated base: the
examination will cause blood to flow. In the early part of this stage,
before there has been much ulceration, the disease is sometimes
mistaken for syphilis and the growths for syphilitic condylomata. It is
not an uncommon occurrence for the disease to propagate itself by
contact, the opposite wall from which it primarily appeared becoming in
this way affected. Later, deeper tissues are infiltrated, the bladder
or rectum becomes implicated, ulceration occurs, and subsequently
perforation. The progress and terminations are similar to uterine
cancer.

TREATMENT.--In carcinoma there seems to be no opportunity for anything
more than a palliative course of treatment. Medicine or surgery is here
of but little avail. If epithelioma be detected sufficiently early,
there is some hope of cure, but this lies only in complete removal. For
this purpose the knife or scissors or the galvano- or thermo-cautery
can be used. When there is much hemorrhage, some styptic, like the
perchloride of iron, should be applied, or the cautery or curette may
be of service. Unfortunately, the physician is seldom consulted early
enough--prior to the cellular tissue being too much infiltrated--for
the thorough eradication of the disease.

Death occurs from exhaustion, hemorrhage, septicæmia, uræmia, or from
infiltration interfering mechanically with the function of the bladder,
kidneys, or intestine.

For the purpose of correcting the offensive odor and lessening pain
there seems to be nothing superior to chloral and glycerin (drachm
j-drachm ij ad ounce ij) on a tampon of cotton; the fluid extract of
eucalyptus combined with the chloral and glycerin (ounce ss ad ounce
ij) has proven an excellent deodorizer in the author's hands.


Vaginismus.

DEFINITION.--This affection, which was first called vaginismus by our
distinguished countryman the lamented J. Marion Sims, consists in a
hyperæsthesia or peculiar sensibility of the site of the hymen and
vaginal {384} outlet, associated with involuntary spasmodic contraction
upon irritation of the sphincters of the vagina.

ETIOLOGY.--Predisposing Causes.--This is sometimes an idiopathic
affection, but more frequently is symptomatic of some other disorder.
When idiopathic, it is due to a diathesis generally termed hysterical,
or an excessive nervous irritability affecting the entire system. The
symptomatic causes are quite numerous--more frequently some
insignificant local disorder than any grave form of disease. The more
common causes are irritated or inflamed carunculæ myrtiformes,
excoriation, and irritable ulcers and eruptions about the vulva,
vaginitis, uterine catarrh, inflammation, growths and fissures of the
urethra, disorders of the bladder, fissure of the anus, and inflamed
hemorrhoids. Other less frequent causes have been mentioned by writers,
as neuromata, an unusually rigid perineum, and a disproportionately
large male organ. Neftel of New York asserts that lead-poisoning has
been the cause of some cases under his own observation.[9] It is
sometimes associated with or apparently caused by congestive
dysmenorrhoea and uterine displacements and engorgements.

[Footnote 9: _N. Y. Med. Journ._, vol. ix. p. 81.]

Emmet's views regarding the etiology and pathology of this affection
differ from those of the majority of writers on the subject. He regards
it as purely a symptom denoting reflex irritation, and says that with
it he has never failed to find some condition, as a displacement, a
limited cellulitis, or a fissure in either the rectum or the neck of
the bladder, as the exciting cause.[10]

[Footnote 10: _The Principles and Practice of Gynæcology_, by Thomas
Addis Emmet, M.D., 2d ed., Philada., 1880, p. 607.]

SYMPTOMATOLOGY, COURSE, DURATION, TERMINATION, AND COMPLICATIONS.--The
most prominent symptom is excessive pain upon the sexual intercourse;
this is often so marked that subsequent attempts, or even a digital
examination, will throw the patient into a state of extreme nervous
trepidation and apprehension. If attempts at coition are persevered in,
the symptoms are further intensified, so that the spasm and violent
contraction of the sphincter vaginal muscles induce agonizing pain.
Besides having the characteristic pain, patients with this disorder
are, as a rule, sterile. If a physical examination be made in a
well-marked case of vaginismus, it frequently occurs that the slightest
touch on the part of the physician about the site of the hymen will
bring on painful contraction of the vagina and sphincters, and cause
the patient to spring up and show much nervous disturbance. In the same
class of cases it may be brought on by walking. Thomas says that "in
some cases a marked tendency to spasm will have been noticed upon
sudden changes of position or washing the genital fissure."[11]

[Footnote 11: _Op. cit._, p. 206.]

Barnes remarks that in some women the irritability of the nervous
centres becomes so great, the sensitiveness of the peripheral nerves at
the vulva so acute, and reflex action thereby so intensified, that the
attempt at intercourse will induce convulsion or be followed by
syncope.[12]

[Footnote 12: Edis, _Diseases of Women_, p. 533.]

One case came under the writer's observation where the sensitiveness
was so marked that a slight touch with cotton or a camel's-hair brush
would bring on severe painful contraction.

Course and Duration.--This is an affection of indefinite duration;
{385} unless relieved it may continue through years of discomfort and
misery. Cases are reported as lasting twenty-five or thirty years.
There is a mild form sometimes occurring among the recently married
which will either disappear of itself or yield to simple treatment.
More generally, the discomfort and pain continue unless successfully
treated, and in well-marked cases attempts at intercourse increase the
suffering; there is nervous exhaustion, the health breaks down in
consequence and from what has been called "the disappointment of nature
under an unfulfilled function."

PATHOLOGY.--In certain morbid conditions the nerves distributed about
the outlet of the vagina may possess such a high degree of irritability
that a foreign substance coming in contact with them will cause
contraction and spasm of the tissue in which they are distributed and
connecting muscles.

Sinéty[13] is of the opinion that "in milder forms of the disorder the
constrictor vaginal muscles alone may be the seat of the spasm; but
more generally all of the muscles forming the floor of the perineum,
the constrictors of the vulva and vagina, muscles of the anus and of
the urethra, superficial and deep," in truth, "all the muscles of the
region," can "simultaneously be the seat of spasm." Emmet[14] considers
vaginismus as kindred to neuralgia, for the reason that it more
frequently occurs among anæmic and excessively nervous women, and those
who have in some manner overtaxed their nervous systems, the locality
being determined as it were by accident, and that only in exceptional
instances can there be any local exciting cause. Thomas[15] says that
it is curious to perceive how, from different standpoints regarding the
pathology, "both parties were led to the same surgical resource."

[Footnote 13: _Manuel pratique de Gynécologie_, par L. de Sinéty,
Paris, 1879.]

[Footnote 14: _Op. cit._, p. 607.]

[Footnote 15: _Op. cit._, p. 205.]

The author's own observation will not permit of his ascribing the
majority of cases wholly to morbid constitutional conditions, to the
exclusion of local lesions. The reason of his belief is that the
greater number of cases he has observed have been treated and cured by
surgical measures, having in view the relief of morbid conditions of
some pelvic structures.

DIAGNOSIS.--The diagnosis is attended with no difficulty, as there is
no other affection presenting similarities.

PROGNOSIS.--Sims remarks that he knows of "no serious trouble that can
be so easily, so safely, and so certainly cured." Scanzoni, Tilt, and
others, who hold different views as to the pathology and means of cure,
express themselves as favorably regarding prognosis. Thomas has never
met with a case that he could not relieve or cure. Nearly all
gynecologists are of the opinion that a favorable prognosis is
warrantable in the majority of cases.

TREATMENT.--In cases where it seems quite difficult to ascertain the
etiology and pathology a palliative course may at first be pursued,
such as vaginal injections of acetate of lead or borax in warm water
(drachm j ad pint j), to which may be added carbolic acid or laudanum
or the wearing of the vaginal rest or dilator, and total abstinence
from any attempts at coition. If the chief cause seems to be in some
constitutional trouble, then as complete physiological rest as possible
should be enjoined. With {386} this in view, all attempts at sexual
intercourse must be discontinued, as it will keep up nervous suffering
and local pain and discomfort. The vaginal dilator of Sims secures a
rest by keeping the walls apart; it also dilates and benumbs the parts,
thus rendering them more tolerant of a foreign body. With every mode of
treatment or in cases occurring from any cause the vaginal dilator is
required; this is to be worn for two or more hours at intervals of six
to twelve hours, according to the degree of tolerance with which it is
borne. It should be smeared previous to insertion with some soothing
lubricant, as iodide of lead and glycerin (drachm j ad ounce j) or
atropia and vaseline (gr. ij ad ounce j) or stramonium ointment.
Vaginal suppositories containing morphia, extract of opium, belladonna,
hyoscyamus, or stramonium will usually prove of great benefit as local
sedatives. In some instances suppositories containing five to ten
grains of iodoform may be of service. Copious vaginal injections of
warm or hot water alone are beneficial in the majority of cases, as
they wash away irritating discharges that aggravate the disease, and by
lessening the congestion frequently do away with the necessity of
surgical operations.

A careful examination should be made in every case for the purpose of
ascertaining whether the vaginismus is not caused or aggravated by
fissures, ulcers, or excoriations about the parts; if any are found,
they should be properly treated. If any symptoms point toward the
rectum or urethra, they should be examined. A patient of the author's
suffered from vaginismus during some years, owing wholly to a fissure
of the anus, and was cured by an operation for the anal disease alone.

Owing to the pain an ordinary examination produces, it will generally
be necessary to etherize the patient before attempting to make a
thorough and careful examination.

In anæmic or excessively nervous patients other treatment than local is
necessary. Tonics, such as iron, quinia, strychnia, sea-bathing, etc.,
change of scene, and such kinds of exercise as improve the tone of the
nervous organism, should be prescribed. If the trouble is due to some
uterine or pelvic disorder, a cure can be effected only by attention to
the primary affection.

Some of the modes of treatment that have been mentioned, if persevered
in, will succeed in curing many cases without having recourse to any
surgical procedure. If, however, a case has not yielded to any of the
means heretofore suggested, then some form of surgical operation
becomes necessary. The simplest is the one advocated by Scanzoni and
Tilt, and consists in a forcible dilatation of the ostium vaginæ with
the thumbs, after the manner first practised by Récamier of forcible
dilatation of the sphincters in fissure of the anus. Temporary
paralysis of the vaginal sphincters is by this means effected, and
should be followed by the insertion of a large vaginal dilator, to be
worn for several days and held in position by a T-bandage. This
sometimes effects a permanent cure, but if a single trial fails to
accomplish it, yet the patient is considerably benefited, it ought to
be repeated; in the mean time the use of the dilator with one of the
ointments previously mentioned should be persevered in.

When the disorder has existed a long time, the muscular power has
increased, and the forcible dilatation may require more exercise of
strength than can be exerted by the thumbs alone; under such {387}
circumstances the writer has been in the habit of using Symes's
universal speculum or a tri-bladed rectal speculum, and gradually
dilating the vagina to the extent required.

If any of the modes of treatment that have been mentioned fail to
effect a cure, or reasons exist for not making use of them, then the
radical treatment of Sims or some one of its modifications will be
requisite.

A full description of the various surgical procedures and the views of
different authorities cannot with appropriateness be presented in this
work.

Sims's operation is made as follows: The patient is fully anæsthetized
and placed upon her back; then with curved scissors every vestige of
the hymen is removed. It is important that this be most thoroughly
done, for it has occurred that by leaving a small portion success has
not been complete. As soon as the bleeding has stopped the fourchette
is put upon the stretch by inserting the middle and index fingers, and
with a scalpel a Y-shaped incision is made through the mucous membrane
and part of the muscular fibres on each side of the perpendicular line
extending into the perineum. After this a glass vaginal dilator is
placed in the vaginal canal and worn two hours each morning and night,
or as much of the night as it can be tolerated. This should be
continued for about a month. There are several sizes of the dilator,
and in selecting one to be worn care should be taken not to use one
that is too large. Morphine suppositories per rectum should be used as
often as is requisite for the relief of pain. A copious vaginal
injection is necessary for the sake of cleanliness after each removal
of the dilator.

Sims's dilators are made of glass, the outer end open, the inner
closed, and of a conical shape; on the upper side is a depression to
avoid pressure on the urethra.

[Illustration: FIG. 27. Sims's Vaginal Dilator.]

Emmet's operation is a modification of the above, and consists in
inserting an index finger in the rectum, and then putting the sphincter
on the stretch, when with scissors he divides the fibres encircling the
vagina on each side just within the fourchette and about three-fourths
of an inch apart. He claims that this method "does not allow a prolapse
of the vaginal wall, as when the perineum is lacerated, but does permit
of an equal extent of dilatation of the outlet by the glass plug."[16]

[Footnote 16: _Op. cit._, p. 609.]

The plan of dividing the pudic nerve, as practised by Sir James Y.
Simpson, has met with little favor.

The author has been successful in several instances by a less
formidable operation than any herein described. His operation has
simply consisted of entire removal of every vestige of the hymen or
carunculæ myrtiformes with scissors, followed by wearing of the glass
plug such length of time {388} as is requisite. This procedure is
simply the first part of Sims's operation.

Parturition would, as a rule, cure this affection in an effectual
manner but its subjects are generally sterile. The reason of sterility
in vaginismus is often owing to the extreme suffering whenever there is
an attempt at coition; this pain prevents its perfect performance, and
often all further attempts are abandoned. When we are convinced that
such a condition is the cause of sterility, the patient may be
etherized, and while in that condition complete coition may result in
fruitfulness and ultimately perfect cure of the vaginismus.

       *       *       *       *       *

DISEASES OF THE VULVA.

The subject will be considered in the following order: Anatomy,
Vulvitis, Phlegmonous Inflammation of the Labia, Furuncles, Pruritus,
Hyperæsthesia of the Vulva, Tumors, Atresia, and Eruptions.


Anatomy.

As regards the anatomy of the generative organs of women in this and
the preceding chapter, it has not been deemed necessary by the author
to consider the subject in extenso, but to give a brief résumé, as
better suited to the needs and wishes of the busy practitioner.

The generative organs of women external to the hymen, in their relative
order from before backward, consist of the mons veneris, clitoris,
vestibule, meatus urinarius, and orifice of the vagina, and the labia
majora and minora on either side. All these are known under the name of
pudendum or vulva.

The mons veneris is a rounded cushion of fatty tissue immediately over
the os pubis, and from puberty is covered with hair.

The labia majora are two folds of skin extending longitudinally from
the mons veneris to the perineum. In them are found all the elements of
the skin. The subcutaneous tissue is of loose texture. A noticeable
fact is that here the sebaceous glands are remarkable for their size,
some of them being 0.5 millimeters in diameter and opening directly on
a free surface. The labia majora resemble the skin of other portions of
the body in that they contain papillæ, nerves, vessels, and Pacinian
bodies. Internally they are lined with mucous membrane in which are
numerous sebaceous follicles. A quantity of fat, areolar tissue, and
tissue analogous to the dartos of the scrotum, including vessels,
nerves, and glands, constitutes the contents of the labia, and gives
them a rounded appearance, larger in front and decreasing in size
toward the perineum. The extremities of these folds, joining together,
form the anterior and posterior commissures of the vulva.

The labia minora, sometimes called nymphæ, are two membranous folds of
erectile tissue within the labia majora, beginning at the anterior
commissure and passing down and disappearing midway between the two
commissures. They also contain sebaceous glands.

{389} The clitoris is an erectile organ covered with mucous membrane,
and is the analogue of the penis. It arises by two crura, is situated
beneath the anterior commissure, and is partially concealed by the
labia minora.

The vestibule and the fossa navicularis are triangular spaces on the
mucous membrane, the first immediately posterior to the clitoris, the
second anterior to the perineum.

The meatus urinarius is the external orifice of the urethra, and is
situated in the vestibule about one inch posterior to the clitoris. The
mucous membrane is slightly raised above the meatus, giving it
prominence, and thus serves as a guide to the introduction of the
catheter without exposing the person.

The orifice of the vagina is an elliptical opening just below the
meatus urinarius. It is partially covered over in the virgin by a fold
of mucous membrane called the hymen.

The vulvo-vaginal glands, or the glands of Bartholin, are two in
number, situated anterior to the hymen, each with a single duct opening
on the inner side of the nymphæ. They are analogous to the glands of
Cowper in the male.

The bulbi vestibuli, on either side of the vestibule, extend downward
from the clitoris for about one inch. They consist of a thin layer of
fibrous membrane ensheathing a plexus of veins.


Vulvitis.

DEFINITION.--Vulvitis is the term used to designate inflammation of the
vulva. It may be purulent, follicular, or occasionally but rarely
gangrenous.

ETIOLOGY.--The purulent form may be specific or the result of want of
cleanliness, exposure to cold, over-exertion, the strumous diathesis,
pruritus, urinary fistula, or cancer. It is also produced by awkward or
excessive coitus and masturbation, the irritation of urine, and
frequently is caused by pregnancy. Vulvitis is not uncommon with little
girls, resulting from some of the innocent causes mentioned, though the
symptoms may expose the patient unjustly to the suspicion of having
been tampered with.

SYMPTOMATOLOGY, COURSE, AND DURATION.--At first there is heat, dryness,
and more or less pain in the affected parts, followed by a profuse flow
of yellow pus. There is also tumefaction, hypersensitiveness, and often
pruritus. Follicular vulvitis is the term employed to indicate an
inflammation of the mucous or sebaceous glands and of the
hair-follicles of the vulva. This disease may be the result of any of
the causes of purulent vulvitis, as alluded to in the preceding clause.
The subjective symptoms are common also to the purulent form.
Objectively, the mucous membrane will appear to be very red in spots,
resembling in this respect the raised papillæ of the tongue. These
spots frequently bleed on slight provocation. The internal surface of
the nymphæ and vestibule is the seat of the disease when the mucous
glands are involved, but where the sebaceous glands are mainly affected
the inflamed papillæ will be found on the surface of the labia and at
their juncture anteriorly. In the course of the inflammation a drop of
pus will exude from the papules, and they then gradually {390}
disappear. Occasionally, collections of exudate from the diseased
glands accumulate beneath the labia minora, concealing the diseased
surfaces and becoming quickly very offensive. The disorder, though
sometimes persistent, is seldom chronic. The acute affection may be the
cause of urethritis in the male closely resembling gonorrhoea if
coition occurs during its existence, and thus not infrequently giving
rise to suspicion of infidelity.

TREATMENT.--In the matter of treatment, touching the inflamed points
with carbolic acid or caustic sometimes favorably influences the course
of the disease. Cleanliness is the most important item in the treatment
of the two forms of the disease, for without it the application of
remedies will be of little avail. Strict attention to this, with
perfect rest of the parts, will not infrequently be all that is
requisite to effect a cure, but in cases that do not yield to this
treatment sedative, astringent, or alterative applications are
indicated. These should be applied after bathing. In the purulent
variety such remedies as the lead-and-opium wash after the following
formula will prove serviceable:

  Rx. Tinct. opii,   fluidounce j;
      Plumbi acetat. drachm j;
      Aquam ad       fluidounce viij.

Lint may be saturated with this lotion and applied between the labia.
If the disease does not yield to the treatment already mentioned in the
course of two or three days, a solution of argentic nitrate (gr. x to
ounce j) should be brushed upon the parts, and between the intervals of
its application bismuth or starch may be kept constantly on the parts.
In cases associated with vaginitis a much stronger solution is
sometimes required. (Vide chapter on Vaginitis.) The author has used
powdered iodoform in some cases with very good results.

[Illustration: FIG 28. Follicular Vulvitis (Huginer).]

In the follicular variety the disease is more severe and usually of
longer duration than the purulent, although the principles of treatment
are essentially the same. In this as in the other variety cleanliness
is of paramount importance, frequent washing being very essential. To
the inflamed follicles such applications as nitrate of silver,
persulphate of iron, and carbolic acid are the more frequent remedies
used in this disease. After the application of any of these remedies
the parts should be rendered dry, and then a piece of soft linen or a
roll of absorbent cotton should be smeared with vaseline or soaked with
carbolized glycerin and inserted within the vulva in a way to keep the
labia apart. Occasionally the practitioner will meet with a chronic
form of vulvitis, and the rareness of its occurrence is fortunate, for
the reason {391} that it is a very obstinate and intractable variety of
the disease. Vulvitis is very frequently associated with vaginitis,
owing to the fact that the mucous membrane is continuous in both vulva
and vagina. On this account the principle of treatment of inflammation
of either locality is essentially the same. To avoid repetition, the
reader is therefore referred to the section on Vaginitis for a more
detailed description of treatment.

There is a form of this disease described by Vinay[17] as ulcerous or
aphthous vulvitis. This is an affection peculiar to childhood,
occurring only when the general health is much impaired. It is often a
sequel of fevers, and may even become epidemic. It attacks children of
any age, but is of more common occurrence in infancy. The disease
appears first upon the mucous membrane in the form of small and round
patches of a white or grayish-white color, which soon ulcerate, and at
a more advanced stage are liable to become gangrenous. This variety of
vulvitis has long been known, and is mentioned in the works of
Hippocrates. This disease is rarely met with in this country.

[Footnote 17: _Nouveau Dict. de Méd._, tome xxxiii., 1885.]


Phlegmonous Inflammation of the Labia Majora.

DEFINITION.--The adipose and areolar tissue which compose the greater
bulk of the labia majora often become the seat of acute inflammation,
in consequence of direct injury, excessive or awkward coition, exposure
to cold, from irritating discharges, scratching in pruritus, vulvitis,
or that peculiar blood-state which predisposes to the formation of
boils or carbuncles.

SYMPTOMATOLOGY AND DIAGNOSIS.--The patient will first complain of heat
and pain, increased by standing or walking, and later throbbing and
shooting pains in the affected parts. In the outset the part is
congested, followed by induration from effusion in the loose tissues,
and next suppuration ensues. An examination in the last-named stage
will reveal the existence of an abscess in one labium. The diagnosis is
by no means difficult, but the physician, however, should bear in mind
that this same locality may be the site for pudendal hernia, a
dislocated ovary, hæmatocele, or vulvitis.

TREATMENT.--In the outset the inflammation may be caused to disappear
by resolution, by means of cold and sedative lotions, such as the
lead-and-opium wash, saline laxatives, non-stimulating diet, and
perfect rest. In the majority of cases the disease proceeds to
suppuration. When it is found that resolution is unattainable, then
means should be taken to promote and hasten suppuration. This is best
effected by the frequent application of hot poultices. The mistake is
often committed of permitting too long intervals to elapse between the
application of poultices, and allowing the one applied to become cold
before another one takes its place. The patient can be saved many hours
of suffering by keeping hot applications constantly on the inflamed
labium. As soon as suppuration is detected the abscess should be
opened, for two reasons aside from the one of affording relief: First,
the tissue resists early natural evacuation; second, owing to the
laxity of the tissues, pus will sometimes force itself upward toward
and through the abdominal ring.


{392} Furuncles of the Labia.

DEFINITION.--Closely resembling phlegmonous inflammation are the
furuncles or boils which are quite common on the labia. They occasion
much pain and distress, for the reason that they are very obstinate and
apt to recur, one forming as soon as its predecessor has apparently
healed. In many instances these boils seem to be consequent upon
inflammation of sebaceous glands. They differ in size, some being no
larger than a pea, while others are the size of a filbert.

TREATMENT.--This should be constitutional and local. Quinine, arsenic,
cod-liver oil, and other remedies of a tonic character should be
administered. The bromide of arsenic has been used by the author in a
few cases with quite satisfactory results. As soon as one of these
furuncles shows that it contains pus, it should be freely opened and a
crucial incision made to prevent immediate healing; after which
poultices should be applied. These small boils are extremely painful,
and are very troublesome, owing, as previously stated, to their
liability of recurrence. To prevent their recurrence is one of the
reasons why immediate healing of the incisions should be prevented. If
contraction of the sacs of the abscesses does not occur, pus will
continue to be formed and the tissues in their immediate neighborhood
will become indurated. In this way the furuncles may become of a
chronic character. To further facilitate healing and aiding their
contraction the sacs should have applied to them some stimulating
remedy, such as carbolic acid or nitrate of silver. Edis says that
painting the surface of the affected labium with tincture of iodine is
beneficial in some instances.

One of the most important requisites in treatment is perfect
cleanliness.


Pruritus Vulvæ.

DEFINITION.--Pruritus vulvæ, although merely a symptom of disease,
characterized by itching of the vulva and contiguous neighborhood at
times wellnigh intolerable, has, because of its occasional obscure
etiology and severity, always been considered by medical authors as a
disease of itself, instead of a symptom of other disorders, in
treatises on diseases of women.

ETIOLOGY.--Predisposing and Exciting Causes.--It frequently occurs from
external irritation, as animal parasites, or such as may be produced by
acrid discharges, particularly in gonorrhoea and uterine cancer,
changes in the normal composition of the urine, especially diabetic,
and not infrequently during the menstrual flow. Pruritus may occur in
connection with inflammation of the uterus and vagina without any
irritating discharge; likewise it occurs in diseases of the urethra,
bladder, and kidneys. Sometimes masturbation may be the cause as well
as the effect of pruritus. Secondarily, there may be an insufferable
itching in consequence of the continued titillation or irritation of
the parts, although masturbation by no means invariably leads to
pruritus. The habitual use of opium or alcoholic drinks often causes
intractable forms of this disorder. Edis states "that the custom of
immoderate tea-drinking is a by no means infrequent cause of pruritus."
But instances of pruritus occur where all {393} of the causes mentioned
are lacking, and they are instead purely of a reflex character, such as
are met with in women about the time of the change of life and during
the latter months of pregnancy, or from the presence of worms in the
rectum. If the worms migrate to the vulva, as they sometimes do, the
irritation then becomes direct. Interference with the circulation of
the vulva by pregnancy and tumors may cause pruritus: unquestionably,
certain varieties of the disorder are idiopathic or neurotic.

SYMPTOMATOLOGY AND COURSE.--When the complaint has existed for some
time, the itching will be pretty well diffused from the pubis backward,
but in more recent cases it may be localized at the perineum, nymphæ,
clitoris, or portions of labia. The itching is not always constant, but
subject to exacerbations. It is usually much worse when the patient
becomes heated from exercise or is warm in bed, thus preventing comfort
or sleep, and thereby adding an additional complication to treatment.
The sufferer naturally seeks relief by scratching the involved tissues,
and for this very transient satisfaction spreads the disease by
increasing the irritability of the parts and inducing a condition
closely resembling eczema.

TREATMENT.--Inasmuch as the etiology of the complaint is often
uncertain, as heretofore stated, it is highly important that the
physician should ascertain if possible the cause of the disease, and
thereby be better enabled to treat the complaint intelligently. In case
the itching can be traced to the animal parasites most common in this
region, such remedies as the black or yellow wash, mercurial ointment,
or the oleate of mercury will usually prove sufficient; but if it be
found that the Acarus scabei is the cause of the itching, the
application of the ordinary sulphur ointment will destroy this parasite
and the itching will consequently cease. If due to uterine catarrh or
any vaginal affection, attention should be directed to the removal of
the primary disorder by appropriate means, for it cannot be expected
that itching of the vulva can be relieved so long as there is any
irritating discharge constantly exciting it. The most important measure
of all is perfect cleanliness. This can be secured by sitz-baths,
sometimes several being necessary daily. At the same time, the vagina
should be syringed with warm water or water with the addition to it of
such remedies as are used for the relief of leucorrhoea. The irritated
surfaces of the vulva should be prevented from coming in contact by
vaseline spread upon absorbent cotton or lint, or by powders, such as
bismuth, starch, etc.

In case there is an unmistakable acrid discharge from the uterus
causing pruritus, proper topical applications should be made to as much
of the endometrium as is diseased; the vagina should be thoroughly
douched night and morning, and then there should be placed against or
around the neck of the womb one or more tampons of cotton saturated
with the boro-glyceride or with glycerin, in which has been dissolved
borax or acetate of lead in the proportion of ounce ss of one of these
salts to ounce ij of glycerin.

In some instances, where there is a profuse discharge, simply packing
the vagina with dry salicylated or borated cotton will suffice. This
should never be allowed to remain longer than twelve hours without
removal. In those cases where the discharge is less acrid a single
tampon saturated with one of the remedies named or glycerin alone, and
placed {394} against the cervix daily, will suffice, as it will prevent
the discharge from coming in contact with the vulva. In severer forms
of this affection a number of tampons saturated in the same manner will
be more efficacious, and still permit the patient to move about. When
several tampons are used they should be loosely rolled, and each one
should have a string attached for convenient removal. In the mean time,
topical applications can be made to the vulva, and washing of the parts
will not interfere with the tampons. The author has found the following
prescription of Thomas very efficacious as a vaginal injection and wash
for the vulva:

  Rx. Plumbi acetatis, drachm ij;
      Acidi carbolici, scruple ij;
      Tr. opii,        fluidounce j;
      Aquæ,            pint iv.  M.

Another prescription which has demonstrated its value is:

  Rx. Bismuthi subnitratis,
      Acaciæ pulv.          aa drachm ij.  M.

Sig. Add water to the consistency of cream and apply frequently with a
brush.

A somewhat similar prescription, to be applied in the same way, is the
following:

  Rx. Pulv. acaciæ, drachm ij;
      Bals. Peru,   drachm j;
      Ol. amygdalæ, drachm iss;
      Aquæ rosæ,    fluidounce j;  M.;

or,

  Rx. Acidi carbolici, drachm ij;
      Glycerinæ,       fluidounce j;
      Aq. rosæ,  q. s. fluidounce viij.  M. Ft. lotio.

In all cases of pruritus, except from parasites, much benefit can be
derived from washing the parts two or three times daily in a weak
solution of bicarbonate of sodium (half a tablespoonful in a quart of
water, with a tablespoonful of eau de Cologne).

In pruritus from diabetes some relief may be afforded by the
administration of alkaline mineral waters or salicylate of sodium. In
pruritus associated with chronic cystitis the last-named remedy is very
useful.

In pruritus of a neurotic character a solution of the muriate of
cocoaine of the strength of 4 per cent., sprayed upon the parts or
applied with a camel's-hair brush, has often in the author's hands
afforded relief when every other application has failed.

One of the latest publications relating to the treatment of pruritus
vulvæ is a paper by Kustner,[18] agreeing with Schroeder that the
results of operative treatment for pruritus vulvæ are encouraging. This
author publishes several cases resulting successfully. A synopsis of
one will suffice to show his mode of treatment. A patient, unmarried,
suffered for a long time from uterine catarrh and pruritus vulvæ: the
former was relieved after prolonged treatment, but there still remained
two symmetrical spots between the hymen and labia minora which were the
seats of most troublesome itching and were exceedingly sensitive to
touch. These portions of the mucous membrane were rich in sebaceous
glands, and were also studded with small retention-cysts. The author
dissected off {395} the two elliptical portions of mucous membrane,
each 1 cm. broad and 3 or 4 cm. long, and containing the small
retention-cysts, and then united each wound with interrupted sutures.
The pruritus entirely disappeared, and did not again return, though
some years after the patient again suffered with uterine catarrh. Other
cases are related by the same author, notably one case of pruritus
where there was a lacerated perineum. The operation for repair of this
perineum was performed, with the result of the permanent disappearance
of the pruritus. The author does not give any definite rule as to how
and in what cases he should have recourse to operative treatment, but,
admitting that pruritus may arise from causes heretofore mentioned in
this article, he asks whether those cases where secondary pathological
changes have occurred in the vulvar mucous membrane cannot be
definitely cured by excision of the affected portion. Not enough cases
of cure of pruritus by surgical treatment have been reported to fully
establish the theory of Kustner, yet it is a matter of sufficient
importance to merit our attention and warrant further investigation.

[Footnote 18: _Centralbl. f. Gyn._, No. 12, 1885.]


Hyperæsthesia of the Vulva.

DEFINITION.--This is a disorder first described by Thomas under the
above caption.[19] It consists of a hypersensitiveness of the nerves
supplying some portion of the mucous membrane of the vulva. Sometimes
the area of tenderness will be confined to one of the lesser lips or it
will be limited to the vestibule, and in other cases a number of parts
may be simultaneously affected. "It is a condition of the vulva closely
resembling that hyperæsthetic state of the remains of the hymen which
constitutes one form of vaginismus," and doubtless is often confounded
with the latter.

[Footnote 19: _Op. cit._, p. 145.]

ETIOLOGY.--It is more common about the time of change of life, and
occurs more frequently among women of hysterical diathesis where there
exists a morbid mental condition with a tendency to melancholia. In
some instances the disease seems to be excited by vulvitis or vascular
growths in the urethra.

SYMPTOMATOLOGY.--The slightest friction causes intense pain and
nervousness, and even a current of cold air produces very great
discomfort. Coition causes such severe pain that for this cause the
subject usually consults her physician. As in vaginismus, the mental
distress is often of an exaggerated character, in some instances
bordering upon monomania.

PATHOLOGY.--In this disorder there are no indications of inflammation
except occasional spots of erythematous redness. It is not a neuralgia
in a true sense of the term, but an abnormal sensitiveness of diseased
nerves supplying the vulva.

DIAGNOSIS.--The affections most liable to be confounded with this are
vascular growths (or irritable caruncles) of the urethra and
vaginismus, but ocular inspection and digital examination will enable
the physician to determine the character of the disease.

TREATMENT.--This is far from satisfactory in many cases. Thomas speaks
most discouragingly concerning it, and states that "the treatment of
this condition is most unsatisfactory."

{396} The author has at this time a patient with hyperæsthesia of the
vulva who has been treated by him for many months, and up to the time
of this writing has obtained no relief. Thomas recommends sending the
patient "away from home, where, in addition to enjoying changes of air,
scene, and surroundings, she would live absque marito."

In this, as in all disorders which depend on or are associated with the
hysterical diathesis, galvanism and massage are, as a rule, of decided
benefit. In addition, general tonics, such as arsenic, strychnia,
quinia, and iron, should be prescribed. If any local affection exist,
such as vulvitis or urethral vegetations, it should be cured first.
Warm fomentations, the frequent use of warm water, sedative lotions,
and ointments consisting of opium or its salts, carbolic acid,
chloroform, and iodoform, are useful topical remedies. Much benefit may
be derived by the application of a 4 per cent. solution of
hydrochlorate of cocoaine by means of a spray or soft brush. Strong
solutions of alum and tannin have sometimes proved beneficial.

No good results have been derived from the use of the knife or caustics
in cases where they have been used.


Tumors of the Vulva.

Under this head will be included any enlargement, neoplasm, or
adventitious growth which has the vulva for its site. The most common
are the following, which will be considered in the order named: viz.
Cysts, Hydrocele, Hernia, Hypertrophy, Elephantiasis, Hæmatoma, Cancer,
and Urethral Caruncle. There are other growths of the vulva, such as
fibroma, lipoma, sarcoma, lupus, etc., but they are of such rare
occurrence that their discussion is necessarily omitted.


Cysts and Inflammation of the Vulvo-Vaginal Glands.

The frequent concomitance of cysts and abscesses in these glands has
caused the author to consider them here under the same caption.

The most frequent cysts of the vulva are those springing either from
the ducts or glands of Bartholini, or, as more commonly known, the
vulvo-vaginal glands, situated near the lower part of the labia. Cysts
having their origin in the ducts are single and are invariably of an
oval form; such also is the more common shape of those springing from
the gland, yet sometimes they are lobulated, of an irregular form, and
comprise one or more in number. Inasmuch as this same locality is
sometimes the site of hernia, and cysts of the labia often of a similar
form, the physician should be positive that the tumor is a cyst before
having recourse to any active mode of treatment.

If fluid accumulates in a cyst in such quantity as to cause the subject
inconvenience or discomfort, surgical treatment will be required, of
which there are three different modes in common use.

The first mode is to remove by scissors a segment of the sac, allowing
escape of its contents, after which the cavity is filled with marine
lint or carbolized cotton, which is allowed to remain for about
forty-eight hours {397} before renewal. By this plan of treatment the
sac will usually be obliterated. Another method is to freely open the
cyst and apply some caustic, preferably the galvano- or thermo-cautery.
In the absence of either of the last named nitric acid may be used with
good effect. The third and last method has in the author's experience
proven the most efficacious, though objection has been made to it on
account of its being a more bloody operation--namely, complete
extirpation of the gland.

The causes of inflammation of these glands are the same as those that
cause vulvitis; in truth, they are often accompanying disorders. The
symptoms are pain, heat, itching, and an increased redness,
particularly about the opening of the duct. If a finger be pressed over
the location of the gland, it will elicit signs of pain.

[Illustration: FIG. 29. Abscess of Glands of Bartholini.]

In the outset of the inflammation it is felt hard and unyielding, but
two or three days later a fluctuating tumor may be easily discerned. An
abscess of the gland should be easily distinguished and rarely mistaken
for a cyst. There are the history and ordinary signs of inflammation to
aid in diagnosis. If, on the contrary, there is simply a cyst, it can
be rolled about under the finger and no indications of pain produced.
Further, it may exist an indefinite length of time, and unless the
gland from some cause become inflamed no great inconvenience is
experienced. It is not an infrequent occurrence, from some cause, for
inflammation to attack a cyst-wall, in which event the symptoms of
inflammation ensue. Where such is the case the treatment should be the
same as in inflammation of the gland--namely, absolute rest and any
soothing or anodyne lotions which favor restoration. Should indications
of suppuration occur, it should be promoted by the frequent application
of hot poultices. If the pain is not severe, the abscess may be left to
nature; but if it be severe, then the abscess should be emptied by a
free incision at the most prominent point.


Hydrocele, or Cysts of the Canal of Nuck.

DEFINITION.--An accumulation of fluid in the canal of Nuck,
constituting a hydrocele or cyst, is of rare occurrence. It is to be
found in the upper part of the vulva. Owing to the rarity of this
affection the greatest caution should be exercised in its diagnosis.
The absence of inflammatory symptoms, of resonance when percussed, and
the ordinary signs of hernia, together with a gradual growth of the
tumor without constitutional disturbance, would by the exclusive mode
of diagnosis leave but little room for doubt as to its character. If,
however, the physician still feels uncertain, the means which are used
for the cure of this disorder will also aid in diagnosis--namely,
aspiration with a fine needle about the size of those used on a
hypodermic syringe. Even where hernia exists no harm will be done, for
this is not an uncommon practice for the reduction of hernia in this
locality.

{398} TREATMENT.--Frequently nothing further is required in the way of
treatment than the reduction of the tumor by aspiration. If, however,
additional treatment seems to be necessary, it is best to inject
tincture of iodine by reversing the action of the syringe. The use of
iodine in this manner is for the purpose of obliterating the sac by
inducing adhesive inflammation, as is done in the treatment of
hydrocele in the male.


Pudendal Hernia.

DEFINITION.--If the process of peritoneum surrounding the round
ligaments as they emerge from the inguinal canal to become lost in the
dartos-like tissue of the labia is not obliterated at birth, the
channel thus formed is known as the canal of Nuck, and furnishes a path
for hernia. Besides a loop of intestine or portion of mesentery the
ovary or bladder may descend through this canal and constitute an
inguinal or labial hernia. The uterus has even been said to have
descended by this route. The infrequency of pudendal hernia makes it
all the more important to recognize it when it does occur, that serious
injury may be avoided when operating on supposed cases of labial
abscesses or cysts.

ETIOLOGY.--Pudendal hernia may be produced by blows, falls, coughing,
or sneezing, and by violent muscular exertions, as in the male.

SYMPTOMS.--The presence of a part of the intestine can be
diagnosticated by the peculiar crackling feeling, the impulse
communicated on coughing, and sometimes the disappearance of the tumor
on taxis. Occasionally reduction is very difficult, and exceptionally
it may become strangulated.

TREATMENT.--The patient being placed on her back with her hips
elevated, a gentle taxis will usually suffice to cause reduction. The
physician should be positive that the tumor has been returned to the
abdomen. After this is accomplished a truss should be adjusted so as to
press on the inguinal canal. Usually a perineal band will be necessary
to keep the truss sufficiently low to accomplish the purpose for which
it was adjusted.

If taxis has proved inefficacious, and strangulation has occurred, a
surgical operation will be necessary.


Hypertrophy of the Vulva.

Hypertrophy of the vulva occurs among certain peoples, as the Bushmen
and Hottentots, so commonly as to constitute a race-peculiarity, and on
account of size and form has been designated as the Hottentot apron.
There is also said to be a peculiar deposit of fat in the nates of
Hottentot women, but this should not be confounded with the vulvar
peculiarity of the same race. Occasionally in our own country
hypertrophy of one or more labia will be met with. Sometimes the nymphæ
are hypertrophied, so that they hang down much lower than the greater
lips; owing to this dependency and their usual pigmentation of a
brownish color they bear some resemblance to elephantiasis. In simple
hypertrophy the progress is gradual, and there is an entire absence of
the inflammatory attacks to {399} which a labium affected with
elephantiasis is subject, nor are there any superficial abscesses as in
the latter affection. Although there is usually the brown color on the
surface in simple hypertrophy, the color is not the same as in
elephantiasis. In the latter there is the peculiar pigmentation, also
roughness and deep crevices in the skin, so closely resembling in
appearance an elephant's skin that there need be no difficulty in the
differential diagnosis of simple hypertrophy and elephantiasis of the
vulva.

Hypertrophy of the clitoris sometimes occurs as a congenital deformity,
and sometimes it is acquired. There has seemed to be quite a general
belief that masturbation is one of its most common causes, but there
are no substantial grounds for such belief. On the contrary, it has
been frequently observed where women were known to have indulged in
this habit that no increase in the size of the normal clitoris could be
perceived.

TREATMENT.--If a subject of hypertrophy of the vulva suffers any degree
of inconvenience therefrom, the affected parts should be removed. A
surgical operation for this purpose is an exceedingly simple one and
demands no special description.

An operation for the removal of an hypertrophied clitoris is more
bloody than one for the removal of the labia; still, with ordinary
precautions it need be neither a severe nor dangerous one.
Clitoridectomy for the purpose of curing masturbation or various
neurotic affections is happily not of as frequent occurrence as
formerly. The author is firmly of the opinion that neither in cases of
masturbation, epilepsy, nor hystero-epilepsy is the removal of the
normal clitoris beneficial or even justifiable.


Elephantiasis of the Vulva.

DEFINITION.--The vulva is sometimes the site of neoplasms known as
elephantiasis arabum. The labia may become so hypertrophied that they
hang down to the middle of the thighs in the form of tumors; the
clitoris and perineum may also be affected. The skin is generally of
the peculiar brownish color of an elephant's skin, and hence the name
of the disease. The surface of the skin will present many tuberosities
due to hypertrophy of the cutaneous papillæ. Superficial abscesses and
ulcerations often occur, causing discomfort and pain.

ETIOLOGY.--It is said that elephantiasis of the nymphæ sometimes
results from onanism; it is also congenital. Scrofula, malaria,
syphilis, and filth are generally considered as among the direct causes
of elephantiasis arabum in the countries where it is the most common.
Occasionally it is produced by a blow or contusion. Although this
disease is not very common in this country, yet a sufficient number of
cases have been seen from time to time to call forth a number of
articles in the medical periodicals of our country.

PATHOLOGY.--The pathological changes, according to Mayer, consist in a
dilatation of the lymphatic spaces and ducts with secondary formation
of connective tissue and thickening of the layers of the cutis vera;
sometimes the papillæ are specially enlarged, producing swellings which
resemble condylomata in form. The labia majora are most frequently
affected, next in frequency the clitoris; more rarely are the labia
minora {400} hypertrophied. This affection is developed during that
period of life when sexual activity is the greatest.

[Illustration: FIG. 30. L, Right labium majus, healthy; A, upper part
of pachydermatous tumor, covering a part of the mons veneris; B, lower
portion of the tumor, occupying the perineum. This tumor measured from
anterior to posterior margins nearly nine inches. In its widest portion
it measured three inches.]

TREATMENT.--The treatment of elephantiasis of the vulva must
necessarily be surgical, and therefore will be omitted here, excepting
that which is embodied in the following report of cases by the author
in the Detroit _Review of Medicine_ in December, 1875, and are briefly
reproduced here:

Case No. 1.--Fig. 30 shows the condition of Mrs. ----, aged thirty, the
mother of several children and four months advanced in pregnancy at the
time she came to my clinic. She walked with difficulty and complained
of pain on the left side of the genitalia. She had been troubled with
the tumor hereafter described for more than two years, and during her
last pregnancy, because of its becoming larger and more painful, it
proved a serious impediment to childbirth. For these reasons she wished
it removed before being further advanced in pregnancy. The contiguous
parts were irritated by fluid discharged from small integumentary
abscesses. I removed the tumor by a surgical operation, and the patient
made a perfect recovery without any return of the growth. A feature of
the case observed during the operation was that an incision made in any
portion of the tumor caused a serous discharge to exude, so that at
{401} all times it was possible to tell whether I was cutting beyond
the diseased tissue or not.

[Illustration: FIG. 31. FF, Folds of anterior portion of labia majora,
the remaining portion of the great lips being hidden from view; L,
anterior part of the left labium minus; R. middle part of the right
labium minus; M, enlarged left labium minus; N, enlarged right labium
minus. A B, the light line between these letters, is designed to
indicate the introitus vaginæ, but the actual opening to the canal had
its anterior boundary immediately backward of the nodule seen near the
letter B. The urine was voided just above the nodular point, near the
letter C. The figure does not well exhibit the elongated clitoris,
which was fully an inch and a half long, and could be felt in the mass
like a hard cord. The tumor seemed to begin at the clitoris and the
anterior portions of the labiæ minora, and as it increased in size the
introitus was filled by it anteriorly.]

Case No. 2.--Miss ----, æt. twenty-two, a brunette of French parentage,
came to the clinic for the purpose of having removed from the vagina a
tumor of a year's growth, which she said was still rapidly growing,
making it difficult and painful for her to walk or engage in any
pursuit. The tumor of which she spoke is the one represented by Fig.
31. The operation for the removal of the tumor simply consisted in
excising the entire mass and putting a ligature around the base of the
hypertrophied clitoris. Three days after a hard-rubber vaginal dilator
was inserted, and ordered to be worn most of the time until the parts
were healed.

In the first case here reported there was no evidence of any syphilitic
taint, but the woman lived in a markedly malarial district. In the last
one there were indications of a syphilitic taint. A microscopic
examination of the tumor of each case plainly showed its pachydermatous
character. Both women were very dark brunettes, each having a coarse,
tawny skin, and neither was over-cleanly in her habits.

An important indication relating to operative treatment in this
locality is the use of the galvano- or thermo-cautery, particularly the
latter, owing to the great vascularity of the parts and the lack of
points upon which to exercise counter-pressure to control hemorrhage.


Hæmatoma.

DEFINITION.--Hæmatoma of the vulva is also designated as thrombus or
pudendal hæmatocele. This affection consists of an effusion of blood in
subcutaneous or submucous cellular tissue of the vulvo-vaginal region;
the effusion occurs usually in one labium or in the cellular tissue
surrounding the vaginal walls, and, later becoming coagulated, forms a
tumor which may vary in size. The tumors sometimes attain the size of a
foetal head.

ETIOLOGY.--Hæmatoma generally occurs during pregnancy or during labor,
usually from some injury, but rarely spontaneously or in the
non-pregnant. Muscular effort during childbirth, blows, kicks, falls,
the passage of the foetal head, or anything which can obstruct the
return of venous blood or produce rupture of the veins, may be a cause.

SYMPTOMATOLOGY.--The patient will have a feeling of discomfort, later
pain of a throbbing character, and often difficult urination on account
of the tumor encroaching upon the urethra. If the tumor is very large
she will experience some degree of faintness.

DIAGNOSIS.--The sudden appearance of the tumor with the symptoms
alluded to usually renders diagnosis an easy task. The affections which
may possibly be confounded with this are abscess of the labia,
inflammation or cysts of the glands of Bartholini, and pudendal hernia.

TREATMENT.--If the effusion should be small and the symptoms light, but
little is demanded except quiet and cooling lotions, like the
lead-and-opium wash. If there is effusion in the labia and there are
indications of suppuration, it should be treated as phlegmonous
inflammation by hot poultices, etc.[20]

[Footnote 20: Vide Phlegmonous Inflammation of the Labia, p. 391.]

{402} It is sometimes necessary during labor, in order to complete it,
that a free incision is made in the tumor and the clot turned out with
the fingers. This same treatment is often requisite when the tumor is
very large and there are good reasons for believing that it will not
undergo absorption. It is generally advisable to pursue the same course
if a thrombus has existed for some time and there are no signs of
absorption or suppuration, by reason of the continued discomfort and
pain to which the patient is subject.

After the clot is removed there is often a renewal of the bleeding, in
which case the cavity should be plugged with lint or surgical cotton
and pressure applied by means of vaginal tampons and external bandages.
Sometimes it is requisite to saturate lint or cotton with liquid
persulphate of iron, and finally pack the cavity with it in order to
check the bleeding. If there is no hemorrhage after the evacuation of
one of these tumors, then there is no need of packing or making use of
styptics, but it is necessary to prevent phlegmonous inflammation or
septicæmia. For this purpose iodoform or carbolic acid should be used
and a free outlet provided for the discharge of pus. Washing out the
cavity with a weak solution of the permanganate of potassium[21] also
serves a good purpose.

[Footnote 21: The author usually directs that from 4 to 8 grains of
this salt shall be added to each pint of warm water when it is to be
used as an injection or wash.]


Cancer of the Vulva.

Cancer is not a common disease of the vulva, yet as a primary affection
it attacks this locality more frequently than the vagina.

Epithelioma is the most common form, and generally appears in the
outset near the clitoris or on one labium as a small hard and warty
growth, which at first itches and later smarts, but is not painful.

After an indefinite length of time the growth, which has increased
somewhat in size, becomes painful, ulcerated, and there is more or less
of an offensive ichorous discharge. If the disease pursues its natural
course, the ulceration will rapidly extend until neighboring tissue
becomes involved; the inguinal glands become affected, and after the
characteristic cachexia becomes apparent there is no known remedy or
means of treatment that can prevent the progress of the disease to a
fatal termination.

If the clitoris becomes affected with this form of malignant disease,
it can be detected earlier than epithelioma of any other portion of the
organs of generation on account of its more external position, its
greater sensitiveness, and the increasing pain which the affection and
its enlargement produce.

TREATMENT.--If the disease is detected sufficiently early, an entire
removal of all the affected parts, including a wide margin of healthy
tissue, will generally effect a cure; but postponement until
neighboring parts, more particularly the lymphatic glands, are
implicated leaves little or no hope of cure through any mode of
treatment. Carcinoma of the vulva is generally an extension of the same
disease from the uterus or the inguinal glands, and rarely occurs as a
primary affection.


{403} Urethral Caruncle.

This painful affection, commonly included by medical authors as among
diseases of the vulva, will be very briefly considered.

DEFINITION.--The most common neoplasm to which the urethra is subject
is known as urethral caruncle, vascular tumor, or irritable vascular
excrescence of the urethra. These growths consist of all excrescences
located at the mouth of the urethra, and sometimes extending within the
canal for a short distance. They are of a deep-red color, soft and
friable, sometimes regular in shape, but more frequently irregular, and
then resemble a small cockscomb. They vary in size from the head of a
pin to a raspberry, occasionally attaining that of a walnut.

ETIOLOGY.--No definite cause can be given for the development of
urethral caruncle. These growths occur among married and single, old
and young.

SYMPTOMS.--The first symptom generally is that the patient experiences
a severe smarting pain during or immediately after voiding urine. Pain
is also caused by walking, pressure, friction, or even the slightest
contact of clothing. Also sleep is frequently disturbed in consequence
of slight movements of the body. Coition not only causes a severe pain,
but, owing to the friable and vascular character of the growth, it
often causes a flow of blood, which leads the subject to believe she
has cancer or some other serious disorder. In addition to the foregoing
symptoms the patient usually becomes fretful, nervous, hysterical, and
melancholy. The severity of one's suffering when thus affected is very
much out of proportion to the size of the growths giving rise to it.

Occasionally there will be a feeling of weight and pain in the pelvic
region, extending down the thighs. There will also be a muco-purulent
discharge from the urethra.

PATHOLOGY.--Urethral caruncles may be briefly defined as consisting of
"dilated capillaries in connective tissue, the whole being covered with
squamous epithelium."[22]

[Footnote 22: Hart and Barbour.]

DIAGNOSIS.--(This has been given in part under head of Symptoms.) If
there is protrusion of any portion of the caruncle the diagnosis is
easy. Yet a prolapse of the urethral mucous membrane or of the urethra
may be mistaken for a vascular tumor, but there will not be the
characteristic pain attending either of these conditions that
invariably accompanies caruncle of the urethra.

Syphilitic growths are sometimes located here, but they are wart-like
and painless, and generally have companions in the same neighborhood.

By placing the patient on her back in the lithotomy position and
carefully inspecting the parts a diagnosis is by no means difficult.
When the growths are within the meatus slight dilatation may be
requisite to see them, for which purpose a pair of ordinary
dressing-forceps will usually suffice.

TREATMENT.--Owing to the liability of the recurrence of caruncles their
simple removal by a cutting instrument will not, as a rule, suffice.
Various modes of treatment have been recommended, but the most
efficacious can be very briefly stated as follows: The patient being
anæsthetized and placed on her back, the growths are then removed and
their bases {404} thoroughly cauterized by Paquelin's thermo-cautery at
a dull heat; if of a large size it is a better plan to first remove
them by scissors and then apply the cautery. If a thermo- or galvanic
cautery is not at hand, a knitting-needle heated in the flame of a
spirit-lamp will serve a good purpose.


Atresia.

Although the subject is referred to here in its regular order, yet for
the greater convenience of the reader vulvar atresia has been included
by the author in the preceding section on Diseases of the Vagina (see
p. 373).


Eruptions.

The skin and mucous membrane of the vulva may develop eruptions common
to such tissues in other parts of the body. Those most often found are
eczema, erythema, herpes, and acne. They are not distinguished from
eruptions located elsewhere, except it may be their greater obstinacy
in responding to treatment.




{405}

DISORDERS OF PREGNANCY.

BY W. W. JAGGARD, A.M., M.D.


"Gestation," says Mauriceau, "is a disease of nine months' duration."
Robert Barnes[1] more truthfully remarks: "Since in pregnancy every
organ and the whole organism are specially weighted, undergoing
extraordinary developmental and functional activity, so any defect or
fault inherited or acquired, however latent, will be liable to be
evolved or intensified under the trial. Hence pregnancy is the great
test of bodily soundness." The pregnant woman is liable to many
disorders which can be distinctly traced to the existence of pregnancy.
The study of the natural history of gestation renders it highly
probable that these disorders are merely pathological exaggerations of
physiological functions. Then, pregnancy confers upon the individual no
immunity from the diseases to which the non-pregnant woman is liable.
But certain acute and chronic diseases, sustaining the relation of
accidental complications, are variously modified in their course and
effects by pregnancy, and accordingly are of interest to the general
practitioner.

[Footnote 1: _Obstetric Medicine and Surgery_, 1884, London, p. 205.]

For convenience of discussion the disorders of pregnancy may be
classified under two headings: I. The Pathological Exaggerations of
Physiological Processes; and II. The Peculiarities of Certain
Accidental Acute and Chronic Diseases occurring in the Course of
Pregnancy.

       *       *       *       *       *

I. THE PATHOLOGICAL EXAGGERATIONS OF PHYSIOLOGICAL PROCESSES.

It is always difficult, frequently impossible, to draw the
boundary-line at which normal functional activity becomes pathological.
As remarked by Spiegelberg, all the diagnostic penetration of the
physician is demanded to recognize this transition. Then, a high
exercise of judgment is necessary to determine when to preserve a wise
and masterly inactivity, when to adopt measures of active interference.


Alterations in the Constitution of the Blood.

CHLOROSIS AND HYDRÆMIA.

Recent investigations show that qualitative and quantitative changes
occur in the constitution of the blood of the normal pregnant woman.
The {406} red corpuscles, albumen, and iron diminish, while the white
corpuscles, fibrin, and aqueous elements increase. Virchow describes
this increase in the number of white corpuscles as a physiological
leucocytosis dependent upon the growth of the lymph-vessels and
corresponding hypertrophic changes in the pelvic and lumbar lymphatic
glands. The total blood-mass is also increased--a change especially
notable in the second half of pregnancy. When the number of red
blood-corpuscles is abnormally diminished the woman becomes chlorotic.
If, in addition, the albumen is abnormally diminished, hydræmia
results. Chlorosis and hydræmia can only be regarded as independent
affections in the absence of cardiac and renal lesions. They are seldom
traceable to pregnancy in the absence of individual predisposition.
Effusions into the subcutaneous connective tissue, pleural and
peritoneal cavities, are liable to occur. Sudden exudations into the
pleural cavity are particularly dangerous, while effusions into the
subcutaneous tissue of the abdomen, vulva, and lower extremities are
annoying and may interrupt pregnancy.

TREATMENT.--The indications for treatment are obvious. The quality of
the blood must be improved, elimination of the aqueous elements
attempted, and local disturbances alleviated. Nutritious food, iron in
combination with non-irritant diuretics, fulfil the first two
indications. Blaud's pill, which Niemeyer and Spiegelberg extol so
highly, is an excellent tonic preparation. Basham's iron mixture is
admirable in its effects.


PROGRESSIVE PERNICIOUS ANÆMIA.

Gusserow[2] was the first to observe and describe a peculiar form of
progressive pernicious anæmia occurring during gestation. The disease
is of rare occurrence, and nothing is known as to its etiology.
Chlorosis and hydræmia, however, may be mentioned as predisposing
causes.

[Footnote 2: _Arch. f. Gyn._, ii. p. 218.]

PATHOLOGY.--The alterations in the constitution of the blood are
identical with those in anæmia and hydræmia, and produce similar
effects. Evidences of fatty degeneration are found in the musculature
of the heart, intima of the arteries, and portions of the capillary
walls; retinal hemorrhages are constant lesions. The number of white
corpuscles is not increased, and signs of leukæmia--splenic tumor,
swelling of the lymphatic glands--are wanting. The condition is that of
oligæmia or oligocythosis.

The prodromal symptoms occur during the first half of pregnancy, are
obscure, and cannot be distinguished from the effects of chlorosis and
hydræmia. After the disease has passed through its incipient stages,
food, iron, and tonics seem to have no influence upon its course.
During the second half of pregnancy abortion or premature labor usually
occurs spontaneously. Under these conditions the shock and hemorrhage
resulting from parturition are sufficient to cause a lethal issue in
many cases.

PROGNOSIS.--Graefe[3] has collected 25 cases of this rare affection: 1
case recovered, 2 cases were discharged improved; the others died
before or shortly after labor. The prognosis is obviously grave.

[Footnote 3: _Diss._, Halle, 1880.]

TREATMENT.--As food, iron, and tonics have little or no effect upon the
disease after it has passed through its incipient stages, therapeutic
resources are limited. The evacuation of the uterine cavity, as shown
by {407} Graefe's cases, exercises a favorable influence upon the
course of the affection. Gusserow advises the artificial interruption
of pregnancy whenever grave symptoms occur, and the weight of
professional opinion is very decidedly in favor of such a course.
Negative results have attended all efforts at transfusion.


HÆMOPHILIA.

Kehrer[4] has recently called attention to the apparent influence of
pregnancy in the development of the hemorrhagic diathesis. This
influence, however, is seldom observed, and then only in cases of
distinct, individual predisposition.

[Footnote 4: _Arch. f. Gyn._, x. p. 201.]

TREATMENT.--The induction of premature labor, or, at times, of
abortion, is indicated.


PLETHORA.

The experiments and observations of Spiegelberg[5] and Gscheidlen prove
the possibility of the occurrence of plethora during gestation. Actual
increase of the red corpuscles, albumen, and iron in the blood is
observed during the second half of pregnancy, and then only under the
most favorable conditions. As described by Spiegelberg, the symptoms
are--mammary and cerebral congestions, palpitation, vertigo,
constipation, hepatic torpor.

[Footnote 5: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 58.]

TREATMENT.--Restricted diet, muscular exercise, and an occasional
saline purge will relieve the troublesome symptoms. Spiegelberg is
convinced of the value of bleeding in selected cases.


Circulatory Disturbances.

Among the circulatory disturbances due to pregnancy, mechanical oedema
and the varices of the pelvis and lower extremities deserve attention.

De Cristoforis of Milan describes a mechanical inferior venous
hyperæmia, the result of the pressure of the gravid uterus on the iliac
veins. The mechanical oedema of the abdominal walls, vulva, and lower
extremities, intensified by chlorosis and hydræmia, is usually
associated with venous ectasis. The oedema may become so excessive that
locomotion is rendered difficult, while the labia are enormously
distended and the subcutaneous tissue of the abdominal walls becomes
pendulous. Toward the end of pregnancy, when the uterus sinks into the
pelvic cavity, the oedema and varices frequently abate.

Active measures for the relief of the symptoms produced by oedema are
frequently indicated. Threatened gangrene of the skin from
hyper-distension may render puncture of the hydropsical regions
necessary. It is quite possible to interrupt pregnancy by this little
operation, especially if the labia are punctured. Elevation of the
lower extremities, rest in the horizontal position, elastic bandages
and stockings, local hot packs, mild diuretics, usually fulfil all
indications for treatment.

Varices are observed more frequently among multiparæ, but may occur in
primiparæ. They are usually developed during the second half {408} of
pregnancy. The principal trunk of the saphena is first involved, and
subsequently the lateral branches. Congeries of veins are observed on
the inner sides of the legs and thighs, especially in the vicinity of
the knees. The iliac veins may become dilated, as shown by the
condition of the vulvar veins and the occurrence of hemorrhoids.
Varices incommode the patient, but seldom cause serious disturbances.
Sometimes, however, their tunics are lacerated, and serious even fatal
hemorrhage may result. Spiegelberg[6] records four cases of fatal
hemorrhage from the rupture of varices in pregnancy. Then there is
always the danger of phlebitis and the processes of thrombosis and
embolism, even when the loss of blood is insignificant.

[Footnote 6: _Lehrbuch d. Geburtshülfe_, Lahr, 1882, p. 235.]

TREATMENT.--The regular and gentle evacuation of the bowels will
frequently relieve the distressing symptoms due to hemorrhoids. Fordyce
Barker points out the fact that aloes is not contraindicated by
pregnancy. A pill containing a grain or a grain and a half of powdered
aloes, with a quarter of a grain of extract of nux vomica, is a very
good remedy. Frequent hot fomentations in conjunction with narcotic
ointments will relieve the pain from the congestion of the piles.
Attempts at reduction must be instituted with extreme care. It is
usually impossible to completely cure the condition during pregnancy,
and there is danger of interrupting gestation. Elevation of the lower
extremities and equable compression by an elastic bandage or rubber
stocking relieve the symptoms caused by varices of the saphena. P.
Ruge[7] and A. Martin have seen favorable results from the hypodermatic
injection of ergotin.

[Footnote 7: _Berl. Beitr. z. Geb. u. Gyn._, Bd. iii. p. 7.]


Disorders of the Alimentary Canal.

THE UNCONTROLLABLE VOMITING OF PREGNANCY.

Nausea, even vomiting, in the morning, before or shortly after meals,
during the early months of gestation, is so common and devoid of
injurious effect that it is regarded as physiological. Robert Barnes
views it as a normal means of discharging superfluous nervous energy.
The uncontrollable vomiting of pregnancy, in which the stomach retains
absolutely nothing, is a grave disorder. The patient vomits glairy
mucus, clear or colored by the bile. Ultimately the vomit is mixed with
blood. Violent retching, intense nausea, pyrosis, and hiccough are
constant and distressing symptoms. The woman becomes emaciated. The
buccal cavity is dry, the tongue red and shining, the teeth and gums
covered with sordes, the breath horribly fetid, the skin dry and harsh.
Salivation is frequently observed. Constipation and extreme thirst
usually coexist. The epigastrium is tender upon pressure. The woman
becomes restless and irritable from loss of sleep and painful efforts
at vomiting. A fever of typhoid type is developed, with a quick, rapid,
thready pulse. The urine is sparingly secreted, concentrated, and
contains albumen and tube-casts. Jaundice is frequently noticed.
Extreme marasmus supervenes, and the woman succumbs to some
intercurrent disease or dies of exhaustion in muttering delirium.
Phthisis and diarrhoea are intercurrent affections which may hasten the
lethal issue.

{409} Between the slight nausea upon rising in the morning and the
state of extreme marasmus thus briefly sketched every degree of
pathological variation may be observed.

It is a remarkable fact that the incessant vomiting, retching, and
hiccough seldom interrupt pregnancy until near its end. The muscular
effort and loss of blood at this time may precipitate the fatal
termination.

Occasionally, spontaneous abortion or premature labor occurs before the
patient's condition is desperate. Under these circumstances the severe
symptoms may disappear immediately. The same sudden cessation of the
vomiting is frequently observed after quickening, rapid excentric
hypertrophy of the uterus, and death of the foetus.

The COURSE of the disorder is chronic. Cases terminate by recovery or
death in from two to three months. Alarming symptoms are usually
developed from the second to the sixth month--very seldom during the
seventh and eighth months.

Fortunately, the uncontrollable vomiting of pregnancy is a rare
affection. So few cases are recorded in German medical literature that
Hohl[8] has denied the existence of the condition. Carl Braun[9] in a
fabulous experience of over one hundred and fifty thousand obstetrical
cases has never seen a fatal case.

[Footnote 8: _Grundriss d. Geburtshülfe_, Kleinwächter, 1881, p. 197.]

[Footnote 9: _Lehrb. d. Gynaekologie_, Wien, 1881, p. 842.]

PATHOLOGY AND ETIOLOGY.--As the essential predisposing cause of this
disorder it is necessary to bear in mind the increased functional
activity of the nervous system in general, and of the spinal cord in
particular, during pregnancy. Increased reflex mobility is apparent in
all the so-called sympathetic affections.

Peripheral irritants are not wanting. The growing ovum stretches the
uterine fibres, and consequently irritates the uterine nerves.
Bretonneau adduces many facts in favor of this theory. Vomiting is
severer in first pregnancies, and occurs during the first half of
pregnancy. Vomiting is observed in connection with passive distension
of the uterus caused by the unusually rapid growth of the ovum, as in
hydramnion and multiple pregnancy. Immediate cessation of all symptoms
is frequently noted after quickening, rapid excentric hypertrophy of
the uterus, death of the foetus, evacuation of the uterine contents.
Henry Bennet directs attention to the importance of congestions,
inflammations, and lacerations of the cervix uteri as etiological
factors. Graily Hewitt maintains that uterine displacements, with or
without incarceration, producing irritation of the uterine nerves, are
potent causes. The round gastric ulcer, chronic catarrhal gastritis,
are sufficient causes in many cases.

Diseases of the endometrium, decidua, foetal envelopes, or of the
foetus itself may supply adequate excentric irritants.

Frerichs has pointed out the connection of hyperemesis with the renal
insufficiency of Bright's disease. Kiwisch finds a sufficient cause in
the relation between the hyperæsthetic gastric nerves and the hydræmic
condition of the blood of the pregnant woman. Lebert and Rosenthal are
of the opinion that hyperemesis is symptomatic of extreme general
inanition of nervous tissue. Numerous other theories more or less
ingenious, and adequately explanatory of certain cases, exist in the
literature of the subject. Notwithstanding the extent and accuracy of
etiological research {410} into the uncontrollable vomiting of
pregnancy, a large class of cases remains in which no organic change
capable of objective demonstration can be found.

DIAGNOSIS.--The diagnosis of the uncontrollable vomiting of pregnancy
is not so easy as at first apparent. Guéniot[10] pertinently calls
attention to three distinct elements: (1) The diagnosis of pregnancy;
(2) the diagnosis of the adjuvant or determining cause of hyperemesis;
(3) the differential diagnosis between the uncontrollable vomiting of
pregnancy and obstinate vomiting from some other cause entirely
independent of the pregnant condition.

[Footnote 10: _Thèse Agrégation_, Paris, 1863.]

Experienced clinicians have committed mistakes, particularly in the
third element. Trousseau once made the diagnosis of uncontrollable
vomiting of pregnancy in a case in which the autopsy revealed cancer of
the stomach. This case was observed by Depaul. Charpentier[11] reports
a serious error in diagnosis made by Beau. The case was diagnosticated
as hyperemesis of pregnancy. The autopsy showed that the obstinate
vomiting was probably due to tuberculous meningitis.

[Footnote 11: _Traité pratique des Accouchements_, Paris, 1883, t. i.
p. 621.]

PROGNOSIS.--Severe vomiting in pregnancy is always ground for anxiety,
and the prognosis must always be guarded. The majority of cases
terminate in recovery without the interruption of pregnancy. Guéniot
records 118 cases: of these, 46 died; of the 72 survivals, 42 recovered
after the spontaneous or artificial evacuation of the uterine contents.
Recovery usually, though not always, rapidly follows the cessation of
pregnancy. The prognosis is absolutely unfavorable after the appearance
of fever and typhoid symptoms.

TREATMENT.--The treatment of hyperemesis may be effective. Its
efficiency, however, depends largely upon the accurate recognition of
the adjuvant and determining causes. A rational therapeusis must
consist in the elimination of these etiological factors. The treatment
naturally resolves itself into (1) hygienic; (2) medical; (3)
gynæcological; (4) obstetrical.

Hygienic.--The hygienic treatment is of avail in the minor degrees of
the disorder, although not without influence in the more serious cases.
Diet is of primary importance. Let the patient breakfast upon a small
cup of strong coffee or tea, half a cup of milk and lime-water, a
morsel of cracker or toast early in the morning, in bed, and lie
quietly for one or two hours following the meal. Small quantities of
easily-digestible food at short intervals will be tolerated when the
patient has given up all pretence at keeping to regular meals. Liquid
foods, as sparkling koumiss, egg-albumen in water, iced milk with
lime- or soda-water, commend themselves. Absolute dietetic rules,
however, cannot be maintained. The stomach of the pregnant woman is
proverbially capricious and fanciful. Charpentier narrates the history
of a case suggestive in connection with this subject. The patient, four
months advanced in pregnancy, in a critical condition from
uncontrollable vomiting, came under the care of Beau in the Hôpital de
la Charité. One day she asked for Bordeaux crawfishes. Beau granted her
request. On the first day two crawfishes were retained; on the second,
six; on the third, crawfishes ad libitum, bouillon, and milk. Within
six days {411} the vomiting disappeared. Cazeaux and Guéniot cite cases
in which ham and paté de foie gras were retained after the rejection of
easily-digestible foods. It is necessary to respect these caprices and
fancies.

When everything is rejected absolute stomach-rest is indicated. Then
nutrient enemata may be tried. Of the great value of rectal
alimentation under these conditions there can be no doubt. Henry F.
Campbell of Georgia relates the history of a case in which he nourished
the patient for fifty-two days by the rectum alone. There is danger,
however, of irritating the rectum and causing diarrhoea--a peculiarly
unfavorable complication at this time; and this fact must be clearly
borne in mind. Of the various nutrient enemata, peptonized milk, cream,
defibrinated blood, Leube's beef-and-pancreas mixture, eggs, and
beef-tea containing albumens are among the best. From four to six
ounces should be exhibited not more frequently than once every six
hours.

Inunctions of oil are of undoubted value. Absolute moral and physical
rest frequently exercises a favorable influence. Seyfert advised his
patients to go home on a visit to their mothers, and return to the
conditions to which they were accustomed prior to marriage. Coitus may
be a disturbing factor. Rest in the horizontal decubitus exercises as
favorable an influence as in sea-sickness.

Medical.--There are few drugs in the Pharmacopoeia which have not been
vaunted as specifics by some and found utterly worthless by others.
This fact indicates, as remarked by Schroeder, that all remedies are
unreliable, and that spontaneous cures frequently occur. Various
effervescent liquids, as dry champagne, carbonic-acid water containing
one drachm of potassium bromide to the siphon, are sometimes grateful.
Subnitrate of bismuth and the antacids are of great value in cases of
excessive gastric acidity. Oxalate of cerium, a much-vaunted remedy, is
of very little value. Small doses of the tincture of nux vomica are
useful in cases of gastric catarrh. The various local anæsthetics are
of great importance. Small doses of creasote, carbolic acid, tincture
of aconite-root, hydrocyanic acid, and the volatile oils have been used
with varying degrees of success. Of this class of remedies cocaine
hydrochlorate deserves especial attention. On a priori grounds there is
much in its favor. Clinical experience with the drug is not such as to
warrant very positive deductions. W. Otto[12] has employed cocaine in
sea-sickness, especially in pregnant women, with favorable results.
Manassein[13] reports several cases of hyperemesis of pregnancy cured
by its exhibition. The subject is certainly worthy of thorough
investigation. G. Gaertner of Vienna states that 0.1 cocainum
muriaticum has no toxic effect upon adults. Doses of 0.015-0.02 of the
solution (cocain. muriat. sol. Merck, 1.0; aq. destill. 9.0) may be
given to an adult three times daily without fear of toxæmia. Goodell
recommends drop doses of wine of ipecacuanha and tincture of
belladonna, repeated every fifteen minutes.

[Footnote 12: _Berl. klin. Woch._, 1885, No. 43.]

[Footnote 13: _Ibid._, 1885, No. 35.]

Of all medical agents, however, opium, the bromides, and chloral are
the most reliable. A clyster containing thirty or forty drops of the
deodorized tincture, or a half-grain suppository of the aqueous extract
of opium, sometimes produces a happy effect. Hypodermatic injections of
morphine will frequently allay the distressing symptoms after the
failure of other measures. In the German hospitals large doses of the
bromides {412} and chloral are exhibited per rectum with gratifying
success in many cases.

Flying blisters, the ether spray, and the faradic current applied to
the pit of the stomach may give relief in the milder forms of the
disorder.

Gynæcological.--Under the gynæcological treatment of hyperemesis quite
a number of important operative procedures are included: 1. If bimanual
examination reveals a displacement of the uterus capable of producing
symptoms, the organ must be replaced if possible, and retained in
position by a properly fitting pessary. 2. Henry Bennet suggested the
cauterization of the cervix in all cases, basing his therapy upon his
peculiar views of the pathology of the condition. Welponer, Sims, and
Jones recommend the application of a 10 per cent. solution of argentic
nitrate to the vaginal portion of the cervix in all cases, irrespective
of the condition of the cervical tissues, when other means have proved
useless. Carl Braun[14] bears testimony as to the value of this
procedure. 3. As an ultimate resource before artificially interrupting
gestation, the plan of dilating the os externum and cervix uteri with
the index finger should be tried. Copeman[15] of Norwich, England,
desirous of inducing abortion in the case of a patient afflicted with
hyperemesis, pushed his finger through the cervical canal to the
membranes and attempted to puncture the amnion with a sound. Failing to
accomplish his purpose, he went home for assistance, and returned at
the expiration of two hours. To his surprise, the uncontrollable
vomiting had ceased. Since 1875, when he published the results of this
experience, cases have accumulated proving the great value of this
method. W. Gill Wylie[16] of New York has devised a steel dilator to
substitute the finger. When the os externum is at all patulous, the
index finger is the safest and most efficient dilator. The method is a
purely empirical one, does not always secure the desired result, and
frequently causes abortion or premature labor. Still, as the ultimate
gynæcological resort it has important functions.

[Footnote 14: _Lehrb. d. g. Gynaekoloqie_, 1881, p. 841.]

[Footnote 15: _Brit. Med. Journal_, 1875, 1879.]

[Footnote 16: _N. Y. Med. Record_, Dec. 6, 1884.]

Obstetrical.--The evacuation of the uterine contents, if effected
before the development of the febrile stage, is usually followed by
immediate disappearance of all distressing symptoms. In the large
majority of cases, however, the same end may be secured by a judicious
combination of the hygienic, medical, and gynæcological methods of
treatment to which attention has been directed. The weight of
professional opinion is decidedly opposed to the procedure. For
practical purposes the induction of premature labor may be excluded
from consideration. The woman usually recovers or dies before the
period of foetal viability. Carl Braun[17] gives expression to the very
general professional conviction upon this subject in the following
words: "I myself have never observed a lethal issue in consequence of
the uncontrollable vomiting of pregnancy, lay the greatest weight upon
the expectant management and more modern medicamentation, and am of the
opinion that after a conscientious estimate of all considerations and
contraindications, artificial abortion can be omitted, notwithstanding
its permissibility from a scientific point of view when extreme danger
to maternal life has been determined by several physicians."

[Footnote 17: _Lehr. d. g. Gynaekologie_, 1881, p. 842.]


{413} PTYALISM.

The excessive secretion of saliva is a rare disorder of pregnancy. At
all times distressing, it may seriously endanger the patient's life
when the quantity of fluid amounts to several quarts per diem. The
parotid and submaxillary glands are swollen and tender. The buccal
mucous membrane is red and tumid. The absence of fetor serves to
distinguish the salivation of pregnancy from the ptyalism of mercurial
poisoning. A generous diet and the free exhibition of iron mitigate in
some degree the distressing symptoms. Dewees recommends a strictly
animal diet. Astringent mouth-washes, small doses of potassium iodide,
and subcutaneous injections of atropine over the submaxillary glands
are indicated, but seldom influence the condition.


TOOTHACHE.

Toothache in pregnancy may be a purely functional disorder. In the
majority of cases, however, actual caries is present. During gestation
the secretions of the buccal cavity are sometimes altered, and become
sufficiently acid to dissolve the lime salts out of the enamel. Again,
when for any reason an insufficient quantity of lime salts is ingested
with the food, the foetus is supplied with ossific materials derived in
part from the maternal teeth. The condition of pregnancy is not
infrequently detected in the dentist's chair from these changes.
Popular recognition of these dental changes gave origin to the familiar
saw, "For every child a tooth." The indications for treatment are
obvious. Quinine and local anæsthetics relieve the symptoms of the
functional forms of the disorder. Caries may be prevented, to a certain
degree, by extreme attention to the teeth and secretions of the buccal
cavity and a free, generous mixed diet. Doubtless, the popular belief,
that an absolute fruit diet will limit the deposition of ossific
material in the foetal skeleton and render labor easier, is responsible
for much of the caries observed in American women. It is needless to
say that such a belief is utterly without foundation in fact. When
structural changes in the teeth have occurred the decalcified dentine
should be excavated, and temporary fillings of oxyphosphates or
gutta-percha inserted. This little operation can be performed rapidly,
without pain or fatigue, and preserves the contour of the teeth.


CONSTIPATION.

Constipation is a usual, sometimes a troublesome, attendant upon
gestation. The etiological factors are mechanical interference of the
gravid uterus with intestinal peristalsis, defective innervation of the
bowels, and alterations in the intestinal secretions. When the rectum
becomes filled with scybalous masses the condition predisposes to
abortion or premature labor. Diet is of primary importance in securing
regular evacuations of the bowels. Fresh fruits, brown bread, oatmeal
porridge are useful to this end. Enemata have obvious advantages over
all drugs. In the selection of aperient remedies care must be taken to
choose laxatives and avoid drastic cathartics. The compound licorice
powder and confection of senna of the U. S. Pharmacopoeia, Hunyadi,
Friederichshalle, and Pullna mineral waters, may be included in the
list.


{414} DIARRHOEA.

Diarrhoea is a less frequent but more dangerous disorder during
pregnancy than constipation. In the early and latter months of
gestation diarrhoea is liable to occur from mechanical compression of
the rectum by the gravid uterus. Dysentery, with tormina and tenesmus,
is a particularly unfavorable complication. The dangers are apparent.
Not only is the blood impoverished, but abortion or premature labor may
be induced. Every diarrhoea occurring during pregnancy demands
immediate attention. Small doses of argentic nitrate in combination
with opium, in pill form, are useful in mild cases of diarrhoea, while
the deodorized tincture of opium in starch-water enemata is indicated
in dysentery.


Diseases of the Liver.

In normal pregnancy the functions of the liver in the secretion of bile
and the excretion of cholesterin are not materially modified. The case
is different with the glycogenic function. Blot in 1856 detected the
presence of glycogen in the urine of nearly half the pregnant women
examined. He concluded that this glycosuria was physiological. Tarnier
in 1857 called attention to certain structural changes in the liver
occurring during normal gestation. The liver is enlarged in volume, and
a peculiar fatty infiltration within the lobule is perceptible. De
Sinéty confirmed Tarnier's observations, finding the fatty infiltration
within the centre of the lobule, seldom near the periphery. Robert
Barnes and Ewart have added corroboratory testimony. Tarnier ascribes
the physiological glycosuria announced by Blot to the fatty
infiltration observed by himself. Each of these three functions of the
liver, the secretion of bile, the excretion of cholesterin, and the
glycogenic function, may undergo pathological exaggeration during
pregnancy.


ICTERUS.

Icterus is observed with relative infrequency during gestation. Two
distinct forms are recognized--simple jaundice, with bright-yellow
coloration of conjunctivæ and skin, without fever and cerebral
symptoms; and malignant jaundice, with dull-yellow coloration of
conjunctivæ and skin, with fever and cerebral symptoms.

Simple Jaundice.--Simple icterus may occur at any time during
pregnancy, runs its usual course, and exercises, as a rule, no serious
influence upon the maternal health. The effect upon the foetus is
grave. If the icterus is intense and lasts for a considerable period of
time, the foetus dies and gestation is interrupted. All the foetal
tissues are found to be stained with the biliary coloring matters--a
condition termed by Lobstein cirrhonosis.

ETIOLOGY.--The causes of simple jaundice in pregnancy are identical
with those which produce the condition in the non-gravid state, and are
frequently obscure. It is in a high degree probable that pressure from
the gravid uterus is without influence, since the symptom may appear at
any time during gestation. The pathological condition usually present
is catarrh of the mucous membrane of the duct or of the duodenum in the
vicinity of the orifice, causing a narrowing of its lumen.

{415} SYMPTOMS.--The conjunctivæ, skin, and urine are colored bright
yellow, and there is entire absence of febrile and cerebral symptoms.

The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the
same as in the non-pregnant state. In view of the possible causative
relation between simple and malignant icterus, and the injurious effect
upon the foetus, medical treatment should be instituted at once.
Restricted diet, mercurials or ipecacuanha, followed by saline
cathartics, are the more important measures. Artificial abortion or the
induction of premature labor has no effect upon the condition. This
operative procedure is indicated in the interest of the child, however,
when the icterus is intensive, of long duration, the foetus living and
viable, the frequency of the foetal heart-beats diminished, and there
is reason to fear its death. Carl Braun recognizes very distinctly the
force of this indication.

Malignant Icterus.--Malignant icterus, due to the acute yellow atrophy
of the liver of the pregnant woman (Rokitansky), is a very rare
disease. Carl Braun has observed the condition only once in
twenty-eight thousand cases from 1857 to 1863.

ETIOLOGY AND PATHOLOGY.--Very little is known as to the causes of acute
yellow atrophy of the liver. Virchow ascribes one case coming under his
own observation to compression of the lower half of the liver and
gall-bladder by the growing uterus. The rarity of the affection and its
occurrence irrespective of the time of pregnancy prove the limited
operation of this etiological factor. It is in a high degree probable
that the disease may have its starting-point in simple catarrhal
icterus.

The liver is ochre-colored, shrunken to one half its volume, and
flaccid. On section no signs of lobular structure are visible.
Microscopical examination reveals total destruction of the acini and
hepatic cells. In the place of the glandular elements, fat-globules,
fine granular detritus, crystals of leucin and tyrosin are noted. The
spleen is enlarged and the kidneys show acute inflammatory changes.
Extensive ecchymoses are observed under the skin, pericardium, and
gastric mucous membrane.

SYMPTOMS.--The prodromal symptoms of acute yellow atrophy of the liver
are usually overlooked. A trivial jaundice with slight elevation of
temperature may precede by several days the development of cerebral
symptoms. Difficulty in speech, headache, disorders of the senses
followed by delirium, convulsions (cholæmic eclampsia), and coma are
the more important symptoms of cerebral origin. The pulse is remarkably
frequent and small. The temperature is at first elevated several
degrees, but becomes subnormal prior to death. The urine is sparingly
secreted, highly colored by the bile-pigments, and contains albumen,
tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the
urates are diminished. The combination of symptoms points to the
retention within the system of the waste products usually excreted by
the liver and kidneys. Ultimately, a condition of complete hepatic and
renal insufficiency obtains.

DIAGNOSIS.--The dull yellow color of the skin and conjunctivæ, with
fever and cerebral symptoms, is a sign of greatest diagnostic value.
Physical exploration reveals tenderness on pressure over the hepatic
region, and rapidly diminishing area of hepatic dulness on percussion.
Care must be taken to exclude acute phosphorus-poisoning--a toxæmia
{416} simulating very closely acute yellow atrophy, and repeatedly
confounded with that affection.

PROGNOSIS.--No case of recovery has been recorded up to the present
time. The disease pursues a rapidly fatal course, terminating within a
few days after the development of the icterus.

TREATMENT.--Therapeutic measures must be addressed to prophylaxis. It
is necessary to regard simple icterus as a possible prodrome of the
malignant form of the disorder.


DIABETES MELLITUS.

The most superficial discussion of the disorders of pregnancy would not
be complete without some mention of diabetes. The existence of
physiological glycosuria during pregnancy and lactation has been
demonstrated. Bernard has shown that sugar appears in the placenta of
calves at an early period, attains its maximum in the third or fourth
month, and when the glycogenic function of the foetal liver is
established entirely disappears. The relation between physiological
glycosuria and that pathological exaggeration of a normal process,
diabetes mellitus, is very obscure. It is, however, a clinical fact
that diabetes mellitus occurs more frequently in the pregnant than in
the non-gravid woman. Diabetic women are less apt to conceive. When
conception does occur, pregnancy is liable to interruption from the
death of the foetus. Under these circumstances glucose is found in the
amniotic liquor and foetal urine. A case related by Bennewitz and cited
by Matthews Duncan indicates that diabetes mellitus may be developed
during successive pregnancies, and entirely disappear during the
intervals. The influence of pregnancy in developing a latent diabetic
tendency may be accepted as established. A clinical observation of some
importance is that diabetic coma is seldom developed.

PROGNOSIS.--Matthews Duncan[18] has collected the histories of 22
pregnancies in fifteen women varying in age from twenty-one to
thirty-eight years: 4 of the 22 pregnancies terminated fatally by
collapse, rather than by coma. The majority of the children died during
pregnancy after attaining to the age of viability. Two children were
feeble at birth, and died a few hours later. One infant was diabetic.

[Footnote 18: _Obstet. Trans._, vol. xxiv. p. 256.]

TREATMENT.--The hygienic and medical treatment of diabetes mellitus
occurring during pregnancy does not differ from the therapy in the
non-gravid state. There is great diversity of opinion upon the subject
of the induction of premature labor. On a priori grounds it would seem
to be indicated in the interest both of the mother and the child in the
graver cases. In the entire absence of authoritative clinical
experience, however, the operation must be resorted to with an extreme
degree of caution.


Diseases of the Kidneys.

Albumen is found in the urine of from 3 to 5 per cent. of all pregnant
women.[19] In parturient women albuminuria is of much more frequent
occurrence. Leube's researches indicate the existence of physiological
{417} albuminuria in the pregnant as in the non-gravid state. It is a
matter of great practical difficulty to determine the limits of this
normal functional activity. In a large proportion of cases the
boundary-line between health and disease is passed. The physiological
function undergoes pathological exaggeration, and various forms of
nephritis are produced.

[Footnote 19: Schroeder, _Lehrb. d. Geburtshülfe_, Bonn, 1884, p. 373.]

ETIOLOGY AND PATHOLOGY.--The types of renal disease to which pregnancy
stands in more or less direct causal relation are numerous.

1. Leyden describes a condition, the kidney of pregnancy, which may be
regarded as the intermediate stage between health and disease. The
amount of albumen is increased; hyaline and granular casts, with renal
epithelium, showing fatty changes, appear in the urine. This fatty
degeneration of the cells covering the glomeruli and lining the
uriniferous tubules is not of an inflammatory nature. Anasarca of the
lower extremities is usually present. The condition may last for an
indefinite period of time without causing serious symptoms. With the
expiration of the term of pregnancy it may disappear, leaving no trace
of its former existence. On the other hand, the kidney of pregnancy may
be the starting-point of some serious renal lesion.

2. Latent chronic interstitial nephritis, chronic tubal nephritis, and
lardaceous degeneration of the kidney are usually influenced
unfavorably by pregnancy, and, in turn, may lead to the interruption of
that state. Chronic interstitial nephritis and chronic tubal nephritis
may have their origin in the kidney of pregnancy. The cirrhotic kidney
is distinguished from the other forms by the abundant aqueous urine,
containing comparatively little albumen--none at all at times--cardiac
hypertrophy, and hard pulse. In the differential diagnosis of chronic
tubal nephritis and the kidney of pregnancy chief reliance must be
placed upon the history of the case and the course of the affection.
Albuminuria is a very inconstant symptom of the lardaceous kidney,
especially in the beginning and ultimate stages of the disease.

3. Mixed types of chronic Bright's disease are frequently observed.
Thus, the interstitial and tubal forms of the disease may be combined.
Lardaceous degeneration may be present with either form, and fatty
changes are common in all the types of Bright's disease. Eclampsia is
of relatively infrequent occurrence in chronic Bright's disease,
although anasarca and its consequences may cause the interruption of
pregnancy.

4. Acute Bright's disease is one of the most serious disorders
occurring in the course of pregnancy. The urine is diminished in
quantity, and contains a large amount of albumen, tube-casts, and red
blood-corpuscles. Eclampsia is of frequent occurrence, and usually
induces abortion or premature labor.

The causes of renal disease and of its symptom albuminuria are not
always evident. In the kidney of pregnancy there is no inflammatory
change. The cells covering the glomeruli and the glandular cells lining
the uriniferous tubules undergo fatty degeneration, and are cast off as
the result of anæmia.

In the acute and chronic forms of renal inflammation there is a variety
of probable etiological factors. Mechanical pressure from the gravid
uterus may impede the return of venous blood and determine congestion
of the kidneys. This explanation is rendered more probable by the fact
{418} that albumen usually appears in the urine after the fifth month,
when the uterus has attained considerable size. Albuminuria is of
comparatively more frequent occurrence in primiparæ with tense
abdominal walls. It is frequently observed in cases of large ovarian
cysts and uterine fibroids. The increased functional activity of the
organs, the elevation of blood-pressure, the alterations in the
constitution of the blood, are doubtless potential factors. When any
latent tendency to Bright's disease exists, exposure to cold and
impeded cutaneous functional activity are more likely to develop the
disease in the pregnant than in the non-gravid state. Compression of
the ureters is regarded by Halbertsma as a cause of great importance.

SYMPTOMS.--The symptoms of Bright's disease in pregnancy are neither
uniform nor constantly present. Anasarca frequently directs attention
to the patient's condition long before the appearance of more
significant signs. Oedematous swellings of the face, hands, arms, feet,
legs, and labia majora are always suspicious, and should lead to an
examination of the urine. These oedematous swellings are
wandering--appear when the patient is lying down, and disappear when
she rises and walks about. Sometimes, toward the end of pregnancy, they
become less marked, not infrequently entirely disappearing, while the
albuminuria is increasing. The skin covering the oedematous portions of
the body is dry, of a chalkish-white appearance, and the surface
temperature is depressed.

Anomalous nervous phenomena, such as headache, vertigo, dimness of
vision, spots before the eyes, ringing in the ears, sudden deafness,
obstinate nausea and vomiting, sleeplessness, neuralgia, are often
observed, and should always excite suspicion. These various nervous
symptoms may be viewed as produced by the retention within the blood of
certain substances normally excreted by the kidneys.

Convulsions, due to renal insufficiency, may occur during pregnancy,
but are observed more frequently during parturition and the puerperium.

Attention has already been called to the characters of the urine. It is
necessary to remember that in the granular, contracted kidney and
lardaceous degeneration albuminuria may escape observation.

Bright's disease strongly predisposes to abortion or premature labor.

PROGNOSIS.--Any organic disease of the kidneys is serious. When the
disease is extensive and involves both organs the prognosis is
especially unfavorable. Accurate conclusions as to the dangers of
Bright's disease during pregnancy are not justified by the present
state of our knowledge. It is only possible to say, in a general way,
that the prospect of recovery is less favorable than in the non-gravid
state. Owing to the strong predisposition to abortion and premature
labor, the chances of the foetus surviving pregnancy are relatively
slight. Even if the child is not prematurely expelled from the uterus,
it usually succumbs to the influence of the excrementitious products
retained within the maternal blood.

TREATMENT.--In view of the serious complications arising in pregnancy
from interference with the functions of the kidneys, the absolute
necessity of chemical examination of the urine at regular intervals in
every case, especially during the latter half of gestation, is
apparent. When pathological albuminuria is present, rational therapy
will be directed to the removal of the cause. Evacuation of the uterine
contents is the only mode of removing the pressure from the gravid
uterus, but {419} we have a variety of expedients, hygienic and
medical, which must be invoked before resorting to such a radical
procedure.

Hygienic.--The diet should be restricted, as far as possible, to milk,
and nitrogenous articles of food must be forbidden. The functional
activity of the skin can be maintained by frequent baths in lukewarm
water. Vapor baths are of still greater value. Hot-water baths are
employed on an extensive scale in the obstetrical clinics of the Vienna
General Hospital. Carl Braun, Josef Spaeth, and Gustav Braun give
testimony to their efficacy. Indeed, in Vienna chief reliance is placed
upon the hot-water bath as a prophylactic and remedial agent. Breus[20]
has recently described the method usually practised. The patient is
placed in a bath-tub filled with water at a temperature slightly above
99° F. The tub is then covered with a heavy blanket, leaving the face
free, and the temperature of the water is gradually elevated to 110° or
112° F. She remains in the bath thirty minutes. A towel wrung out of
ice-water and placed upon the head relieves any distressing cephalic
sensations. While in the bath the patient drinks large quantities of
water. Upon emerging from the bath she is covered with a warm sheet and
enveloped in an upper and lower layer of thick blankets, so that only
the face is exposed. Within a very few minutes free perspiration is
observed. The sweating is continued for two or three hours. According
to the gravity of the case the hot-water bath may be repeated once
daily for an indefinite period. The relief of all threatening symptoms
under this simple plan of treatment alone is surprising. Sometimes the
hot-water bath acts as an efficient excitant of uterine contractions,
and premature labor is induced. A. Sippel[21] calls attention to this
fact, and proposes hot-water baths as a harmless method of induction of
premature labor. Although such an event is not undesirable, it is
unusual, and occurs only when the temperature of the water reaches a
great elevation or the baths are frequently repeated, or, finally, when
there is a very decided predisposition to the interruption of
pregnancy. The lateral or latero-prone posture during sleep serves to
relieve in some degree the kidneys of the pressure from the gravid
uterus, and should be advised.

[Footnote 20: _Arch. f. Gynaek._, vol. xix. p. 219.]

[Footnote 21: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]

Medical.--The exhibition of non-irritating diuretics, such as the
acetate and bitartrate of potassium, in large quantities of water,
causes an increased secretion of urine and lessens the congestion of
the renal vessels. Among the mineral waters Bilin, Giesshübel, Preblau,
Selters, and Vichy deserve commendation. Benzoic acid, in conformity
with Frerichs' suggestion, is employed in Vienna. The tincture of the
chloride of iron, alone or in combination with small doses of tincture
of digitalis, is an efficient diuretic, and at the same time an
excellent tonic.

Cathartics which produce large, watery stools without much irritation
supplement the action of diuretics. The compound powder of jalap and
the saline purges fulfil this indication. Care must be taken, however,
to avoid the drastic effects of too large a dose.

Jaborandi and pilocarpine have been, and are at the present time,
extensively used to aid in the elimination by the skin of retained
excrementitious matters. The weight of authority is decidedly against
the exhibition of this remedy. At best, it is uncertain in its action.
It is a cardiac depressant, and frequently stands in a causal relation
to {420} pulmonary oedema. For these reasons the drug has been
condemned in unequivocal terms by Carl Braun and Fordyce Barker. The
same effect, with less risk, can be produced by the hot-water baths.

Local Treatment.--In the acute forms of Bright's disease various modes
of counter-irritation are useful. Wet and dry cups and leeches applied
to the loins are indicated. Frerichs recommends pills of the extract of
aloes and tannin with the view of restoring the normal tonus to the
blood-vessel walls.

By a judicious combination of these varied therapeutic resources,
hygienic and medical, threatening symptoms may be averted. Cure of
Bright's disease, acute or chronic, is seldom if ever achieved during
pregnancy. Not unfrequently, however, notwithstanding all efforts, the
amount of albumen steadily increases, hydræmia becomes more pronounced,
hydropsies appear with threatening cerebral, cardiac, or pulmonary
symptoms. More active treatment is demanded, and the subject of the
induction of premature labor must be seriously considered. Without
entering into a detailed discussion of the arguments for and against
the artificial premature interruption of pregnancy under these
conditions, let it suffice to say that clinical experience furnishes
overpowering evidence in favor of the operation. The weight of
professional opinion is also very decidedly in favor of the artificial
induction of premature labor. In the selection of the method for the
induction of premature labor it is well to bear in mind the possible
excitant effect on uterine contractions of hot-water baths, as pointed
out by A. Sippel.[22]

[Footnote 22: _Centralb. f. Gynaek._, No. 44, 1885, p. 693.]


Skin Diseases.

Diseases of the skin occur with comparative frequency during pregnancy.
Latent diatheses are roused into activity. The graver forms of skin
disease usually disappear during or shortly after the puerperium. These
facts point to some causal relation between the diseases and gestation.
Under the increased activity of the glandular system the growth of hair
may be stimulated, giving origin to a condition termed by
dermatologists hirsuties gestationis. Slocum[23] relates the history of
a case in which a woman in successive pregnancies grew a full beard.
Anomalous deposits of pigment, constituting the condition known as
chloasma uterinum, are observed, more especially among pregnant women
exposed to sunlight. Chloasma is interesting from a diagnostic point of
view, since it is liable to be confounded with pityriasis versicolor,
an affection of frequent occurrence during pregnancy. The red nose of
acne rosacea may be one of the first signs of pregnancy. General
pruritus, a rare affection, belongs to the class of idio-neuroses
(Hebra). Spiegelberg relates the history of a case of general pruritus
occurring in an old primipara. The affection made its appearance in the
second month, and continued without material abatement of symptoms
throughout the period of gestation. Pruritus of the vulva is a common
disorder of pregnancy. It is usually symptomatic of eczema, some
inflammatory condition of the genitalia, or diabetes mellitus. The
treatment must be directed to the removal of the cause. Vaginal douches
containing vegetable or mineral astringents will {421} afford relief
when the itching is due to acrid vaginal secretions. Dilute solutions
of corrosive sublimate in water or alcohol (1:100 or 200), followed by
compresses saturated with tar-water, are recommended very highly by
Spiegelberg.

[Footnote 23: _New York Medical Record_, 1875.]

Pregnancy cannot be regarded as a cause of psoriasis. When that
affection exists, however, it is usually aggravated. The elder
Hebra[24] in 1872 described a rare form of skin disease occurring in
the course of pregnancy which he called herpes impetiginiformis, and of
which he encountered five cases. Grouped vesicles upon inflamed bases
appear about the genitalia, and subsequently diffuse themselves by
successive crops over the body. Great prostration, rigors, and intense
fever accompany the eruption. Four of the five cases terminated
fatally. Milton and Duncan Bulkley a few months later described a rare
skin affection peculiar to pregnancy which they designated herpes
gestationis. Erythema, papules, vesicles, and bullæ are developed.
Vesicles predominate, appear on the lower extremities, subsequently
spreading over the body. Intense itching and burning attend the
vesicles. Urticaria, neuralgia, and other neurotic troubles accompany
the affection. The disease appears early in pregnancy, continues until
after delivery, and is apt to recur with succeeding pregnancies. The
constitutional symptoms are much less severe than in the condition
described by Hebra. At the meeting of the American Dermatological
Society, 1885, L. A. Duhring[25] called attention to the relation of
impetigo herpetiformis, herpes gestationis, pemphigus, and certain
other forms of disease to dermatitis herpetiformis. Attention was
briefly directed to the identity of the impetigo herpetiformls of Hebra
with dermatitis herpetiformis. Herpes gestationis was a misnomer, the
affection being found in men as well as in women. The disease was the
vesicular variety of dermatitis herpetiformis. The peculiar forms of
pemphigus observed during pregnancy, not of syphilitic origin, may be
viewed as examples of the same disease. Duhring thinks that "we stand
on the threshold of our knowledge of the disease."

[Footnote 24: _Wiener Med. Woch._, No. 48, 1872.]

[Footnote 25: _Journal of Cutaneous, etc. Dis._, October, 1885, p.
317.]


Neuroses.

Of all the neuroses occurring in the course of pregnancy, puerperal
eclampsia is of chief clinical importance. Puerperal convulsions,
however, occur more frequently during labor and the lying-in period
than during gestation. For this reason the subject is usually discussed
in connection with the pathology of the puerperium. The various
psychoses are referred for a similar reason to the same chapter.


TETANUS.

Tetanus, a rare affection, especially in women, is occasionally
observed in pregnancy. It occurs with greatest relative frequency in
hot climates after abortion and the removal of placental or decidual
remains. Sir James Y. Simpson collected 28 cases which sustained some
relation to abortion or labor. Mr. Waring[26] has collected 232 cases
occurring in a tropical climate.

[Footnote 26: _Indian Annals_, 1855.]

{422} The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases,
only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.

In the entire absence of knowledge of the pathology of the disease,
TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite
of amyl are the remedial agents usually employed.


CHOREA.

Chorea occurs in pregnancy as an accidental complication or as the
direct result of that state. It is a rare disorder of pregnancy.
Spiegelberg has observed 3 cases; Barnes has collected 56 cases;
Fehling[27] brings the number up to 68; altogether, 84 cases are on
record.

[Footnote 27: _Lehrb. d. Geburtshülfe_, 1882, p. 239.]

ETIOLOGY.--The investigations of Robert Barnes show that where chorea
arises in pregnancy in the large majority of cases there is a history
of chorea in childhood, acquired predisposition prior to pregnancy, or
hereditary "nervous diathesis predisposing to chorea." The connection
between rheumatism, endocarditis, and chorea is a well-established
fact. The precise nature of this relation is unknown. Hughlings Jackson
has constructed the theory of "embolism of the small branches of the
middle cerebral artery supplying the structures near the corpus
striatum." Robert Barnes[28] calls attention to the following facts,
which invalidate this ingenious theory: "(1) The frequent recovery of
choreic patients; (2) the occasional immediate cessation of choreic
fits upon delivery; (3) the progressive character of the disease during
pregnancy, convulsions increasing in severity, and the gradual
development of mania in some cases; (4) the fact that embolism is rare
during pregnancy." In the absence of any definite cause, Spiegelberg
refers a large number of these cases to the class of reflex neuroses.
All the elements essential to a reflex neurosis are present. We have
(1) a predisposition to chorea, inherited or acquired; (2) inanition of
the central nervous system incident to the hydræmic state of the blood
in pregnancy; (3) various potential peripheral irritants in connection
with the sexual organs. Intense emotions, terror and the like, may act
as exciting causes.

[Footnote 28: _Obstetric Medicine and Surgery_, London, 1884, p. 379.]

COURSE AND SYMPTOMS.--Chorea usually makes its appearance in the course
of the first half of pregnancy, and continues until the beginning of
labor. Sometimes choreic attacks are witnessed during parturition. In
only 3 out of the 84 recorded cases the disease continued after the
puerperium. Primiparæ are more frequently affected than multiparæ. The
disease is liable to recur with succeeding pregnancies, entirely
disappearing in the intervals. The choreic movements are the same as in
the non-gravid woman affected with the disease. They are usually
bilateral. As in chorea in the non-gravid state, transitory albuminuria
and glycosuria may be observed. The increase of urates and phosphates
in the urine is interpreted as the result of nervous excitement and
muscular activity. Pregnancy is interrupted in about one-half the
cases. The child may be born alive and affected with the disease.

PROGNOSIS.--Out of the 84 cases, 23 terminated fatally as the result of
complications. Mania, loss of memory, grave cerebral and spinal lesions
are occasionally traceable to the chorea of pregnancy. The {423}
prognosis with reference to the child is unfavorable, from the tendency
to the premature interruption of pregnancy.

TREATMENT.--The palliative treatment of chorea occurring in pregnancy
is unsatisfactory in the extreme. All the specifics of greater or less
value in the non-gravid state are frequently without influence during
gestation. The diet must be nutritious and easily digestible. Large
doses of iron and quinine are indicated. As in other convulsive
disorders, during the paroxysms chief reliance is placed upon
anæsthetics, subcutaneous injections of morphine, potassium bromide,
and chloral. Charcot recommends the exhibition of large doses of
bromide of potassium through a considerable period of time. Clifford
Albutt extols succus conii. In over one-half the recorded cases the
most judicious combinations of hygienic and medical therapeutic
resources have proved of no avail. In view of the prognosis, the
induction of premature labor is usually indicated, in the interest of
both the mother and child, at an early stage of the disease. Sometimes
the question of the artificial induction of abortion comes up for
consideration. In view of the grave cerebral and spinal lesions which
may result from the affection, the mother is justly entitled to the
benefit of the doubt. It may not be amiss to add that this indication
for the induction of abortion is not generally recognized.


EPILEPSY.

Epilepsy is usually an accidental complication of pregnancy.
Spiegelberg[29] is responsible for the observation that in chronic
epilepsy pregnancy sometimes modifies the course of the affection in a
favorable manner. The seizures occur less frequently and are not so
violent in character. Acute epilepsy may be developed as the result of
pregnancy when a latent predisposition, inherited or acquired, exists.
The epileptogenous zone in acute epilepsy comprehends the distribution
of the ischiatic nerve. Acute epilepsy disappears with the cessation of
pregnancy, but is apt to recur with succeeding gestations.

[Footnote 29: _Lehrb. d. Geburtshülfe_, 1882, p. 241.]

The occurrence of acute or chronic epilepsy during pregnancy is of
great diagnostic interest from the resemblance of the epileptic
seizures to the convulsions produced by renal inadequacy. The urine
secreted during or after an epileptic fit is usually free from albumen.
In the severest forms of puerperal eclampsia the urine may also be
entirely free from albumen and tube-casts. In the ultimate stages of
amyloid degeneration[30] and atrophy of the kidney, the most formidable
forms of Bright's disease, albumen may not appear in the urine.

[Footnote 30: Carl Braun, _Lehrb. d. g. Gynaek._, 1881, p. 827.]

The DIAGNOSIS is usually cleared up by the history of the case and the
course of the affection.

The PROGNOSIS with reference to mother and child is favorable. Epilepsy
rarely leads to the premature interruption of pregnancy.

The TREATMENT is the same as in the non-gravid state.


Disorders of the Special Senses.

Disorders of the special senses usually occur in the course of
pregnancy as symptoms of acute or chronic Bright's disease. Amblyopia,
amaurosis, {424} ringing in the ears, sudden deafness, loss of taste
and smell, may be developed under the influence of renal inadequacy
before or after the occurrence of puerperal convulsions. Apart from the
disorders of the special senses dependent upon lesions of the kidney,
disturbances of vision are of chief clinical interest.

Amblyopia, hemeralopia, and color-blindness are occasionally observed
as the result of nutritive disturbances in the retina. Nyctalopia,
Spiegelberg says, is not recorded in the literature of the subject.

The PROGNOSIS is favorable as a rule. The disorders of vision usually
disappear during the puerperium, and evince no tendency to recurrence.

Generous diet, iron, and a tonic plan of treatment are indicated.

       *       *       *       *       *

II. THE PECULIARITIES OF CERTAIN ACCIDENTAL ACUTE AND CHRONIC DISEASES
OCCURRING IN THE COURSE OF PREGNANCY.


The older obstetricians believed not only that pregnant women possessed
a certain immunity from accidental diseases, but also that the course
of such affections was favorably modified by gestation. Modern research
has demonstrated the groundless nature of this belief. It is an
established fact that pregnancy confers upon the individual no immunity
from the disorders to which the non-gravid woman is liable. Moreover,
such accessory diseases are usually aggravated by pregnancy, and, in
turn, exercise an unfavorable influence upon gestation, frequently
leading to its interruption.


Acute Infectious Diseases.

Of all the so-called accessory diseases occurring in the course of
pregnancy, the acute infectious diseases are of the gravest clinical
significance. These diseases are peculiarly dangerous complications for
two reasons:

I. They have a marked tendency to cause the death of the foetus and the
interruption of pregnancy, when the loss of blood and the muscular
exertion consequent upon the expulsion of the product of conception
from the uterine cavity seriously imperil the mother's life.

II. Hemorrhagic endometritis, caused in part by changes in the
constitution of the blood, is not an uncommon symptom in the course of
acute infectious diseases in the non-gravid state. In pregnancy this
symptom is of more constant occurrence, just as it is of graver
prognostic moment, both with reference to the mother and to the child.

I. The death of the foetus and the interruption of pregnancy may result
from the operation of a variety of etiological factors.

1. The foetus usually dies in consequence of the elevation of maternal
temperature. The case is a veritable example of that condition which H.
C. Wood of Philadelphia terms heat-stroke. The normal foetal
temperature is slightly more elevated than the maternal. The foetus in
its membranes, surrounded by maternal tissues, must possess at least
the {425} same temperature as the maternal body. But it has its own
heat-producing apparatus in addition. A very slight elevation of the
maternal temperature produces a disproportionate rise in the
temperature of the foetal body. Kaminsky[31] has shown that an
elevation of maternal temperature to 104° F. imperils foetal life.
Increased frequency of the pulsation of the foetal heart and abnormally
active foetal movements are followed by diminished cardiac and muscular
activity, and the foetus dies. The autopsy reveals the characteristic
lesions of heat-stroke.

[Footnote 31: _Moskauer Med. Z._, 1867, Nos. 13-19.]

2. Runge[32] has demonstrated the occurrence of foetal death from
asphyxia when the maternal blood-pressure is seriously lowered. This
lowering of the maternal blood-pressure occurs as the result of
diminution in the force and frequency of the heart's action observed in
the course of acute infectious diseases or from the sudden loss of
blood. Asphyxia may also be caused by structural changes in the
epithelium covering the foetal placenta, due to the state of the
maternal blood.

[Footnote 32: _Arch f. Gyn._, Bd. xii. p. 16.]

3. The foetus may perish in consequence of infection with the specific
poison of the acute disorder. Death as the result of acute infection
has been observed in variola and relapsing fever.

4. Pregnancy may be interrupted, independently of the condition of the
foetus, as the result of the thermic irritation of the uterine muscular
fibre by the maternal blood. Spiegelberg on a priori grounds asserted
the possibility of this event. Runge[33] has since demonstrated by
experimental methods its actual occurrence.

[Footnote 33: _Volkmann's Sammlung_, No. 174; _Arch. f. Gyn._, Bd. xii.
p. 16.]

II. Hemorrhagic endometritis in the course of acute infectious diseases
complicating pregnancy has been demonstrated by Slavjansky's[34]
researches. In cholera this symptom is observed with relative
frequency. Following hemorrhage into the decidua, according to the
time, extent, and site, pregnancy may be immediately interrupted, or
secondarily as the result of the pathological changes in the placenta
or membranes induced by the extravasated blood. The hemorrhage may be
so severe as to jeopardize the life of the mother.

[Footnote 34: _Arch. f. Gyn._, iv. p. 285.]

Of the eruptive fevers, smallpox, scarlet fever, and measles are of
especial clinical interest. Smallpox is observed most frequently. The
eruptive fevers usually occur early in pregnancy, but the disposition
to the severer forms and the mortality, as remarked by Spiegelberg,
grow with the duration of gestation.


SMALLPOX.

A mutually unfavorable relation exists between smallpox and pregnancy.
A distinct tendency to the hemorrhagic form of the disease is notable.
Pregnancy frequently terminates in abortion or premature labor under
circumstances which seriously imperil the mother's life from loss of
blood. When the disease pursues its course without interrupting
pregnancy, the effect upon the foetus is interesting and instructive.
The child may be born alive with characteristic variolous cicatrices or
in the eruptive stage. Usually the eruption appears from eight to ten
days after birth. Very rarely the child may escape infection
altogether. The foetus may be infected in utero, while the mother {426}
remains apparently unaffected. Fumée of Montpellier narrates the
history of a remarkable case of twin pregnancy. Only one of the
children showed variolous pustules.

During smallpox epidemics abortions and premature labors, accompanied
by abnormally severe hemorrhages, are frequently observed when no
exanthem or other sign of the disease is noticeable in the mother. The
healthy child of a mother affected with variola in the course of
pregnancy is usually insusceptible to vaccinia for a long time after
birth.

In the event of a smallpox epidemic the vaccination or revaccination of
pregnant women is advisable. The effect of the vaccination of the
pregnant woman upon the foetus is still a subject of controversy.
Thorburn in 1870 successfully vaccinated a number of pregnant women,
and found no insusceptibility in their children. Behm[35] vaccinated 33
women pregnant in the eighth, ninth, and tenth months. The vaccination
was completely successful in 22 cases, partially in 7, and failed in 4.
Of the 33 children, 25 were successfully vaccinated. In 8 cases
vaccination was not attended with success. Failure was ascribed in 7
cases to bad lymph, leaving only 1 case of presumed protection from
intra-uterine vaccination. Bollinger and Burckhardt, supported by the
results of Rickett and Roloffs in the inoculation of sheep, maintain
that over one-half the infants are protected from vaccinia and smallpox
by the vaccination of the mother during pregnancy.

[Footnote 35: _Centralbl. f. Gynaek._, 1882.]


MEASLES.

Rubeola, of infrequent occurrence in the adult generally, is a very
rare complication of pregnancy. It is of serious prognostic moment,
from the tendency to the hemorrhagic form of the disease, and
pneumonia.


SCARLET FEVER.

Scarlatina, like measles, occurs infrequently in the course of
pregnancy. Olshausen has collected 7 cases. Pregnancy was interrupted
in 4 out of these 7 cases, probably as the result of the elevation of
maternal temperature. The renal complications also add an unfavorable
element to the prognosis.


TYPHOID FEVER.

Typhoid fever occurs with greatest frequency during the early months of
gestation. It is a very rare complication of the puerperium. Pregnancy
is usually interrupted. Abortion rather than premature labor is
observed. This tendency to the interruption of gestation is more marked
than in any of the acute infectious diseases with the possible
exception of smallpox. Of 98 cases collected by Kaminsky, interruption
of pregnancy occurred in 63; Zülzer reports 14 interruptions of
pregnancy in 24 cases; Scanzoni, 6 out of 10 cases. In about 63 per
cent. of the cases collected by these observers pregnancy was
interrupted. The causes of abortion or premature labor in typhoid fever
are found in the elevation of maternal temperature, the hemorrhagic
endometritis, and perforation (Kleinwächter). The transmission of the
infection from mother to child is a disputed point. The prognosis
depends largely upon the stage of the disease in which the interruption
of pregnancy occurs. If abortion or {427} premature labor occurs early
in the course of the disease, before the mother is exhausted, the
outlook is naturally more favorable.


RELAPSING FEVER.

Murchison states very positively that pregnancy is invariably
interrupted by the occurrence of relapsing fever. Recent
investigations, however, indicate that this assertion is entirely too
general. Weber[36] has collected 63 cases of pregnancy complicated by
this disease. Pregnancy was interrupted in 23 cases, or 36.5 per cent.
Hemorrhagic endometritis is of less frequent occurrence than in typhoid
fever. In two cases (Wyss-Ebstein and Albrecht) spirilla were found in
the foetal blood, indicating the infection of the child by the mother.

[Footnote 36: _Berlin. klin. Woch._, vii., 1870, p. 22.]


TYPHUS FEVER.

Typhus fever manifests much less tendency to the production of
hemorrhagic endometritis than typhoid and relapsing fevers. The
interruption of pregnancy is the exception rather than the rule. When
abortion or premature labor occurs, it is usually caused by the
elevation of the maternal temperature. There is no evidence pointing to
the infection of the child with the specific poison of the disease.


MALARIAL FEVER.

The popular belief that pregnant women enjoy a certain[37] immunity
from malarial fever seems to have some foundation in fact. This
apparent immunity may be due in part to the environment and freedom
from exposure to the malarial poison--in part to the condition of
pregnancy. In latent, chronic malarial poisoning gestation may be the
cause of the explosion or acute exacerbation of the affection. The
course and symptoms of malarial fever are materially modified by the
coexistence of pregnancy. The attacks lose something of their
rhythmical character. Chills are of irregular occurrence, and the fever
assumes a remittent or continued type. In the latter months of
gestation acute attacks of malarial fever are especially distressing to
the patient.

[Footnote 37: Ritter, _Virchow's Archiv_, 1867.]

The interruption of pregnancy is not an uncommon event. Göth has
recently reported 46 cases, in 19 of which either abortion or premature
labor took place. When pregnancy is interrupted hemorrhage is apt to be
profuse.

The communication of the disease to the foetus is a well-authenticated
clinical fact. Hubbard reports an interesting case of intra-uterine
malarial fever. Autopsies of infants born of mothers affected with
acute or chronic malarial poisoning reveal the characteristic lesions
of that pathological condition. Malarial paroxysms are usually
suspended during labor, but may reappear during the lying-in period.
Very rarely the fever assumes a pernicious type, and then may stand in
a certain causal relation to the essential anæmia of pregnancy, of
which mention has already been made.

In the TREATMENT of malarial poisoning during pregnancy large doses of
quinine are indicated. Spiegelberg points out the important fact that,
owing to the impairment of the digestive and assimilative functions,
only {428} a portion of the quinine is absorbed. There is no ground for
fearing any untoward effect from quinine. The researches of Chiara of
Milan and numerous other observers prove that even the largest
therapeutic doses of quinine are not abortifacient in malarial fever or
in health.


CHOLERA.

Pregnant women evince no proclivity to, nor immunity from, cholera. As
in variola, the disposition to, and mortality of, the disease grow with
the duration of gestation. The prospect of recovery is especially
unfavorable during the sixth and seventh months. Pregnancy is usually
interrupted when the woman survives the terribly rapid course of the
disease. Many women die with the product of conception in the cavity of
the uterus. Exceptionally, in the lighter forms of the disease recovery
may occur without the interruption of gestation. The causes of
premature labor or abortion may be found in the constant hemorrhagic
endometritis and the changes in the pressure and constitution of the
maternal blood. As the result of the operation of the two latter
factors, asphyxia is usually produced. Buhl, Gütterbock, and others are
of the opinion that the disease may be communicated by the mother to
the foetus.

Pregnancy undoubtedly exercises an unfavorable influence on the course
of the disease, chiefly from the tendency to uterine hemorrhage.
Pregnancy is interrupted in over 50 per cent. of the cases. Premature
labor is observed more frequently than abortion. The prognosis with
reference to the life of the child is absolutely unfavorable.

In very exceptional cases the evacuation of the uterine cavity has
seemed to exercise a favorable influence on the course of the disease.
Upon this ground the induction of abortion or premature labor has been
seriously proposed. The operation, after an extended trial, has fallen
into deserved disrepute.


SYPHILIS.

Syphilis is a frequent complication of pregnancy. Sigmund[38] has
observed and described the characters of syphilis contracted at the
beginning or during the course of gestation. The duration of the stage
of incubation is abbreviated. Two weeks is the rule, six weeks the
exception. The initial lesions are characterized by an unusual degree
of intensity, occasionally involving the vulva, vagina, cervix, nates,
and inner surfaces of the thighs. The intensity of the initial lesions
is due to the anatomical relations of the genitalia in the pregnant
woman and the increased nutritive activity of the parts. The symptoms
are marked local reaction, reddening and excoriation of the skin and
mucous membrane, swelling, oedema, eczema, follicular abscesses, and
necrosis of the connective tissue. Induration is not a characteristic
of chancre situated about the genitalia of the pregnant woman.
Phagedenic ulceration sometimes attacks the chancre, and then the case
may be mistaken for one of phagedenic chancroid. The secondary symptoms
are unusually mild. Condylomata appear about the genitalia, and
psoriasis is noticeable on the palms of the hands and soles of the
feet. Glandular infiltration follows slowly, and alopecia, iritis,
laryngitis, and the skin manifestations are observed with comparative
infrequency.

[Footnote 38: _Wien. Med. Presse_, 1873, No. 1, xiv.]

{429} Constitutional Syphilis.--The influence of constitutional
syphilis upon the foetus is marked, and always unfavorable. The foetus
may be infected through the medium of the spermatic fluid, the ovum,
and by the mother after conception. From an enormous number of
carefully-recorded observations it is possible to deduce the following
conclusions with reference to the modes of infection and the effect
upon the product of conception:

1. When the mother is perfectly healthy, but the father is affected
with constitutional syphilis, the foetus is infected by the diseased
spermatozoids. The intensity of the foetal disease will depend upon the
degree of latency and age of the paternal affection. This mode of
infection is observed in the severer forms of hereditary syphilis.
Usually the mother is not infected. Occasionally the disease is
communicated to her by the foetus in the mode termed by the French
syphilographers choc en rétour.

2. When the mother has had constitutional symptoms prior to conception
the ovum is infected before its fertilization. The child usually dies
in utero, and is expelled in a state of maceration.

3. When the mother is infected during the act of coitus it was formerly
believed that the foetus could only be syphilized during its passage
through the parturient canal. Sigmund and Vajda have shown that even
under these circumstances the infection may be communicated by the
mother to the foetus in the course of pregnancy. If the father is
affected with constitutional syphilis when the mother acquires the
initial lesion, the result sketched in the first proposition follows.

4. Infection of the foetus may occur during its passage through the
parturient canal. Weil[39] records a case of this nature.

[Footnote 39: _Deutsch. Zeitsch. f. prakt. Med._, 1877, No. 42.]

5. When both parents are affected with constitutional syphilis the
disease will be communicated to the foetus. The intensity of the foetal
syphilis will depend upon the degree of latency and age of the parental
affection. When both parents have passed through the tertiary forms an
apparently healthy child may be born. Evidences of hereditary syphilis,
however, are usually developed before puberty.

According to the intensity of the poison the foetus dies in utero,
causing the interruption of pregnancy; is born alive, with
manifestations of hereditary syphilis, seldom acquired; or may give
evidence of the inheritance of the disease after a variable interval of
from weeks to months.

TREATMENT.--Fortunately, syphilis as a complication of pregnancy is a
very tractable affection. The interruption of pregnancy may be
prevented and the effect of the syphilitic poison upon the foetus
favorably modified in the large majority of cases by appropriate
specific treatment. Mercurial inunctions are preferable to the
exhibition of the remedy by the mouth. Iodide of potassium must be used
with care, on account of its tendency to provoke uterine contractions.

Attention must be paid to local primary or secondary lesions, since the
child may be infected during its passage through the parturient canal.


Cardiac Diseases.

The mutually unfavorable relations between acute and chronic cardiac
diseases and pregnancy depend largely upon the seat and character of
the affection.


{430} ACUTE ENDOCARDITIS,

occurring in the course of gestation, evinces a distinct tendency to
the malignant, ulcerative form. This disposition is much more marked
during the puerperium. The dangers of the detachment of particles of
valvular vegetations, giving origin to the processes of thrombosis and
embolism, are obvious.

The PROGNOSIS of acute endocarditis during pregnancy and the puerperium
is much more unfavorable than in the non-gravid state.


CHRONIC HEART DISEASES.

The mode in which pregnancy, parturition, and puerperium exert an
unfavorable influence on chronic heart diseases is still the subject of
controversy. Spiegelberg accounts for the disastrous results attending
aortic insufficiency observed in the second half of pregnancy on the
ground of the inadequacy of the compensatory hypertrophy of the left
ventricle. The intercalation of the placental circulation, the increase
of the total blood-mass, the increase in arterial tension, throw an
extra amount of work upon the left heart, which it is not able to
perform. Irregular heart-action and dyspnoea, sometimes leading to the
interruption of pregnancy, are the results.

After labor the placental circulation is eliminated, arterial
blood-pressure is lowered, venous blood-pressure is elevated, and the
right heart is threatened. In case of mitral insufficiency and
dilatation of the left ventricle, without compensatory hypertrophy of
the right heart, the effect of these sudden variations in vascular
tension is obviously serious. Dyspnoea, pulmonary catarrh, general
oedema, albuminuria, ascites, pleural effusions, occur. Fritsch[40] is
of the opinion that these phenomena, sometimes observed in the course
of mitral disease after labor, are due to the sinking of
intra-abdominal pressure, the accumulation of blood in the great
abdominal vessels, and cardiac paralysis from insufficient
blood-supply.

[Footnote 40: _Arch. f. Gyn._, viii. p. 373; x. p. 270.]

During parturition Spiegelberg[41] thinks the chief danger in all forms
of valvular defects consists in pulmonary oedema as the result of
circulatory disturbances.

[Footnote 41: _Lehrbuch d. Geburtshülfe_, 1882, p. 248.]

Löhlein and Kleinwächter[42] believe that the chief danger of chronic
valvular disease occurs during the puerperium, and lies in the tendency
to the recurrence of endocarditis.

[Footnote 42: _Kleinwächter's Grundriss d. Geburtshülfe_, 1881, p.
190.]

TREATMENT.--The treatment of acute and chronic heart disease is not
materially modified by the coexistence of pregnancy.[43] In threatened
asphyxia the induction of premature labor is indicated in the interest
of the child. During labor the timely performance of version or
application of the forceps lessens the bearing-down efforts, and may
prevent alarming complications.

[Footnote 43: Carl Braun, _Lehrb. d. g. Gynaek._, 1881, p. 708.]


Diseases of the Lungs.


ACUTE LOBAR PNEUMONIA.

This is a rare affection in women at all times, and is a very
infrequent complication of pregnancy. Occurring with greatest relative
frequency {431} in the early months of pregnancy, the unfavorable
character of the prognosis grows with the duration of pregnancy.
Interruption of pregnancy may occur as the result of a variety of
causative agencies. The elevation of maternal temperature, insufficient
oxygenation of the maternal blood, placental anæmia from inadequate
supply of blood to the left heart, are of chief etiological moment.

The PROGNOSIS with reference to mother and child is always grave.

The TREATMENT is that of pneumonitis in the non-gravid state.
Parturition exerts a prejudicial influence by overtaxing the failing
heart-power and increasing the hydræmia. The induction of premature
labor is therefore strongly contraindicated. In the event of labor
every effort must be made by operative procedure to save the mother's
strength.


ACUTE PLEURITIS

is nearly as fatal a complication of pregnancy as pneumonitis, and for
the same reason. The danger is especially great during labor.


CHRONIC PLEURISY, EMPHYSEMA, AND EMPYEMA

are dangerous complications of pregnancy, limiting respiratory space
and producing cardiac complications. The induction of premature labor
may be indicated by these conditions in the interest of mother and
child.


PULMONARY TUBERCULOSIS.

Pregnancy exerts a prejudicial influence on hereditary or acquired
tuberculosis as a rule. Latent tendencies to the disease are developed,
and the progress of the existing affection is hastened. These effects
upon the course of phthisis, Lusk says, are most frequently observed
between the ages of twenty and thirty years, although of not infrequent
occurrence between the ages of thirty and forty years. To these general
propositions there are occasional rare exceptions. The disease is
sometimes--very rarely--observed to make no progress during gestation
and the patient may decidedly improve during the lying-in period. The
puerperal phases, says Spiegelberg, exercise such varied influences
upon the development and course of tuberculosis that it is an
imperative necessity to individualize in every case.

When the disease progresses during pregnancy, abortion or premature
labor may take place, or the woman may die undelivered. Infants born of
tuberculous mothers are usually weak and sickly, and perish during the
first months of life.

For these reasons it is an established rule in practice to inform women
of the tuberculous diathesis of the dangers entailed by the marital
relation. A woman affected with tuberculosis ought never to nurse her
own child. As a rule, however, there is seldom any necessity for such a
warning, as the function of lactation is rarely established under these
conditions.




{432}

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.

BY W. W. JAGGARD, A.M., M.D.


DEFINITION AND TERMINOLOGY.--The time of life in a woman when the
natural cessation of ovulation and menstruation occurs has received a
variety of appellations more or less descriptive of the phenomena which
are supposed to precede, attend, and follow that event. Change of life,
Turn of life, Critical time, Climacteric, in English; Das klimacterium,
Das aufhören menstrualer Ausscheidung, Das aufhören der Weiblichen
Reinigung, in German; Ménopause, Âge de retour, Âge critique, Temps
critique, in French; Cessatio mensium, Climacterium, in Latin;
Menolipsis, in Greek,--are terms used to mark out a certain period of
time commencing with the functional and organic disorders connected
with the cessation of ovulation and menstruation in a causal relation,
and terminating with the permanent resettlement of health.

DATE OF CESSATION OF MENSTRUATION, AND DURATION OF THE CHANGE OF
LIFE.--The function of ovulation, as far as we know, ceases with the
discontinuance of menstruation, although immature ova still exist in
the ovaries. The date of natural cessation of menstruation and
ovulation is variable in different women. It is difficult to determine
an average date, because the menopause may be gradually ushered in, and
then women are apt to interpret any genital hemorrhage as menstruation.
In certain cases the menstrual flow may cease between the ages of
thirty and forty years, or even at an earlier period. On the other
hand, the function has been noted by competent observers[1] to continue
up to and beyond the sixtieth year. According to tradition, Cornelia,
the mother of the Gracchi, was confined in her seventieth year.
Parvin[2] has recently called attention to another historical instance
of alleged late menstruation, recorded in a note to the fifty-sixth
chapter of the _Decline and Fall of the Roman Empire_. On the authority
of D'Herbelot's great work, _Bibliothèque orientale_, 1777, Gibbon
mentions the case of Asima, the mother of Abdallah. When the tidings of
the death of her son were borne to Asima her menses reappeared at the
age of ninety as the physical effect of her grief. The historian
informs us that the flow proved fatal in five days. These anomalous
cases of so-called protracted menstruation are frequently examples of
pathological hemorrhages dependent upon structural changes, sometimes
of a malignant character. Even admitting the {433} possibility of the
condition of extremely protracted menstruation, such cases, as remarked
by Playfair, like examples of unusually precocious menstruation, cannot
be regarded as having any bearing on the general rule.

[Footnote 1: Tilt, _The Change of Life_, 4th ed., 1882, p. 24.]

[Footnote 2: _The Medical News_ 26th Sept., 1885, p. 352.]

The periodic discharge of blood from the uterus usually ceases between
the ages of forty and fifty years. Raciborski[3] concludes, from the
observation of a large number of cases, that the average date of
cessation is the forty-sixth year. This estimate is confirmed by the
observations of Brierre de Boismont, Guy, and Tilt. The average date of
cessation in 1082 cases,[4] collected by these three observers, was
forty-five years and nine months.

[Footnote 3: _Traité de la Menstruation_, Paris, 1868.]

[Footnote 4: Tilt, _The Change of Life_, 4th ed., 1882, p. 22.]

Climate, race, and the various accidental circumstances which exercise
such potent influence upon the establishment of the functions of
ovulation and menstruation have measurably less effect upon their
cessation. Mayer[5] attaches some importance to social condition as
determining the date of cessation. From the observation of a large
number of cases belonging to the higher classes he determines the
average age to be 47.138 years. It is a popular belief that the period
of menstrual life is a constant number of years, usually from thirty to
thirty-five; that is to say, if a woman commences to menstruate when
very young, cessation will occur at an earlier age than in a woman who
begins to menstruate later in life. Cazeaux, Raciborski, Frank,
Dusourd, and Tilt, supported by Guy's[6] analysis of 1500 cases, are of
the opinion, on the contrary, that the duration of menstruation is
longest in women who have menstruated earliest. In the words of
Négrier,[7] "It seems well proved that the ovarian function, creative
of germs, is prolonged in life in direct ratio of the volume of the
ovaries and of the precocity of ovulation; thus the girl nubile at
twelve will continue menstruating until fifty or even fifty-five;
whilst the girl who did not menstruate until eighteen or twenty--a fact
which reveals feeble development and small energy of the organs--will
cease to menstruate at forty, an early age."[8] Cessation occurs later
in women who have passed through repeated normal pregnancies than in
virgins or sterile females. Cohnstein[9] observed the longest duration
of menstruation in women who had menstruated early, married, and borne
more than three children, suckled their offspring, and were normally
confined for the last time between the ages of thirty-eight and
forty-two years. An interesting opinion with reference to the relation
between longevity and the date of cessation was expressed by Robert
Cowie at the Paris Medical Congress in 1867. According to Cowie, there
is a direct and constant relation between longevity and protracted
menstruation. A woman who menstruates up to an advanced period of life
has more chances of attaining extreme old age than one whose menstrual
function has ceased earlier. Cowie derives this opinion from the
observation of numerous cases of longevity and coincident protracted
menstruation which occurred in the Shetland Islands.

[Footnote 5: Schroeder, _Handbuch der Krankheiten der Weiblichen
Geschlechtsorgane_, 1881, p. 321.]

[Footnote 6: _Medical Times and Gazette_, 1845.]

[Footnote 7: Barnes, _Diseases of Women_, 1878, p. 194.]

[Footnote 8: T. Gallard, _Pathologie des Ovaires_, Paris, 1885, p.
114.]

[Footnote 9: _Deutsche Klinik_, 1873, No. 5.]

Among the pathological factors which determine the early occurrence
{434} of cessation, puerperal atrophy of the uterus,
syphilis--especially the graver forms--and chronic alcoholism deserve
particular attention (Lancereaux).

The average date of cessation of menstruation may be regarded as the
fixed time from which to estimate the duration of the pre-cessation and
post-cessation periods of the menopause. The duration of the
pre-cessation period--or the dodging-time, as it is popularly
termed--is subject to many and extreme variations. Tilt[10] places the
limits of normal variation between a few months and six or seven years.
The average length of the dodging-time in 275 cases Tilt estimates at
two years and three months. The same observer claims to have seen cases
of morbid prolongation of the pre-cessation period through ten and even
twelve years. Equally variable and indefinite, in point of duration, is
the post-cessation period. From the study of his 500 cases, Tilt
concludes that cessation of menstruation divides involution into two
periods of nearly equal length when no disease of the uterus or adnexa
is present. In 383 cases, three or four years after cessation all
functional disorders due to the menopause disappeared. But the length
of the post-cessation period, as in the case of the dodging-time, is
liable to abnormal protraction. Tilt is very positive in the assertion
that disturbances directly traceable to the menopause may continue ten
or twelve years after cessation of menstruation. The statistical
evidence adduced by Tilt in support of his peculiar views as to the
possible protraction of the pre-cessation and post-cessation periods
(twenty to twenty-four years) may well be questioned. His analysis of
cases does not indicate rigid scrutiny. The line between merely
coincident phenomena and disorders which are directly traceable to the
menopause is nowhere clearly and distinctly drawn. Robert Barnes[11] is
of the opinion that the average duration of the change of life,
comprehending the pre-cessation and post-cessation periods, is from two
to three years--an estimate more in accord with the experience of the
majority of clinicians.

[Footnote 10: _The Change of Life_, 4th ed., p. 46 _et seq._]

[Footnote 11: _Diseases of Women_, 1878, p. 287.]

THE NATURAL HISTORY OF THE CHANGE OF LIFE.--In order to gain an
adequate conception of the dynamic disorders in connection with the
menopause, it is necessary to bear clearly and distinctly in mind the
alterations in functional activity of a purely physiological character
which attend that event. Many of the so-called functional disorders of
the change of life are merely physiological processes consequent upon
the transition from active ovario-uterine life to sexual decrepitude.
There is nothing remarkable in the fact that the cessation of
menstruation and ovulation, after functional activity of an average
period of time varying from thirty to thirty-five years, is sometimes
attended by a series of disturbances of a local and constitutional
character. The changes of functional activity under these conditions
are in analogy to the course and constitution of nature as observed in
connection with dentition, puberty, and other epochs in human life.

The physiology of the menopause is a subject extremely difficult of
investigation. The reasons are obvious. Our knowledge of the nature and
significance of the function of ovulation and menstruation is very
defective. The phenomena in connection with the change of life are
numerous and complex. All interpretations of the appearances are
peculiarly liable to fallacies and unavoidable sources of error.
Correction {435} and confirmation by anatomical research are usually
impossible. Then the number of recorded cases in which the phenomena
have been rigidly analyzed is very limited. But, despite the difficult
nature of the subject and the poverty of the literature, a solid
nucleus of acquired truth exists. Familiarity with these definitely
established facts will clear up many obscure points in the pathology of
the menopause.

RESPIRATORY CHANGES. The researches of Andral and Gavarret[12] indicate
that the quantity of carbonic acid exhaled by the lungs during the
second infancy (eight years to puberty) is increased in man and woman.
With the establishment of menstruation the quantity of carbonic acid
exhaled by the female becomes constant, and persists in this state
throughout her menstrual life. During the pre-cessation period the
quantity of carbonic acid exhaled by the lungs is rapidly augmented,
attaining its maximum about the time of cessation. During the
post-cessation period the quantity gradually diminishes until the
resettlement of health is effected. After this period it remains
relatively constant. In the male, on the other hand, the quantity of
carbonic acid exhaled increases up to the thirtieth year, and then
progressively diminishes until the end of life.

[Footnote 12: "Recherches sur la quantité d'Acide carbonique exhalé par
les Poumons dans l'Éspèce humaine," _Annales de Chimie et de Physique_,
3^e Série, t. viii.]

During pregnancy the amount of carbonic acid exhaled is approximately
the same as at the time of cessation.

Aran[13] recognizes in this augmented excretion of carbonic acid during
the change of life a critical or compensating discharge--a waste-gate
or outlet, to use the figurative expressions of Tilt and Barnes, for
the energy set free in the system by the more or less suddenly
suppressed functions of ovulation and menstruation. Gallard,[14] on the
other hand, has pointedly called attention to the fact that the
menstrual blood carries out of the system a quantity of carbonic acid
which during pregnancy and change of life is excreted by the
lungs--that, accordingly, the increased exhalation of carbonic acid
during the climacterium cannot be regarded in the light of a critical
discharge.

[Footnote 13: _Leçons cliniques sur les Maladies de l'Utérus et de ses
Annexes_, Paris, 1858-60, p. 284.]

[Footnote 14: T. Gallard, _Pathologie des Ovaires_, p. 87, Paris,
1885.]

ALTERATIONS IN THE FUNCTIONS OF THE SKIN.--It is a matter of common
observation that the functions of the skin are profoundly influenced in
many cases by the changes consequent upon the menopause. Tilt records
300 cases of more or less profuse perspiration, occurring in 500 women,
due in some degree at least to the change of life. This estimate is
probably exaggerated. A variety of agents influences the total amount
of perspiration, as well as the relation between sensible and
insensible perspiration, at all periods of life. The dryness,
temperature, and amount of movement of the surrounding atmosphere,
nature and quantity of food taken and liquid drank, exercise, mental
condition, medicines, poisons, diseases, and the relative activity of
the other excreting organs (_e.g._ the kidneys), are factors which
deserve due consideration before attributing all increased activity of
the sudoriparous glands about the forty-fifth year to the effects of
the change of life. In the tables mentioned no distinction is drawn
between mere coincidence and causal relation.

{436} The perspirations due to the change of life may have prodromal
signs. These symptoms are--sensations of cold, shivering, chills,
sinking or faintness referred to the pit of the stomach. Usually,
however, they are not attended by any premonitory phenomena. They are
frequently accompanied by dilatations of the skin blood-vessels,
corresponding to definite areas of distribution of the vaso-motor
nerves, which are popularly known as flushes. When the perspirations
following the dilatations of the skin blood-vessels are insensible,
women are in the habit of terming the symptoms dry flushes. The number
and duration, as well as the time of occurrence, of these sweats and
flushes are various in different women. Tilt has observed them to occur
as often as five or six times in an hour, and last from two to fifteen
minutes. They are usually noticed during the daytime. The regions
involved are, in the order of frequency, face, chest, lower portions of
the trunk, upper and lower extremities. Very seldom the entire skin
surface is affected. In point of intensity the heightened activity of
the sudoriparous glands varies from a gentle perspiration to a
drenching sweat.

The function of these perspirations and flushes cannot be regarded as
definitely settled. The popular opinion is that they constitute an
important outlet for the actual energy liberated by the cessation of
ovulation and menstruation. Tilt, adopting the popular view, thinks
that the relief obtained by increased perspiration is the most
important and habitual safety-valve of the system during the change of
life. There are certain a priori considerations which render this
hypothesis in some degree probable.

The quantity of matter which leaves the human body by the skin, per
hour, is considerable. Seguin[15] has estimated it at eleven grains,
while the quantity excreted by the lungs is seven grains. It is
possible to isolate three factors which directly influence the
secretion of sweat: (1) The skin, apart from its glandular apparatus,
is a simple animal membrane, and permits a relatively small quantity of
water to transude through the portions intervening between the mouths
of the glands. As pointed out by Erismann,[16] this function of the
skin is a subordinate one. The simple transudation of water is greater
through those portions of the skin abundantly supplied with glands than
through those in which they are sparsely distributed. (2) Vascular
dilatation accompanies, and at least aids, the secreting activity of
the cutaneous surface. Bernard's experiments on the division of the
cervical sympathetic and clinical observation abundantly demonstrate
the operation of this etiological factor. (3) Independently of vascular
supply, it is in a high degree probable that there are special nerves
directly controlling the activity of the sudoriparous glands.
Stimulation of the sciatic nerve causes an increase in perspiration in
the toes of the dog, without any concomitant hyperæmia, as shown by the
experiments of Kendal and Luchsinger.[17] In a word, the skin is
adequate to the regulation of aberrations in nerve-force and
blood-supply and to the restoration of equilibrium. If superfluous
actual energy is liberated by the cessation of the monthly ovarian
stimulus and determination of blood to the uterus, it is not improbable
that the perspirations and flushes of the menopause may constitute an
efficient means of discharge.

[Footnote 15: _Ann. de Chim._, xc. pp. 52, 403.]

[Footnote 16: _Zeitschrift f. Biol._, xi. p. 1.]

[Footnote 17: _Pflüger's Archiv_, xiii., 1876, p. 212.]

{437} ALTERATIONS IN THE SECRETION BY THE KIDNEYS.--In many cases of
the menopause important changes occur in the urine. The secretion
becomes turbid and the quantity of sediments is large. These sediments
usually consist of the inorganic salts. The phosphates, carbonates, and
sulphates are increased, while no change is observed in the quantity of
sodium chloride. The quantity of nitrogenous crystalline bodies is
apparently not influenced in the great majority of cases. Occasionally
the quantity of uric acid is increased,[18] and gives origin to many
distressing symptoms. In the absence of accurate data respecting the
changes in the constitution of the urine it is useless to speculate
about the significance of the occasional increase in the quantity of
inorganic salts and uric acid. Doubtless the functional activity of the
skin and lungs, diseases of the genito-urinary tract, and diet play an
important part in the production of the alterations in the chemical
constituents of the excretion. It cannot, however, be denied that the
menstrual flow performs some office as an emunctory, and it is not at
all improbable that its cessation throws additional work on the
kidneys.

[Footnote 18: Barnes, _Diseases of Women_, 1878, p. 285.]

ALTERATIONS OF NUTRITION.--Of the various alterations of nutrition
consequent upon the change of life, obesity is of greatest clinical
interest. It is a matter of common observation that women frequently
grow fat coincidently with the cessation of menstruation. Out of 383
cases collected by Tilt, 121 women grew stouter within five years after
cessation; 3 women became suddenly fat when the menstrual flow ceased
to recur. Barnes, Baillie, Fothergill, and numerous other clinicians
abundantly confirm this observation. Adipose tissue is usually
deposited in the omentum, abdominal walls, breasts, face, and limbs.

The nature of the relation between the formation of fat and the change
of life is obscure. In the attempt to ascribe due influence to the
menopause in the production of adipose tissue it must not be forgotten
that in males the maximum of weight is attained, according to Quetelet,
about the fortieth year. But the accumulation of fat in many of the
lower animals after the extirpation of the ovaries, and the frequent
occurrence of obesity in women after normal ovariotomy and the
Porro-Müller operation of Cæsarean section (Braun, Spaeth), indicate
that in some cases, at least, there is a necessary relation between the
two phenomena. The generally received view is that the formation of
adipose tissue is an outlet for the more or less sudden aberrations in
nerve-force and blood-supply following cessation. The weight of
probable evidence is very decidedly in favor of this opinion.
Physiology teaches that fat fluctuates in bulk more than any other
tissue in the body. As remarked by Foster,[19] a large amount of
adipose tissue may disappear within a very short space of time, or the
quantity in a body may be multiplied many times within an equally short
time. Although the direct influence of trophic nerves on metabolic
activity has not been demonstrated, there is still evidence of a high
order in favor of such a view.

[Footnote 19: M. Foster, _Physiology_.]

The Mammary Glands.--Apart from the enlargement of the mammary gland
from the deposition of adipose tissue, the organ may be the seat of
active secretory changes. Tilt observed this phenomenon in 15 out of
his 500 cases. The breasts increase in size and become tender. Blue
veins are visible through the skin, and changes resembling in kind
{438} those of pregnancy may be observed about the nipples and areolæ.
A milky fluid is sometimes secreted. Semple has described a case in
which a monthly discharge of blood continued for five years after
cessation. Tilt has published a case in which a painless exudation of
red serum, lasting for several days, recurred every three weeks.

In view of the intimate connection between the ovaries and uterus and
mammary glands at other periods of life, it is in a high degree
probable that many cases of active nutritive disturbances in the
mammary glands, occurring about the forty-fifth year, are directly due
to cessation. The exact nervous mechanism has not been fully worked
out. These nutritive disturbances are probably physiological, and
partake of the nature of the so-called critical discharges.

HEMORRHAGES AND MUCOUS AND SEROUS DISCHARGES.--Vicarious hemorrhages
are occasionally though rarely observed in connection with the change
of life. These more or less regular discharges of blood occur from a
great variety of sites. The region is usually so located that the
external escape of blood can easily be effected. The more usual forms
of vicarious hemorrhage are hæmatemesis, epistaxis, hæmoptysis, and
bleeding from hemorrhoids. General hæmatidrosis, bleeding from the
nipples, intestinal hemorrhage, bleeding from the alveoli of the teeth,
and subcutaneous ecchymoses are more uncommon types. Every case of
suspected vicarious hemorrhage deserves most rigid scrutiny. The
condition is such a rare one, and so many local causes sufficient to
explain the phenomena frequently exist, that a certain amount of
scepticism in the concrete case is perfectly justifiable.

The nervous mechanism of these hemorrhages, so far as it has been
worked out, may be stated in a very few words. The cessation of
menstruation causes an increase in vascular tension, and consequent
irritation of the vaso-motor centres. Various local hæmostases result,
which cause the symptoms of suffusion of the face, tinnitus, headache,
giddiness, etc. In a limited number of cases these local congestions
are relieved by the escape of blood. Vicarious hemorrhages seldom lose
their physiological character.

Metrorrhagia is a less uncommon event than vicarious hemorrhage during
the climacteric. Uterine hemorrhage is regarded as a critical discharge
due to the changes brought about by the menopause, when it occurs, in
the absence of local disease or constitutional vice, in connection with
the perspirations, flushes, obesity, nervous phenomena, and other signs
of cessation. In point of time these uterine hemorrhages, or floodings,
usually occur after cessation. The causes of the floodings of the
menopause are not at all evident. Barnes[20] is of the opinion that
they are ultimately referable to imperfect functional activity of the
liver and kidneys. Local congestions occur, vascular tension is
increased, the heart and blood-vessels are engorged, and a disposition
to uterine hemorrhage is created. In many cases flooding seems to exert
a salutary influence upon the health of the individual. J. Frank says
he has observed cases of critical floodings after cessation in which
checking the bleeding caused apoplexy. Tilt[21] confirms this opinion
by the citation of two cases. Not infrequently, however, metrorrhagia
during the change of life exceeds physiological limits and endangers
the life of the individual. In the {439} large majority of cases
flooding after cessation is always a cause for anxiety, and constitutes
an urgent indication for a physical examination. By careful indagation
it is usually possible to eliminate cases of metrorrhagia due to
carcinoma, fibroids, and diseases of the endometrium.

[Footnote 20: _Diseases of Women_, p. 283.]

[Footnote 21: _Change of Life_, p. 197.]

Leucorrhoea.--Closely allied in function to the floodings of the
menopause is the profuse flow of mucus, unmixed with pus, from the
cervix and vagina. This phenomenon is of frequent occurrence in
connection with the other signs of the change of life. In the absence
of local disease and constitutional vice it may be regarded as a
critical discharge, an effort of nature to relieve pelvic
congestion.[22]

[Footnote 22: Emmet, _Gynæcology_, 1884, p. 184.]

Diarrhoea.--The recurrence of a profuse serous diarrhoea at more or
less regular intervals during the change of life is common. Gendrin,
Brierre de Boismont, and Chambon regard diarrhoea as habitual at this
time. It acquires particular prominence as a symptom in the absence of
the other critical discharges already mentioned. Indeed, it may
constitute the only sign of the menopause apart from cessation of the
menstrual flow. Care must be exercised, however, to differentiate in
the concrete case between the purely functional serous diarrhoea of the
change of life and those forms of the affection which depend upon local
or general causes.

The explanation of the serous diarrhoea of the menopause, viewed as a
critical discharge, is simple when the intimate connection between the
pelvic circulation and that of the mesentery is considered.[23]

[Footnote 23: _Ibid._]

FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.--Vague,
indefinite, and speculative as our conception of the physiology of the
climacterium is, the deficiency of precise knowledge becomes more
apparent when we come to consider the functional disorders of
cessation. Many women pass through the change of life without the
slightest disturbance of normal functional activity. In such women
menstruation has usually been established at an early age and without
local or general disorders. Moreover, all traces of disease of the
uterus and adnexa are usually absent. Again, it is not an uncommon
observation to see hysterical women, afflicted for years with uterine
disease, begin to improve in health at an early stage of the
pre-cessation period. These facts indicate that the change of life does
not necessarily involve morbid phenomena.

In the large majority of cases, however, various functional and organic
disorders are observed during this period of life. Under these
circumstances it becomes a matter of extreme difficulty to distinguish
between accidental complications, dependent upon collateral disease and
pathological conditions of the pelvic viscera, and those disorders
which stand in some causal nexus with the change of life. The scanty
literature of the subject is to a great extent a mass of confused
generalizations, in which the distinction between the relation of cause
and effect and mere coincidence in point of time is seldom adequately
drawn. Tilt's meritorious treatise is not free from this defect. In
Table xxi., among the morbid liabilities at the change of life in five
hundred women, heart disease, rheumatism, erysipelas, hysteria,
epilepsy, cancer of the womb, ovarian tumors, and more than one hundred
and fifty other pathological states are mentioned! Any paper on the
subject at the present time, to perform a {440} serviceable office,
must direct attention to the obscure, confused, inadequate state of
knowledge rather than aid in the perpetuation of error by the
description of purely hypothetical forms of disease. The comparatively
few functional disorders which stand in direct pathological connection
with the change of life are, in the large majority of cases, examples
of pathological exaggerations of physiological processes. Under these
conditions it requires an unusual degree of diagnostic skill and
penetration to draw the boundary-line between health and disease. Then
in the matter of treatment, as remarked by Spiegelberg, it requires
tact to determine how long a purely expectant attitude should be
maintained and the time when active interference should be instituted.

The woman passing through the change of life possesses no immunity from
accidental diseases. But some of these accidental diseases may be
modified in symptoms and course by the changes consequent upon the
climacterium.

DISORDERS OF THE ALIMENTARY CANAL.--Salivation.--Ptyalism has been
observed by Bouchut and other observers to occur in connection with the
other symptoms of the change of life. It is a phenomenon of infrequent
occurrence. In the absence of any other adequate explanation it may be
regarded as an example of sympathetic irritation strictly analogous to
the salivation sometimes observed in pregnancy.

The milder degrees of this affection deserve slight attention. When,
however, the flow of saliva is so great as to incommode the individual
or seriously endanger her health, active treatment must be instituted.
Chalybeate tonics, quinine, hypodermatic injections of atropia over the
glands--especially the submaxillary--and iodide of potassium, are among
the more reliable remedies. Astringent mouth-washes are grateful and
relieve the congestion of the mucous membrane.

Constipation.--The habit of constipation, although not induced, may be
aggravated, during the change of life. Interference with the action of
the voluntary muscles and intestinal peristalsis by the deposition of
adipose tissue in the abdominal walls and omentum, diminution of the
intestinal secretions as the result of profuse perspirations and
critical discharges, are etiological factors frequently referable to
the menopause. Alterations in the innervation of the intestinal walls
are probably productive of conditions which tend to constipation. The
nature of the changes in the functions of the abdominal sympathetic
nervous system during the menopause is a matter of pure speculation.
There are many a priori considerations, however, which render probable
the view that the constipation in connection with the menopause is, in
some degree at least, a visceral neurosis. The prominence of the
symptoms, enteralgia and flatulence, lends additional probability to
this opinion. The treatment of constipation in connection with the
menopause is a subject of the greatest practical importance. Many of
the obscure nervous symptoms, distressing perspirations, and critical
discharges may be relieved, if not prevented, by attention to the
regular daily evacuation of the bowels. The specific hygienic and
medical means to be used to secure this end are fully discussed in
other portions of this work.

Diarrhoea.--Diarrhoea referable to the menopause and regarded simply as
a critical discharge, sometimes, though rarely, passes beyond
physiological limits and demands active remedial treatment. This
statement {441} holds true especially in cases of chronic diarrhoea
aggravated by cessation. It is frequently a matter of extreme
difficulty to draw the boundary-line between the physiological process
and its pathological exaggeration. Careful attention to the symptoms,
however, will usually disclose the fact whether or no the frequent
alvine dejections conduce to the patient's well-being. Sometimes the
stools are very profuse, and threaten life from the loss of large
quantities of serum. Entorrhagia and colic are frequently observed
under these circumstances. Rest, restricted diet, opium, the vegetable
and mineral astringents, usually suffice to fulfil all the indications.

DISORDERS OF THE LIVER.--Many eminent clinicians unite in the opinion
that functional derangements of the liver are peculiarly liable to
occur during the change of life. Sir J. Y. Simpson, Robert Barnes,
Tilt, Gardanne, Gendrin, Meissner, and Otterburg may be mentioned among
the observers who hold that there is some direct relation between
certain dynamic disorders of the liver and the menopause. There are
also many a priori considerations in favor of this view. Habitual or
long-continued constipation--a condition frequently observed in
connection with the change of life--interferes materially with the
secretion and excretion of bile. Barnes ascribes to the menstrual flow
an excretory function. In the absence of this emunctory an increased
amount of work is thrown on the liver and other secretory organs. The
portal venous system is engorged. Under these circumstances disorders
are apt to arise as the result of increased functional activity in an
organ which may be undergoing organic change.

Well-pronounced jaundice, however, is of infrequent occurrence during
this period in the absence of more potent factors than those just
mentioned. It is not more justifiable to speak of the icterus of the
menopause than of the icterus of menstruation. Flint[24] has justly
said that the occurrence of jaundice at the menstrual periods is too
infrequent to suppose that there is any direct pathological connection,
as implied in the term icterus menstrualis proposed by Senator.

[Footnote 24: _Practice of Medicine_, 1881, p. 637.]

On the other hand, that condition vaguely described as biliousness,
implying the constitutional effects of chronic hepatic hyperæmia, has
been noted by many clinical observers. The derangement referred to is
aptly described in the words of B. Lane and quoted by Tilt:[25]
"Nothing can be more common than to find severe biliary derangement
occurring at or about the period of menstrual cessation; and, looking
at the great physiological change which then takes place in connection
with hepatic development, it is naturally to be expected. A woman will
complain of being bilious; there may be a bitter taste in the mouth, a
burning in the throat, frontal headache, nausea, and even vomiting, the
urine high-colored, the bile abounding in the alvine dejections, and
perhaps causing heat and a stinging sensation in the rectum; the tongue
furred, a biliary tinge pervading the cutaneous surface." The propriety
of ascribing the symptoms so graphically described in these words to
excess, deficiency, or vitiation of the biliary secretion, in the
entire absence of precise knowledge, may well be questioned. Tilt is of
the opinion that the gastro-intestinal disorders produced by functional
disturbances of the liver during the menopause are peculiarly obstinate
in their resistance to {442} treatment. Many other clinicians bear
testimony to the truth of this statement. This fact increases the
importance of the subject of treatment. As this matter is very fully
discussed in other parts of this work, it is only necessary to call
attention at this time to the importance of directing the therapy to
the gastro-intestinal disorders, such as the accompanying subacute
gastro-duodenitis and constipation, rather than to the hepatic viscus
itself.

[Footnote 25: _The Change of Life_, 4th ed., p. 227, 1882.]

Incidentally, it may be remarked that gall-stones are apt to give
origin to distressing symptoms during the menopause. The causes in
operation are substantially the same as those already mentioned in
connection with the functional disorders of the liver.

CLIMACTERIC NEUROSES.--Incidental mention has been made, in the
discussion of the physiology of the menopause, of functional changes in
the nervous system, as involved in the perspirations, flushes,
hemorrhages, and other so-called critical discharges. Knowledge at the
present time of the physiological changes undergone by the nervous
system during the menopause is limited to these few general statements,
all of which are not yet definitely established facts. The field has
always been a fascinating one to the medical writer, probably because,
in the utter absence of precise information, the widest play is given
to the most vivid and fertile imagination. The literature of the
subject abounds in vague terms, figurative expressions, and rhetorical
forms. Numerous ingenious and interesting speculations may be found in
the writings of systematic authors from Gardanne[26] to Barnes and
Tilt.

[Footnote 26: _Aris aux Femmes entrant dans l'Âqe critique_, 1816.]

Tilt, following in the wake of the French writers, asserts that the
nervous system is in a state of irritability or nervocism. This
assertion conveys no information, as irritability may be the expression
of weakness as well as of strength. The system is said to be in a
condition of nervous plethora. We have seen that the rôle of plethora
in recent pathology is insignificant. Cohnheim denies its existence
altogether, except as a transitory state. Even admitting the existence
of that state, what evidence is there that nerve-force accumulates in
the body under the same conditions as the blood?

We have no desire to minify the importance of the physiological and
pathological changes in the nervous system connected with the
menopause. In comparison with these alterations the other phenomena of
the menopause are insignificant. In the absence of precise knowledge,
however, it is useless to devote time and attention to empty
speculation.

In no part of the subject of climacteric neuroses are notions more
obscure or information less precise than in connection with the
diseases of the sympathetic or ganglionic nervous system. Under the
term gangliapathy Tilt[27] has grouped a number of symptoms frequently
observed during the menopause, which have their origin in a condition
of "more or less debility associated with paralysis, hyperæsthesia, or
dysæsthesia of the central ganglia of the sympathetic system."
Gangliapathy includes the functional disorders described by other
observers under the terms cardialgia, gastralgia, gastrodynia, and the
like.

[Footnote 27: _The Change of Life_, 4th ed., p. 109, 1882.]

But it is impossible to view affections of the sympathetic apart from
disorders of the general nervous system. It is impossible to
distinguish {443} the conditions described by Tilt as ganglionic shock,
paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and
many of the functional and organic diseases of the abdominal viscera.
Finally, the connection of these various disorders, entirely
irrespective of names, with the change of life has never been
demonstrated, nor even rendered in a high degree probable.

Cerebral Hyperæmia.--The older authors dwell with especial emphasis
upon hyperæmia of the brain as an important functional disorder in
connection with the change of life. The condition is supposed to be apt
to occur, in the absence of perspirations, flushes, and the other
so-called critical discharges, as the result of plethora. Headache,
tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the
face and neck, bounding pulse, are among the symptoms which have been
referred to the lighter forms of cerebral hyperæmia. Few systematic
writers, however, sustain Dusourd in his assertion that apoplexy and
the severer forms of hyperæmia of the brain are frequently caused by
the cessation of menstruation.

Under the impression that plethora actually caused cerebral hyperæmia
and the symptoms mentioned, and doubtless influenced by the teachings
of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding
in the treatment of climacteric neuroses. Fordyce Barker and Tilt may
be mentioned among modern clinicians who retain the old opinion as to
the nature and treatment of this condition.

Cohnheim,[28] representing the modern school of pathologists, says
"that except as a transitory state polyæmia does not occur under any
circumstances." In recent pathology the various appearances of plethora
are regarded as caused chiefly by dilatations of the skin
blood-vessels, and not by an increase in the total blood-mass. The
changes in the character of the pulses are referred to alterations in
the vessels or their innervation. Even admitting the existence of the
so-called plethora universalis, it does not follow that headache,
dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia.
Andral has well said that these symptoms might with equal justice be
ascribed to qualitative changes in the constitution of the blood.

[Footnote 28: Pepper, _System of Medicine_, Vol. III. p. 886.]

Whatever view may be accepted as to the pathology of cerebral
hyperæmia, and as to the necessary connection with the change of life,
two important facts derived from experimental physiology deserve
careful consideration before bleeding is performed for the relief of
the symptoms mentioned:[29] (1) A high blood-pressure does not imply an
augmentation of the total blood-mass. A large quantity of blood may be
injected into the vessels without any considerable elevation of
pressure. (2) Bleeding does not directly lower blood-pressure unless
the quantity of blood removed be dangerously large.

[Footnote 29: M. Foster, _Physiology_.]

In the lighter cases the so-called derivative treatment fulfils all the
indications. Hot, irritating foot-baths, purgatives, saline diuretics,
are indicated for the relief of distressing symptoms. Diet, exercise,
frequent bathing, and other hygienic resources exercise a most
important prophylactic function.

Hysteria.--The occurrence of hysteria during the menopause, as at other
periods of life, is a well-established fact. Whether or no there is
{444} any direct pathological connection of cause and effect between
the change of life and the disorder is a question which has been the
subject of much controversy, and at the present time is unsettled.
Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation
one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are
of the opinion that the climacteric may stand in a causal relation.
Tilt's tabulated cases bearing upon this subject show nothing more than
the coincidence of the two conditions, and contribute nothing to the
solution of the problem. There are important considerations which favor
the view that while the menopause may influence hysteria favorably or
unfavorably, it is only in exceptional cases that the climacteric is
the immediate cause of the affection. While hysteria may occur at any
time of life, it is most frequently observed between the ages of
fifteen and twenty years. It is in a high degree probable that a woman
who has arrived at her forty-fifth year without hysterical
manifestations will not be molested during the change of life. It is
not an uncommon observation to see hysterical woman rapidly regaining
health during the pre-cessation period, and making complete recoveries
before the permanent resettlement of health.

Hysteria during the menopause does not differ as to symptoms from the
affection at other periods of life. It retains its protean character.
Almost all the described forms of nervous disease may be accurately
simulated. The severer forms of the disorder are paroxysms
characterized by convulsions, coma more or less complete, or delirium.
Coma enters to a greater or less degree into the paroxysms
characterized by convulsions. Lypothæmia--a term used by the older
writers to signify an hysterical semi-unconsciousness with feeble pulse
and widely-dilated pupils--is frequently observed. This condition, as
well as a state termed pseudo-narcotism by Tilt, may be regarded as a
lighter form of coma.

Functional paralyses and pareses of motion or sensation, or both, are
occasionally observed. Paraplegia is of relatively frequent occurrence.
Not infrequently this condition is of reflex origin, the eccentric
irritant residing in the uterus and adnexa or the gastro-intestinal
canal. Hemiplegia and general paralysis are observed less frequently.

In the differential diagnosis it is necessary to exclude epilepsy and
eclampsia, although it is well to bear in mind the fact that both these
conditions may coexist.

The treatment of climacteric hysteria differs in no essential
particular from that of the same disorder at other periods of life. The
practitioner, however, has the comfortable knowledge that with the
resettlement of health all symptoms, in the absence of local disease,
will probably disappear.

It may not be amiss, in passing, to notice the value as a palliative
measure of that old and well-tried remedy, the hot-water enema
containing asafoetida. One to two ounces of the tincture of asafoetida
in one quart of hot water, carried well up into the colon, is usually
productive of excellent results, moral and physical.

Climacteric Pseudocyesis.--False or spurious pregnancy is a neurosis of
not infrequent occurrence at or about cessation. It may justly be
regarded as one of the mimetic forms of hysteria. The symptoms which
give origin to the illusion may be observed in young, unmarried women
or long after the cessation of ovulation and menstruation. In {445} the
large proportion of cases, however, the phenomenon is noticed at or
about the climacteric. The subjective and objective signs of this
curious condition may simulate pregnancy very closely. The breasts are
swollen and tender, and a milky fluid may exude from the nipple. Nausea
and vomiting in the morning and the various sympathetic disorders of
pregnancy may be feigned. The abdomen may become enormously distended
from the deposition of adipose tissue in the abdominal walls and
omentum and the flatulent distension of the intestines. Foetal
movements are simulated by intestinal peristalsis and irregular
contractions of the abdominal muscles. The ensemble of symptoms may be
very deceptive, as shown by the famous case of Joanna Southcott.
Crichton Browne[30] relates the history of an illustrative case which
came under his observation in the West Riding Asylum. A woman long past
the menopause claimed to be two months advanced in pregnancy. At the
end of seven months she informed her friends that she was about to be
confined. Accordingly she went to bed, and the process of simulated
parturition lasted four days, terminating with a bloody discharge from
the vagina.

[Footnote 30: _British Medical Journal_, 1841.]

The differential diagnosis is easy. The mammary changes, upon close
examination, will be found to differ from those of pregnancy.
Inspection, palpation, percussion, and auscultation will disclose the
fact that the woman is only big with fat and wind, as Barnes puts it.
Anæsthesia will facilitate the examination. Bimanual examination
usually reveals the characteristic senile changes in the uterus or a
pathological enlargement differing essentially from the gravid organ.

The so-called phantom tumors sometimes observed during the menopause
are closely analogous to spurious pregnancies.

Epilepsy.--Epilepsy is a relatively uncommon disorder during the
menopause. The present state of our knowledge indicates that the
climacteric cannot be regarded as a distinct cause of the disease in
the absence of previous epileptic seizures or inherited predisposition.
Out of 200 cases of epilepsy occurring during the climacteric, observed
by Jewell of Chicago, not a single case could be traced by the most
rigid analysis to the change of life. Considering the rôle the
sympathetic nerve plays in the etiology of epilepsy, it would not seem
improbable, on a priori grounds, that the disease should be aggravated
at the menopause. Evidence derived from clinical observation, however,
is entirely inadequate to settle this question.

Insanity.--Various opinions are held as to the relation between the
menopause and insanity. Mania, monomania, dementia, and even idiocy,
are among the forms of mental alienation which have been attributed to
climacteric influences.

Monomania.--There is much probable evidence in support of the view that
the change of life may stand in a direct causal relation to monomania.
On the other hand, no proof exists sufficient to establish a necessary
pathological connection between cessation and mania, dementia, or
idiocy.

Gardanne, Dubois d'Amiens, and Chambon have called attention to the
occurrence of melancholia and hypochondriasis at this period. This
opinion is confirmed by the results of Battey's operation in the hands
of Lawson Tait, Bantock, Thornton, and other operators of large {446}
experience. In many of the cases of artificial induction of the
menopause melancholia has been observed as a most distressing sequela.
However, in connection with Battey's operation there are numerous and
important considerations which must be carefully weighed in order to
distinguish between a relation of cause and effect and mere
coincidence. The number of women operated upon is now large, and some
of the cases of melancholia following ovarian extirpation are probably
examples of the return of a disease of earlier life or of the influence
of heredity. Then, the fact of disqualification for maternal duties
supplies in many cases an adequate psychological cause for more or less
complete mental alienation. The important effects of chronic hepatic
hyperæmia and the coexisting gastro-intestinal catarrh--conditions so
frequently present at cessation--must not be forgotten when disorders
of the intellect are referred to the cessation of the ovarian stimulus.

The positive diagnosis of climacteric melancholia and hypochondriasis
is always difficult, frequently impossible. After the careful exclusion
of all other possible causes, it may be assumed with a certain degree
of probability that the intellectual disorder is due to the change of
life.

The prognosis of climacteric melancholia and hypochondriasis is not
necessarily unfavorable. In a large proportion of cases sanity returns
with the re-establishment of health. The treatment, in the absence of a
positive diagnosis, must be expectant. Effort must be addressed to the
removal of any possible cause. Hygienic measures fulfil all the
indications for treatment in the disorder when it is caused by the
change of life. Opium and alcohol must be employed with extreme care in
view of the great danger of the formation of obstinate habits.

Uncontrollable impulses and perversions of moral instincts are
frequently observed during the climacterium, as at other periods of
life. There is no reliable statistical evidence sufficient to establish
a necessary pathological connection between cessation and
uncontrollable peevishness, impulse to deceive, suicidal impulse,
nymphomania, dipsomania, kleptomania, and the like. Nor is it possible
to assert that these various disorders are of more frequent occurrence
during the menopause than at other periods of life.




{447}

DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.

BY W. W. JAGGARD, A.M., M.D.


Acute Metritis.

The occurrence of an acute inflammation of the parenchyma of the
non-gravid uterus has been denied by many systematic writers. Wenzel[1]
says the condition is a figment of the imagination; Duparcque is
sceptical; Klob[2] up to 1864 had never seen a case in which a positive
diagnosis was possible. Emmet[3] writes in the last edition of his
valuable book, "Inflammation of the uterine body never occurs except
after parturition."

[Footnote 1: _Krankheiten des Uterus_, p. 42.]

[Footnote 2: _Pathol. Anatomie der Weibl. Sexualorgane_.]

[Footnote 3: _Gynæcology_, 1884, p. 31.]

Comparatively recent investigations, however, have established the fact
of occurrence beyond doubt or question. While a relatively uncommon
condition, many facts with reference to its causation, pathological
anatomy, and clinical course are definitely known.

ETIOLOGY.--Disturbances in connection with menstruation play a rôle of
great importance in the production of acute inflammation of the uterine
parenchyma. The rapid cooling off of extensive areas of the skin
surface, as in wetting the feet in cold water, severe exertion, or the
cold-water vaginal douche, may transform the normal menstrual
congestion into an acute inflammation. The retention of menstrual blood
within the uterine cavity, the result of organic stenoses, flexions, or
tumors, occasionally gives origin to acute septic metritis. The
inflammatory process frequently extends from the endometrium to the
muscular substance. Gonorrhoeal endometritis is of chief clinical
significance in this connection. Duparcque's observations, confirmed in
1872 by Noeggerath, have recently attracted a great deal of attention.
Säuger's statement at Magdeburg, that one-ninth of all gynæcological
cases are of gonorrhoeal origin, created some surprise at the time. In
the light of the recent investigations of Schroeder, Bumm,[4] Lomer,[5]
Oppenheimer,[6] and others, it is not considered an exaggeration,
although it is still unsettled whether or no the gonococcus of Neisser
is the agent of infection.

[Footnote 4: _Arch. f. Gyn._, xxiii. 3.]

[Footnote 5: _Deutsch. Med. Wochenschrift_, 22d Oct., 1885.]

[Footnote 6: _Arch. f. Gyn._, xxv. 1.]

Under the heading of traumatism a great number and variety of
etiological factors are included. Operations on the cervix, curetting
the uterine cavity, and other minor gynæcological procedures, in the
absence {448} of careful antisepsis, may cause traumatic inflammation
in the vicinity of the wound, which may involve the entire organ. An
ill-fitting pessary, especially the intra-uterine stem, cauterization
of the cervix or endometrium with the solid stick of nitrate of silver,
intra-uterine injections, the careless passage of the sound, inordinate
sexual indulgence,--are all potential causes. Bloeschke[7] relates the
history of a case in which a piece of straw penetrated the cervix of a
peasant-woman working in the fields. An acute metritis was the result.

[Footnote 7: Säxinger, _Prager Vierteljahrschrift_, 1866, i. p. 130.]

Finally, acute inflammations of the muscularis may be lighted up in the
vicinity of new growths, as in the case of carcinoma of the cervix or
mural fibroids. Such inflammations, however, as remarked by Schroeder,
possess only a secondary significance.

PATHOLOGICAL ANATOMY.--The uterus, of a bluish-red color, is enlarged,
especially in its upper two-thirds, to the size of a goose's egg, and
is thickened in its antero-posterior diameter. Its walls, filled with
venous and arterial blood, are soft and succulent from the transudation
of serum. The bundles of muscular fibres are swollen, and the
inter-muscular tissue is infiltrated with white blood-corpuscles and a
few pus-corpuscles. Extravasations of blood, sometimes larger,
sometimes smaller, are usually observed in the connective tissue. These
changes are most marked in the innermost layers, where there is a
greater abundance of connective tissue, and the inflammatory process is
propagated toward the periphery. The endometrium, pelvic peritoneum,
and connective tissue are usually involved. The tubes and ovaries are
less frequently affected except in the case of gonorrhoeal infection.

SYMPTOMS.--The attack is usually ushered in by a chill, followed by
elevation of bodily temperature--a symptom which is apt to persist
throughout the course of the disorder. Pain, referred to the lower
portion of the abdomen and sacral region, is constant. The sensation
may be dull, gnawing, or boring, like the pains in the first stage of
labor or abortion, or sharp and lancinating. Tenderness on pressure,
indicating involvement of the perimetrium, is marked. The pain is
increased in intensity by standing, walking, coughing, straining at
stool, or any act which causes an elevation of intra-abdominal
pressure. Distressing symptoms arise in connection with the bladder and
rectum. Urination is frequent and painful, while the secretion may
contain blood. Griping pains are felt along the colon and rectum; the
sensation of fulness or the presence of a foreign body excites a
frequent or constant desire to defecate, and the act is accompanied
with straining.

When acute metritis is caused by wetting the feet in cold water during
the period, the menstrual flow may be suddenly arrested, to return
after a variable interval. In very rare cases menstruation is
permanently suppressed, and even atrophy of the uterus may result. In
other cases profuse menorrhagia may occur. Not infrequently this
copious hemorrhage is physiological, relieving as it does the
congestion of the organ.

Various sympathetic disturbances, as nausea and even vomiting, are
occasionally observed.

Acute metritis is frequently complicated by inflammation of the
endometrium, pelvic peritoneum, and connective tissue. Under these
circumstances the symptoms peculiar to inflammation of the muscular
substance {449} are masked. Acute metritis may terminate (1) in
resolution, with gradual resorption of the exudation and return of the
organ to its normal relations. (2) New connective tissue may be formed,
giving origin to induration of tissue and permanent increase in
size--the chronic uterine infarct of Kiwisch. The acute inflammation
has become chronic. While admitting the possibility of this mode of
termination, A. Martin[8] is of the opinion that a causal nexus is only
demonstrable in isolated cases. (3) A very rare mode of termination is
suppuration and the formation of abscesses in the muscular tissue. In
these cases it is necessary, as pointed out by A. Martin,[9] to exclude
myomata, which have undergone suppuration in the process of retrograde
metamorphosis.

[Footnote 8: _Pathologie und Therapie der Frauenkrankheiten_, 1885, p.
181.]

[Footnote 9: _Ibid._]

DIAGNOSIS.--The more or less sudden occurrence of a chill, fever, and
localized pain and tenderness urgently indicates a careful examination
of the pelvic viscera by bimanual palpation. The uterus is exquisitely
painful upon the slightest touch, even in the absence of any exudate.
The organ is enlarged, especially in its upper two-thirds, and
thickened in its antero-posterior diameter. The uterus is softened,
resembling in its consistence the organ in the early months of
pregnancy. During the stage of active hyperæmia the secretions are
diminished in amount; at a later period profuse leucorrhoea, especially
in the absence of menorrhagia, is a prominent symptom. The diagnosis of
abscess in the uterine walls is difficult, if not impossible, when the
collection of pus is small. The gradual enlargement of the uterus, the
presence of fluctuation, the indications of pointing, and the
constitutional symptoms are usually sufficient to establish the
diagnosis when the pus-cavity has attained a considerable size.

PROGNOSIS.--Under appropriate treatment the prognosis of acute metritis
is not unfavorable. It must, however, always be guarded, as it will be
governed to a great degree by the causation, clinical course, and
complications. Acute metritis from wetting the feet in cold water
during the period and the like usually terminates in resolution. It is
necessary to bear in mind the fact that in rare cases the function of
menstruation may be permanently arrested, and even atrophy of the
uterus induced. In acute metritis from traumatism the danger of general
sepsis constitutes the unfavorable prognostic element. In gonorrhoeal
infection the tendency to involvement of the tubes and peritoneum is
great; moreover, the condition is apt to recur. In all forms of the
disorder the relation to chronic uterine infarct deserves
consideration. Finally, death may result from the rupture of an
abscess, located in the uterine walls, into the abdominal cavity.[10]
Fortunately, these abscesses usually open into the uterine cavity,
rectum, or through the abdominal parietes.

[Footnote 10: Scanzoni, _Krankh. d. Weibl. Sexualorg._, iv. Aufl. Bd.
i., p. 203; Lados, _Gaz. médic. de Paris_, 1839, p. 605.]

TREATMENT.--In general terms, the treatment may be described as
vigorously antiphlogistic.

Chrobak[11] has pointed out in a detailed manner the absolute necessity
of the most rigid attention to antisepsis in all the minor as well as
the major operative procedures in gynæcology. The prophylaxis, a
subject {450} of vital importance, is limited, so far as the general
practitioner is concerned, to the enforcement of absolute cleanliness
in all manipulations of the female genito-urinary tract.

[Footnote 11: "Untersuchung. der Weibl. Genitalia und Allgem. gyn.
Therapie," _Deutsche Chirurgie_, Lief. 54.]

Absolute rest in bed in the dorsal decubitus, with the pelvis elevated
or depressed according to the patient's sensations, is a matter of
primary importance. Pain demands for its relief the free use of
morphine hypodermatically or opium per rectum. Chloral is a valuable
adjuvant.

In the absence of menorrhagia free and repeated scarifications of the
cervix are indicated to deplete the uterus. Twelve to twenty leeches
applied to the abdomen above the symphysis will measurably relieve the
congestion of the perimetrium. At a later stage, when the disorder does
not occur at a menstrual epoch, mediate cold-water irrigation, by means
of Leiter's modification of Petitgard's tubes, over the hypogastric
region is an invaluable therapeutic resource. When the affection occurs
during the period, hot compresses applied to the abdomen, hot
sitz-baths, and even hot-water vaginal injections, are grateful.

The rectum and sigmoid flexure frequently require evacuation. A simple
warm- or hot-water enema will usually secure this result. Occasionally
a dose of castor oil is indicated, but drastic cathartics are
distinctly contraindicated.

When the acute metritis is caused by traumatism, as in the case of
operations on the cervix and curetting of the endometrium, the wounded
surfaces demand attention. Under these conditions the neck of the
uterus and the uterine cavity require careful antiseptic local
treatment.

Abscesses in the uterine walls rarely indicate operative interference,
except in case of pointing in the direction of the abdominal cavity.
When incision is indicated the pus-cavity is usually large and
superficial, and its evacuation involves no especial difficulty.

The treatment of the later stages of acute metritis will be considered
in connection with the subject of Chronic Metritis.


Chronic Metritis.

SYNONYMS.--Chronic uterine infarct (Kiwisch); Diffuse connective-tissue
hyperplasia of the entire uterus (Klob, C. Braun, Wedl); Induration of
the uterus (Wenzel); Engorgement (Lisfranc); Hysteritis, Phlegmasie
rouge (Duparcque); Congestion ou engorgement hypertrophique métrite
(Becquerel); Interstitial metritis (De Sinéty); Congestive hypertrophy
(Emmet); Areolar hyperplasia, Diffuse interstitial hypertrophy,
Sclerosis uteri (Thomas, Skene); Subinvolution, Irritable uterus
(Hodge).

In the absence of exact knowledge with reference to the ultimate
pathology of so-called chronic metritis, it is impossible to frame a
definition which cannot be justly criticised. Schroeder's definition
answers all practical purposes, and probably contains as few
objectionable terms as any other in the literature of the subject.

DEFINITION.--Hyperplasia of the connective tissue of the uterus
combined with increased sensibility.

ETIOLOGY.--1. Subinvolution of the puerperal uterus is a frequent cause
of chronic metritis. But the number of etiological factors which {451}
interfere directly and indirectly with the retrograde metamorphosis of
the puerperal uterus is immense. Getting up too early from childbed,
inability to suckle the child, too early sexual intercourse, retention
within the uterine cavity of blood-clots or placental remains, acute
inflammations of the uterus during the puerperium, retroversions and
flexions of the puerperal uterus, severe exertion and the like,--are
some of the more usual causes in this connection. Involution of the
puerperal uterus is effected by contractions of the muscular walls,
fatty metamorphosis of the uterine substance, and profuse secretion.
Disturbance of any one of these processes may defer indefinitely the
return of the organ to its normal relations. When pregnancy is
prematurely interrupted the operation of each of these factors is
materially modified. Uterine contractions are relatively feeble. The
stimulus of a nursing child is also lacking. The albuminoids of the
muscular protoplasm are not so readily converted into fat capable of
easy resorption. A comparatively large quantity of decidua vera--even
in the absence of portions of the foetal envelopes--is retained within
the uterine cavity, and the secretory activity of the endometrium is
seriously disturbed. Then, women are less careful after miscarriages
than labor at term.

Laceration of the cervix uteri--an accident liable to occur in abortion
as well as during confinement at term--if at all extensive, usually
interferes with the retrograde metamorphosis of the uterus.

2. Continuous or repeated hyperæmia, active or passive, frequently
exceeds physiological limits and leads to chronic metritis. Menstrual
subinvolution, dysmenorrhoea from organic stenoses, flexions, changes
in position with retained menstrual fluid, excessive venery,
masturbation, conjugal onanism, chronic endometritis--especially
gonorrhoeal--inflammations of the pelvic cellular tissue, chronic
oöphoritis, new formations as in the case of carcinoma and
myoma,--result in the production of active flexion and venous
engorgement. The pernicious effects of conjugal onanism in the
causation of chronic uterine infarct have been dwelt upon with
particular fondness by Wenzel, Scanzoni, Emmet, Goodell, and numerous
other ancient and modern gynæcologists of distinction. Van de
Warker,[12] on the other hand, is of the decided opinion that the
operation of this etiological factor has been exaggerated. His
conclusions are based upon an incomplete gynæcological study of the
Oneida Community. Onanism was practised on a colossal scale by this
strange people for a number of years. Summing up the results of his
imperfect investigations, Van de Warker says: "I can discover nothing
but negative evidence relating to the effect of male continence upon
the health of the community." It is quite possible that too much
importance has also been attached to excessive venery. Fritsch[13] does
not stand alone when he says, "I have examined puellæ publicæ for
years, but have not gained the impression that metritis chronica is of
frequent occurrence."

[Footnote 12: Ely Van de Warker, "A Gynecological Study of the Oneida
Community," _The American Journal of Obstetrics, etc._, August, 1884.]

[Footnote 13: Heinrich Fritsch, _Die Lageveränderungen und die
Entzündungen der Gebärmutter_, 1885, p. 318.]

3. Venous stasis from organic hepatic, cardiac, and pulmonary diseases
doubtless predisposes to chronic inflammation of the metrium. {452}
Constipation, usually habitual with invalids, and an over-distended
bladder, are causes which are more frequently and directly operative in
the production of vascular engorgement and displacements of the uterus.

4. Various operative procedures upon the cervix, ill-advised and
frequently repeated intra-uterine applications, must be included in the
list of causative agencies.

5. Chronic metritis is one mode of termination of acute inflammation of
the uterine parenchyma. This method of origin, however, is seldom
observed except after repeated attacks of acute inflammation, as in the
case of gonorrhoeal infection.

The enumeration of possible causes might be indefinitely prolonged.
Scanzoni's classical monograph on chronic metritis contains a much
larger number. As remarked by Fritsch,[14] "In the elastic bands of his
conception of the disease every catarrh, every affection of the uterus,
fitted finally snugly into place." The more common efficient causes
have been indicated.

[Footnote 14: _Op. cit._, p. 299.]

PATHOLOGICAL ANATOMY.--Modern pathological doctrines on chronic
metritis are largely modifications of the opinions so ably advocated by
Scanzoni[15] in 1863. Scanzoni, while fully recognizing the various
forms of chronic uterine infarct, simplified the study of the subject
by comprehending them all under two stages: I. the stage of
infiltration; II. the stage of induration.

[Footnote 15: _Die Chronische Metritis_, Wien, 1863.]

I. In the first stage the uterine tissue is infiltrated with serum,
blood, and fibrin (serös-blutige, serös-faserstoffige Infiltration).
The organ is in a state of engorgement oedema, the consequence of
active and passive hyperæmia. It is enlarged in volume, altered in
shape, reddened and more or less sensitive on pressure, soft and doughy
to the sense of touch. The uterus may remain in this condition, or,
after a longer or shorter interval, pass over into the stage of
induration. Long-continued venous hyperæmia leads with comparative
infrequency to induration, although intercurrent inflammations,
exudations, and new formations of tissue may produce that effect. This
stage cannot be invariably viewed as of an inflammatory character.
These enlargements of the uterus are frequently examples of the
nutritive disturbances commonly observed in other organs in consequence
of long-continued venous hyperæmia. The close correspondence of
Scanzoni's stage of infiltration with Emmet's congestive hypertrophy is
at once apparent.

II. In the stage of induration a luxuriant growth of connective tissue
replaces the specific tissue-elements which are destroyed by a chronic
inflammatory process. Early in this stage there may be an actual
increase in size of the individual muscular elements. Ultimately, the
hypertrophy disappears, the soft and succulent connective tissue
becomes fibrillated, and the vessels are narrowed, sometimes
obliterated, by its contraction. The uterus, though still enlarged and
altered in shape, is of a pale color, anæmic, dry, tough, and hard.
Ultimately, the uterus is reduced in size by the cicatricial
contraction of the firm, fibrillar connective tissue. On section the
tissue is white, of cartilaginous consistence, and the knife creaks as
it divides the structures. Scanzoni's stage of induration is thus
nearly identical with the areolar hyperplasia, diffuse interstitial
hypertrophy, sclerosis uteri, of Thomas and Skene.

{453} Klob[16] a pupil of Rokitansky's, attributes the hyperplasia of
connective tissue to nutritive disturbances, considers the terms
chronic metritis and chronic infarct anatomically incorrect, and
classes the condition among the new formations. Carl Braun[17] and Wedl
in 1864 assumed the same position.

[Footnote 16: Jul. M. Klob, _Pathologische Anatomie d. Weibl.
Sexualorgane_, Wien, 1864.]

[Footnote 17: _Lehrbuch d. g. Gynaekologie_, Wien, 1881, p. 351.]

Klebs[18] is of the opinion that, although the so-called chronic
uterine infarct may be of inflammatory origin, in the majority of cases
the clinical and anatomical demonstration is lacking. With Scanzoni and
Virchow, he distinguishes two forms of the disease, the one consisting
in hyperplasia of the muscular elements, the other in a similar change
in the connective tissue.

[Footnote 18: _Handbuch der Pathologischen Anatomie_, Berlin, 1873, iv.
p. 878.]

Birch-Hirschfeld[19] supports the doctrine of Scanzoni, that the stage
of induration at least is of an inflammatory nature. The connective
tissue is formed out of emigrated white blood-corpuscles. Hypertrophy
of the muscular elements is also observed in certain cases.

[Footnote 19: _Pathologische Anatomie_, p. 1131.]

Fritsch[20] has materially strengthened the position of Scanzoni by his
recent anatomical investigations. Mayrhofer[21] substantially
reproduces Scanzoni's doctrines.

[Footnote 20: _Op. cit._, p. 309 _et seq._, Stuttgart, 1885.]

[Footnote 21: _Entwicklungsfehler und Entzündungen des Uterus_.]

Finally, the great majority of modern clinicians have accepted
Scanzoni's teachings as originally uttered or as modified in
non-essential details. Schroeder,[22] De Sinéty,[23] and A. Martin[24]
are notable examples of the truth of this statement.

[Footnote 22: Carl Schroeder, _Handbuch der Krankheiten d. Weibl.
Geschlechtsorgane_, Leipzig, 1881, p. 91.]

[Footnote 23: L. de Sinéty, _Manuel practique de Gynécologie et des
Maladies des Femmes_, Paris, 1879.]

[Footnote 24: _Op. cit._, Wien, 1885, p. 185.]

The hyperplasia of the connective tissue may be diffuse or
circumscribed. It may be limited in development to the collum or corpus
uteri. The perimetrium is usually thickened, and other signs of chronic
inflammation of that structure are usually present. Chronic
endometritis is a constant accompaniment. The pelvic connective tissue
is not commonly involved. The plexus pampiniformes and utero-vaginales
frequently undergo varicose dilatation.

SYMPTOMS.--The onset of the disease is so insidious and protracted that
it is difficult to determine the exact order of occurrence of the
symptoms in point of time. Then the complications are so numerous and
important that the symptoms of the chronic metritis are frequently
masked. A sensation of weight, fulness, or pressure within the pelvis
may direct the patient's attention to her condition. This sensation may
increase to such a degree that the woman complains of heavy, dull,
dragging pains, referred to the centre of the pelvis or the sacral
region. Backache is a constant and distressing symptom. Pains radiating
up over the abdominal parietes and down the thighs are frequently
experienced. Coitus may be productive of acute distress. When the
uterus is anteverted, pressing against the bladder, ischuria is the
usual result. Constipation, usually present as one of the etiological
factors, is aggravated by the retroversion or retroflexion of the
top-heavy uterus. Under these {454} circumstances one or both ovaries
may be drawn down along with the prolapsed, retroverted uterus, and add
materially to the woman's discomfort. The act of defecation is painful;
the woman avoids the water-closet, days and even weeks elapsing between
evacuations.

Disturbances of the menstrual function are constant. All forms of
dysmenorrhoea, including dysmenorrhoea membranacea, are liable to
occur. Menstruation is usually profuse, giving origin to menorrhagia,
which usually results in the production of an alarming degree of
anæmia. The periods are irregular in recurrence and duration. The
periodic discharge of blood may last from one to three weeks, and then
cease, to reappear after a variable interval of from six to eight
weeks. In other cases menstruation may last the usual length of time,
but recur every two or three weeks. Amenorrhoea may be observed in the
stage of induration.

Priestly,[25] Fasbender,[26] Fehling, and numerous other clinicians
have called attention to intermenstrual pain (règles surnuméraires) as
a tolerably constant symptom of chronic metritis. From fourteen to
fifteen days after and before the regular time for menstruation vague
intrapelvic pains are complained of, and the woman is of the opinion
that the monthly flow of blood is about to begin. The pains, however,
are not so severe, and do not last so long, as those of menstruation.
Occasionally bloody mucus may escape from the vagina. Fehling ascribes
this intermenstrual pain to the swelling of the mucous membrane
preparatory to the next monthly discharge of blood. The symptom is not
at all pathognomonic, as it occurs in connection with oöphoritis and
other pathological conditions.

[Footnote 25: _Brit. Med. Journ._, 1872, p. 431.]

[Footnote 26: _Zeitschrift f. Gebürtskulfe und Frauenkrankheiten_, i.
1.]

As the result of the chronic endometritis, which usually follows
parenchymatous inflammation, metrorrhagia is frequently observed.
Leucorrhoea, more or less profuse, is a constant symptom. Opinions vary
extremely as to the systemic reaction following chronic metritis.
General failure of nutrition, functional disturbances of the
gastro-intestinal canal, hysteria, headache,[27] facial neuralgia
(Barnes), coccygodynia, vaginodynia, skin diseases, alopecia (Hebra),
and a host of other affections, have been ascribed from time to time to
the direct influence of chronic uterine infarct. Doubtless, the
condition under discussion plays an important rôle in the production of
these and other disorders. But the position is utterly untenable at the
present day that chronic parenchymatous inflammation of the uterus is
the efficient cause in the absence of all other etiological
factors.[28]

[Footnote 27: Peaselee, "Uterine Headache," _American Medical Monthly_,
1860.]

[Footnote 28: Fritsch, _op. cit._, 1885, p. 323.]

Intercostal neuralgia and mastodynia, with swelling of the breasts and
darkening of the areolæ, are phenomena of such constant occurrence in
connection with chronic uterine infarct that a direct causal nexus is
in a high degree probable. The investigations of Krause[29] have
established the fact of anastomotic communication between the arteries
supplying the mammary gland and those distributed to the uterus. The
perforating branches of the internal mammary artery supply in part the
mammary gland. The superior epigastric artery, one of the terminal
branches of {455} the internal mammary, anastomoses with the inferior
epigastric, which arises from the external iliac a few lines above
Poupart's ligament. The inferior epigastric sends off a spermatic
branch which passes along the round ligament and anastomoses with the
ovarian artery derived from the aorta, and the uterine artery derived
from the anterior trunk of the internal iliac. The nervous
communication is effected through the sympathetic and spinal nerves.
There is nothing remarkable, therefore, in the occurrence of
intercostal neuralgia, mastodynia, and nutritive disturbances in the
mammary gland as the result of chronic parenchymatous inflammation of
the uterus. The intercostal neuralgia and mastodynia are examples of
reflected neuroses the result of compression of nerve-fibres by the
infiltration or of an ascending neuritis (Fritsch).

[Footnote 29: _Specielle und Makroskopische Anatomie_, Hannover, 1879.]

PHYSICAL SIGNS OF CHRONIC METRITIS.--Bimanual palpation prior to the
stage of cicatricial contraction reveals alterations in size, shape,
position, consistence, and sensibility of the uterus. Variations in
size are extreme. Veit[30] has recorded a case in which the fundus
extended two inches above the umbilicus. The uterus is usually
thickened, especially in its antero-posterior diameter. As regards
position, the organ may be prolapsed, elevated, or remain in situ. The
consistence will depend upon the stage of the disease. During the stage
of infiltration the organ is soft and imparts a doughy sensation to the
examining finger. During an exacerbation of acute inflammation the
vagina is hot and dry; the uterus is swollen with blood and very
sensitive on pressure. During the intervals between exacerbations no
change in sensibility is noticed. The sound demonstrates a varying
degree of elongation of the uterine cavity. During the second stage,
after cicatricial contraction of the connective-tissue elements, the
uterus is relatively small, hard, and insensible.

[Footnote 30: _Frauenkrankheiten_, 2 Aufl. p. 367.]

The cervix is hard or soft according to the time of examination. In
virgins or women who have not borne children enlargement is of
relatively infrequent occurrence. In multiparæ, especially in cases of
bilateral cervical laceration, the increase in volume is great. The
mucous membrane of the cervical canal is everted and studded with
minute cysts--distended follicles.

The influence of chronic metritis upon conception is not direct. When
the endometrium is not seriously involved the condition seems to
exercise no untoward influence. However, associated with chronic
uterine infarct as complications we have endometritis, salpingitis,
oöphoritis, perimetritis, and displacements, pathological states which
may obviously cause sterility.

When conception does occur, abortion follows with relative frequency.
The reason why is not clear. The chronic endometritis may interfere
with the development of the decidua; the parenchyma may not be able to
undergo evolution. When pregnancy reaches its normal termination, labor
is not materially influenced by the pathological condition of the
uterus, but complications are liable to occur during the puerperium.
Postpartum hemorrhages which do not readily yield to ergot are observed
as the result of the deficiency in muscular elements. The hyperplasia
of the connective-tissue elements and destruction of the muscular
tissue is a distinct predisposing cause of complete or incomplete
uterine inversion. {456} Subinvolution is increased. Menstruation
recurs soon after pregnancy, and the chronic metritis is
aggravated.[31]

[Footnote 31: A. Martin, _op. cit._, Wien, 1885, p. 189.]

Occasionally, gestation, parturition, the puerperium, and lactation
seem to exercise a favorable influence on the state of the parenchyma.
In exceptional cases all traces of the original chronic metritis
disappear with the puerperium. The connective-tissue hyperplasia may
undergo the same involution to which the hypertrophied muscular tissue
is subject. This favorable termination of the disease is seldom
observed during the stage of induration.

TERMINATIONS.--I. Chronic metritis may terminate during the stage of
infiltration in resolution. This mode of termination is rare. It is
observed occasionally as the result of involution in the puerperal
uterus. Judicious treatment in favorable cases may reduce the size of
the uterus and relieve all distressing symptoms. Recidiva of the
disease are liable to occur, however, and all traces of the former
condition seldom disappear.

II. Usually, the condition persists, with acute exacerbations, through
years, until cessation of menstruation and ovulation occurs. Under the
influence of the change of life the symptoms may gradually disappear
and the uterus may undergo senile atrophy. In some cases chronic
uterine infarct seems to defer the climacteric changes. Finally, the
disease may continue after the menopause, usually with abatement in the
severity of the symptoms.

III. The morbid condition may terminate in induration. The uterus
becomes comparatively small, hard, and insensible. Amenorrhoea may be
the result. This process may be viewed as a relative cure, since it is
attended, as a rule, with amelioration of all the troublesome symptoms.

DIFFERENTIAL DIAGNOSIS.--It is not always an easy matter to institute a
differential diagnosis between chronic metritis and pregnancy and
fibroid tumors by bimanual palpation. Alterations in the volume, form,
position, consistence, and sensibility of the uterus occur in pregnancy
as in chronic metritis. But in pregnancy the uterus, particularly in
its vaginal portion, is softer; the organ is not so sensitive; the
cyanotic hue of the vaginal mucous membrane is more marked; arterial
pulsations in the vagina are more evident; the uterus enlarges more
rapidly; finally, there is the history of the case. Pregnancy may
occur, however, in a chronically inflamed uterus, and this fact must be
borne in mind.

The alterations in the size of the uterus are usually circumscribed in
fibroid tumors. One wall is thickened; the other retains its normal
relations. In submucous fibroids the cervix is shortened; in chronic
metritis it is usually enlarged. In both submucous and interstitial
fibroids the cavity of the uterus is encroached upon--a fact to be
determined by the use of the sound. The history of the case will throw
some light upon the differential diagnosis. Frequently, however, it is
impossible to exclude fibroids by any of the means already mentioned.
Dilatation of the cervix, and the careful examination of the walls by
the finger introduced into the uterine cavity, will clear up the
diagnosis in the most obscure case.

PROGNOSIS.--The prognosis with reference to life is favorable. The
duration of life however, may be abbreviated in exceptional cases by
{457} disturbances of nutrition, anæmia the result of menorrhagia and
metrorrhagia, extension of the inflammation to the peritoneum, and the
like--conditions which predispose to some intercurrent affection.

Although the immediate danger of death is minimal, the woman is
rendered wretched by the frequent exacerbations of acute inflammation
and other symptoms already mentioned. The spontaneous disappearance of
the affection with the puerperium or menopause is of such seldom
occurrence as to have but slight bearing on the general rule.

Under judicious treatment disappearance of the more distressing
symptoms may be confidently expected during the stage of infiltration.
The outlook is especially favorable in cases of puerperal subinvolution
in the absence of chronic inflammations of the endometrium and
parametrium. A perfect restitution of the uterus to its normal
condition is so seldom effected by any rational therapy that for
practical purposes this desirable result may be excluded from
consideration. Recidiva of the disease are liable to occur at any time.

TREATMENT.--Prophylaxis.--Very much can be done to prevent the
occurrence of chronic metritis. A careful consideration of the etiology
of the disease will at once suggest the principles of prophylactic
treatment. The conduct of the second stage of labor, the puerperium,
lactation, the hygiene of menstruation, are subjects especially
significant in this connection. Antecedent acute metritis and
endometritis under a rational therapy usually terminate in resolution,
and their pernicious influences as etiological factors may be avoided,
or at least modified, in the large majority of cases. The early
rectification of uterine flexions and displacement is urgently
indicated in view of the probable consequences.

Uncomplicated chronic metritis is such a rare affection that efforts at
curative treatment are seldom addressed to the condition of the
parenchyma, to the exclusion of the endometrium, perimetrium, and
parametrium. Certain special indications, however, exist in the case of
chronic uterine infarct, and the discussion of treatment is limited
here to their consideration.

1. Local Treatment.--In view of the pathology of the condition, local
treatment, especially in the first stage, is antiphlogistic.

Hot-Water Vaginal Douche.--The irrigation of the vagina with hot water,
of different degrees of temperature according to the indications in the
concrete case, deservedly occupies the high position in American
gynæcological therapeutics which Emmet[32] in particular has assigned
it. The smooth muscular fibres of the uterus are excited to contract,
and the whole pelvic circulation is directly or indirectly influenced.
During the stage of infiltration--Emmet's congestive
hypertrophy--hot-water vaginal irrigation is simply an invaluable
adjuvant. But to secure the maximum benefit from this remedy it must be
rationally employed. With reference to posture, Emmet recommends the
dorsal decubitus, with elevation of the hips, or, better, the
genu-pectoral position. The temperature of the water should be rapidly
elevated from blood-heat to 110° F., or to as high a degree as the
patient can tolerate. The quantity of water will vary with the stage of
the treatment and the improvement in health of the patient. It is
customary to begin the irrigations with one to two {458} gallons of
water, and to increase or decrease the quantity according to
circumstances. Two irrigations per diem--one at night before going to
bed, one in the morning upon rising--are usually sufficient.
Fritsch[33] has tried on an extensive scale the plan of continuous
vaginal irrigation with hot water through five and even ten hours, but
has obtained better results with the simple periodic vaginal douche as
recommended by Emmet.

[Footnote 32: _Principles and Practice of Gynæcology_, 3d ed. 1884, pp.
85, 113.]

[Footnote 33: _Op. cit._, 1885, p. 337.]

During the stage of induration, when the muscular elements have been
destroyed and replaced by connective tissue, the beneficial effects of
the hot-water douche are decidedly less evident. Nor is the plan
applicable to all cases during the stage of congestive hypertrophy.
General nervous excitement, insomnia, and even positive intrapelvic
pain, sometimes, though rarely, may result. The range of therapeutic
application of the hot-water vaginal douche is largely empirical.

Local Depletion.--The local bloodletting of from a drachm to one ounce
of the fluid, repeated according to the indications every three or four
days, ranks next to the hot-water vaginal douche in importance as an
antiphlogistic agent. This plan of treatment is of especial value as an
adjuvant during the stage of infiltration in cases of menorrhagia,
metrorrhagia, exacerbations of acute inflammation, and the like. Local
depletion, however, is a double-edged sword. It may cause an increased
determination of blood to the uterus and aggravate the pathological
condition already existing. This effect is observed when the
bloodletting is practised at too short intervals.[34] Thus, frequent
scarifications of the cervix constitute a most important therapeutic
resource in the treatment of certain forms of atrophy of the uterus.

[Footnote 34: A. Martin, _op. cit._, 1885, p. 59.]

Local depletion of the cervix is effected by scarification, puncture,
leeches, wet and dry cupping. Scarification and puncture have almost
entirely superseded the other two methods.

Local depletion has fallen into a state of comparative disuse in
America. In the Woman's Hospital of New York[35] it has almost
completely passed out of vogue. In Germany, however, it constitutes the
basis of all methods of treatment. Schroeder, A. Martin of Berlin, H.
Fritsch of Breslau, Carl Braun, Spaeth, and Chrobals of Vienna unite in
enthusiastic advocacy of its intelligent employment in suitable cases.

[Footnote 35: T. Gaillard Thomas, _Diseases of Women_, 5th ed., 1880,
p. 334.]

Glycerin Tamponade.--Sims many years ago called attention to the
employment of cotton tampons saturated with glycerin in the treatment
of chronic metritis and kindred affections. In virtue of its avidity
for water the glycerin tampon, when placed in the vagina, provokes a
profuse aqueous discharge. The albuminoid constituents of the blood are
not affected, while the capillaries are drained of their aqueous
elements. Emmet[36] has substituted oakum for absorbent cotton. Oakum,
when saturated with glycerin, becomes soft as a sponge, is perfectly
antiseptic, and will remain odorless in the vagina a much longer time
than cotton. Glycerin dissolves the salts more readily than water.
Boric acid (1:10), potassium iodide (5:100), iodoform, chloral, and a
variety of substances may be applied locally by means of this
menstruum. Glycerin, employed in conjunction with hot-water vaginal
irrigation and scarification, or used {459} alone in cases
contraindicating these procedures, is an important addition to our
therapeutic resources.

[Footnote 36: _Gynæcology_, 1884, p. 128.]

Local Alteratives.--Much importance is attached in the United States to
the application of various alteratives to the vaginal portion and
endometrium in cases of chronic uterine infarct. They may accomplish
good results indirectly--for example, by curing the accompanying
endometritis--but it is doubtful whether they have any direct effect in
hastening the resorption of the infiltration.

The vaginal vault and intravaginal portion of the cervix are usually
painted with the compound tincture of iodine; mercury, potassium
iodide, iodoform, and other substances are introduced into the vagina
by means of vaseline, gelatin, and cacao butter.

Operative Treatment.--1. Repair of Lacerations of the Cervix.--The
importance of the repair of lacerations of the cervix for the cure of
chronic uterine infarct and allied conditions was recognized by Emmet
in 1862. In the autumn of 1862 he devised and performed the operation,
which is now known the world over as Emmet's operation. This highly
original and valuable surgical procedure has been but little modified
in the years which have intervened since its first full description in
1869.

2. Amputation of the Collum Uteri.--Carl Braun[37] and Wedl in 1864
pointed out the fact that amputation of the neck of the chronically
inflamed uterus is frequently followed by a more or less complete
involution of the whole organ, resembling very closely the reductive
metamorphosis of the puerperal uterus. August Martin in recent years
has called attention to Braun's observation, and at the
Naturforscherversammlung in Cassel described a series of seventy cases
in which amputation of the collum uteri had been performed for the
relief of chronic metritis. As an ultimate resort in extreme cases,
amputation of the neck of the uterus is now a generally well-recognized
operative procedure.[38]

[Footnote 37: _Wiener Med. Jahrbücher_, Wien, 1864.]

[Footnote 38: H. Fritsch, _op. cit._, 1885, p. 343.]

3. Castration.--At a comparatively recent date a determined effort has
been made to include desperate cases of chronic metritis under the
indications for the performance of oöphorectomy. Numerous and
distinguished surgeons have taken this advanced position. But at the
present time the cases in which the operation has been performed are
too few in number and too recent to warrant positive deductions with
reference to the effects of the operation.

2. General Treatment.--It is not possible to adequately discuss the
subject of the general or constitutional treatment of chronic metritis
in the limited space at our command. It is scarcely necessary to add
that the subject is of vital importance, and more frequently neglected
than the local treatment. The indications for therapeutic aid are
usually apparent, and are not always peculiar to the condition.
Attention has been directed, in other portions of this work, to the
importance of the observation of hygienic laws, in the widest sense of
that expression, with respect to diet, rest, clothing, recreation,
personal cleanliness, temperance in sexual intercourse, and other
bodily habits.

Habitual constipation, involving as it does engorgement of the portal
system and pelvic veins, demands especial consideration. In the absence
of regular daily alvine dejections the most elaborate plan of local and
{460} constitutional treatment will fail to effect amelioration of
symptoms. Diet, exercise, and the like are not sufficient, as a rule,
to correct this most obstinate habit. Among remedial agents, senna,
rhubarb, cascara sagrada, and the milder laxatives deserve particular
mention. The compound licorice powder and confection of senna of the
U. S. Pharmacopoeia are comparatively innocent in their effects, even
when used through long periods of time. Aloes must be employed with a
certain amount of caution. As pointed out by August Martin,[39] when
there is a disposition to uterine hemorrhages the drug, in the exercise
of its well-known influence on the pelvic circulation, may increase
this tendency. Clysters may be employed to advantage in connection with
hygienic and medical means.

[Footnote 39: _Op. cit._, p. 195.]

Ergot, hydrastis canadensis, potassium iodide, ammonium chloride,
strychnia, are among the remedial agents which are supposed to have
some direct effect upon the condition of the uterine parenchyma. Ergot
may be exhibited by the mouth or hypodermatically. Squibb's fluid
extract, while an active and tolerably agreeable preparation, is not as
effective as the decoction employed on an extensive scale in many of
the German hospitals, and the formula of which we append:

  Rx. Secalis cornuti recent. pulver.,  15.0
      Alcohol.,                          5.0
      Acidi sulphurici,                  2.0
      Aquæ,                            500.0
      Coque ad                         200.0
                      Ne cola.
      Adde Syr. cinnamom.,              30.0

Dose: Two to three teaspoonfuls, pro re nata. This unfiltered decoction
is extremely distasteful, and its continued use is not without effect
upon the gastric mucous membrane. It is, however, physiologically very
active. Subcutaneous injections of Squibb's aqueous extract of ergot
may be occasionally employed with benefit to keep up the impression of
the remedy when exhibition per os is interrupted. Schatz speaks in high
terms of the fluid extract of hydrastis canadensis in doses of fifteen
to twenty drops two or three times daily.

All European writers ascribe an important influence to the numerous
watering-places and baths of the Continent in the treatment of chronic
uterine infarct. The rigid observance of hygienic rules, the imbibition
of enormous quantities of water more or less impregnated with salines
and carbonic acid, the frequent bathings, exercise, and recreation,
undoubtedly effect amelioration of symptoms in many desperate cases.


Acute Endometritis.

ETIOLOGY.--An acute inflammation of the mucous membrane of the uterus
is a rare affection before puberty. The acute infectious diseases play
an important rôle in the production of the condition. The acute
exanthems--smallpox, measles, scarlet fever, cholera, typhus, typhoid,
and relapsing fever, certain forms of malarial fever--deserve mention
in this connection. Probably owing to some change in the constitution
{461} of the blood, these diseases predispose to the hemorrhagic form
of acute endometritis. The rapid cooling off of extensive areas of the
skin surface during menstruation frequently leads to an acute
inflammation of the endometrium, with suppression of the flow as one of
the first symptoms. Gonorrhoeal infection and sepsis are most important
causative factors. Ill-advised therapeutic procedures, as in the case
of acute metritis, must be included in the list of causative agencies.
Finally, acute endometritis may be caused by various poisons. Among
toxic agents which may give origin to the condition under discussion
phosphorus is especially noteworthy.[40]

[Footnote 40: Hausmann, _Berl. Beitr. z. Geb. u. Gyn._, Bd. i. S. 265.]

PATHOLOGICAL ANATOMY.--The entire lining membrane of the uterine cavity
may be involved in the inflammatory process; usually, the mucosa of the
body and fundus is affected, the mucosa of the cervical canal remaining
normal. The mucous membrane is of a dark-red color, swollen, softened,
and presents a velvety appearance. Its connection with the muscularis
is loosened, so that it can frequently be stripped off with the handle
of a scalpel. Minute extravasations of blood are visible in the
superficial layers and on the surface. The interglandular connective
tissue is the seat of the inflammatory process. The glands are involved
secondarily. The ciliated epithelium is destroyed and cast off at an
early stage. The bloody discharge from the uterine cavity becomes
serous, and finally purulent, during the progress of the condition. The
cervical secretion becomes thin, turbid, and profuse.

The inflammatory process is seldom limited to the endometrium. It
involves, as a rule, the tubal mucous membrane, the uterine parenchyma,
and the perimetrium.

DIAGNOSIS.--The symptoms resemble closely in kind, but differ in degree
from, the appearances in acute metritis. The uterus is smaller and not
so painful on pressure. The endometrium is sensitive to the slightest
touch--a fact elicited upon the passage of the sound. The
characteristic symptom is the discharge from the uterine cavity of a
more or less profuse secretion possessing the character already
mentioned. An absolute differential diagnosis is impossible, nor is it
necessary, seeing that the treatment of the two conditions is nearly
identical.

PROGNOSIS.--Acute endometritis terminates in resolution or chronic
inflammation. The latter mode of termination is of more frequent
occurrence, particularly in the presence of gonorrhoea, sepsis, and the
like as etiological factors. The disease endangers life when the
peritoneum is involved by the propagation of the inflammatory process
along the tubes or through the uterine parenchyma. Then the acute
endometritis may be the starting-point of general septic infection
through the media of the veins and lymphatic vessels.

TREATMENT.--Absolute rest in bed, the relief of pain by morphine, the
evacuation of the bowels by enemata or mild laxatives, the free
imbibition of bland mucilaginous fluids for the vesical tenesmus,--are
measures which usually fulfil all indications for treatment. Even in
the case of gonorrhoeal infections astringent applications to the
endometrium are contraindicated. Usually, various complications mark
the endometritis, the starting-point of the pathological condition, and
these complications demand more active interference.


{462} Chronic Endometritis.

ETIOLOGY.--Attention has been called to the etiology of chronic
metritis in a somewhat detailed manner. The limits of this paper will
not admit of adequate mention even of the more common causative factors
of chronic endometritis. All the conditions which determine an active
fluxion or passive hyperæmia of the uterus may operate as causative
factors. Hypersecretion of mucus is frequently observed in chlorotic,
scrofulous, and tuberculous females. Syphilis and gonorrhoea are
potential causative agents. Climate seems to exercise a more or less
direct influence. Thus, we are informed by Schroeder[41] that chronic
endometritis is observed with relative frequency in damp, cool regions,
such as Holland, Belgium, and certain parts of England. Europeans who
reside in hot climates--for example, the Englishwomen living in
India--are said to be affected with leucorrhoea to a degree entirely
out of proportion to local or constitutional causes.

[Footnote 41: _Handbuch der Krankheiten der Weiblichen
Geschlechtsorgane_, 1881, p. 111.]

PATHOLOGICAL ANATOMY.--An analogy of striking character exists between
the structural changes in chronic endometritis and chronic metritis. In
chronic endometritis, as in chronic metritis, it is possible to clearly
distinguish two stages in the inflammatory process. In the first, or
stage of infiltration, a more or less acute inflammation is observed,
which involves, primarily, the interglandular connective tissue;
secondarily, the glands themselves. When the stage of infiltration does
not terminate in resolution with the resorption of the exudate, the
newly-formed connective-tissue elements contract, and the glands are to
a greater or less degree obliterated.

1. Chronic Catarrhal Endometritis.--The endometrium during the first
stage is swollen, vascular, soft, and succulent. Small extravasations
of blood and pigmentary deposits from ecchymoses are observed in the
interacinous connective tissue. The surface of the mucous membrane is
smooth or roughened in spots. The orifices of the glands are visible.
The mucous membrane of the cervix is infected, its transverse folds
distended, the follicles filled with mucus, the canal plugged with
tenacious turbid secretion; the vaginal portion is enlarged, spongy,
and its mucous membrane exhibits hypertrophic changes in the papillary
body. The os externum is frequently patulous. The uterine walls having
undergone excentric hypertrophy, the cavity is usually enlarged, and
contains a translucent alkaline secretion which resembles mucus.

Microscopical examination of the endometrium reveals a variety of
structural changes. A luxuriant development of embryonal
connective-tissue elements is observed with relative frequency in the
interacinous connective tissue. Olshausen has applied the term chronic
hyperplastic endometritis to this condition. The term chronic
interstitial endometritis has been more generally accepted. While the
newly-formed connective-tissue elements are soft and succulent,
hemorrhages are frequent.

Changes in the glandular structures may become more prominent features
than alterations in the connective tissue. The laminæ of the glands and
the cells of the acini increase in size. The glands branch, frequently
resulting in the production of a dendritic network. Schroeder and Carl
Ruge have termed this glandular endometritis diffuse adenoma.

{463} The thickness of the mucous membrane may increase in spots from
three or four millimeters to fourteen or fifteen millimeters, and there
is produced a form of chronic endometritis which is known as fungoid or
polypoid.

Under the name endometritis villosa Slavianski described in 1874 a
condition of the uterine mucous membrane which consists in a papillary
growth of the endometrium with myxomatous degeneration of the vessel
tunics.

During the stage of induration the ciliated epithelium, destroyed and
cast off during the stage of infiltration, is replaced by cells which
resemble squamous epithelium. The utricular glands, with dilated
cavities, are flattened out, entirely obliterated, or present the
appearance of shallow crypts. The secretion is gradually diminished,
until finally the endometrium is converted into a layer of connective
tissue.

Under the names erosion, ulceration, granulation, and the like a
variety of pathological conditions, entirely distinct from, sometimes
in connection with, cervical laceration and ectropium, are included.
The flattened epithelium covering the vaginal portion may be cast off,
and replaced by the dark-red subjacent cylindrical epithelium, giving
origin to the condition known as simple erosion. Occasionally,
glandular canals, formed out of these cylindrical cells, and
penetrating the mucous membrane in every direction, present the
appearances of papillary erosion; and the condition has accordingly
been termed by Carl Ruge papillary ulcer. Cervical secretions may
stagnate in these glandular tubes, retention-cysts appear, and the
condition technically termed follicular erosion results. In all forms
of cervical erosion or laceration the secretions are increased in
amount and altered in physical and chemical characters during the stage
of infiltration. In a later stage of the disease the hyperplasia and
subsequent contraction of the connective-tissue elements may result in
the total obliteration of all traces of glandular structure. There is a
certain amount of probable evidence in favor of the view that these
changes in the cylindrical cells normally situated beneath the squamous
epithelium covering the vaginal portion may terminate in malignant
disease. These erosions, in the present state of our knowledge, must be
viewed as symptomatic of chronic endocervicitis.

2. Dysmenorrhoea Membranacea.--The exfoliation and casting off of large
pieces, or even of the superficial layers, of the entire endometrium
during menstruation has been observed from the days of Morgagni up to
the present time. Peter Frank pointed out the resemblance between this
exfoliation and the membrana caduca. Simpson, recognizing the
sieve-like perforations caused by the utricular glands, termed the
condition exfoliation of the hypertrophic mucous membrane. Virchow
erroneously termed the membrane decidua menstrualis. Olshausen, Wyder,
and v. Recklinghausen (1877) have demonstrated the truth of Simpson's
view, and have shown that the condition must be regarded as a symptom
of a series of endometritic inflammatory processes. In all cases in
which a decidual membrane is cast off the diagnosis of abortion must be
made, whether the pregnancy be intra-uterine or extra-uterine.

Wyger has reported a case in which syphilis was regarded as an
etiological factor. This observation has not been confirmed.

3. Chronic Croupous Inflammation of the Endometrium is sometimes
observed in connection with carcinoma of the corpus. It may follow
{464} gangrenous vaginitis in diphtheria and the acute infectious
diseases. The interacinous connective tissue is infiltrated with
fibrinous materials, and extravasations of blood are everywhere
visible. The superficial layers of the mucous membrane become
gangrenous, are cast off, and occasionally the entire intra-uterine
expanse is converted into a wound surface.

DIAGNOSIS.--The symptoms of chronic endometritis and endocervicitis are
usually masked by the appearance of the accompanying chronic metritis.
Intrapelvic pains, disturbance of the menstrual function,
extra-menstrual hemorrhages, the presence of a more or less profuse
leucorrhoea, are signs which urgently indicate bimanual palpation.

The catarrhal secretion from the utricular glands may be imprisoned
within the uterine cavity by a functional or organic stricture of the
internal os, resulting in periodic discharges of a thin, translucent
alkaline fluid, readily distinguishable from the thick, tenacious
cervical mucus. In certain cases, particularly in old women, the
blenorrhoeal secretion may be permanently retained within the uterine
cavity, constituting the condition hydrometra.

The introduction of a small sharp spoon within the cavity of the uterus
will enable the observer to remove sufficient tissue for microscopical
examination without entailing the slightest injury on the patient. A
positive diagnosis can be made in this way, and a rational therapy
instituted.

Digital and specular examinations disclose the condition of the vaginal
portion of the cervix. The amount and physical characters of the
cervical secretions are items of important diagnostic moment. In
suspicious cases of cervical erosion a small bit of tissue may be cut
away from the surface and subjected to microscopical examination.

Secondary disturbances in connection with the gastro-intestinal canal
and nervous system occur in chronic inflammations of the endometrium,
as in the case of chronic uterine infarct.

PROGNOSIS.--Chronic inflammations of the corporeal and cervical mucous
membrane seldom threaten life directly. The continuous loss of blood
and serum, however, may produce a condition of profound anæmia and
render the individual more susceptible to intercurrent disease.

Then the hyperplastic condition of the endometrium is always an
occasion for anxiety. The relation between polypoid and fungoid growths
of the corporeal mucous membrane, erosions of the vaginal portion of
the cervix, and malignant new formations is not settled. The
possibility of malignant residua, however, must be admitted.

Sterility, acute and chronic decidual inflammations, adherent placenta,
disturbances in the involution of the puerperal uterus, and the
like--direct results of chronic endometritic inflammation--are
conditions which confer an unfavorable element upon the prognosis.

Finally, while it is possible to effect a material amelioration of all
the symptoms by a judicious general and local treatment, a complete
restitutio ad integrum is seldom or never achieved. Recidiva are always
liable to occur.

TREATMENT.--Prophylaxis.--The remarks made with reference to the
prevention of chronic uterine infarct apply with equal force to the
prophylaxis of chronic corporeal and cervical endometritis.

{465} Curative.--Of chief importance, in the very large majority of
cases, is the subject of general treatment. Many cases of chronic
catarrhal endometritis are improved by the regulation of the functions
of the gastro-intestinal canal, skin, kidneys, and hæmatopoietic
viscera in the absence of all local treatment. This statement holds
true with particular force when scrofulosis, tuberculosis, syphilis,
and the like are chief etiological factors.

Local Treatment.--The methods of local treatment at the present time
are infinitely various. For convenience of description they may be
collected under three headings:[42]

    I. The washing out of the uterine cavity;
   II. The cauterization of the uterine cavity;
  III. The curettement of the uterine mucous membrane.

[Footnote 42: H. Fritsch, _op. cit._, 1885, p. 419.]

To Schultze, in particular, are we indebted for methods of washing out
the cavity of the uterus. The cervical canal is dilated by means of the
finger, tents, or metallic instruments, and the mucous membrane lining
the cavity of the uterus is cleansed with dilute solutions of carbolic
acid, boric acid, bichloride of mercury, and other solvent and
antiseptic fluids.

Cauterization is usually effected at the present time by the
application of pure tincture of iodine, iodine with glycerin, or
carbolic acid, to the endometrium. Bandl's canulæ for the washing out
of the uterine cavity with solutions of alum and cupric sulphate are
valuable instruments in this connection. The application of the solid
stick of nitrate of silver and intra-uterine injections of liquor ferri
are gradually passing into disuse.

The curettement of the diseased endometrium has been rapidly gaining
ground within recent years, and now constitutes the most reliable
method of treatment in obstinate cases in which local interference is
indicated at all. Martin, Düvelius, and other clinicians have
abundantly established the fact that, after the mechanical removal of
the old diseased mucous membrane, a new endometrium of relatively
normal functional activity is formed.

The number of operative procedures for the relief of chronic
endocervicitis is enormous. In the majority of cases occurring among
multiparæ it will be found that the condition is aggravated, if not
caused, by cervical laceration with ectropium. Under these
circumstances, and under the indications and conditions insisted upon
by the author of the procedure, Emmet's operation will alleviate, if it
does not cure, the pathological state of the mucous membrane.




{466}

{467}

ABORTION.

BY GEORGE J. ENGELMANN, M.D.


DEFINITION.--Abortion, the mishap of popular parlance, the fausse
couche of the French, is the premature interruption of intra-uterine
pregnancy, the expulsion of the non-viable ovum, whether the result of
natural causes or criminal interference.

SYNONYMS.--Common as the accident unfortunately is, the nomenclature,
both popular and scientific, is somewhat indistinct, the terms abortion
and miscarriage being used in a variety of ways, so that the physician
is liable to be misunderstood by his professional brethren and in
danger of causing serious offence to his patients. A strict definition
of the terms is hence of importance, and in order not to add to the
confusion we can do no better than adopt the one now adhered to by the
authorities of the day. Abortion and miscarriage are strictly
synonymous, notwithstanding the popular belief that the term abortion
is restricted to the criminal interruption of pregnancy, whilst
miscarriage is supposed to designate the accident resulting from
natural causes. Again, some make a difference in time between abortion
and miscarriage--abortion being the expulsion of the ovum in the first
four months of pregnancy; miscarriage, or the partus immaturus, in the
next three months, from the fourth to the seventh; and the partus
prematurus from the seventh to the ninth month.

CLASSIFICATION.--We might, indeed, in regard to importance, cause, and
course of expulsion, designate four different periods of gestation--the
first two during the continuance of the chorion frondosum, and the last
two during the period of placental development: the first during the
first two months of pregnancy, before sufficient adhesions have formed;
the second, still during the period of the chorion frondosum, until it
begins to disappear, from the second to the fourth month; the third, in
the early stages of placental development, before the term of foetal
viability, from the fourth to the seventh month; and the fourth, which
is everywhere recognized as the partus prematurus--premature
delivery--from the seventh to the ninth month, when the placenta is
fully developed with firm adhesions and the child viable.

For practical reasons and simplicity's sake we will distinguish only
between abortion and premature labor--miscarriage, abortion, abortus,
being the expulsion of a non-viable foetus, of the ovum before the time
of complete placental development, in the first seven months of
pregnancy; and premature labor, the interruption of pregnancy in the
last two months, from the seventh to the ninth, when the foetus is
viable and {468} formation and attachment of the placenta has been
completed. These two classes naturally blend, but are strikingly
different in cause, symptoms, and treatment if we consider the type
about which they are grouped--abortion proper as most frequent in the
third and fourth month, and premature labor in the seventh and eighth.
It is abortion or miscarriage of which we shall treat in this article,
more especially its characteristic form before the formation of the
placenta, whilst we shall touch but lightly upon those forms which
approximate premature labor and come within the sphere of the
obstetrician; that is, abortion in the sixth or seventh month, when the
placenta is more fully developed.

FREQUENCY.--With regard to the frequency with which this accident
occurs, we can but form an estimate, as there are but few of the
pathological conditions to which the human constitution is subject in
regard to which we are more at fault as to statistics: neither the
case-book of the physician nor the hospital or post-mortem record
permits of more than an indefinite approximation as to the frequency of
its occurrence. During the first six or eight weeks of gestation,
certainly the first four, the patient herself is often ignorant of her
condition, and the ovum passes off amid a more profuse menstruation,
with only the symptoms of simple menorrhagia; the same may be true at
later periods by reason of coexisting conditions. Some knowingly
conceal the fact; many, knowing it, call no assistance; others have
midwives, the physician seeing only the more threatening cases; and but
few enter the hospital, where our most reliable statistics are
gathered.

All points considered, it has been stated that to every 5.5 labors at
term we will find 1 case of premature expulsion of the ovum (Busch and
Moser). Whitehead asserts that 90 per cent. of married women abort, or
that 37 out of 100, somewhat over one-third, of all mothers abort at
least once before their thirtieth year. Hegar estimates 1 abortion in
the early months to 8 or 10 labors at term, which harmonizes very well
with the figures given by Busch and Moser. Multigravidæ abort more
often than primigravidæ, although there are certain causes peculiar to
primigravidæ which tend to abortion, such as the indiscretions of early
married life: uterine disease, perimetritis, and endometritis, on the
other hand, are more common in multigravidæ, and, again, the number of
multigravidæ is by far greater than that of primigravidæ.

These estimates are all somewhat general, but even if exact statistics
could be gathered as to any one locality, they would not hold good in
others--true of one region, they would not be so of another. Climate,
habits of life, and morals of the community very greatly affect the
completion and interruption of pregnancy.

IMPORTANCE.--Frequent as the occurrence of abortion is--common almost
as childbirth--its importance is universally underrated. Many of the
ills to which women are subject result directly or indirectly from this
accident, or, we may justly say, from an undervaluation of its
importance. If not criminal or traumatic, it is the result of
pathological changes either in the maternal system, in the sexual
organs, or in the ovum itself; labor is brought about amid these
conditions at a time when neither ovum nor uterus is properly prepared,
as in labor at term, and under these conditions, especially in a
diseased system or diseased uterus, involution will not so readily take
place. Morbid conditions of {469} the sexual organs follow, and affect
the health of the patient more or less, though death but rarely
results, either directly or indirectly. These evils are more commonly
the consequence of mismanaged abortion and neglected after-treatment
than of the accident itself; hence the result depends rather upon a
thorough appreciation of the importance of this condition by both
patient and physician, especially the general practitioner, the family
physician; if assistance is sought, it is he who is called, and not the
specialist--not the gynecologist or the obstetrician. It is the
physician conversant with the family secrets whose aid is sought in
this matter, which is considered by the mother rather as a delicate and
disagreeable than an important affair.

Women should be given to understand more thoroughly the serious results
which so often follow neglected abortion or abortions which, for the
very reason of their being rapid and favorable in their course, are
neglected as to after-treatment. Women must be impressed with the
necessity of proper attention during the progress of miscarriage from
its very initiation, and the even greater care that is necessary after
the ovum is expelled and all is supposed to be over, and involution of
the uterus at this period must be guided and guarded as after expulsion
at term.

Much suffering would be avoided if women were taught to consider
abortion as a disease, a pathological condition, demanding immediate
and active attention, and not simply as a disagreeable and disgraceful
accident, to be concealed if possible. The patient would then no longer
endeavor to worry through without assistance or call in nurse or
midwife; and, thoroughly knowing the possible dangers, they would be
more cautious, and the frequency of criminal abortions would also
decrease: these, above all, cause injury to health, because medical
attendance is avoided if at all possible, and care likewise, as the
patient is anxious to conceal her indisposition. Then also the
practitioner must bear in mind the great importance of this accident,
both that he may anticipate and prevent it, and if inaugurated he may
guide it to a rapid and successful termination and guard his patient
throughout the period of involution. Great temporary pain, and often
lifelong suffering, will thus be prevented.

A thorough knowledge of abortion, of its causes, course, and treatment,
is equally necessary to the physician, that he may guard his own honor
and that of the profession: an abortion, due to uterine disease or
malnutrition of the ovum, occurring during some period of medical
attendance is often blamed upon the physician by those anxious for
offspring, whilst, on the other hand, that large and shrewd class who
are seeking to avoid childbirth not infrequently resort to the trick of
urging certain methods of treatment during early pregnancy, with the
hope that the physician himself may thus induce abortion, or he is
called, with all appearance of innocence, by the criminal who has
interrupted gestation to complete the abortion once commenced. His own
reputation and that of his profession is then at stake: to guard this
and to preserve the health of the mother entrusted to his care he must
be conversant with the pathological conditions involved and the
importance which attaches to them.

Woman requires skilled aid in labor, the physiological termination of
pregnancy; more necessary still is this in the premature pathological
interruption of this condition, in abortion! The attendant is often
{470} responsible for two lives, as in labor, although under the
conditions usually existing medical aid is not summoned until the life
of the embryo is already destroyed--a most urgent argument in favor of
timely medical advice and of close attention to prevention, a proper
management of the pregnant state, and the treatment of threatening
abortion, as at this time both lives may still be saved. This accident,
so frequent in its occurrence, so disastrous to the health of woman, is
important in all its phases, not only in the stage of expulsion and
retention, to which attention has been directed on account of the
surgical interest, but as well in its incipience, the time of
prevention, and its after-treatment; abortion demands, and is worthy
of, the most careful study and the best efforts of the physician.

HISTORY.--The history of abortion, it has often been stated, is the
history of civilization, but I would rather say that it is the history
of races--of their rise and fall. Abortion in consequence of natural
causes, as well as criminal, is now, and has at all times been,
practised among savage as well as civilized peoples, and develops with
the progress of civilization, with the deterioration and fall of races,
civilized and savage, as shown by history ancient and modern.

Abortion consequent upon natural causes is by far less frequent among a
vigorous and healthy people still struggling for supremacy, full of
youth and strength, than among nations who have reached the height of
power, who have been enfeebled by indolence and the luxuries of
civilization, by vice and fashion. Of criminal abortion this is
naturally true to a far greater extent, yet this is common and
customary among many primitive, semi-civilized peoples. As nations
advance they become debilitated and demoralized amid the brilliancy and
luxuriousness of their surroundings, and they rapidly retrograde toward
the very worst vices of primitive humanity: they are thus undermined,
and succumb to the attacks of their more vigorous neighbors, and
magnificent empires are overthrown and extinguished by the youthful
vigor of a hardy, simple people. The more civilization progresses, the
greater the apparent abhorrence of the crime of abortion, the more
numerous the laws enacted to guard against it, the more frequent does
the crime become; and, strange though it may seem, it is nowhere
punished. Abortionists everywhere are known; in the larger cities of
this continent as well as Europe they achieve a widespread fame, are
well known, and yet rarely if ever convicted. It is a notorious fact in
our community that these worst of criminals almost invariably escape,
and even in the states of Germany, where the laws are strict and
rigidly enforced, where the crime of abortion is punished by
imprisonment of from five to twenty years, that eminent teacher of
medical jurisprudence, J. L. Casper, says that "Of all the many
accused, never a one was condemned, and in no one case was the crime
proven." They are sheltered by the words of the law and the sympathy of
the community, which, notwithstanding the abhorrence expressed, still
accompanies these criminals, though not to so great an extent as it
does those equally forlorn women who are guilty of killing the child
when born; for, as Hodge truly says, "There is no class of criminals
who meet with so much sympathy as women guilty of foeticide." Greece
and Rome when at the height of their power favored by their laws, and
almost openly advocated, abortion, whilst among the ancient Germans it
was {471} one of the crimes most deeply despised and most severely
punished--just as it was condemned by the laws of the Goths. How
different is it now among the races sprung from these proud conquerors
of Rome, now that they have reached the very acme of their career! The
more civilized, the more powerful they become, the more does this crime
develop, as in Germany and France, where it is practised upon a most
extensive scale, and yet, as we have seen, the criminals escape,
notwithstanding the most rigorous laws. Condemned from the bench and
the pulpit, the crime still progresses. There is the poor girl who has
yielded her honor for the sake of bread for herself or those dependent
upon her; there is the lady of fashion, by far more culpable, who
cannot give up the time she owes to society to the cares of maternity;
or the society belle, who would resort to any and every measure that
she may escape maternity for the sake of retaining her beauty and the
freshness of her charms, a slender waist and a well-shaped breast;
others resort to it that their round of pleasure may not be disturbed.
Many an unborn child is executed upon the plea of limited resources,
that the family cannot continue to live in their accustomed luxury if
an additional member should appear.

Neither the laws of God nor man will affect the hearts of women thus
brutalized: it is the physician alone who can interfere; it is to him
they come most often; it is he, the trusted family friend, who will do
more than judge or priest to change this unfortunate condition of
affairs. In crowded countries abortion is looked upon as a necessity of
nations, just as it is here considered a necessity in a family too
numerous; hence in China, Japan, and Hindostan it is common; in Arabia
and in New Caledonia it is produced on account of the scarcity of
nourishment and the difficulty of raising children. Among some crude
people it is not the wish of the individual, but the law of the land,
which determines the course of gestation; so upon the island of Formosa
a woman is not allowed to bear a child before her thirty-sixth year,
and priestesses fulfil a social law by kicking the belly of the woman
who becomes pregnant before the proper age, lest the population grow
too large for the resources of the island. So it is among other
islanders also--upon the Sandwich Islands, the South Sea Islands, whose
population was reduced from two hundred thousand to seven or eight
thousand in the course of thirty years. Upon Tahiti and King's Mills
Islands it is equally common. Upon the latter a more generous feeling
prevails, and the woman is at least allowed to have a family of three,
but not beyond that; and upon the Feejee Islands one of every two
conceptions is supposed to be destroyed before the period of gestation
is completed.[1] So also among the New Zealanders, the Hottentots, and
the inhabitants of Madagascar. By the Icelanders this crime is
committed as an heirloom left by their Norwegian ancestors.

[Footnote 1: Trader, _Criminal Abortion_.]

Not alone upon the islands, but among the inhabitants of states not
overcrowded like China and Japan, abortion is legalized; so in Paraguay
and La Plata, where it is caused in every family after the birth of two
living children. Some of the African negroes produce abortion on
account of limitation of resources; among the Buddhists, otherwise so
humane in their laws, it is frequent--a wonderful disharmony between
{472} the conduct of individuals and the dictates of their political
and religious laws.

Wherever celibacy is demanded crime and abortion result, as among the
Buddhists, whose laws condemn large numbers of vigorous subjects to
this existence; and in our own civilization we see the same inevitable
result in many of the most closely-populated Catholic countries. Thus
abortion is frequent among the Anamites and among the Kambysians, who
marry late and are frequently obliged to produce abortion before the
time of marriage. Among the Brahmans it is a common practice, induced
by religious and political arrangements, the direct result of a law
which encourages sexual excesses, and frequently of the restrictions
placed upon the needs of woman (widows are condemned by law to eternal
celibacy); yet this terrible crime is looked upon as most harmless by
the people of India, the destruction of a child that has not seen day
being, according to their view, less of an evil than the dishonor of a
woman. In Turkey it is so common that a certain price is paid for
abortion and another for infanticide, and the law is indulgent to the
crime, as it can be paid for cheaply. The cost of removing a non-viable
foetus, or even an embryo, is equivalent to a tenth of the price paid
for the murder of an infant.

The methods by which expulsion is accomplished are everywhere the same
among people civilized and savage, ancient and modern--local and
general. Among the local measures external violence is the most simple,
as among the Tasmanians, who practise abortion by striking the belly,
just as it is done by the priestesses of Formosa; and this is quite
common in our day and in our communities. The introduction of
instruments and implements into the womb is more intricate, but
likewise common; the knitting-needle is a favorite resort in our
country, and among primitive peoples a similar practice is resorted to;
thus some of the negroes of Africa introduce the sprouting stem of a
plant into the uterine cavity. Venesection, the drawing of blood from
the vulva, anus, and foot, was often resorted to for the purpose of
producing abortion.

Among the more common remedies used in former times are emetics, which
are still very often resorted to, cantharides, emmenagogues, sabin,
snakeroot, and the famous pennyroyal; so also ergot; the compound
cathartic pill of the United States Pharmacopoeia is a favorite
remedy,--all of which maim or kill the patient as often as they produce
abortion. In New Caledonia a decoction of red-bud and banana-peel or
green fruit is taken boiling: in China aperient medicines are publicly
advertised for sale, and aphrodisiacs under the name of remedies to
free the stomach and give back virginity. Certain negro tribes bring on
abortion by manipulation of the abdomen and the use of purgative
substances, such as the bark of the koche and sonnaly, which are also
used to facilitate labor. Pen-tsae enumerates a large number of
remedies as accelerators of abortion or purgatives according to the
dose; many of them have a very doubtful action, however. The natives of
India most commonly use the black annin, vulgarly called black anise or
fourspice; fifteen grammes is an emmenagogue and larger doses produce
abortion. The Arab women seek to produce sterility and escape the
annoyance of numerous pregnancies, and imagine that they can arrive at
that end by drinking a solution of sal soda, a decoction of
peach-leaves, and the sap of the male fig tree.

{473} Among peoples savage and civilized, for good reasons and bad,
villains sufficient are found to do the bidding of thoughtless and
misguided women; the remedies used, internal and external, local and
general, are very often so violent as to be followed by the death of
the victim. The plea of limited resources, of the inability of
supporting a large family, is one common to people of all races in all
stages of civilization: permitted by the unwritten law among some, it
is practised with equal frequency by others, though strictly condemned.
As we have stated, among many of the American nations it is legalized.

Again, there have been people at all times who have scorned the crime,
but this is only among those pure, primitive, and still-developing
peoples, as, for instance, the ancient Goths and Germans; and the Noxes
of South America, as well as some of the negroes of Africa, even permit
the husband without hesitation to kill his wife if she should abort. It
is among those of the primitive peoples where the blessing of offspring
is held in high esteem that the crime of abortion is most condemned and
most rare. With the progress of civilization and religion, of
refinement and knowledge, this crime, strange as it may seem, rapidly
develops. It is not among the low and ignorant--it is among the
educated and refined, among the wealthy--that it is most common; and
the plea given in excuse of this crime is one most especially urged by
the educated and refined, by the devout Christian, that the embryo is
not an animated being, not an individual existence--that it does not
attain the dignity of a living being until the time of quickening,
until the middle of pregnancy. Religious and scientific reasoning is
brought to bear in support of this theory in excuse of the many refined
criminals; and it is this very point which the physician must urge:
that the ovum, the embryo, from the moment of conception is an animated
being, an individual existence with a life of its own. Important as the
treatment of abortion, in consequence of natural causes, is, its
prevention, and, above all, the prevention of criminal abortion, is
still more so; and it is this which lies in the hands of the physician,
whose most forcible argument must be in the evident and glaring crime
which is committed by the destruction of a living being, as is the
embryo from the moment of conception, not to forget the injury
resulting to the mother. The former appeals to the moral, the latter to
the physical, elements of womanly nature.

Whilst abortion, in consequence of natural causes, is a condition more
dangerous than labor at term, the interruption of pregnancy by forcible
means--criminal abortion--must necessarily be more grave in its
consequences. The interference is often a violent one; the aborting
woman is in mental distress, unable to seek the necessary comfort or
attention; she is oppressed by the crime in her inner conscience; under
unfavorable conditions, physical and mental, for the suffering which is
most likely to follow.

With the progress in the practice of medical science the art of the
abortionist keeps pace, and in civilized communities of to-day one
cause of this growing frequency is in the increased numbers and the
increased skill of practitioners ready to pander to all the whims of
their degenerated customers: but the greater should be the efforts of
honorable physicians to dispel the false illusions by which women seem
to justify their doings, and to erase this darkest of all thoughts that
lurks amid the {474} noblest sentiments in woman's mind. A strong
effort was made not long ago by the American Medical Association to
urge the importance of this matter upon the profession, resulting from
the earnest efforts of that honored obstetrician Hugh L. Hodge, which
culminated in a report of the Committee on Criminal Abortion, read
before the American Medical Association in 1871, and a number of papers
written upon the subject at that time, prominent among which I would
mention those of Van de Warker, Tabor Johnson, and John W. Trader. The
wave has swept by: what has been accomplished may be gleaned from the
police records of our cities.

PHYSIOLOGY OF EARLY PREGNANCY.--For an understanding of the
pathological conditions which determine, precede, and accompany this
accident a knowledge of the physiological state is as important as
normal anatomy is to the pathologist. But as this subject is treated of
in full in other articles, we will confine ourselves to a few of the
leading features which are most important for purposes of diagnosis and
treatment.

The changes, local and general, resulting from the physiological state
of pregnancy are extremely variable, often approximating or simulating
pathological conditions, so that we must differentiate and discriminate
between such as pertain to the normal condition and such as indicate
pathological changes and threatening danger. This is necessary, as
prevention is, above all, important, it being often possible thus to
save two lives with by far less danger and suffering to the mother than
is to be expected from the treatment of abortion once inaugurated after
the time of possible prevention has passed. Moreover, a correct
post-abortum diagnosis is important for the future welfare of the
patient, if not from a medico-legal point of view; and this is equally
impossible without a knowledge of the physiological condition. This
will enable us to determine whether the ovum expelled is healthy or
not--whether the causes are traumatic or criminal, or whether the
abortion is due to pathological changes; which, again, must guide us in
treatment.

Abortion is the expulsion of an ovum the product of a conception, and
can only occur during the period of menstrual life, as conception, the
impregnation of the female ovule by the male semen, is the consequence
of fruitful intercourse, liable to take place at any time during the
period of womanhood, the thirty years of female menstrual life from
puberty--the appearance of the catamenia--to the time of their
cessation. Its occurrence is followed by intense physiological activity
of the maternal organism, lasting throughout gestation to the time of
its natural termination with the expulsion of the fully-developed ovum
at term at the end of the tenth lunar month. This is made evident by
striking changes in the entire system, but especially in the sexual
organs, which in the earlier period of pregnancy are entirely
progressive, developmental, whilst in the later months, toward term,
the character is changed to that of a retrograde metamorphosis,
preparatory to the separation and expulsion of the ovum and final
restitution of the organs. This hyper-activity inaugurated by
impregnation becomes evident by marked changes in the system of the
mother, in the sexual organs, and in the ovum itself.

Changes in the Maternal System.--These are most peculiar and varied,
differing in repeated pregnancies in the same patient, sometimes
entirely absent, at others most distressing, even fatal; sometimes
appearing at one {475} period, sometimes at another. Healthy, robust
women may suffer throughout the entire period of gestation, whilst
those at other times ailing are well only in this condition. The most
marked of these symptoms are the hystero-neuroses, disturbances of the
entire nervous system, central and peripheral; mental depression, more
rarely excitement; gastric disturbances, nausea and vomiting; increased
activity, renal and pulmonary, consequent upon changes in the
circulation; discoloration of the skin upon the forehead, the linea
alba, and areola; oedema and varicosities of the veins upon the lower
extremities. All these, and many others still more erratic, may
accompany the normal physiological condition.

Changes in the Uterus and Pelvic Viscera.--Whilst the ovum develops in
the uterus, this organ, its appendages, and the viscera surrounding it,
enclosed together within the pelvic cavity, undergo the most marked
changes. The early months of pregnancy are those of greatest
physiological activity in the uterine muscle, the period of its
hypertrophy. This is inaugurated from the very moment of conception, at
first increasing, then gradually lessening, until within the last
months, when it becomes passive, the rapidly-growing ovum merely
distending the hypertrophied uterus, apparently increasing in size, but
merely distended by its contents, as a rubber bag would be. In the
earlier months the growth of the uterus is entirely due to muscular
development--after the fifth month to distension. The individual
muscular cells attain enormous growth, and a large number of
pre-existing embryonic cells are developed; so also in the interlacing
connective tissue. The blood-vessels as well as the lymphatics increase
in size and length; the arteries become tortuous; the capillary
circulation is to a great extent supplanted by sinuses.

Weighing in its normal condition, when at rest, little above an ounce,
the uterus attains within the first four or five months a weight almost
fifteen times greater. Remaining the first four months within the
pelvic cavity, the increase in size is not of that diagnostic
importance which it attains in the later months, when it is to be felt
beneath the abdominal walls, though at the end of this period it is
distinctly perceived above the symphysis; about the fifth month,
between navel and symphysis; and at the sixth month, at the height of
the navel. At the end of the third month the uterus is some 4½ to 5
inches in length, by 4 in breadth and 3 in thickness; at the end of the
fourth month, 5½ to 6 inches in length, by 5 in breadth and 4 in
thickness; at the end of the fifth month, 6 to 7 inches in length, 5½
in breadth, and 5 in thickness; at the end of the sixth month it is
some 8 to 9 inches in length.

The changes which take place in the cervix are a merely passive
accompaniment of the uterine hypertrophy, it being enlarged more
especially by reason of the succulence of its tissues consequent upon
the congestion and activity of the body. It is somewhat enlarged in all
its dimensions, thickened, and elongated, soft, velvety to the touch,
appearing, however, somewhat shortened by reason of the hypertrophy of
the vaginal attachment--a condition that approximates rather that of
the vagina and external sexual organs than that of the uterus,
softened, succulent, somewhat hypertrophied, congested, of a deeper
bluish-red wine color, its cavity occluded by thick tenacious mucus, as
the secretions of the mucous membrane of the vagina and external sexual
organs are also augmented. In the first and second months the uterus is
retroverted, the cervix seems to {476} descend as the enlarged organ,
by reason of its weight, settles in the pelvis, the fundus sinking down
in the hollow of the sacrum, the cervix consequently pointing more
forward; as the organ increases in size and rises above the brim in its
endeavor to escape the confining space of the pelvic cavity, the
enlarged fundus, meeting with the resistance of the promontory, seeks
the point of least resistance, and the uterus begins to assume that
position of anteversion which continues to become more marked as
pregnancy progresses: the cervix points backward into the hollow of the
sacrum, and rises gradually (as the fundus increases in size and
withdraws from the pelvic cavity).

The Uterine Mucosa.--This structure is as interesting as it is
important. The wonderful changes which it undergoes go hand in hand
with the various changes and stages of female life: it is the nidus for
the reception of the impregnated ovum; it serves to shelter and nourish
the delicate ovum, and if diseased, affording insufficient nutrition,
leads to the death and expulsion of the embryo. Its shreds when
expelled are of diagnostic importance, and in early abortions its
massive thick tissues, changed by disease, often cause greater trouble
than the ovum itself, forming, alone or with the membranes proper of
the ovum, what is so commonly but erroneously called the placenta in
abortion. The membrane which lines the cavity proper of the uterus,
passing at the internal os into the mucous membrane of the cervical
canal, is characterized by the absence of even the slightest trace of
submucous or areolar tissue--by its peculiar substratum of connective
tissue abounding in cells and tubular glands. It is closely and
inseparably attached to the muscular coat. In a state of rest it is a
little over 0.04 inch in thickness at the fundus,[2] and the anterior
and posterior walls diminishing toward the sides, the cervical and
tuber ostea. It is traversed by a series of tubular glands, wavy in
their upper part, bifurcated toward their base, running more or less
parallel to each other. In this membrane, so important for the
preservation and development of the ovum, the physiological activity of
the system is inaugurated, and seems to centre during the first week of
gestation. With the impregnation of the ovule the uterine mucosa, its
earliest shelter, begins to hypertrophy: the rapid development which
now takes place is owing to the proliferation of the cells of the
stroma and the enlargement of the individual cells of all kinds,
including those of the glands themselves, as well as the increase of
the succulent homogeneous and cellular substance. The glands throughout
their greatest extent are enlarged: the increase in thickness is more
especially due to the hypertrophy of the superficial layer, the upper
half, in which the stroma appears less compact, growing far above the
original gland-openings, circumvallating the enlarged ostea, and thus
causing those funnel-shaped depressions which give the membrane its
sieve-like, cribriform appearance when seen from above. In the third
month of pregnancy the mucous membrane attains its greatest thickness,
forming a soft succulent lining to the uterine cavity, by its
distension closing the various ostea. It is then as much as 0.236 inch
in thickness in the anterior and posterior walls, lessening toward the
ostea, and begins to present the characteristic layers which become so
distinct in the later months--a dense upper and a very loose lower one,
comparable to a lax meshwork. Its growth now ceases, {477} and as the
uterine cavity increases in size and the ovum in growth, it is
distended to cover the rapidly-expanding surface, and becomes thinner
and thinner, the upper dense layer remaining as such, whilst the
glandular sinuses of the lower layer of the membrane are stretched
transversely until they become mere flat meshes like a network
stretched along the surface of the womb.

[Footnote 2: Engelmann _Mucous Membranes of the Uterus_.]

The impregnated ovum, as it rapidly enlarges during the first two or
three weeks, becomes imbedded in the thickened succulent decidua; and
we may compare this to the sinking of a bullet into soft dough: the
soft mass of the dough yields to the weight of the superimposed body,
and gradually closes over it, so the tissue of these overlapping folds
soon unites, completely surrounding the ovum, the nidus thus formed, in
which the ovum settles, being usually in the upper portion of the
fundus upon the posterior wall of the right side. We now distinguish in
the mucous membrane of the uterus three parts: the decidua vera, the
greater part of the membrane lining the cavity of the womb where it is
not in contact with the ovum; the decidua serotina, which is that part
directly beneath the ovum, between it and the uterine wall, which is in
connection with the tufts of the chorion, later in part develops to
form the placenta; and the decidua reflexa, that part of the mucosa
which overlaps and has overgrown the ovum. This membrane is little
known and rarely recognized, though always present. It is of no
practical importance; a delicate membrane even at the time when it is
the great safeguard of the tender ovum, serving to protect it and hold
it within the soft bed formed by the decidua serotina; this function of
the reflexa continues until the third month, when the ovum has
developed sufficiently to occupy the entire uterine cavity and is
everywhere in contact with its walls. The thin tissues of the reflexa
become more transparent and delicate as they are distended and
compressed between ovum and decidua vera, which now with the muscular
wall of the uterus surround the ovum and continue the previous function
of the reflexa.

The Development of the Ovum.--Practically, we may distinguish two
periods in the development of the ovum: the first, that in which we are
here interested, before the development of the placenta, where it is a
cyst-like body surrounded by the shaggy chorion, the chorion velosum;
and after the development of the placenta, after the fourth or fifth
month, when the foetus is more fully developed and the ovum is covered
with the smooth chorion, the chorion levæ.

The period scientifically the first, and the most interesting stage of
development, during the first three or four weeks, when segmentation
takes place and the form is moulded, we shall in no way consider. The
ovum may then be cast off, perhaps at a succeeding monthly period,
unbeknown to any one, perhaps not even to the unconscious mother:
certainly the services of an accoucheur are not called for. In the
third or fourth week it is a delicate cyst-like body of the size of a
hazel-nut, some half an inch in diameter, surrounded by its translucent
chorion, and is crushed in the passages or disappears amid the clots of
blood of an apparently profuse menstrual flow. The following periods of
development are, however, of practical importance, as they will serve
diagnostic purposes, as well as an understanding of the appearance of
the ovum and the symptoms accompanying miscarriage.

{478} The ovum during the first months of pregnancy is an oval
cyst-like body surrounded by the chorion, the shaggy tufts of which
give it a characteristic readily-recognized appearance. Enclosed within
is the delicate transparent amnion, and the embryo, attached to the
navel-string, floating in the clear liquor. At six weeks the size of
the ovum is likened to that of a pigeon's egg; at eight or nine weeks
to that of a hen's egg, perhaps 1½ inches in length; at the twelfth
week, to that of a goose-egg, some 4 inches in length. In the second
month the ovum forms a bulging prominence in the uterine cavity,
usually toward the fundus, and reveals all the parts recognized at term
with the exception of the placenta and the still distinct umbilical
vesicle: its surface is covered by the tufts of the chorion and
surrounded by the decidua reflexa. In the third month it is so far
developed as to completely occupy the uterine cavity, as yet but
slightly adherent, approximated, a part of it agglutinated to the
uterine mucosa, to the decidua serotina, the greater mass of the
chorion being in no way adherent to the surrounding reflexa. The tufts
of the chorion begin to sprout and develop more fully at its point of
contact with the uterine wall above the decidua serotina, whilst upon
the remaining and greater portion of its surface their growth ceases,
and as the membrane distends the delicate filaments gradually
disappear. At the end of the third month, in the fourth month, the
tufts of the chorion have sufficiently developed in its adherent
portion to form the rudimentary placenta, and at the end of the fourth
month this is developed still more--has become more dense and large,
whilst the remaining portion of the membrane appears smooth and barely
shows a few scanty remnants of the once-shaggy tufts.

The growth of the ovum now rapidly outstrips that of the uterine
cavity; the membranes are pressed more firmly against its walls,
approximated to the decidua vera, but not by any means agglutinated. In
the sixth month the placenta has been thoroughly formed--it has become
dense and large, the foetal membranes beginning to agglutinate to the
uterine wall, and the conditions existing at term are rapidly
approached. The embryonic tissues are supplied with the necessary
nutriment by endosmosis from the surrounding maternal structures during
the first months; the entire surface of the chorion absorbs, whilst
this function is delegated to the proliferating villi as they develop
and agglutinate with the decidua serotina, foreshadowing the activity
of the placenta by which the foetus is nourished to term.

Practically, the most important period in the development of the ovum
is the one most dangerous to its existence--in the third and fourth
month, that period of intense activity of chorion and decidua, the time
of the formation of the placenta, when hemorrhage is likely to occur
from the congestion of the vessels so necessary to the nutrition of the
rapidly-growing and delicate tissues. Nutriment is no longer merely
absorbed by the succulent embryonic cells of the ovum from the tissue
in which they are in contact, but the embryo is forced to seek
sustenance through those now fully-developed tufts of the chorion--from
the proper site, the decidua serotina and the surrounding
vessels--directly from the uterine structures. If hemorrhage interferes
or disease prevails, the healthy growth of the ovum is checked, and a
morbid development ensues, to result sooner or later in death of the
embryo and expulsion.

{479} The embryo in the early months of pregnancy is small as compared
to the size of the sac, the membranes, liquor amnii, and navel-string;
at the end of the fourth week the embryo measures from 1/3 to 1/4 of an
inch in length; at the end of the eighth week, from ¾ to 1 inch: the
arms and legs become visible, the umbilical vesicle, though reduced in
size, still exists; the small body with large upper extremity is
pendent from the short, thick navel-string. At the end of the twelfth
week the embryo measures from 2 to 3 inches in length; fingers and toes
can be distinctly seen; mouth and nose are also recognizable. At the
end of the sixteenth week, the fourth month, the embryo measures some 4
to 5 inches in length; sex can be distinguished; the head assumes
shape, but it is still immense in size, perhaps an inch in length; the
features of the face are all formed. At the end of the twentieth week,
the fifth month, there is no longer doubt as to sex; the nails, which
were previously visible, have become distinct; the soft, woolly lanugo
begins to develop; hair may be noticed upon the head; motion,
inaugurated weeks before, is felt by the mother. Toward the end of the
sixth month, in the twenty-fourth week, the embryo is some 12 inches in
length. As has been before stated, with the cessation of the
development of individual organs and parts growth in size becomes more
rapid. As this was less in the earlier months, it is now very marked.
With the seventh month, as the foetus becomes viable, it is some 12 to
14 inches in length, weighing 2 to 3 pounds; the body is covered with
lanugo; the hair on the head becomes quite marked; the papular membrane
disappears.

It is well to bear in mind the leading features in the development of
the uterus, decidua, and the ovum, and more particularly its membranes,
as a guide in the treatment, that we may recognize the parts expelled
and know what remains to be removed--as an aid in diagnosis, that we
may properly judge the conditions, whether healthy or morbid, and
post-abortum, when we may be forced to determine by the corpus delicti,
as the all-important evidence in criminal cases, as to the duration of
pregnancy and the causes which led to its termination.

ETIOLOGY.--Causes of Abortion.--Interesting as the etiology of disease
is to the inquiring mind, to the progressive physician it is of great
practical importance as well; and this is eminently true of the causes
leading to abortion. More so of (A) spontaneous or accidental abortion,
though by no means to be neglected in (B) criminal abortion. Etiology
is important in both, as it is a knowledge of cause alone which can
lead to prevention, that most valuable of all methods of treatment, and
in criminal abortion to detection, thus indirectly to the prevention of
recurrence.

A. Accidental or Spontaneous Abortion, or Abortion as the Result of
Natural Causes.--The etiology of non-criminal abortion is indispensable
to the practitioner, as it is this alone which will enable him to
prevent its occurrence and recurrence, thus leading to the preservation
of the lives of mother and child, doing away with the danger and
suffering of actual treatment, and frequently serving as a guide in the
latter. We will meet with some difficulties in our endeavor to analyze
these causes, as they are so varied in their nature and differ so
greatly in the medium through which they act. There are causes
predisposing and exciting, local and general, internal and external,
and causes which depend upon father, {480} mother, and ovum. The direct
dependence of treatment upon the exciting causes seems to necessitate a
simple and practical delineation of the etiology of abortion. A direct
reference of the cause to the offending organ is understood most
readily, and will point most directly to the necessary measure of
relief; hence we will consider such causes as spring from or act
through mother and child--more properly, the maternal system and its
individual organs on the one hand, and the ovum and its parts upon the
other. We cannot, however, pass by these without giving a thought to
such causes to which great importance is attached by many, and which it
is best to consider separately.

Predisposing Causes.--Almost all abnormal conditions, whether
pertaining to the system or external to it, are more or less
predisposing causes, whilst direct exciting causes are few; they may or
may not be followed by the premature interruption of gestation; they
tend to death and expulsion of the ovum, making it likely to occur
whenever the exciting cause arises. We may say all those by which the
occurrence of abortion is favored are predisposing causes: they are
conditions under which we may expect its occurrence; and, knowing them,
it is the duty of the physician to guard his patient. The
classification is indefinite. Thus Naegele considers as predisposing
causes anæmia, congestion local and general of the maternal system,
neurotic influences; and as exciting causes--1st, those which tend to
sever the amnion from the surrounding uterine structures; 2d, those
which cause malnutrition, disease, and death of the embryo or foetus;
3d, those which directly arouse uterine contraction. Others consider
diseases acute and chronic on the part of the mother, local and
general, as well as diseases on the part of the father, predisposing
causes, whilst traumatism and neurotic influences are considered as
exciting causes. All are classifications based upon no strict
foundation. I wish, however, to call attention to certain conditions
which I look upon as predisposing to abortion: that is, a pregnant
woman while under the influence of such condition, such cause, is more
liable to abort upon the occurrence of some directly exciting cause.
The existence of one or more predisposing causes does not necessitate
abortion; pregnancy may continue without interruption if exposed to any
of the conditions which we will term as exciting causes.

First. Climate.--We find abortion, both accidental and criminal,
prevalent in certain countries and in certain districts, dependent upon
climate--in the deltas and valleys subject to malaria, upon barren soil
where food is wanting or where the work of woman is particularly
laborious.

Secondly. Number and character of the population: this mishap is most
common in large cities, where morals are lax, where the ill-fed poor
are crowded into tenement-houses and the rich live in the whirl of
social dissipation, or in thickly-settled regions where there is an
intermingling of sexes, where women are neglected and ill-fed. I may
here add an observation which truly shows the difference of locality.
Both Playfair and Philippeaux[3] claim that abortion is especially
prevalent in the country. This may be true of the rural districts of
England, France, and Germany, especially the latter military
government, where it is in the country that young, able-bodied women do
the hardest and most of the work, as is seen when passing through these
regions in harvest-time. In {481} America the very opposite is true, as
in the country here abortion is most rare.

[Footnote 3: _Annals Gynécologie_, 1881.]

Third. Certain periods in woman's life eminently predispose to
abortion. There are those important epochs in woman's life during which
her nervous system undergoes a severe strain wrought by those changes
which are all-important to her existence. These are, first, in early
married life, when intense hyperæsthesia exists due to changes wrought
in the sexual system: the young wife is, moreover, exposed to injurious
external influences, certain forms of traumatism; and secondly, toward
the approach of the menopause, as the activity of sexual function and
the uterine organ diminishes and the nervous system is undergoing those
changes with periods of intense neurotic excitement which accompany the
menopause. Finally, we may look upon the morbid conditions of the
system, all unfavorable changes in the surroundings, as predisposing
causes.

Exciting Causes.--We have seen that Naegele considers malnutrition and
all causes which lead to separation of the ovum from its surroundings,
and even uterine contractions, as exciting causes, whilst Spiegelborg
considers hemorrhage so much so that to him the history of hemorrhage
during gestation is the history of abortion. As exciting causes I
consider uterine contractions and such conditions as directly lead to
hemorrhage in the uterine or foetal membranes; but I cannot class
either as exciting causes direct and primarily, both being merely
sequents dependent upon some more remote cause. The varied importance
of predisposing and exciting causes will be best appreciated if we but
recollect the ordeals which a healthy woman may undergo--the direct
exciting causes which may act upon her--and yet abortion not occur,
provided no predisposing causes exist. Thus we have the
well-authenticated statement of a pregnant woman being run over, the
wheels of a physician's carriage passing directly over the abdomen, and
yet abortion not following. I myself know of the attempts of a husband
to produce abortion upon a willing wife by beating the abdomen, finally
stamping and sitting down upon it, and yet not succeeding. I have the
statement of a reliable physician as to the continuation of
intra-uterine application of iodine and astringents to the cavity of a
uterus supposed to be diseased, which proved to be pregnant, until the
fourth month, and yet abortion not following. We know how women with
criminal intent produce local injuries, even such as result in death,
whilst the ovum remains undisturbed. These are cases in which no
predisposing cause existed. On the other hand, the careless washing of
the feet in cold water, a single effort at the wash-tub, a rapid drive,
fright, a piece of bad news, coitus, the slightest nervous or physical
disturbance, may produce abortion where predisposing cause sufficient
does exist. We will here classify the exciting causes of abortion, in
reference to the consequent treatment and the possibility of
prevention, as maternal and foetal, dependent upon, acting by means of,
the maternal system and organs or those of the ovum. Those dependent
upon the mother are amenable to preventive treatment; not so those
dependent upon the ovum.

A. Causes of spontaneous or non-criminal abortion:

1. Causes due to pathological changes in the maternal system, general
and local. These are by far most important to the practitioner, as they
{482} are amenable to treatment. His attention should most especially
be directed to--

_a_. General causes acting through the system. These are--

(1) Diseases acute and chronic;

(2) Causes acting through the nervous system, neurotic;

(3) Physical or traumatic;

And (4) I shall classify what I might term social causes, such as
result from custom and fashion, which form an important element in the
etiology of abortion, and one more particularly open to and demanding
prevention.

_b_. Local causes on the part of the uterus and its adnexa.

2. Causes on the part of the ovum.

1. Causes Maternal.--These may be general or local. General causes,
arising either in the maternal system or exterior to it, but acting
upon it, may be either physical or nervous, arising from diseased
morbid conditions of the maternal system.

_a_. General causes acting through or resulting from changes within the
maternal system.

The premature interruption of pregnancy may frequently be traced to
disturbance of the maternal system or external influences which act
upon it, either directly by traumatism or indirectly through the
nervous system, and the uterus, hypersensitive in this state of intense
physiological activity, responds. It is the point of least resistance
to which the shock is conducted; as the electric current invariably
passes through the best conductor in a network of wires to the point of
greatest attraction, so shock follows the course of the uterine nerves,
at the time most tense, and the explosion follows in that organ.

(1) Disease, acute and chronic, on the part of mother and father
interferes with the nutrition and development of the ovum--on the part
of the father, through the semen; on the part of the mother, by
malnutrition of the growing germ.

Acute Diseases.--A vitiated condition of the blood, as well as the
increase of temperature, local and general, which accompanies
constitutional disturbance, affects nutrition and development of the
ovum. Zymotic infectious diseases, as well as those accompanied by
congestion of the pelvic viscera, are most liable to affect gestation:
the excessively high temperature of the nutrient fluid and of the
surrounding viscera, if not direct infection of the germ, leads to
death of the embryo and consequent abortion in the course of zymotic
disease. The localization of the morbid affection in the vicinity of
the uterus affects the existence of the embryo by reason of the
consequent congestion and irritation, as well as by depletion of the
system, as in dysentery; direct infection, as in variola or scarlatina.
This delicate existence is threatened in various ways by traumatic
injury, as may occur in eclampsia. Fortunately, abortion in the course
of disease is not the rule, but the exception, and usually accompanies
morbid conditions of the system only if most intense or if predisposing
causes exist; yet gestation is at all periods endangered by
intercurrent disease in the early as well as the later stages. It is in
the later stages only that the existence of direct infection can be
determined, and, though perhaps not common, well-authenticated cases
are recorded: I have myself delivered a mother, just recovering from a
severe case of {483} variola, of a seventh-month foetus covered with a
typical eruption. That abortion occurs in the course of malarial fever
is well known in the valleys and deltas of our great rivers, and it has
been most erroneously ascribed by some to the energetic medication
which is called for. If the disease attacks pregnant women, its
continuance, but not the medication, may lead to abortion: it is not
quinine given upon correct indications--it is the existing
disease--which causes the accident, and must hence be checked as
speedily as possible; it is the uterus which shelters the developing
ovum, congested, hyperæsthetic, which is at the time the centre of
physiological activity, and, we may say, the most sensitive portion of
the body, most easily affected by an accidentally existing disease, as
the non-pregnant woman, one more sensitive or feeble, always suffers
most during an accidentally existing disease in that organ which is
habitually most sensitive or weak or at the time under an unusual
strain; if throat, lungs, or heart is weakened, it is that part which
suffers most in the acme of malarial fever; if a woman is exposed to
cold during the menstrual period, the pelvic viscera will respond most
readily.

Chronic diseases affect growth and development of the ovum by reason of
malnutrition, local and general anæmia. As has before been stated, the
impregnation of even a healthy ovule by diseased semen or the semen of
a diseased father may result in morbid development, which sooner or
later ends in expulsion of the affected ovum. Of the diseases on the
part of the father it is more especially--and I may say almost
alone--syphilis which exerts a direct influence upon the ovum. Debility
of the system is more likely to result in sterility, whilst the ovum,
if impregnation takes place by such semen, remains healthy though
feeble, and the traces are indelibly marked upon the offspring. The use
of liquor, like the morphine habit, may lead to sterility, but not to
abortion; though the offspring of a phthisical father rarely escapes,
the disease is inherited, but does not develop during the early stages
of gestation, and does not affect the ovum in its growth.

Chronic diseases on the part of the mother would seem as if readily
leading to abortion, though the result is comparatively a rare one. The
diseased, badly-nourished, often anæmic system offers an unfavorable
nidus for the rapidly-developing ovum, which is so much in need of
healthy and abundant nutrition; but as the feeble, sickly mother often
has an abundance of healthy milk for the new-born child, a healthy
physiological activity seeming to exist in those parts in the time of
functional activity, so may the ovum find a sufficiency whilst other
parts are affected. The intense activity existing in the uterus
attracts an abundance of the circulating fluid; women low with chronic
diseases, phthisis, or cancerous growths, often in the last stages,
will bear children, yet they are fortunately not so free to conceive,
and if impregnation does occur the healthy growth of the ovum is soon
interrupted.

The causes which lead to an enfeebled condition of the system may lead
to abortion, whether it be an anæmia, the result of disease or lack of
food, of the mode of life, or the locality in which the sufferer
lives--of poisonous gases or poisons of other kinds slowly admitted to
the system. These poisons, however, whether acute or chronic in the
mother, may directly affect the foetus. Lead and noxious gases, like
the infection of variola or smallpox, are examples of the latter; more
rapidly-acting {484} poisons, like strychnia, opium, carbonic oxide
gas, and syphilis, of the former.

Death of the foetus and abortion may result as a consequence of
syphilis on the part of either father or mother, or of primary
infection during gestation, and are liable to occur at the same period
in successive pregnancies; if in the later stages of gestation, the
ovum, especially the foetus, bears its characteristic marks. The
effects of treatment and improvement are readily visible: abortion is
more and more delayed; if the afflicted parent but slowly improves,
abortion will occur at a later period during each subsequent gestation
until a foetus is carried to term, but stillborn--the next living,
perhaps, for a brief period. If vigorous treatment be applied in the
early stages, abortion may cease altogether. The results of disease can
be more readily seen in the foetus than in other parts of the ovum. The
gummata of the placenta, the syphilitic indurations, are difficult to
distinguish from other conditions, and appear only at later stages. The
syphilitic pemphigus, when occurring upon the foetus, is
characteristic, but the mucous membranes are most liable to show its
traces. The gummata in the large viscera are frequent, especially in
the lungs and liver; but most typical is the osteo-myelitis in the long
bones, between epiphysis and diaphysis, a pale-red line in the earlier
stages, resulting in a thickening of the parts at later periods.

(2) Causes acting through the Nervous System.--During pregnancy, that
stage of intense uterine activity, of gestation and increased growth,
we find an increased nervous excitability, motor and vaso-motor, the
nerves responding violently to slight causes which would arouse no
reaction during the normal condition. There is an increased reflex
activity which may lead to a disturbance in the circulation or in the
nutrition of the ovum, or to uterine contraction upon some slight
excitement. This condition varies exceedingly, the causes which excite
these reactions and the extent of the reaction excited differing
greatly in degree. Uterine hemorrhage, contractions, and expulsion of
the ovum in consequence of neurotic influences are more likely by far
to occur during the existence of predisposing causes. Fright, a nervous
shock of any kind which in no way affects healthy gestation in a
healthy woman, will result in abortion in a person afflicted with
uterine disease or in a system otherwise weakened.

The frequent occurrence of abortion in early married life and toward
the menopause is mainly referable to nervous influences. Marriage is a
period in woman's life comparable to puberty and the menopause--a
period of heightened nervous excitability: a change takes place in all
the modes of life, and, in addition to the many other causes which at
that time unite to interfere with conception, increased nervous
excitability is one of the most important, as it is toward the
climacterium. We shall consider this period more particularly under the
head of Social Causes. As the change of life is approached, the
activity of the sexual organs, their nutrition, the blood-supply, and
especially the healthy activity of the mucous membrane, are lessened,
and hence the growth of the ovum is endangered; but the condition of
the nervous system at this period certainly has an equally powerful
influence in producing the tendency to abortion. During this
hyperæsthesia an existing predisposing cause or some slight additional
excitement will arouse the vigorous action of the tensely-strung {485}
vaso-motor nerves; coitus even at these periods may be looked upon as
dangerous to continued gestation. It is not alone the traumatic
influences which must be considered, but the effect upon the nervous
system as well, especially the vaso-motor nerves, in the state of
intense excitement which accompanies the sexual orgasm. During these
periods of increased nervous tension during pregnancy coition is more
liable to produce abortion than at other times. It is in the coming
together of numerous causes that one more intense than the others,
though harmless alone, will be followed by sudden response.

Much has been said as to the injurious effect of coition during
pregnancy. Those who look to physical causes as mainly tending to
abortion claim the injurious effect to be purely physical, traumatic;
whilst others, and I believe more justly, claim that the influence is
strictly neurotic. Parvin says that coition is so frequent a cause that
he blames upon this half the cases which are termed spontaneous
abortions; certainly it has a most unfortunate effect, so that we
frequently see the expulsion of a healthy ovum from the second to the
fourth month in young women recently married, mainly in the higher
walks of life and among delicately organized women, who are more
intensely sensitive to the great change which they have undergone. I
have repeatedly had occasion to see these unfortunate cases, and almost
look for the occurrence of an abortion within the first six or eight
months after marriage in the bride of fashionable society. Though the
statement of Parvin may seem somewhat forcible, the fact is not to be
ignored: the ovum expelled in such an abortion gives evidence of being
of healthy growth, so that the cause must not be sought for in
malnutrition or local disease. The laws of many peoples are as strict
in regard to coition during pregnancy as they are about the care of
menstruating women: by some it is forbidden; among the ancient Mexicans
it was regulated, it being ordained that sexual intercourse should be
exercised to a moderate extent during pregnancy in order that the
healthy development might be furthered and strength given to the child.
The injurious effect of coition is everywhere acknowledged, and, I can
say, not unjustly. Total abstinence was looked upon by the Mexicans and
other peoples as likewise harmful.

The changes wrought in the nervous and physical condition of women
after marriage and toward the menopause are such that the menstrual
periodicity is interfered with, dysmenorrhoea sometimes existing, at
times menorrhagia, so that the expulsion of an ovum of from eight to
ten weeks is ignored, passing away with the clots of a profuse
menstrual flow: it is often not even known to the mother, being
considered by herself and family as merely a profuse flow; the
accompanying pains are often no greater than those of the dysmenorrhoea
common at such times; no precautious are taken, and thus the foundation
is often laid for uterine disease.

We know that the emotions--fright, fear, joy--may check the menstrual
flow or produce menorrhagia; in the gravid uterus hemorrhage may be
caused or contractions aroused, and abortion results. In a misled girl
or a young married woman the fear of pregnancy may frequently cause
cessation of the menstrual flow: the effect of the mind and nervous
system upon these organs is equally evident in the cessation of the
menses when pregnancy is longed for, though it does not exist: I have
even {486} known of the summoning of midwife and physician by an aged
bride with distended abdomen (gastric hystero-neurosis) who longed for
pregnancy and thought she felt uterine contraction and the inauguration
of labor. As the emotions affect the general health, the ovum may
likewise suffer as a part of the maternal system; but when they are
sudden, such as by fright or shock, the effect upon the vaso-motor
centres by reflex action is so forcible that the uterine vessels are
paralyzed, dilated, and hemorrhage follows; or a tetanic contraction of
the vessels may result, and then the nutrition of the embryo is
checked.

The evil effect of nursing during pregnancy is due in part to the
withdrawal of nutrition from the ovum, but in part to the contraction
of the uterus and its vessels, which may result as a reflex symptom
from the irritation of the nipples, and thus cause abortion. The
frequent occurrence of abortion upon ships at sea is due in part to
traumatic influence, the vomiting of sea-sickness; in part it is
neurotic, due to the changed mode of life, the leaving of a home by the
emigrant for foreign lands, just as the menstrual flow is stopped for
months and months in the immigrant girl upon her first arrival in a
strange country.

(3) Traumatic influences are comparatively rare as a cause of natural
spontaneous abortion; and it is true of these as of every other cause
that it depends upon existing conditions whether abortion will result
or not. The pounding of the belly is an ordinary method of producing
abortion among primitive peoples: a fall, a jump from a wagon, may
disturb the progress of gestation, while traumatism far more violent
may not affect it, as in the case of the woman in the later months of
pregnancy over whose abdomen the wheels of a physician's carriage
passed without causing any injury whatever.

In the earlier months, while the ovum is still sheltered in the pelvic
cavity, injuries are still less liable to cause abortion. I have myself
seen a pregnant woman severely bruised about the lower bowels and go to
term. I have been told by reliable physicians that local treatment of
uterine disease has been continued by reason of the non-cessation of
the menses to the third and fourth month, when pregnancy was
discovered, and yet abortion did not follow, though I regret to say
that quite a number of cases have come to my knowledge where the
treatment of supposed uterine disease, especially of uterine
tumor--pregnancy in fact--was suddenly terminated by the appearance of
the corpus delicti, a four or five months' embryo. The intensity of the
resistance is well illustrated in a case which it was my good fortune
to see in consultation, where the most brutal local treatment had been
resorted to for three or four months and abortion did not occur; the
patient had left her persecutor and travelled hundreds of miles to seek
treatment. The manipulations had been so violent as to produce metritis
and cellulitis, yet the growth of the ovum continued, as demonstrated
by the healthy foetus of five months which was at last expelled. I have
but recently examined a lady who has been treated locally for uterine
disease, and found her in the beginning of the third month of
pregnancy, so far undisturbed.

We may well place the uterine sound and applicator among the traumatic
causes. The physician himself, especially the gynecologist, has been
sought out by women to aid in relieving them from the product of
conception, and it is through sound or applicator that {487} he is
expected to accomplish the work. Among the many devices to which
women--and, I am sorry to say, those in the most fortunate
circumstances, in the best walks of life--resort to attain this end is
one which certainly shows knowledge and shrewd calculation, but most
villainous intent, which is not unfrequently practised, and against
which it is well for the physician to be on his guard. It is that of
forcing the attendant to uterine examination and treatment upon the
plea of disease, well knowing that the germ must thus be destroyed. The
woman calls upon a physician--in preference upon some specialist not
attending in her family--upon the plea of uterine suffering, well
knowing, either from personal experience or the gossip so common among
ladies, some of the more common symptoms of this disease--backache,
pains in the side, nervousness, weakness, menstrual suffering. She
relates her case; upon questioning states that the period is just
passed; and, though the examination may reveal nothing, though no
application may be made, she well knows the uterine sound will be used.
That is what she desires. If an application of iodine or nitrate of
silver follows, all the better. Though for reasons far more important
the physician should listen to the history of a patient with distrust,
and rely must thoroughly upon his own examination, this course is
especially indicated in gynecological cases without distinct sign of
disease; and these very cases again point to the importance of a
careful bimanual examination, and a resort to all other methods before
the sound is used; and that in case of an enlargement of the uterus,
discoloration of the cervix and vagina, we should under no
circumstances introduce an instrument into the cavity unless it is
established with absolute certainty that the congestion and increased
size are due to pathological and not physiological causes.

Social Causes.--I wish to call attention more particularly to some of
the abuses of modern life which not unfrequently interfere with
gestation. These exist among all classes of society, high and low:
among the poor they are unfortunately forced; among the wealthy they
are the result of devotion to fashion and society. As we have seen that
in the Old World abortion is common in the rural districts, it is an
evidence of hard labor, especially in the field, at the wash-tub, and
labor by which the abdomen is compressed, the abdominal muscles freely
exercised. It is not only physical labor, but exposure to cold and wet,
cold feet, which are to blame; in those more fortunately situated tight
lacing, dancing, and consequent colds have a like injurious influence.

I would again allude to the newly-married, who are so subject to the
lighter forms of traumatism, the always greater frequency of coition,
the congestion and mechanical insult, the bridal trip being especially
injurious. During this period of hyperæsthesia it is too great a strain
upon the body as well as upon the nervous system: the young husband,
unacquainted with woman's strength and needs, is always liable to judge
her powers by his own. Railroad travel, the fatigues of sight-seeing,
pleasures, theatre, and the dance, are all borne by the patient bride,
anxious to please the groom: upon returning home the cares of the new
house, excessive social duties, all combine to undermine the strength
of a delicate woman in her first gestation. Enfeebled, often depressed
by reason of gestation or nervous changes, excessive pleasures are
forced upon her by reason of her condition--_i.e._ bride--and abortion
follows; and, we {488} may say, follows in consequence of traumatism.
In other walks of life we find other conditions, still with the same
unfortunate developments--excessive labor and pleasure during this
period, when rest and care are so necessary. It is in young married
women partly the pleasures of society, partly the unaccustomed duties
imposed, which lead to injury. Ignorant of their condition, ignorant of
the care necessary, even when aware of injury unwilling to acknowledge
it, desiring to bear up, to show no weakness, they lay the foundation
of much future suffering. The cause of so much uterine and pelvic
disease in the unmarried, in the society girl, exists to the same
extent in the newly-married, only that the injuries caused are far
greater in the first period of married life, as the strain both of body
and mind is increased in this most susceptible condition.

Local Causes.--Though the local causes on the part of the mother which
lead to abortion, diseases of the uterus, especially of its mucous
membrane, are equally frequent and equally amenable to treatment, they
are of less practical interest to the general practitioner. Diseases of
the uterus itself are not so important etiologically as those of its
lining membrane: uterine tumors, unless of enormous size, usually admit
of the completion of gestation; flexions and versions rarely interfere
with the development of the ovum; a prolapsed uterus may bear the
foetus to term unless the adhesions are unyielding and impregnation is
impossible, because the uterus as it develops with the growth of the
ovum rises beyond the confines of the pelvic cavity, and the
displacement is thus remedied. Anteflexions and anteversions are always
rectified; retroversions in rare cases only lead to abortion; adherent
retroflexions are most to be dreaded; when the uterine body, bound down
to the pelvic floor, expands within the cavity to such a size as to
make escape through the brim impossible, abortion must necessarily
follow. Deep lacerations of the cervix make conception improbable and
interfere with gestation; cervical catarrh in no way affects its
progress. Those morbid conditions of the uterine tissues which are
unaccompanied by disease of its mucous membrane rarely lead to
abortion.

Uterine contractions due to reflex nervous excitability are perhaps the
most common of all these causes, yet here the uterus primarily is not
at fault. A state of intense excitability is very often due to general
causes, to intense febrile action, to congestion or anæmia; high or low
temperature, whether due to external or internal causes, and irritation
of the surrounding parts,--all of which conditions tend to increased
contractility. Such diseases of the uterus as cause induration of the
walls may lead to abortion, like the incarceration of the organ in the
pelvic cavity, by reason of prevented distension.

Uterine Mucosa, Decidua.--Of far greater consequence than the
conditions existing in the muscular tissue of the uterine wall upon the
vitality and development of the ovum are those of the uterine mucosa in
its state of physiological hypertrophy as the decidua of pregnancy.
This soft, succulent tissue, rich in lymphatics and blood-vessels, is
the nidus in which the ovum rests, its immediate protecting shelter,
and the source from which nutrition is derived; hence morbid changes of
this structure react promptly and forcibly upon the ovum--most so in
the earliest stages, when it is altogether dependent upon this
structure; less so as gestation progresses. As the ovum grows it
becomes more resistant, its {489} tissues more dense, and the source of
nourishment is gradually changed to the large uterine sinuses at the
placental site. Moreover, the decidua after the third and fourth month,
when it has served its term, performed its function, gradually
diminishes in thickness, until toward term retrograde metamorphosis is
initiated preparatory to the expulsion of this structure, at that time
merely forming a line of demarcation in the lax meshwork in its lower
layer between the healthy tissue which remains and those structures
which are passed off in labor. An inactivity of the mucous membrane, an
imperfect development of the deciduous structure due to disease of the
mucosa, is a frequent source of abortion. In chronic disease of the
uterus or its lining membrane this rapid and healthy development of the
decidua after conception is prevented, the delicate membranes of the
ovum do not absorb the necessary nutrition, the development of the
embryo is checked, morbid conditions of the ovum follow, and abortion
results, especially at that time of active development, the period of
placental formation. The decidua vera is the least important part of
this structure, serving nutritive purposes only in the very first weeks
at the site of placental formation, and sheltering the delicate ovum in
the nest formed by its soft tissue: it is the decidua serotina, and
especially that membrane which holds the ovum in place, the decidua
reflexa, which claims attention. But morbid conditions of the vera, the
greater part of the mucous membrane, are naturally accompanied by
imperfect development of serotina and reflexa, and hence the imperfect
imbedding and nutrition of the ovum.

Hypertrophy or excessive morbid development of the decidua may
accompany acute infectious diseases, as we find similar conditions in
other organs of the body, especially in the larger viscera. These
changes, morbid in their character, interfere with development as do
the atrophic forms. These hypertrophies may, however, exist independent
in their nature, due to local disease of the uterus and its parts, as
in chronic endometritis, where in place of the succulent deciduous
structure we find an induration and a proliferation of the active
tissue usually throughout the entire membrane, rarely localized, of a
polypoid form: the chronic catarrhal affections are accompanied by an
increase of secretion, morbid in character, which is liable to
interfere with the development of the germ. Moreover, hemorrhage more
readily occurs under these pathological conditions, usually secondary
in character, brought about by minor insults, trivial causes, which
would not affect healthy tissues. These hemorrhages, all-important in
the early stages, affect development less and less as gestation
advances, the importance of the decidua lessening and its functions
being superseded. Where a slight extravasation of blood within the
deciduous structure may lead to separation and expulsion of the ovum in
the first and second months, larger hemorrhages are often without
consequence when occurring within the same tissues in the fifth or
sixth.

2. The Ovum.--Pathological changes of the ovum itself, of the embryo,
of the surrounding membranes are less frequent as primary causes of
abortion, and they are of less importance to the practitioner as being
in no way amenable to treatment. When they do occur they usually lead
to expulsion in the earlier months.

Those conditions liable to lead to abortion are especially diseases of
the {490} chorion, placenta, and umbilical cord, rarely of the amnion,
the embryo itself, or the amniotic fluid.

Chorion and Placenta.--The chorion being the nutritive organ, supplying
the means of communication between mother and child in the earlier
stages by the villi over its entire surface, later by the placenta,
must necessarily determine the progress or cessation of foetal
development by the conditions existing within its own tissues. One of
the most striking and notable changes to which it is subject is the
hydatiform degeneration of the villi, leading to a formation of the
grape mole or hydatiform mole. This is a cystic degeneration of the
terminal sprouts, an hypertrophy of the germinal tissue, the young
connective-tissue cells, which usually begins at a very early stage:
the vascular development is interfered with, the nutritive material is
directed to the morbid activity of the chorion, which in its exuberant
growth, usually inaugurated in the first weeks, destroys that of the
other structures; the delicate tissues of the embryo are soon absorbed,
and even the amniotic sac may disappear, the within-lying cavity, which
always remains in every malformation as an unmistakable trace of the
ovum--a characteristic which serves at once to mark the product of
conception. A mole of this kind usually attains the size of an apple,
but may grow to that of a child's head, and the period to which it is
carried is much longer than that of the mola carnosa--usually five to
seven months, sometimes eight or ten. The appearance is that of a
conglomeration of cysts, usually the size of a currant or gooseberry,
though they are often from that of a pinhead upward, connected
everywhere by thin connective-tissue strands; they consist of a
delicate transparent membrane enclosing a pale, colorless fluid: in the
earlier stages the amnion with its cavity remains, but with the
development of the growth that is destroyed, and the appearance of the
hydatiform mole as a product of conception even becomes unrecognizable
when no longer surrounded by the decidua; as in cases of excessive
development, the morbidly-enlarged villi may even break through the
decidua vera in their growth, and we find a dense mass consisting of a
conglomerate of small cysts united by connective-tissue shreds enclosed
in the cavity of the uterus.

Hemorrhage.--In the third or fourth month, at the time of most active
development of the villi at the placental site, primary hemorrhage may
occur, due to the active vascular development, and thus lead to
abortion, but this is rare; frequent as hemorrhage is, it is almost
invariably to be traced to some cause.

The Placenta.--In later stages, when the greater part of the chorion
appears as a more firm, non-vascular membrane, that part which in
connection with the decidua serotina is developed to the placental
formation is the most vulnerable point, as it is the connecting link
between the foetus and the maternal tissues, and the one source of
nutrition. Hemorrhage in this structure, whether in its maternal or
foetal portion, if excessive, must lead to a cessation of development,
to abortion. Slight hemorrhages, such as must have proved fatal in the
earlier stages, no longer interfere with the growth of the ovum, but
are absorbed or remain as small hemorrhagic spots, the tufts or
cotyledons in which they have occurred appearing as a hard whitish mass
of connective tissue. If the hemorrhage is more profuse or widespread,
it may lead to abortion directly or to inanition--to death of the
foetus, and secondarily to {491} abortion. Inflammation may occur
throughout the entire placental site or localized, as in all other
points in the connective tissue of the structure, accompanied by
vascular development in the first place, followed by induration and
shrinkage; frequently remaining as small irregular or conical
indurations between the villi or cotyledons, leading to abortion,
either by the tendency to hemorrhage thereby excited or the death of
the foetus if sufficient of the tissue is destroyed to cause inanition.

Fatty degeneration occasionally results in consequence of insufficient
nutrition due to hemorrhage, or after death of the foetus preparatory
to premature expulsion--a morbid approximation to the condition upon
its maternal surface and in the decidua serotina at term.

Syphilis.--The changes in the chorion and placental tissue accompanying
syphilitic disease are rarely the direct cause of abortion or premature
expulsion of the ovum; as a rule, they are mere local manifestations of
the morbid condition existing in all the foetal structures, and
frequently in those of the mother. In the early months, during the
period of the chorion frondosum, abortion results from insufficiency of
the nutriment absorbed by the indurated villi of the chorion, lacking
in vascularity and in succulent embryonic tissue; the structures are
more dense, the villi hypertrophied, in the more aggravated cases the
vessels entirely obliterated, whilst after the formation of the
placenta in later months the existence of syphilis is made evident by
appearances similar to those which accompany other chronic inflammatory
conditions. The appearance presented by a syphilitic placenta is
usually that of cellular hypertrophy, the centre in a state of whitish
induration or fatty degeneration according to the stage of the disease.
But it is hardly possible to diagnose syphilis with certainty from the
appearance of the placenta alone, nor is the placenta usually affected
to such an extent as to appear as the prime cause of foetal death. The
placenta is usually large as compared to the size of the child, in
appearance similar to other inflammatory conditions presented by the
placenta, the growth of the foetus being interfered with, whilst that
of the placental structure continues until the retrograde metamorphosis
is sufficient to result in expulsion. The placenta in a syphilitic
foetus is larger than ordinary, 1 to 4, whilst usually 1 to 6. Gummata
are rare, so also tumors of the placenta. A myxoma developing from the
embryonic tissue is occasionally found. If the foetal portion of the
placenta alone is affected, or in the earlier stages the chorion and
the decidua healthy, we may with safety infer syphilis on the part of
the father alone previous to impregnation.

The Amnion.--The amnion, which serves merely as a container for the
preserving fluid, is wanting in vascularity, and consequently but
little subject to morbid changes. The only pathological condition which
we find in this structure is an inflammatory development, the formation
of amniotic bands stretching across this delicate sheath or from some
portion of it to the foetus, crippling or cutting its membranes in such
a way as to interfere with gestation. Nor does an abundance or want of
amniotic fluid affect the development of the embryo or ovum during the
earlier stages. It is no more a cause of abortion than the slight
changes occasionally found in the amnion itself.

The Umbilical Cord.--The navel-string, however--the sheath stretching
from amnion to foetus, enclosing the umbilical vessels--is subject to
quite {492} a number of changes, frequently the cause of abortion,
occasionally mere results of other complications. Excessive or
insufficient length of the cord, which may seriously complicate labor
at term, in no way affects the development of the ovum; in the third or
fourth month the length of the cord is naturally much greater than that
of the embryo, and the resulting coils and knots seem in no way to
endanger its existence. Knotting of the navel-string may lead to death
of the foetus, but only in the last months, rarely at earlier periods.
Stenosis of one or the other of the vessels sometimes occurs, leading
to the death of the embryo and consequent abortion: a condition which I
have found remarkably frequent is that of torsion of a very long and
thin cord in the third and fourth months; but this torsion of the cord
seems so frequent in abortion that it must appear as a consequence,
movement of the dead foetus apparently leading to a twisting during
inactivity of the tissue. A very striking condition of the cord has
frequently attracted my attention--lack of embryonic tissue, the
gelatin of Wharton, with excessive torsion; the cord flat, thin, in
parts thread-like, and usually very much twisted; the embryo retarded
in development as compared to the size of the ovum, no other cause
being at the same time discernible, neither disease of the uterus nor
affection of the system. The torsion is secondary, often wanting, the
cord being very thin and thread-like in places, consisting of the
amniotic sheath and the vessels, obliterated entirely or in part.
Torsion I believe to be secondary, as I have noticed these excessively
twisted cords otherwise healthy in cases of abortion; but this peculiar
state, which I cannot term otherwise than atrophy of the cord, appears
as a frequent primary cause of abortion in the second to the fourth
month; torsion and knots may occur at later periods. Ruge of Berlin,[4]
who has investigated this subject, thinks that stenosis of the cord in
the vicinity of the umbilical insertion is rarely the primary cause of
abortion, though often a secondary, resulting from motion and traction
on the inactive, dead vessels; whilst Leopold seems to look upon it as
the primary cause.

[Footnote 4: _Zeitschrift für Gynäcol. u. Geburtsh._, vol. i. 1, p.
57.]

I have endeavored to call attention to the various conditions which may
lead to abortion, but it is almost impossible to place an estimate upon
their relative importance. Whilst uterine contractions, hemorrhage, and
abortion may result in one case from a slight nervous excitement, a
trifling annoyance, the most violent nervous irritation will in no way
affect another; whilst a fall, a jump from a buggy, may lead to a
mishap in one patient, the crushing of the abdomen beneath its wheels
will not affect another; a trifling fever may appear as the cause in
one, and again the most severe pneumonia or typhoid condition will not
impair development in another; the child may be carried to term by a
mother in the last stages of consumption, whilst a very trifling
affection may lead to abortion at other times. So it is with remedies
taken internally, though as a rule they have but little effect: a
violent aperient may cause abortion, and again, as in one instance
which I recall, a woman in the fourth month of pregnancy died rapidly
of dysentery resulting from the taking of cathartic pills to produce
abortion, and the post-mortem revealed a perfectly healthy ovum in a
healthy uterus, whilst the dysentery consequent upon the remedy killed
the mother. The careful introduction of a sound into the gravid uterus
has led to a separation of the ovum, to hemorrhage, {493} and to
abortion, whilst a knitting-needle has been passed into the uterine
cavity and through the womb, causing the death of the criminal mother,
without in any way disturbing the ovum. The uterus has been regularly
treated for supposed disease for three and five months by internal
applications, and gestation has progressed. So it is with all these
cases: at one time, especially with pre-existing disposition, a slight
interference may result in the cessation of development, and at another
the most violent insults in no way disturb gestation.

B. Causes of Criminal Abortion.--The causes proper of criminal abortion
are immorality among all classes, high and low--among the wealthy
fashion, the pleasures of society, and the desire to limit the number
of children--a common cause, strange to say, mostly among those very
people who can actually afford the expense. The cause direct, the means
by which the crime is accomplished, should be known to the practitioner
in order that he may detect the deception which is so frequently
practised upon him--that he may prevent it if possible, and at least
not, by reason of ignorance, be made particeps criminis.

The means resorted to are either external or internal, traumatic and
instrumental, or by medication.

Traumatic.--When produced by the patient herself it is either by
violent exercise, running up and down stairs, walking and dancing,
occasionally by pressure upon the abdomen or by the use of the
knitting-needle, catheter, or similar instrument. The more expert or
daring only attempt to enter the uterine cavity, as the organ itself
may be pierced; if the catheter is successfully introduced, the
attachment of the ovum is severed, and with the knitting-needle the sac
is punctured.

These attempts are usually made in the second or third month at the
second or third missed period. There is, however, a class of experts
among the most elegant who have attained such remarkable dexterity as
invariably to introduce the instrument successfully into the uterine
cavity; and these are in the habit of regularly practising this
dangerous experiment when the first days of the expected period have
passed without the coming of the flow.

The abortionist either injects fluid into the uterus or introduces a
probe or catheter into the cavity. Customs vary in different countries;
so Van de Warker states that in France puncture of the membranes is
fashionable, whilst here a syringe or sound is used.

Among the most common--and perhaps most harmless--means is the hot
foot- and hip-bath, the "sitz-bath," often with the addition of
mustard: this, as well as the steaming of the parts by sitting over a
chamber filled with hot chamomile tea, is the first step taken by the
nervous wife when the menstrual flow has failed to appear sharp on time
and she still lives in hopes that it is but a cold which has interfered
with the regularity of its return. Even physicians, respectable men in
good practice, who may not venture upon bolder measures and wish to
keep their conscience clear, are known to advocate this course, though
they well know what such a cold means.

Medication is perhaps more commonly attempted, but less successfully,
notwithstanding the injuries caused to the system. To follow Van de
Warker's thorough study, the remedies used are mainly of two
classes--those which act directly, the emmenagogues, oxytoxics, and
reflex {494} abortifacients. Notwithstanding the firm popular belief in
their efficiency, they are less harmful to the ovum than to the system
of the mother, and, as Van Warker says, there is more science and skill
used than is generally supposed in the various pills and teas, which
are less simple, but no less common, than the foot-baths and the
gin-bottle. Ergot is almost sure to be called upon to perform its
office. Its action is very uncertain, but if persistently used is
readily recognized by its effect upon the vascular and nervous
system--uterine or ovarian pains and depressed action of the heart
where in spontaneous abortion an acceleration is to be expected; the
temperature is lowered, and the sphygmograph shows a remarkably
flattened apex with an almost senile pulse. Cotton-root is also
commonly used, especially in the South, and is marked by its narcotic
action.

Among those termed reflex abortifacients, acting more indirectly by
their effect upon surrounding organs, we may notice cathartics,
principal among them aloes, which, notwithstanding its purgative
action, does not appear to deplete the circulation, but, on the
contrary, results in pelvic congestion; but even its excessive use need
not in any way affect gestation. I have seen a patient dying amid the
resulting dysenteric symptoms, frequent, scanty, and bloody
evacuations, accompanied by excessive tenesmus, inflammatory
conditions, and abdominal pain, though the uterus did not react and the
ovum remained intact. The odor of the drug is imparted, it is said, so
intensely to the evacuations that it is unmistakably noticed.

Juniper and black hellebore, the latter especially endangering the life
of the patient, are both toxic in their effects. The painful fluid
evacuations, accompanied by bearing down, tenderness of the abdomen,
pain and sickness at the stomach, dry throat, would characterize the
former; the odor the latter, as well as the flushed appearance of the
face, with heaviness and pain in the head and frequent micturition. But
one of the first and most common remedies to which the desperate woman
resorts when she finds a day of the menstrual period passing by without
the appearance of the flow is tansy, which seems to act by reason of
the uterine congestion which it causes. Though undoubtedly effective at
times, it will, like all other drugs thus used, more often cause
injury, and even the death of the mother, without disturbing gestation.
"Disturbance of the nervous system, profuse salivation, immobility and
dilatation of the pupils, and severe strangury," are noted as the
symptoms of such poisoning. Hardly less popular is the still more
dangerous cantharides.

The female pills and various mixtures more or less openly sold by
druggists are, according to the researches of Van de Warker, composed
of one or more of the above-mentioned ingredients, and the immense
quantities disposed of show how truly abortion is called the crime of
the period. Knowledge of the remedies used for these purposes will aid
the physician in arriving at a correct diagnosis and enable him to save
the child and guard his patient.

PATHOLOGY AND MORBID ANATOMY.--I have endeavored to describe with some
accuracy the appearance of the healthy ovum, the sac, and surrounding
structures during the various periods of early pregnancy, as it is the
comparison with these which will enable the practitioner to distinguish
between spontaneous and criminal abortion, enable him to determine the
duration of pregnancy, guide him as to the cause, and thus serve to
{495} facilitate treatment and perhaps to prevent recurrence. Knowing
what has been expelled, whether it is ovum and decidua entire or only
in part, the line of action is evident. In all abortions due to an
immediate and active exciting cause, whether criminal or resulting from
shock or accidental trauma, the ovum is healthy, normal in all its
parts, size and development of the embryo corresponding to the period
of pregnancy at which the accident occurred; whilst in spontaneous
abortions due to accidental causes more or less marked changes exist:
the development of the embryo especially is retarded; its life has been
destroyed, and growth has ceased, whilst the morbid development of the
membranes continues, so that the mass expelled presents more or less of
a mole formation--comparatively solid, with thick walls formed by the
foetal membranes infiltrated with blood, the cavity often compressed by
the surrounding extravasation, the embryo comparatively small or
disintegrated in whole or in part.

The ovum is usually separated in its upper portion by hemorrhage, which
comes from that point at which the vessels are most fully developed,
the future placental site, though still agglutinated. With the
inauguration of uterine contractions separation takes place at its
lower pole by dilatation of the os, and retraction of the uterine walls
from the ovum proper surrounded by the reflexa; as the abortion
progresses, the muscular fibres of the fundus force it down into the
dilating cervix through the still partially adherent decidua, and the
intact ovum is expelled, the inverted decidua following it as the
membranes do the placenta in labor at term. Yet these conditions vary
greatly with the existing morbid changes.

In traumatic or criminal abortion the perfectly-formed ovum, the
delicate cystic body surrounded by its shaggy chorion, is first
expelled, to be followed by the decidua, usually--when in a healthy
state--first by its anterior and then by its posterior half; whilst if
the abortion has been inaugurated by some slowly-acting cause the
decidua is hardened, infiltrated with compressed and clotted blood, the
small ovum forming merely a part of the solid mass; and thus a firm
oval body, coated with blood upon its rough, irregular exterior,
appears.

Up to the third month the ovum is, as a rule, expelled as a whole,
often even in the fourth. Later, unless decided pathological changes
have taken place, the membranes are mostly ruptured and the embryo
separately expelled, as in labor at term. In later months this is
always the case, and the progress of abortion is greatly impaired by
the adherent tissues: the mass of the ovum, which serves so much to
excite uterine contractions and promote expulsion, is destroyed by the
collapse of the amniotic sac, and separation and expulsion of the
membranes are hindered by reason of the smaller amount of resistance
offered. Hemorrhage is most likely to occur in the villi of the
chorion, between its tissues and the surrounding decidua; if occurring
in the latter structure, it appears thick, hard, infiltrated with
blood, and no longer presents that soft, succulent appearance, but is
firm and brittle.

The ovum as expelled presents three typical forms: First, as above
stated, in accidentally-occurring traumatic or criminal abortion we
find a healthy ovum with its shaggy chorion, and the inverted decidua
attached or soon following, usually in two sections; most common,
however, and almost without exception in spontaneous non-criminal
abortion, is the {496} mole formation, rarely the hydatiform mole,
which has been described, and results only from the peculiar
pathological condition of the chorion. The common form is the flesh
mole, the mola carnosa, characteristic in appearance, resembling a
polypoid growth, a reddish oval or rather pyriform mass with shreds of
tissue (the decidua) adherent to its larger upper extremity, darker
clots at the elongated lower pole. Upon section the walls show a
brittle reddish structure, that of compressed and inspissated coagula,
and in the centre a cavity containing fluid and detritus, if not the
embryo, lined with a delicate membrane, amnion or amnion and chorion:
the shape of the cavity is rather irregular by reason of the bulging
protuberances formed by the contraction of the inspissated mass of
blood extravasated between or within the tissues. These moles have very
much the appearance of uterine polypi, and are often considered as such
by physicians who pride themselves greatly upon curing their patients
of tumors and the accompanying hemorrhage by a few doses of ergot.
Though the macroscopic resemblance is such as to be quite deceptive,
the mole upon section will always reveal a cavity, even if very small,
containing fluid; and this cavity reveals the above-described
characteristic slight bulging protuberances lined with a delicate
membrane; whilst the microscopic examination shows the firm walls to
consist of nothing but blood-corpuscles: the outer covering, often
thoroughly infiltrated with blood, consists of the decidua serotina and
reflexa, with more or less of the infiltrated shreds of the vera
usually pendent from its upper extremity; when floated in water and
cleansed, the outer or uterine surface of these shreds is ragged,
rough, often appearing somewhat like the villi of the chorion, hence
looked upon as placenta; this peculiar appearance is caused by the torn
tissue in the line of demarcation in the lower or central meshy layer
of the decidua vera, where it is separated from the lowest layer which
remains adherent to the uterine wall. The inner surface toward the ovum
will show a slightly wavy, cribriform appearance, the openings of the
ducts appearing as fine depressions in the surface. (It must be
remembered that this smooth inner surface is in the expelled specimen
generally the outer one, as the decidua follows the ovum mostly as the
membranes do the placenta at term--inverted.) If the disturbance
causing the abortion has been of rapid progress, the cavity is large,
the embryo approximating in development the period of expulsion; whilst
if the changes have taken place slowly, the walls are thick, the cavity
small, and the embryo may appear merely as a small mass pendent from
the navel-string, or may have entirely disappeared, and can be traced
only by the fine detritus in the amniotic fluid, the cord itself
perhaps only in part remaining, and even this may have disappeared. The
cavity will always be found toward the pendent pole of the decidua
reflexa, as the extravasation takes place mainly in the serotina,
giving it the appearance of a thick mass of clotted, compressed blood,
and forcing the cavity toward the opposite extremity. These moles are
usually more elongated and pyriform, one or two inches in diameter at
their upper or larger extremity, three or four inches in length, with a
greatly elongated and narrowed lower end, which has been so formed by
being first wedged into the slowly-distending cervix.

Such is the appearance in those cases of slow progress in which death
of the embryo has probably occurred at an early stage and hemorrhage
{497} has been the exciting factor, whether due to disease of the
mother or other causes that may have destroyed the vitality of the
germ. When resulting from disease of the mucous membrane, especially
endometritis or catarrhal affections, it is a more oval tough mass, the
main part of which is formed by the thickened and indurated vera; and
if this be opened the ovum, in a very early stage of development, will
be found within.

The uterus itself presents very much the appearance of the organ after
labor; the external os, however, closes more rapidly, less rarely
showing the funnel-shaped appearance of the puerperium; the cervix,
though somewhat enlarged, is normal in appearance; the cavity is lined
by the lower layer of the decidua, soft shreds covered with coagula;
but it is lacking in the placental site and the putrid thrombi visible
in labor at term.

Involution is slow if we take into consideration the slight distension
of the uterus as compared to the process after delivery at term. The
organ is in a state of healthy development, not prepared for the
following retrograde metamorphosis, unless the expulsion of the ovum
has been due to local disease, when some retrograde changes may have
been inaugurated; if it results from constitutional causes, the
existing depression naturally interferes with restitution. If shreds of
tissue, parts of ovum, or decidua remain, absorption or expulsion is
retarded. As a morbid or atonic condition so often exists, at least in
abortion consequent upon natural causes, subinvolution or inflammatory
conditions of the organ itself or the surrounding tissues are hence a
frequent sequence.

SYMPTOMATOLOGY.--It will be remembered that abortion is more likely to
occur among multigravidæ on account of the greater frequency of
disease, especially pelvic affections; that it is most likely to
accompany the periodic congestion which recurs at the time of expected
menstruation; that it is more frequent in early married life, on
account of the greater liability to traumatic injury and the existing
nervous disturbance, and toward the menopause in that state of nervous
and physical disturbance and lessening uterine activity. The third or
fourth month of gestation is the dangerous period, as it is one of
change of nutrition for the ovum, of the highest development of the
decidua, and intense activity and congestion of the chorion, the
rapidly-sprouting vessels finding but little resistance in the
embryonic structures of the villi which surround them. Chronic disease
of the mother is more likely to interfere with gestation at a later
period; and, when knowingly undertaken with criminal intent, the time
of choice is either the first month, when the first indications of
pregnancy become evident and the menstrual period does not appear at
the usual time, or more commonly at the time for reappearance of the
third menstrual flow, when the fact of conception has been established
to a certainty, and the conscious mother, firm in the belief of the
nonviability of the embryo before the fourth month, thinks it harmless
to rid herself of the ovum, which she considers a mere growth without
life or soul, while she would shrink from destroying what, at a later
period, she calls a living being.

SYMPTOMS AND COURSE OF ABORTION.--General Remarks: Preliminary
Symptoms.--1. Course of early abortion, first two months.

2. Abortion at the time most common, the third or fourth month: _a_,
spontaneous; _b_, criminal and traumatic.

{498} 3. Later abortion--in the fifth and sixth months--and hydatiform
mole.

The expulsion of the ovum during all periods of pregnancy is
characterized by two inevitable symptoms--hemorrhage and pain. It is
the time of appearance as well as the relative intensity of these
symptoms by which the period of gestation at which the expulsion takes
place is at once indicated. In early abortion the hemorrhage is
excessive and precedes the pain, the pain being comparatively slight;
in labor at term pain is the prominent symptom and precedes the
comparatively slight hemorrhage, which does not appear until the pain
has almost ceased, and labor is completed after the expulsion of the
placenta. Expulsion of the ovum in intervening periods is marked by an
approximation of symptoms, though the existing conditions which
characterize individual cases greatly modify this typical course.

I have, for the sake of conveniently grouping the symptoms, accepted
three periods which serve well to characterize the course which
abortion is wont to take in the progressive months of pregnancy.
Hemorrhage and pain are the never-failing symptoms--hemorrhage due to
the separation of the membranes; pain in the earlier months is due to
the dilatation of the rigid, unprepared cervix, which greatly
preponderates over the pain which accompanies the expulsion of the
comparatively small mass through the once-dilated passage. In the later
months, the cervix being gradually prepared, the pain is almost
altogether due to the increased effort which is necessary to expel the
large mass of the ovum.

1. Early Abortion.--In the first and second months the ovum is small,
the vascular development trifling; the decidua preponderates, being
greatest in mass and in extent of its vessels; hence this is the most
important part. The hemorrhage is considerable, due to the separation
of the vascular and hypertrophied mucous membrane, the decidua. The
ovum is very small and expelled with comparatively slight pain, the
symptoms often resembling those of membranous dysmenorrhoea; no great
dilatation of the os is even necessary.

2. In the third and fourth month, the period at which abortion both
spontaneous and criminal is most common, the placental formation is
inaugurated by the growth of the vascular tufts of the chorion; and it
is now that the ovum in toto--or we may perhaps say the membranes, as
they are by far the greater part of the ovum--assumes the most
important rôle. The abortion is still inaugurated by hemorrhage due to
the separation of the vessels, but the pain is greater, as the cervix
must dilate more to admit the passage of this larger mass, and an
expulsive effort as well is necessary to force the mass out. The
greatest amount of pain is caused by the dilatation of the rigid,
unyielding cervix, which fortunately remains in this undilatable state
until after the period of viability of the foetus, and serves to a
great extent as a check upon its more frequent expulsion.

3. Late Abortions.--Now the ovum and foetus are of pre-eminent
importance; though the parts are still unprepared, hemorrhage continues
to be the preliminary symptom, yet pain follows rapidly upon the
inaugural flow, because the ovum is now so large that it cannot descend
without dilatation: it must have advanced before abortion can progress
to any extent, and the expulsive pains assume greater prominence on
account of {499} the increased size of the ovum; the symptoms of labor
at term are approximated, and, as the placental formation is developed
in the sixth month, pains may at times precede, certainly rapidly
follow upon, the preliminary hemorrhage. It is now the placenta which
plays the most important part, as in labor at term it is the foetus
which is all-determining, upon which all the efforts of expulsion are
centred; the membranes, amnion and chorion, are secondary, and the
decidua, which was so important a feature in the first months, has by
this time entirely disappeared as a factor in the act. The remaining
shreds are partially adherent to the ovum, and in part passed slowly
off with the lochial flow. Thus we see how the symptoms, at extreme
periods so varying, approximate and interlace, and the various organs
gradually yield in importance to newly-developing structures.

In the first period, then, the decidua is all-important, whilst the
small and yielding ovum causes but little disturbance, not to mention
the embryo. In the second period the membranes of the ovum are more
important, and together form what is most erroneously termed the
placenta in abortion. Then, as the placenta develops, this with the
membranes predominates; finally, in labor at term the decidua, first
all-important, has vanished as a factor of consequence, and the embryo,
in the first stage a minimum, assumes such dimensions as to concentrate
upon itself every effort of the obstetrician.

Pain, especially in the earlier months, is liable to be more excessive
in primigravidæ, as the external os is closed, the cervix rigid, the
time necessary for the expulsion of the ovum greater. In multigravidæ,
with ordinarily more yielding and relaxed cervical tissues, the effort
of the uterine muscle is concentrated upon the expulsion of the ovum
from the cavity proper; and when it once passes the internal os a path
is opened, and little or no force but that of gravity is often
necessary to complete expulsion, whilst the cervical canal and external
os offer formidable opposition in primigravidæ to the forcing out of
the ovum, even though it has passed the os internum. A wide range of
varying conditions naturally exists, due to the very different states
of the cervical tissues: they may be relaxed in primigravidæ or firm
and unyielding in multigravidæ, though the opposite is true in typical
cases.

PRELIMINARY SYMPTOMS.--The symptoms which accompany death of the embryo
and precede the expulsion of the ovum develop with the growth of the
latter and its encroachment upon the cervix; although they vary as
strikingly as do the symptoms of pregnancy, yet we may say that the
larger the ovum, the greater the foetal and placental circulation, the
more marked must be the effect of their cessation; the larger the
uterus and ovum, the more distinct this feeling of fulness, of pelvic
dragging, which accompanies the descent of the gravid organ previous to
expulsion of the ovum. The larger the ovum, the more distinct the pains
which accompany beginning separation, the more the encroachment upon
the cervix, the greater the dilatation which gives rise to the earlier
symptoms. These symptoms, however, vary so greatly, and are so often
altogether wanting, that they are hardly to be considered, especially
during the period in which abortions are by far the most common, in the
third and fourth month; and as, in all but traumatic and criminal
abortions, the disappearance of such symptoms of pregnancy as have
existed {500} is indicative of coming abortion, the death of embryo and
ovum often precedes expulsion for a considerable period of time, and
the symptoms of pregnancy consequently cease. Symptoms of pelvic
congestion, bearing-down pains, pressure upon rectum and bladder, are
among those frequently preceding abortion. At times we see a rigor,
feverishness, rapid pulse, nervous disturbances, lack of appetite,
anæmia, fulness of the head, also palpitation, cold extremities, heavy,
uneasy feeling at the pubes and coccyx, lumbar pains, and vesical
tenesmus--symptoms which are all unusual, with the exception of the
latter. The descent of the enlarged and congested uterus in the pelvis,
which always precedes the expulsion of any body from its cavity,
frequently causes dragging pains in the pelvis, a fulness, heaviness
with pressure upon the bladder and rectum, and an uneasiness at the
pubes and coccyx or lumbar and vesical tenesmus. Later, the death of
the ovum and foetus will cause more striking symptoms; the cessation of
pregnancy will be more marked in mammary changes, but reliable symptoms
are rare at all times, and usually wanting in the earlier months.

SYMPTOMS OF ABORTION.--Early abortion is frequently ignored, the
symptoms greatly resembling those of profuse and painful menstruation.
The course of abortion is inaugurated by hemorrhage, occasionally
ceasing: sometimes there is very little pain: again it is quite severe;
but the period of expulsion is well characterized; when completed the
pain ceases, and with it the hemorrhage. Often the ovum is passed
without the knowledge of the mother, even when accompanied by pain, as
it is at this time more like that of a dysmenorrhoea.

Abortion in the Third and Fourth Month.--Spontaneous, Non-criminal
Abortion.--At this period the ovum usually passes en masse;
occasionally, and more often as the fifth month is approached, the
membranes are ruptured in the course of its expulsion.

Normal Course.--We have already delineated the normal course of
abortion at this period. The death of the embryo has usually preceded,
often for weeks, and is characterized by the feeling of pelvic
congestion, gastric and vesical irritation, weariness, weakness, and
increase of uterine and vaginal secretion; the membranes have developed
more or less; expulsion is inaugurated by hemorrhage. If the cause be
more violent, the flow of blood is free. Usually there is but a slight
oozing, which ceases at times, but gradually increases; the suffering
which accompanies uterine contraction is present. Separation of the
decidua and dilatation of the cervix are indicated by pain, which is
intensified in case of uterine disease, so often present as the cause
of abortion: the ovum is expelled as a pyriform mass, its apex imbedded
in clotted blood, the inverted decidua adherent to its larger upper
pole. If hemorrhage has taken place in the decidua, or the abortion be
due to disease of this membrane, it is the most prominent feature and
envelops the expelled ovum like a rigid mantle. In traumatic abortion
it usually follows; ordinarily the membrane in part or in shreds is
expelled with or very soon after the ovum.

Traumatic and Criminal Abortion.--Traumatic, especially criminal,
instrumental, abortion varies in its symptoms, so well characterized by
Van de Warker, from the spontaneous occurrence. The latter is
inaugurated by hemorrhage; constitutional symptoms are wanting, and if
they {501} occur usually follow upon injudicious interference. In the
former constitutional disturbances are present from the first; so also
pains with inflammatory symptoms, mostly in the hypogastric region,
abdominal tenderness: the pains of dilatation may even precede
hemorrhage, whilst in spontaneous abortion they follow, often after
days. The pulse is accelerated from 100 to 120 as a result of the
primary insult; tenderness of the sensitive and congested uterus and
cervix is rarely wanting; it is, in fact, characterized by Van de
Warker as the one almost invariable symptom; vaginal hyperæsthesia,
heat, and tenderness of the os are natural results. We have no history
of previous accidental or spontaneous abortion: preliminary symptoms
are wanting; the occurrence, on the contrary, is inaugurated by
violence and shock; constitutional disturbance and hemorrhage follow.
The consequences also are liable to be more severe, in accordance with
the insults offered.

Recurring Abortion.--Morbid conditions, which interfere with the
development of the ovum and lead to abortion, tend greatly to produce
similar results if conception again takes place; hence we not
infrequently find the repeated occurrence of abortion in a patient once
afflicted; and this was formerly looked upon as a habit and known as
habitual abortion--a term which must yield to the more correct repeated
or recurring abortion, as no such habit exists: it is the continuance
of the same cause which brings about a recurrence of the accident in
repeated pregnancies. The cause being the same, the results are
similar: the abortion will recur at about the same period if conception
again take place; if due to a disease of the uterine mucosa, an early
interruption is to be expected. The death of the foetus is usually the
indirect cause of the abortion, and always precedes it: in these cases,
in most instances, it is due to syphilis; at times to other cachectic
conditions of the mother or an affection of the uterus or its mucosa.
The development of the ovum continues for some time until abortion
takes place, and this occurs, if due to changes in the mucosa or
decidua, in the first months; if the result of anæmia or cachectic
conditions of the mother, of syphilis, in the sixth or seventh month,
or toward term. The death of the embryo is followed by retrograde
metamorphosis, thrombosis of placental or uterine vessels, and
expulsion from one to three weeks later.[5]

[Footnote 5: Geonbert, _Thèse de Paris_. 1878.]

Plethora as well as anæmia may cause this occurrence; thus Campbell
relates a case of seventeen successive abortions occurring in an
extremely plethoric person, who was finally enabled to bear a child to
term by repeated venesections made monthly; and others record cases of
a similar nature: lack of nutrition, anæmic conditions, brought about a
remarkable increase in the number of abortions during the siege of
Paris and in the succeeding year of want. Chronic endometritis with
cystic formations has been repeatedly recognized as leading to
recurring abortion; so also laceration of the cervix in case conception
does take place. The continuation of the same cause should lead to its
recognition, as in most cases it is amenable to treatment; syphilis,
inflammation of the endometrium, and laceration of the cervix, among
the most frequent causes of such repetition, are the very diseases most
thoroughly under our control, so that in the present advanced stage of
our knowledge we should no longer hear of such a condition as recurring
abortion. Ruge of Berlin {502} considers syphilis as the cause of death
of the foetus in 83 per cent. of such cases.

VARIATIONS.--A cessation of the symptoms not infrequently occurs:
either with or without treatment the oozing may stop; even if
hemorrhage and pains have existed all symptoms may cease. Large clots
of blood have been expelled, the patient rests quietly in her bed, and
gradually becomes easier; contractions and hemorrhage cease altogether,
and she recovers, regains her vigor, and begins to move about. At the
time of the following menstrual period the same cycle is repeated, and
not until then is the ovum expelled. If the membranes are delicate,
these may be ruptured by uterine contraction or by artificial or
mechanical interference, and with the collapse of the ovum or the
expulsion of its greater mass irritation is lessened and the symptoms
subside. Exercise or the congestion and irritation consequent upon the
return of the menstrual period will again arouse uterine activity, and
the remnants are then expelled, a month or two after the inaugural
hemorrhage.

These are conditions which are very frequent when the expulsion is left
to nature or the aid of the midwife is sought, but they are with equal
frequency produced by unskilful interference. The efforts of the
physician are not unfrequently directed to a lessening of the
hemorrhage, regardless of the existing conditions: applications are
made to the abdomen and ergot is given, both methods of treatment which
tend to stimulate uterine contraction; the more powerful circular
fibres predominate and contract, the os is closed, the symptoms cease,
and the conditions above mentioned are produced. Abortion is prevented
for the time being, and sooner or later the patient is astonished by a
return, which is, however, accompanied by less hemorrhage and more
active labor-pains with a more rapid expulsion. If styptic injections
are made into the uterine cavity or pieces of the ovum removed with the
uterine dressing-forceps, a similar effect is produced, though the
result is a more unfavorable one, as parts of the ovum are removed, and
the collapsed membranes and shreds which remain are liable to prolong
and aggravate the case, as they do not irritate the uterus and
stimulate it to healthy action like the intact ovum.

The interval between the period of expulsion and the inaugural
hemorrhage is often one of complete rest and health, more usually one
of occasional oozing and malaise. As a consequence, we must have
putrefaction and sepsis or the development of placental polypi and
hemorrhage. Air is often admitted, either during the efforts at removal
or later; if the cervix is not fully contracted, the secretions are
more copious and liable to putrefy with the retained shreds. The
symptoms are, however, unlike those of septic infection after labor at
term, on account of the comparatively intact surface, the absence of
the large uterine sinuses: they are insidious, not intense and
acute--lack of appetite, weakness, slight increase of pulse and
temperature--so that assistance may not be sought until increased
suffering, putrid discharge, and high fever necessitate interference.
This putrefaction is more liable to take place when the greater mass of
the ovum has been expelled and parts alone remain, but will also occur
when the entire mass is retained. Even without active interference the
symptoms may subside as the disintegrating masses pass away as a putrid
discharge, intercurrent hemorrhages at times carrying away larger
shreds.

{503} The so-called placental polypi result from the retention of parts
of the ovum, especially of the placental portion, chorion, or decidua
serotina, which, enveloped in fibrinous coagula, are entered by the
proliferating vessels of the surrounding tissue. Such growths,
sometimes of the size of a hazelnut or walnut, even to that of a small
egg, may be unnoticed for months, but sooner or later give rise to
oozing and hemorrhage, and in more fortunate cases are finally
expelled. The expulsion of these retained membranes is inaugurated by
hemorrhage, which may be preceded by more or less oozing: it is rapid
in its course, accompanied by that pain which characterizes the last
stage of abortion, and terminates with the appearance of the corpus
delicti. It is merely the final scene of the abortion, which was but
partially completed weeks or months ago, and the task is greatly
simplified. Dilatation of the cervix and separation of the tissues were
accomplished in the first stages, and during the interval of rest
nature has been quietly making the necessary preparations to facilitate
and complete the task undertaken, precisely as during the last months
of gestation. Consequently, this expulsion is rapidly accomplished:
pain and hemorrhage, even if severe for a time, are not of long
duration. I have such a mass--which upon section reveals distinctly the
villi of the chorion--which was cast off with all the symptoms of
abortion four months after the occurrence of the inaugural hemorrhage
and partial expulsion. More frequently I have been called to remove
these masses, which have given rise to constant oozing and actual
hemorrhages, two and three months after the occurrence of abortion, the
adhesion to the uterine wall being so firm that the sharp scoop was
called for, and sometimes I have been obliged to remove them piecemeal
like a small uterine fibroid.

Late Abortion.--All abortions in the fifth and sixth month approximate
in their symptoms those of labor at term; the membranes are ruptured,
the ovum is never expelled in toto; the foetus may either precede the
placenta or be expelled with it. It is at this period also that the
hydatiform mole usually passes away, though it may be retained for a
much longer period of time, even beyond the duration of normal
pregnancy, the symptoms resembling those of abortion in the third or
fourth month. After complete expulsion of the ovum and membranes more
active hemorrhage and pain cease, the uterus contracts, but a slight
oozing follows, and this becomes more pale and gradually merges into a
serous flow.

DURATION.--The course of abortion varies greatly in its duration, and
is usually prolonged, death of the ovum frequently occurring weeks
before active symptoms are inaugurated, and even these may be slow in
developing: a slight and often interrupted oozing may precede a more
profuse flow and the dilatation of the cervix, or, as we have seen, the
symptoms may cease for weeks and months even after they have been fully
inaugurated; again, the ovum may be expelled in part and the remnants
be retained for months--four months being the extent of time in which I
have seen such retention terminate in expulsion without interference.
By the formation of placental polypi the period may be protracted
indefinitely.

The question how long abortion may be delayed, for what length of time
the membranes may be retained, is far more important than is {504}
generally supposed, both from a social and medico-legal standpoint, and
is by no means thoroughly understood. I have recently seen a mole
formation, the infiltrated foetal membranes, and part of the decidua
which had been retained nearly four years--three years and nine
months.[6] For four consecutive years the foolish woman, who had
brought about abortion and expulsion of the embryo, suffered from
occasional menorrhagia, and nausea and vomiting like that which had
existed in the first months of pregnancy, until the annoyance became
unbearable and medical advice was sought. An examination revealed an
enlarged anteflexed uterus, from which a peculiar compressed and
elongated mole was removed, after which the symptoms ceased. The case
is moreover peculiar, as several of the symptoms were those of
pregnancy, which do not generally continue after death of the embryo.

[Footnote 6: Ovum retained nearly four years, E. C. Gehrung, _Weekly
Medical Review_, St. Louis, April 25, 1885.]

For a term of three years a twin embryo has been retained, causing
violent epileptiform attacks, always most severe during the menstrual
period, which first appeared four weeks after the last labor and
continued, to the great detriment of the patient, until the macerated
embryo was removed, when recovery took place. This was most probably a
twin intramural pregnancy, the twin developing in the tubo-uterine
cavity being retained after the expulsion of the one properly located,
and then gradually forced into the more commodious uterine cavity.[7]
These cases indicate the extent of this still unsettled question.

[Footnote 7: C. K. Patterson, _Weekly Medical Review_, June 13, 1885.]

TERMINATION.--Dangers of Abortion.--Though fatal results are rare and,
when occurring, due to sepsis rather than to hemorrhage, much of female
suffering is traceable to this accident, the pathological interruption
of pregnancy. Uterine and pelvic disease, especially subinvolution and
consequent displacement, diseases of the endometrium and cervical
tissue, result from abortion; sterility as well--all diseases which
leave their traces indelibly marked upon the system of woman. They are
not the direct or necessary consequences of abortion, but rather the
results of the underrating of this most decidedly pathological
occurrence--an underrating which is unfortunately prevalent among the
profession and universal among the laity.

The direct consequences of hemorrhage are rarely severe: if harm ensues
from loss of blood, it is not from profuse hemorrhage, but from
long-continued oozing, generally that which accompanies the oozing
following incarceration in the efforts at delivery, by which the system
is depleted, and so weakened that years of care may be necessary for
perfect restitution: evil results are much more liable to follow upon
ill-timed or injudicious interference, the removal of part of the ovum
or the checking of hemorrhage, the closing of the os by cold
applications or ergot; equally serious consequences arise from sepsis
if putrefaction of the parts retained takes place. The indirect results
are even more common, and I cannot too often repeat that these, as well
as the before-mentioned direct results, are due to a misapprehension of
the existing condition--to an underrating of the importance of
abortion. It is looked upon by women as no more than a profuse
menstruation; some follow their daily vocations, bearing the suffering,
or they may remain in bed during {505} the most profuse flow and the
greatest agony, but with the expulsion of the ovum or after a day's
rest they resume their daily toils and pleasures. Frequently the
midwife or nurse is called, and thus after-treatment neglected; and
even the physician too often discharges his patient after a few days'
confinement.

The worst consequences follow upon comparatively rapid and easy
abortions, which are treated lightly, even by the practitioner; and
should he by chance take the proper view of the case, the patient
herself is unwilling to observe the necessary care. If she is prudent,
she awaits the cessation of the discharge; daily work is then resumed
by some, the usual round of pleasures by others. Gradually annoying
symptoms appear, local or general; health fails; backaches,
dragging-down pains, appear after so long a period that so slight a
matter as the abortion, which has occurred months before, is never
thought of as the cause of the suffering, and subinvolution is thus the
most common result. As in all but traumatic and criminal abortions
pathological conditions precede, especially of the pelvic viscera, it
is often a diseased organ in which the abortion takes place, and
restitution will only be accomplished by time and care, rest and proper
treatment.

Subinvolution, chronic uterine lesion, and sterility are a common
result of the first abortion in young married women, and in most
instances it is the neglect of after-treatment to which these results
must be ascribed; it is the underrating of abortion by the laity, and
even by the profession; and as natural, healthy labor with too rapid
getting up is liable to result in evil consequences slowly developing,
so it is true to a far greater extent of simple abortion. The usual
termination is in subinvolution, chronic cervicitis, and endometritis.

It is the duty of the physician to impress upon his patient the fact
that equal if not greater care is necessary in the management of the
pathological condition, of the early termination of pregnancy, than of
normal labor at term, and that abortion is to be compared to a severe
labor rather than to a simple menstruation. Were the physician summoned
at once, much evil would be prevented. But if called at all, it is only
when hemorrhage and pain become alarming; yet I am sorry to say that I
have seen those who have suffered most, ruined in health and sterile,
women in the best walks of life, who have closely followed the advice
of able physicians, who skilfully managed the existing trouble, but
undervalued the consequences--not giving the necessary time for
involution, comparatively slow at this period when the system is so
unprepared for a process to which its course is slowly shaped as term
approaches.

DIAGNOSIS.--It is of importance to know, when called to a patient,
first whether abortion is threatening or actually inaugurated--that is,
whether the patient is pregnant, and whether the existing symptoms are
those of abortion or of dysmenorrhoea; secondly, whether the abortion
can be prevented, and if not, what treatment is to be pursued; and
thirdly, whether the abortion is completed?

1. Does pregnancy exist and is abortion inaugurated? or are the
symptoms those of dysmenorrhoea, metritis, or uterine tumor? The
existence of pregnancy is a condition often difficult to discover,
especially in unmarried women intent upon deceit, or in cases where the
patient is herself in ignorance and no cessation of the menstrual flow
has {506} occurred. The symptoms of pregnancy must be carefully
inquired into, as well as the condition of the patient, local and
general, during the previous months and previous pregnancy.
Dysmenorrhoea, menorrhagia, and membranaceous dysmenorrhoea may
simulate abortion; but the pain in dysmenorrhoea is relieved by the
discharge, whilst this is not the case in the pain of abortion: on the
contrary, as the flow increases, with the dilatation of the cervix and
the separation of the ovum, the pain increases; shreds of membrane
accompany the discharge of dysmenorrhoea, whilst in the case of
abortion the membranes follow the ovum when pain and discharge have
almost ceased. In dysmenorrhoea the pain is ovarian, more violent, and
aggravated with the cessation of the discharge, whilst in abortion it
is uterine, more particularly referable to the cervix in the period of
dilatation and to the fundus in that of expulsion, and lessens or
ceases with the cessation of the discharge. The hemorrhage due to
fibroids and polypi may greatly resemble that of abortion, especially
if mole formations occur, but the pregnant and aborting uterus is
greater in size than the congested menstrual organ. In the abortion of
a comparatively healthy ovum the uterus approximates in size the period
of gestation; the ovum as it descends during the pain becomes more
broad, round, and tense, whilst in the case of a growth or clot the
part which is forced down during a pain is more pointed at its
presenting extremity than in the interval. In most cases of abortion,
however, the uterus is rather smaller than it should be at the period
of pregnancy at which the interruption occurs, and as the membranes are
infiltrated with blood a mole formation is approximated; the ovum is
more pyriform, pointed in shape; the apex imbedded in clots of blood,
so that it resembles in feel, as it descends during the pain, a clot or
polypus. The pregnant uterus, however, is more soft and elastic than
the diseased organ.

2. Can abortion be prevented? The presence of an ovum being determined,
our attention must next be directed to the possibility of its
preservation. The distension of the os, especially the amount of
hemorrhage, must guide the practitioner in seeking an answer to this
important inquiry, upon which treatment must depend. The amount of
hemorrhage is indicative of the separation of the ovum, but a slight
flow continued for days is by no means as dangerous to gestation as a
profuse instantaneous discharge. The os may be dilated, but if the
hemorrhage is slight and the ovum out of reach, the progress of
abortion may yet be prevented even after pains have been inaugurated,
the first pains being those of dilatation. The appearance of rhythmical
pains, indicative of expulsive contractions, leaves little hopes for
the practitioner to check the course inaugurated. Even if the ovum can
be felt, abortion may still be prevented, but if it protrude through
the gaping os, little is to be expected, though even under these
circumstances prevention is still said to be possible if the hemorrhage
has not been severe. But if the liquor amnii has passed, there is no
possibility of saving the ovum at any time, though it is claimed that
even this can be done if pain or hemorrhage alone exists and the latter
be not too severe. Even if the separation has not progressed so far
that abortion is inevitable, the question must arise whether it be
judicious to attempt prevention or whether abortion should be
furthered. This depends upon the condition of the embryo, whether it is
destroyed or not; if no previous abortions have occurred, and no {507}
known cause, especially predisposing or local, exist, if the size of
the uterus corresponds to the period of pregnancy, and there are no
symptoms of mechanical interference or trauma, an effort should be made
to preserve the ovum; but if there be cause sufficient to account for
its death, if the uterus be more hard and round, wanting in the elastic
oval of normal gestation, if it be smaller than usual at the period of
gestation at which the interruption has occurred, death of the embryo
and ovum may be supposed, and, notwithstanding the possibility of
prevention, abortion should be hastened and completed, the ovum and
membranes expelled.

3. Is abortion completed? Difficult as it often is to answer the
question whether the ovum has been expelled, it is almost impossible to
say whether the abortion has been fully completed, whether the last
remnants of tissue have been evacuated. If the physician has been
present or the clots have been saved from the time of the inaugural
hemorrhage, it may be easy to determine the condition of affairs; but,
unfortunately, these are usually thrown away, and the attendant comes
at a late period, at one of suffering and exhaustion, when masses of
blood, quantities of clots, with whatever of the ovum they may contain,
have been removed. If present, he should crumble each clot and float
the coagula in water. Fibrin and blood will soon wash away, and the
shreds of tissue become separated and remain floating in the fluid.

An examination of all pieces that have passed will readily reveal the
existing stage; but ordinarily the physician has no such clue. The
hemorrhage has ceased, the uterus is firmly contracted, the os is
closed, and the diagnosis is exceedingly difficult, but it must be
determined. If left to nature, time will disclose the true condition of
affairs: if the ovum has been expelled, the uterus will rapidly
diminish in size, the appearance of the discharge will change--it will
become more thin and pale; but if the uterus remains firmly contracted,
and does not diminish in size, it is probable that the membranes are
retained, and the renewal of exertion, of work, or of a succeeding
menstrual period--if not the first, the second--will bring about a
recurrence of the hemorrhage and the completion of abortion. If the
uterus remains large, hard, globular, it is probable that the ovum, or
at least the greater part of the membranes, remains in the cavity.

Unless the hemorrhage has ceased and the os be closed for some time
previous to the coming of the physician, he will find the uterus low in
the pelvis, the os still yielding, except when ergot has been given or
ice applied, and by the introduction of the finger into the uterus the
condition of the cavity will be determined: this will in all cases be
readily accomplished by pressing with one hand firmly upon the fundus
and examining with one or two fingers of the other; if not easily done
in this way, the entire hand should be introduced into the vagina; the
uterine cavity may then be thoroughly swept with the examining finger;
but, though this will reveal an enclosed ovum, the membranes can by no
means be detected with ease, and will often escape observation; hence
the dull curette is in place: it will sever such tissues as may still
be adherent. All excellent instrument, especially if the os be small,
is the Récamier curette, or the modification which I have devised for
the purpose. Should any doubt exist, dilatation should be at once
resorted to for {508} curative as well as diagnostic purposes; a rapid
dilatation is in place--not instrumental, but by the tupelo or
sea-tangle: this affords positive knowledge of the state of the case,
and the cavity can then be thoroughly cleansed. Even the sponge tent is
harmless if the abortion is completed, as the cervix is still dilatable
and yielding, easily expanded. At all events, the diagnosis is
unquestioned and the treatment clear. This is by far better than the
expectant plan, which is most commonly followed for fear of
interference, allowing the patient to continue perhaps for a month or
more in ignorance of her condition--allowing her to resume her labors,
exposed to sepsis, hemorrhage, and, in the most favorable case,
expulsion of the ovum at any time.

If the os is dilated, the finger should be introduced--if necessary the
hand--into the vagina, which can easily be done if the fundus be
approximated by the other hand; better still, to use the curette, and I
would advise the large blade of my instrument; the small one can at all
times be passed into the cavity of the uterus during or immediately
after abortion, and usually the larger one also. This examination, if
with the scoop, consequent upon dilatation, should be followed by an
antiseptic injection, but I would unquestionably advocate a correct
diagnosis, whatever means may be necessary to obtain it, as appearances
are so deceptive. We need but recall those by no means rare cases which
to all appearances are those of completed abortion, yet the patient
does not perfectly regain health and strength, and if an examination is
made the os is found patulous and membranes or parts of the ovum are
retained. If examination and dilatation be neglected, a coming
menstrual period will discharge the disintegrating mass, or local and
constitutional disturbances, even septicæmia, may be looked for.

PROGNOSIS.--As to prognosis, it is the mother whom we must consider,
the dangers present and future, the attachment and dimensions of the
ovum, and the possibility of continued gestation. The prognosis of
traumatic or criminal abortion is worse than that of the spontaneous
form, the result of natural causes, because it is inaugurated by shock,
by injury, and inflammatory conditions which are aggravated by the
congestion and contraction accompanying the expulsion, for which the
tissues are entirely unprepared; whilst in natural, spontaneous
abortion, usually the result of some morbid condition, some disease of
the system, a cachexia, uterine disturbance, or death of the embryo and
ovum has preceded, and a retrograde metamorphosis to a certain extent
has been inaugurated; some preparation at least has been made for the
coming expulsion; hence the separation is more natural, less violent,
less liable to be followed by evil results.

The prognosis is invariably favorable if proper medical aid is summoned
in the early stages, but actually it varies greatly, as does the course
of abortion--whether completed in a reasonable time or of longer
duration, more favorable in the former, less propitious in the latter;
if hemorrhage has been profuse or comparatively slight, but of long
duration, anæmia is liable to result: if expulsion is long protracted,
the dangers of subinvolution, metritis, and perimetritis are great: if
the expulsive pains cease before the complete expulsion of ovum or
membranes, retention, putrefaction, and sepsis may be inaugurated, and
subinvolution, endocervicitis, and endometritis will follow.

{509} The embryo is scarce to be considered: it may be saved if the
hemorrhage has not been too severe and accompanied by pain, if the ovum
does not protrude into the cervix. The inflammation which usually
accompanies traumatic or criminal abortion greatly aggravates the
prognosis, but, however good it may be in individual cases, the result
will depend greatly upon the after-treatment, upon the time allowed for
proper involution, and upon the assistance given it. Though the
prognosis at the time of abortion may be a most favorable one for the
mother, the result is seriously affected by the care taken during the
period of involution, the after-treatment, which is by far more
important than generally supposed.

TREATMENT.--The successful treatment of abortion requires knowledge,
judgment, and resolution on the part of the practitioner, and in
importance it is equivalent at least to the management of labor at
term. Two lives may even be at stake, though the opportunity of saving
the embryo is, as a rule, afforded only during the period of
prophylactic and preventive treatment, as vitality is ordinarily
destroyed in the embryo when abortion, as the result of natural causes,
is once inaugurated: the life of the mother is not in question, as it
is in labor at term, but her health is even more endangered. Attention
is now forcibly called to the subject by earnest discussions between
the adherents of the expectant and those of the progressive method of
treatment, but mainly to the treatment of actual abortion; prevention
and after-treatment have been neglected. Important as is the method of
treatment employed in case of retention of membranes or ovum, the
necessity for such interference, especially the frequency of abortion,
would be greatly diminished if the family physician were thoroughly
imbued with the importance of the subject and could impress the same
upon his patients. If the dangers arising from such premature
interruption of gestation were appreciated by the laity and medical
attention summoned in the early stages, the management of abortion
would become more simple and more successful, and the cases of
retention which cause such suffering and injury to women would be far
less frequent.

Before entering upon the treatment proper it may be well to review
briefly the necessary adjuncts, as proper preparation will aid
materially the course to be adopted.

Preparations Necessary with Regard to the Patient.--Many of the
preparations necessary in the lying-in chamber are desirable in cases
of abortion as well. Attention should be paid to the bowels, as a
costive condition will interfere to some extent with the manipulations
as well as a rapid and favorable course of expulsion and involution; at
best, it is liable to make the patient uncomfortable. The bladder
should be evacuated, especially before active measures are resorted to,
and the patient should be so clad in night-gown and sacque, with long
hose and drawers, that she may be moved and manipulated without
exposure.

The bed should be prepared with rubber cloth and quilts, and sufficient
quilts, cloths, and towels should be on hand; a bed-pan is desirable,
and also a fountain or bulb syringe; the bed should be so placed that
the physician may be at the right hand of the patient, and convenient
to the light when she is placed in Sims's position of the dorsal
decubitus for operative interference.

{510} Antisepsis.--Cleanliness and antisepsis should be observed in the
management of abortion as strictly as in that of labor or in surgical
operations, as sepsis, either in the form of acute infection or an
insidious undermining of the constitution, is among the more frequent
of the dangerous consequences which follow in the wake of abortion.
Circumstances permitting, it is desirable that carbolated vaseline or
vaseline with iodoform, carbolated or some similarly prepared soap, be
on hand, and also permanganate of potassium, carbolic or boracic acid,
and iodoform. I am in the habit of prescribing carbolic acid for the
convenience of use: carbolic acid 2 ounces, alcohol 1 ounce, with 7 of
glycerin, which is as concentrated as may be well used (1 to 5, or 20
per cent.), and a proportion readily diluted to 2½ or 5 per cent.

Before and after examinations the hand should be washed in carbolated
water or some such disinfectant--permanganate of potassium, corrosive
sublimate, or boracic acid--as it appears desirable to use. If carbolic
acid is used, the parts should be cleansed with a 2 or 3 per cent.
solution. After interference or repeated examinations the vaginal
douche should be used, certainly after completion before leaving the
patient. If instrumental interference be necessary, and the ovum or
membranes forcibly removed, the cavity of the uterus should be washed
with hot water, from 115° to 125° F., containing 5 per cent. of
carbolic acid, the hot water serving styptic purposes. This may
suffice, but it is frequently desirable to mop the cavity with the
above-named solution or even the pure liquid after more active
interference, especially if some disintegration has taken place and is
indicated by odor.

After the use of tampons the vagina should be washed with a 2 or 3 per
cent. solution, or 1:2000, of corrosive sublimate; and it is even well
that the cotton, before being introduced, should be anointed with
either carbolized vaseline or carbolized oil (carbolic acid 2 drachms,
olive oil 3 ounces). Iodoform serves an excellent purpose for
disinfection of tampons, especially such as are packed into or against
the cervix, and as an application to the cavity after the removal of
the putrid contents following the hot douche. Borated cotton, or even
ordinary cotton or prepared tow, should be on hand to use during the
after-treatment in place of cloths for the purpose of receiving the
discharge: it is warm, soft, forms a good filter, and can be thrown
away or burnt when soiled, whilst the cloths ordinarily used, and often
very offensive, are kept for the wash.

Medication.--The most important of all the remedies is opium; in
preventive treatment it may be called a specific. It is far preferable
to the hypodermic injection of morphine, serving to relax and quiet the
uterine muscle and to lessen hemorrhage; for the latter purpose it is
often combined with acetate of lead--from ¼ to 1 grain of opium mixed
with ½ to 1 grain of acetate of lead, to be given at a dose and
repeated when necessary. Ipecacuanha combined with opium acts well in
relaxing the tension.

Viburnum prunifolium has long been used as a uterine sedative in these
cases in those States where the plant is endogenous, and its use has
been widely disseminated since it has found so able an advocate in
Jenks. The preparations are not all equally effective, but in the early
stages the fluid extract given in teaspoonful doses, according to the
amount of hemorrhage and pain either hourly or every two or three
hours, has a most {511} decided effect in allaying threatened abortion,
in checking hemorrhage, and in quieting pains. It seems to be a uterine
sedative. Several ounces may be taken, and successful cases are
reported where the pending expulsion was averted and gestation
continued to a successful termination after four ounces had been used.
Digitalis combined with acetate of lead also deserves recommendation as
an effective remedy in the early stages. Quinine may be given to
stimulate the system and further uterine contraction, and is invaluable
in an asthenic condition or if disintegrating shreds be present.

Nervines, valerian, asafoetida, valerianate of ammonia, bromide of
potassium, are of great service throughout the entire course of
abortion, as the patient is usually in a nervous almost febrile state.
Alone they may serve to allay the irritating symptoms in the early
stages, and answer well in preventing the disagreeable effects of
opium. Asafoetida may be given by injection or in pills, from ½ to 2
grains at a dose.

Clysmata tend to irritate, and should not be used as long as we may
hope to prevent threatened abortion. Such remedies as are indicated in
the treatment of this condition, especially opium and nervines, must
nevertheless at times be given by injection, as the stomach may refuse
to receive and retain them in the irritated condition which accompanies
this state. The clysms should always be warmed, of body temperature:
two tablespoonfuls of milk of asafoetida or gum arabic form an
excellent vehicle, though water or milk thickened with flour or starch,
which is always on hand, will do quite well.

Should it be necessary to move the bowels, castor oil is one of the
best remedies, whilst cathartics, especially aloes and similar drugs,
must be avoided as long as there is hope of preserving the ovum: they
certainly further expulsion. Ergot should not be used until after the
uterine cavity is emptied, and is decidedly contraindicated whilst the
ovum or any of its parts remain adherent in utero. The dangers arising
from the use of ergot in the early stages, whilst the ovum is still
intact, are rupture of the membranes and forcible contraction, which
always prolongs expulsion of the ovum or its membranes; the circular
fibres, which predominate, are stimulated most forcibly to action, more
particularly so under the conditions which usually exist in abortion:
the muscle of the uterine body is hindered in its contraction by the
adhesions of ovum and decidua, especially if these membranes are
infiltrated; and, moreover, in cases of abortion the tissues of the
womb itself are often more or less diseased; the lower portion of the
uterus and cervix alone is free to act, the circular fibres of the
internal os contract most readily under the influence of ergot, whilst
the activity of the fundus is interfered with; thus closing of the
outlet and incarceration of the membranes are liable to result. This
popular and dangerous drug must not be given until the tissues are
expelled, or, if desirable by reason of excessive hemorrhage, its use
may be resorted to under one condition: if the membranes are detached,
not only free in the uterine cavity, but entering that of the cervix;
they may be found massed together firmly, by compression of the uterine
walls, into a conical or pyriform mass; and when this has to a great
extent passed the internal os ergot may be given. This drug, so
dangerous in obstetric practice, is still used with altogether too much
freedom in this country, and it would be far better to do without it
than to {512} continue the prevalent abuse. I have insisted that this
drug must not be given in labors or abortion until the contents of the
uterine cavity have been removed. Although but one of our prominent
obstetricians approved of the position I took in 1883, and I was then
freely attacked, I now urge the point more earnestly, and the doctrine
is more commonly accepted: in Germany such men as Martin, Spiegelberg,
and others have succeeded in doing away with this dangerous remedy
altogether in the institutions under their care, restricting its use to
the non-gravid uterus.

As a styptic, hot water, carbolized, serves the best purpose: in the
early stages as vaginal douche, in the later as an intra-uterine
injection at 120°, it is an invaluable remedy, preferable to other
styptics, as it cleanses and removes the coagula. When the cavity has
been emptied, especially after the forcible removal of the membranes,
it is well to apply carbolic acid to the surface; and it is better for
this purpose than tincture of iodine or perchloride of iron, either of
which is only to be used in case that hemorrhage does not yield to the
before-mentioned remedies.

Anæsthetics.--Though bromide of potash, morphine, or opium may suffice
for the relief of the pain in ordinary cases, the use of an anæsthetic
is not only desirable, but necessary, if more active measures are
resorted to. For purposes of rapid dilatation and the removal of an
adherent ovum or membranes anæsthesia is almost indispensable; without
this the suffering of the already nervous, debilitated patient is
excessive; the uterine and abdominal muscles are tense, and operations
thus greatly impeded. An anæsthetic should be given in a rapid
dilatation on account of the pain, as well as the greater facility of
operating; and it is most necessary in an attempt at expression, as, if
made without an anæsthetic, the abdominal muscles are so tense that the
uterus cannot be well manipulated from without. I myself prefer
chloroform.

Instruments.--A speculum, a dull curette, a sharp scoop, a vulsellum
forceps, and uterine dressing-forceps are essentially necessary. Any
speculum may be used. The best is Sims's if the semi-prone position be
used, or Simon's in the dorsal decubitus. The Schroeder's or my forceps
is necessary to steady and bring down the uterus for the introduction
of tent or finger and the use of the scoop or the application of
styptics. This is in the main the American bullet-forceps, an
instrument far superior to the sharp vulsellum which is so popular. The
curette I would most recommend is my own modification of Récamier's
instrument of pliable metal, one blade resembling that of Récamier's,
but curved somewhat more like the uterine sound--sharp upon one side,
dull upon the other--to be used for the purpose of severing the ovum or
membranes in the line of their adhesion: this is so narrow that it can
be introduced into the os even after contraction if this be not almost
tetanic, as after the giving of ergot. The other blade is larger, broad
and flat, more spoon-like, to be used in case of moderate dilatation of
the os, both, however, being for the purpose of severing the adhesions
and leaving the ovum intact. The broad blade serves as a lever to
remove the ovum or membranes when detached. But if the membranes be
ruptured, it is of service in separating these from the uterine wall,
leaving them as complete as possible, which will always facilitate
removal or expulsion. The irritation caused by the severing of the
adhesions with this instrument frequently suffices to inaugurate
uterine contraction; and ovum or {513} membranes, being once liberated,
are then compressed by the uterine muscle into one mass, thus affording
a resistance which the uterus is enabled to grasp and expel. This
method I believe to be far more rational than the removal of the
membranes with the sharp instrument: it furthers the process of nature
more strictly, separating rather than cutting away the tissues, as does
the latter. The sharp scoop is an instrument which is only to be used
for firm adhesions in secondary cases, where the progress of abortion
has temporarily ceased and the membranes have become more firmly
attached, especially where disintegration of such adherent parts has
taken place to some extent; it is necessary and cannot be dispensed
with where remnants have been retained for months and have become
firmly attached, simulating polypoid growths. I object to the use of
the sharp scoop in recent cases, because it is preferable to follow the
line of demarcation indicated by nature, and separate the membranes or
the ovum, if still entire, in this strait; whilst the sharp scoop
removes them piecemeal, cutting deep into the mucosa at one place, and
possibly leaving pieces of embryonic tissue in another.

Dressing-Forceps.--These are serviceable for the introduction and
removal of tampons, the cleansing of the uterine cavity, and the
removal of a detached ovum when in the cervical canal or almost
extruded; but the very common habit of seizing the ovum with this
instrument as soon as the apex appears is a most pernicious one: the
membranes are ruptured, the continuity destroyed, the mass collapses,
and the resistance offered to the contracting muscle as well as the
dilating wedge is thus destroyed, and the course of abortion greatly
prolonged. No narrow grasping instruments should ever be used to make
forcible traction upon the ovum; the tissues, if healthy, are very
often delicate, and if degenerated into mole formations, infiltrated
with blood, brittle, breaking beneath the instrument, which is always
withdrawn grasping simply what is seized between its blades. I know of
none of the many ovum-forceps which I can recommend.

Position of the Patient.--For purposes of instrumental interference the
patient may be placed on side or back, in the left-lateral, semi-prone
position if Sims's speculum be used; I prefer the dorsal decubitus,
using Simon's speculum. The bivalve specula might be used if short,
like the operating speculum of Albert Smith, but they are not to be
recommended, on account of their small diameter and their usually too
great length, by which they push the uterus away. The organ should be
approximated as nearly as possible to the vulva and finger by the
instrument, and this is best done either by a short, broad Sims's or
Simon's speculum. Simon's speculum in the dorsal decubitus has among
its other advantages that of greater convenience for the purpose of
injections. The patient is transversely brought on the bed, with the
hips upon the edge, elevated by a folded blanket or hard cushion; the
legs are flexed, the feet placed upon two chairs; an oil cloth directly
under the parts is folded into a slop-jar standing underneath, so as to
receive all refuse matter, which enables the physician to use the
douche freely. Bozeman's catheter, with double current for
intra-uterine injection, is a very convenient and valuable instrument,
though not an absolutely necessary addition to the armamentarium.

The use of gynecological instruments is even more important in {514}
abortion than in labor at term: it is by far more convenient to
introduce the tent or dilator, and even to use the scoop through the
speculum, than blindly with the aid of the finger, guided only by the
hand on the fundus. Knife and scissors, needle and thread, may be of
use in difficult cases, or in case of a firmly-contracted os with
putrefaction of the membranes, for rapid dilatation. German authorities
advocate incision with a knife in preference to rapid dilatation where
it must be done quickly for purposes of immediate evacuation; should
this be resorted to, it is very necessary that after abortion is
completed the parts should be again carefully united by close
sutures--a method which is only to be recommended to the expert in
extreme cases. The Récamier or my own curette can be used effectively
without dilatation in ordinary cases, even if the os is somewhat
contracted; there is so much relaxation that these instruments can be
readily introduced, the os being dilated during the act; and if the
sharp instrument be used the particles cut are carried out by the
spoon, the douche taking away the remnants. With my own instrument I am
in the habit of separating the adhesions and removing the mass more, as
with a lever, especially if the ovum be intact. The large blade of the
spoon is used to press the ovum down into the hollow of the sacrum,
very much as the placenta at term is removed.

PROPHYLAXIS.--In primigravidæ the physician should urge careful
attention to all conditions that may further a healthy state. As
indicated by the physiology of early pregnancy, this lies mainly in a
proper preparation for the changes wrought by the physiological
activity of the sexual organs; free scope must be given for their
development, and this guarded against all injuries, nervous and
traumatic: the congested developing parts and the sensitive,
tensely-strung nervous system must be protected against insult; a
healthy condition of the system must be established, and possibly
existing predisposing causes counteracted.

Young married women, above all, are liable to injury from coition, from
over-exertion in this period, from amusement or labor, as well as from
the demands of fashion. It is the mother, and more often the family
physician, who must see that a free and healthy development is
permitted: let it be remembered that the close-fitting corset, the
heavy dresses suspended from the hips, exertion whether for pleasure or
work, frequent intercourse, as well as mental condition, all affect the
fate of the ovum. The menstrual congestion, recurring with greater or
less periodicity at the usual time of the flow, is a period of especial
danger at which still greater care is necessary. As a rule, we can only
say that a strict attention to dietetic laws, which should be observed
in every gestation, is of the greatest prophylactic importance. In the
case of multigravidæ, especially such as have previously aborted, the
same rules must be observed, and, in addition, especial attention must
be paid to the removal of such causes as may have resulted in previous
abortions. The proper prevention, however, lies in treatment of these
conditions before the occurrence of conception: as we have seen, these
may be either plethora, anæmia, most usually syphilis or uterine
disease, and a lacerated cervix, endometritis, pelvic cellulitis, or
retroflexion. The treatment of such morbid conditions should be
inaugurated as soon after recovery from an abortion as possible, and
continued, in case of constitutional disturbance, after conception has
again occurred. Though the avoidance of excessive exercise and perfect
quiet {515} are desirable, especially during the menstrual congestion
and at that period of gestation when abortion has previously occurred,
it is ridiculous to confine the patient to bed at this time, without
further treatment, with a view of preventing the recurrence of abortion
by rest alone. This is a common practice, and can result in good only
in isolated cases; it usually annoys and weakens the patient; and it is
high time that this antiquated doctrine should be exploded, and that
the attending physician take sufficient interest in his patient to urge
examination and local treatment by the specialist if he himself cannot
detect and relieve the trouble which has caused, and will continue to
cause, such serious disturbance. It is a paramount duty of the
physician to inquire into the cause of the previous abortion and to
prevent recurrence by its removal: if he himself should have attended
her, he should examine the ovum most carefully, and later the patient
as regards her constitution and the condition of the uterus and pelvic
viscera. If the abortion be due to syphilis of mother or father, this
must be treated, an existing disease relieved, a retroflexion of the
uterus replaced, a lacerated cervix repaired, or the disease of the
endometrium overcome; but the confining to bed of the patient during
the period of danger, or even during the many months of pregnancy, will
aid but little: this is advisable only when the symptoms of threatening
abortion again appear. Moderate exercise is conducive to health, and
hence to the development of the ovum, and only in rare cases can
abortion be prevented by rest alone: confinement to bed may be resorted
to as our only means if we are in a state of ignorance, where the
original cause has not been detected or treatment is at the time
impossible; and this is partially true in pregnancy of a uterus with a
lacerated cervix which has not been repaired. An inflamed or irritated
cervix is open to treatment, and even a lacerated cervix can be
improved during the existence of gestation.

Preventive Treatment.--If symptoms of threatening abortion, or such as
resemble them--oozing, hemorrhage, uterine pain--appear in the pregnant
woman, however questionable the diagnosis, the treatment must
invariably be directed toward the prevention of threatened abortion. If
the symptoms are indistinct, the oozing may be merely that of a
congested or eroded cervix during the menstrual period or the existing
pains--a reflex symptom due to other causes--and should be treated; but
then in addition the necessary means must be at once adopted to prevent
threatened abortion; and if we are ignorant of the condition of the
ovum, whether healthy with a living embryo or pathologically changed,
treatment must be directed toward its preservation until absolute
knowledge to the contrary is obtained; and this is, above all,
necessary in the earlier months, when it is almost impossible to
determine as to its condition. Every effort must be made to preserve
the ovum as if healthy; and if it be so, success is by far more likely
to crown the efforts of the physician, whilst he will strive in vain if
it be a healthy effort of the uterus to rid itself of a dead embryo and
the diseased membrane surrounding it. Perfect quiet, mental and
physical, rest of body and mind, is necessary; the patient is put to
bed and kept quiet, excitement and irritation prevented; no coffee,
tea, or stimulants should be given, but acids, cool drinks, sour
lemonade, aromatic sulphuric acid, opium alone or in combination with
other remedies according to the conditions, are in place. If hemorrhage
is profuse, we should further vascular {516} contraction sufficiently
to check the flow with chinine, ipecacuanha, or, best, viburnum
prunifolium, the fluid extract in teaspoon doses, if very profuse every
hour, otherwise every two or three hours; digitalis may be added in
case of nervous excitement, which is often intense; so also bromide of
potassium, valerian, or asafoetida. Ergot and cold applications to the
abdomen must be avoided; the latter are frequently resorted to, as they
tend to allay hemorrhage, but at the same time they stimulate uterine
contractions too freely. No unnecessary examination must be made, and
the patient must be kept in perfect repose until the symptoms have
completely disappeared.

TREATMENT OF ABORTION WHICH IS FULLY INAUGURATED AND PROGRESSING.--If
all means to overcome the existing conditions and check threatening
abortion have failed, if the pains continue, the os dilates, or
hemorrhage becomes profuse, the treatment is radically changed. Before
this period it was directed to the preservation of the ovum, whilst the
object is now to complete delivery. The practitioner must now endeavor
to check hemorrhage, allay suffering, and above all empty the uterus at
the earliest possible time, and to this latter end all his efforts
should be directed. By accomplishing this all other symptoms will be
most satisfactorily and perfectly relieved; and though time and
patience are remedies which cannot be dispensed with even in this
stage, more active interference and local measures are now indicated,
which, it will be remembered, were to be avoided if prevention seemed
still possible.

The progress of dilatation and separation is often slow, and during
this stage one precaution must be observed: whatever measures be
adopted, the membranes must be preserved intact. We must avoid all
interference with the foetal sac; after this is ruptured the hemorrhage
is liable to become more profuse, as an additional source of bleeding
is added by the collapse of the ovum, which causes a diminution of the
intra-uterine pressure. The succulent and vascular tissues are no
longer compressed between the resistant mass of the ovum and the
uterine walls, and ooze freely into the cavity; moreover, the
resistance and irritation previously existing, whilst the ovum was
unbroken, is removed, and uterine contractions, the expulsive efforts,
are diminished or cease entirely.

The prominent indication for interference is given by hemorrhage, and
such means must be adopted to check this as will at the same time
promote the expulsion of the ovum.

Pain.--Opium must now be most sparingly used. Complete relief of pain
is not desirable in this stage; uterine contractions, the dilatation of
the cervix, should be furthered; nervous irritation and excessive
suffering may be relieved by nervines--valerianate of ammonia, bromide
of potash, perhaps a hypodermic injection of morphine; regular pains
indicative of uterine contraction must not be interfered with under any
circumstances.

Hemorrhage.--The treatment previously inaugurated--rest, quiet, cold
iced drinks--may be continued, but in addition more active measures
must be employed: our main resort in this stage is in local measures,
mainly in the tampon. Ergot must not be given, as it may lead to
rupture of the membranes or incarceration of the ovum, or both.

The tampon is all-important in the management of this stage of {517}
abortion, as opium is in the first and the curette in that of
retention; according to the method of its use it will serve a variety
of purposes, and by skilful manipulation the object desired can be
attained with a fair degree of certainty. The cervical tampon is
preferable if the os is contracted and the cervix not dilating;
pledgets of cotton have been used to plug the cervical canal, but the
tent is far preferable; tupelo or slippery elm should be used. In cases
where rapid dilatation as well as relief of hemorrhage is desired the
sponge tent may be resorted to, but is, as a rule, to be avoided on
account of the dangers of infection and the liability of adhesion of
particles of soft tissues with which it comes in contact within the
cavity. The tupelo is preferable to sea-tangle, as it may be had in
more serviceable size and shape; the slippery elm is most excellent, is
everywhere within reach, especially of the country practitioner, and
has no superior: when cut in proper size, the edges slightly smoothed,
and placed for a moment in warm water, it is soon covered with mucoid
exudation, which makes its introduction extremely easy, and its
presence within the uterine cavity decidedly less harmful than any
other substance: it will readily find its way between the membranes,
and a number of tents can be placed side by side, so that the
disadvantages of inferior distension are equalized.

The tent is best introduced through the speculum, the cervix being
fixed by a tenaculum, Engelmann or Schroeder forceps, and a tampon of
salicylated or carbolized cotton placed in the vagina for the purpose
of retention as well as disinfection. Care must always be taken that
the tent be of sufficient length and passed well into the uterine
cavity, to within a half inch of the fundus, as it will then serve not
only to compress the bleeding vessels and dilate the cervical canal,
but to separate the ovum and stimulate uterine contraction. When the
tent or cervical tampon is used the vaginal tampon is unnecessary; each
has its proper office to perform.

The Vaginal Tampon.--The vaginal tampon is preferable where the os is
patulous and the cervix dilating; if small, packed merely in the
cul-de-sac and directly about the cervix, it irritates but little;
tents should be thus used if it be desirable to check hemorrhage and
the possibility of prevention still exists. If larger and the vagina is
more thoroughly packed, it is a violent excitor of uterine
contractions, and is used in part for this purpose. The rubber bag or
colpeurynter, even when filled with hot or cold water, is of little
service in checking hemorrhage, though it serves to stimulate uterine
contractions; hence it is of no value in those cases where the vaginal
tampon is usually called for. The best method of checking hemorrhage
and furthering separation and expulsion of the ovum, when intact, is
the thorough packing of the cul-de-sac and larger part of the vagina
with balls of cotton; wads of the size of a walnut should be made, and
strong thread or string should be tied to each to facilitate removal:
clots should be removed and the vagina cleansed with an antiseptic
injection of 2 or 3 per cent. of carbolized water preparatory to their
introduction. If convenient, salicylated or carbolated cotton should be
used; the ordinary cotton wadding or cotton wool may be taken, but then
it is desirable to soak at least the first which are introduced in
carbolized water, 5 per cent., or carbolized oil, 10 per cent.

Tampons are best placed with the aid of Sims's or Simon's speculum,
{518} though the bivalve may also be used. If no instrument is at hand,
the vagina may be distended by the fingers, which are so introduced
that they separate the parts thoroughly and press down the perineum;
the prepared tampons are now seized with the dressing-forceps and
securely packed in the cul-de-sac and against the cervix, so that it is
firmly surrounded by a compact plug; then the entire vaginal canal is
similarly packed to the vulva. Hemorrhage is perfectly checked if the
tampon be properly applied; if not, it ceases for a time until the
cotton or other material used has been saturated, and then continues as
before. If the desired object be attained, the pains will become more
severe and rapid and the tampon will be expelled: upon examination the
ovum will be found in the vagina or at least within the cervix, and is
easily removed. It is stated that the tampon should not be left in
place over twenty-four hours: this is certainly the limit, as,
saturated with blood and secretions, it is liable to putrefy and thus
lead to more unpleasant results. Twelve hours is, as a rule, ample
time. If the vagina has been properly packed, hemorrhage is stopped and
uterine contractions aroused which should be sufficient to cause
dilatation and separation of the ovum. If the desired result be not
accomplished at this time, it is best to remove the tampon, and,
according to circumstances, introduce another or resort to other
measures. After removal of tampons the vagina should always be cleansed
by a disinfectant injection. If the os be found closed and uterine
contractions have ceased--which is very rarely the case when the vagina
has been properly packed--no further measures should be resorted to, as
the continuance of gestation may be hoped for.

In case of very profuse hemorrhage the tent or vaginal tampon is
necessary, but the hot antiseptic douche is but little inferior as a
hæmostatic and excitor of uterine contractions. If carbolic acid is
used, 2 or 3 per cent. may be added of corrosive sublimate, 1:2000, and
the temperature of the water should be at least from 115° to
125° F.--if gauged by the hand, so hot that the fingers can hardly be
kept in the water, at least not without moving them about. The external
parts, especially the perineum, must be coated with lard, as they are
particularly sensitive and liable to be scorched (vaseline washes off
too easily). Emetics or purgatives, though still occasionally
recommended, must not be given with a view of promoting separation or
expulsion of the ovum.

Removal of the Ovum.--The tampon has been expelled by uterine
contractions, and the ovum, as before stated, will probably be found
within the vagina or separated and easy of removal. Should the tampon,
however, have been previously removed by reason of insufficient action,
the hot antiseptic douche may be tried and the vagina again packed.

Constitutional symptoms, excessive suffering, nervousness, debility,
rise of pulse or temperature, necessitate immediate removal of the
ovum. Under ordinary circumstances this is allowable only if the os be
patulous, the cervical canal sufficiently dilated, and the ovum
detached; and if the above preliminary steps have been taken, this will
usually be the case in an abortion during the first three months. If
the cervix permits of the introduction of the finger, a satisfactory
examination may then be made if the patient be placed in the proper
position, with the hips elevated, the limbs flexed, and the uterus
{519} approximated to the examining finger by pressure upon the fundus
with the other hand. If this be not possible by reason of thick
abdominal walls, the fixation of the cervix with Engelmann or Schroeder
forceps is called for. Expression is then preferable to extraction. The
dressing-forceps, and even the ovum-forceps, are of but little service
for this purpose unless the os be dilated and the ovum completely
detached, as they are liable to rupture the sac, and thus increase the
difficulty of extraction. The broad, blunt blade of my curette,
Récamier's instrument, or Munde's, should be passed into the uterine
cavity and swept around the entire circumference of the ovum: the
uterine sound properly bent may be used for the same purpose, and if
liberated it may be removed by using my instrument as a lever, placing
it beneath the ovum in case of retroflexion of the uterus, and
anteriorly in anteflexion, and pressing it down toward the pelvic
outlet. Expression by hand is still recommended, and is very efficient
in relaxed or thin abdominal walls, where both hands may be readily
used for manipulation. The fingers are pressed against the uterine
fundus--anteriorly in case of anterior displacement, posteriorly if the
uterus is retroflexed or retroverted--whilst firm counter-pressure is
made by the other hand upon the abdominal walls; the ovum being thus,
as it were, squeezed out.

In later months greater dilatation is necessary, the importance of
preserving the ovum intact is augmented, and the greatest care must be
taken that efforts at expression are not made whilst the ovum is still
adherent. I have found great difficulty in detaching the membranes,
even when the canal is permeable, with the finger, as has been
recommended; and it is for this purpose especially that I have found
the large blade of my instrument so valuable. It is readily introduced,
pliable, so that it may be bent and properly adapted, and the point of
attachment being found it can be passed about the entire ovum in the
same plane, loosening without rupturing; and the irritation caused by
this manoeuvre is often sufficient to stimulate contractions, so that
expulsion will follow. In fact, I consider this of less importance than
separation, retention being mostly due to adhesions, especially at the
point of placental formation. Once separated, it is a foreign body and
an irritant, which is readily expelled. Nature thus teaches us the
course which we must follow, to complete separation and dilatation
before attempting removal.

TREATMENT IN CASES OF RETENTION OF OVUM OR MEMBRANES.--These are by far
the more trying conditions, and, unfortunately, the ones to which the
physician is most frequently called. Aid is not summoned at an earlier
stage on account of that dangerous underrating of abortion or for fear
of unnecessary expense, and the position of the practitioner is made a
trying one, as he is ignorant of the state of the case. Clots of blood
have passed, but as to the precise conditions he is left in doubt;
whether the membranes have ruptured, whether the ovum is expelled in
whole or in part, he is not told. He may find the os closed; the size
of the uterus reveals but little, as in many cases, at least those of
spontaneous abortion, development is retarded; it is smaller than would
be supposed at that period of gestation. It is only in case the uterus
corresponds at least approximately in size to the time, or if the os be
sufficiently dilated, that he can at once decide positively as to the
presence of ovum or membranes.

A closed internal os may usually be looked upon as evidence that the
{520} retained masses, whether ovum or membranes, are adherent, though
in case of sepsis more or less dilatation exists; yet in the latter
case the indications afforded by those symptoms are of little
importance, as the constitutional symptoms, with the character and odor
of the discharge, clearly indicate the existing conditions, and
consequently show the course to be pursued. No question exists as to
the necessity of immediate delivery in these cases, but as to the
manner of treatment in retention of ovum or membranes not
disintegrating there is a wide difference of opinion: able men are
still inclined to urge a reliance upon nature, yet it is a dangerous
course for the practitioner to pursue: successful as it may prove in
many cases, it is certainly fatal in some, and but too often followed
by the insidious consequences so frequent in its tracks.

Labor at term may be left far more readily to the powers of nature than
abortion: the former is a physiological process, the latter
pathological. The expulsion of the ovum at term has been preceded by
preparatory changes in maternal and foetal parts; the separation of the
membranes is facilitated by the fatty degeneration of decidua serotina
and vera; the hypertrophied uterine muscle is strained to its utmost,
its fibres increased and strengthened for the ordeal, but in the early
months no such conditions exist. Though expulsion has been anticipated
and the preceding hemorrhage frequently serves to separate the
structures, and development ceases with the death of the embryo, a
retrograde metamorphosis is inaugurated only in certain cases, and then
incomplete, and the frequency of intermittent abortion which we find in
cases left to nature is evidence of incompetency to fulfil the task
attempted: hemorrhage, more or less protracted, and contraction of the
uterus cease; the ovum has been partially separated; its growth is
checked, and then a retrograde metamorphosis is inaugurated in the
tissues which have been in so active a state of development; this
continues until a recurring menstrual period or excessive exercise
brings about a renewal of the expulsive effort; and if sepsis has not
taken place we usually find that the ovum is expelled with rapidity.
When the attempt was first made, it proved ineffectual and the effort
ceased; the tissues were impaired in their nutrition, underwent a fatty
degeneration tending toward disintegration, and the second attempt of
nature, with the parts properly prepared, terminates rapidly and
effectually. Though the tendency of the profession at large seems
toward a more expectant plan, guided by able authorities--such as
Parvin, who urges attention to the old-time remedies, rest, time, and
laudanum; and Leishman, who advocates this treatment when hemorrhage
has stopped and the os is closed, perhaps aiding nature by the use of
ergot--I would advise more active interference. It is indeed true that
the ovum or some of its parts may remain in utero for months and then
be expelled by a healthy effort of nature, without injury to the
patient; but this is not the rule. I have seen such cases, but mostly
the health of the patient is affected; even if more active symptoms,
such as hemorrhage and sepsis, do not appear, subinvolution certainly
follows. In cases less severe the patient is nervous, restless, suffers
from insomnia, uterine colic, and occasional oozing; perhaps there is
an offensive discharge,--all symptoms which are not sufficient to cause
great anxiety, but we may with certainty expect them to result in
serious inflammations of the uterus and surrounding tissues--metritis,
thrombosis, cellulitis, {521} endometritis, peritonitis; hence why
should we wait? Why allow these dangerous membranes to remain, as
claimed by some, "as long as no injurious effects appear"? Why wait for
these more threatening symptoms when evil results are almost certain to
follow upon the retention of such masses, even though hemorrhage and
sepsis be at the time wanting? I have removed thoroughly healthy,
semi-organized remnants as late as the fifth month after partial
expulsion of the ovum; the patients were suffering no very serious
inconvenience at the time, nor did any grave consequences directly
follow; yet it would have been far better for them had decided steps
been taken at the time of the inaugural flow; they were forced to seek
advice in some instances by reason of uterine pains and oozing, in
others by profuse and sudden hemorrhage; and, though decided injuries
were not at the time evident, subinvolution and uterine displacement
were certainly threatened.

Various periods are mentioned as preferable for interference. Some say
that there is no need for alarm if the placenta remains in utero for
twenty-four or forty-eight hours, provided the patient be under
observation; but the os is liable to contract, always within a week,
sometimes within forty-eight hours, after preliminary hemorrhage, and
it certainly is unreasonable to allow complete contraction of the os
and thorough cessation of the efforts of nature to take place, with the
probability of evil results before us. If the physician is called at a
time when the course of abortion seems retrogressive, the os closing,
and he is uncertain as to the complete emptying of the uterine cavity,
he should satisfy himself of the existing condition; and there is no
reason whatever to the contrary in the present era of antiseptic
gynecology. He should explore the uterine cavity, determine the state
of affairs, and act accordingly. The proper course is clearly
indicated: retained tissues should be removed, though it is difficult
to formulate precisely the conditions by which action should be guided.

The circumstances permitting of interference and removal are a patulous
os, an open cervical canal, and detachment of ovum or membranes: these
existing, removal is easily accomplished, and should be undertaken even
though no threatening symptoms be present. The indications which at all
times determine and obligate immediate removal are--a putrid discharge,
hemorrhage and constitutional symptoms, debility, fever or sepsis; then
immediate removal is necessary at all hazards.

Though it does not appear advisable to remove the ovum, as urged by
Fehling, at once, if the tampon fails after ten or twelve hours' trial,
the physician must not wait until threatening local or constitutional
symptoms appear, as various evils develop insidiously long before
removal is so loudly called for. There are no conditions which could,
by any possibility, contraindicate immediate interference if the
indications above mentioned exist--not even inflammations, pelvic
cellulitis, or fixation of the uterus, as is claimed by some. The
limits of active interference being given by the above indications, the
practitioner must determine by the greatly-varying symptoms of the
individual case, as he does upon the proper time of applying the
forceps in labor at term. If parts of the ovum remain in utero, they
should be removed as irritating and dangerous; and a patulous os must
necessarily lead the practitioner to infer the presence of such a mass;
yet this is not a constant symptom: if the os is closed and {522} the
presence of membranes presumptive, he should dilate and satisfy himself
as to the true state of affairs, dilatation with antiseptic precautions
being entirely harmless. If remnants are found, the first step to their
removal has already been accomplished in the diagnostic dilatation.
This is best attained with the patient in complete narcosis and in
proper position. The dorsal decubitus and Simon's speculum are
preferable to the left-lateral semi-prone position, as we are better
able to manipulate the uterus both externally and internally,
especially to control the fundus. If the os be not too firmly
contracted, the finger may be introduced when anæsthesia is
established, and sufficient dilatation thus accomplished, or the scoop
may be at once used without further preparation. If time is no object,
the uterus is best dilated with a tupelo or carbolized sponge tent;
where immediate action is indicated, the finger or steel dilator is
best. Molesworth's instrument, even if ready for immediate action, is
liable to dilate within the cervical and uterine cavity, remaining
contracted at the point of greatest importance, the internal os.
Incision with the knife, the splitting open of the cervix, is now
recommended by German authors.

The tampon can be of service only where a larger mass is retained, not
if the membranes alone remain. The use of the tent for the purpose of
dilating is of advantage if introduced well into the uterine cavity,
stimulating the muscle, so that expulsion frequently follows
dilatation; but even then the curette should be used--the dull
instrument--for a careful examination of the cavity. I have already
stated the conditions indicating a resort to the sharp scoop, the
Simon's or Sims's, or the dull curette, such as Munde's or my own. The
wire loop of Thomas is too weak, and serves more for the removal of
already loose masses than for the separation of the tissues, which I
consider by far the most important. Where possible, it is always
preferable to use the dull instrument for purposes of separation; and
there is no better than Récamier's old instrument, or, in case of a
large cavity, the broad blade of my own; both may be used without
dilatation if the contraction of the os is not excessive. If firmer
masses are found, as is frequently the case when the placental remnants
have been retained for several months, Simon's sharp scoop is
indicated, and the smaller size can be used without previous
dilatation; the speculum is not necessary, but desirable, but for the
effective handling of the instrument it is best that the patient be
placed in the lithotomy position, upon the edge of the bed, the hips
elevated, with a rubber cloth underneath. It is all-important that the
movement of the scoop should be thoroughly controlled by the unengaged
hand grasping the uterine fundus: this will serve to fix the organ well
and prevent its escaping the instrument. Where the fundus is out of
reach, as in retro-displacement, the Schroeder forceps, which is always
of great service in bringing the uterus within reach, must be used. In
case Récamier's or my own instrument is used, it is curved to adapt
itself to the cavity, and, with one edge pressing firmly against the
uterine wall toward the point of attachment of the membrane, it is
carried around the entire space, so as to separate such adhesions as
may exist, and the released membranes are then forced or pressed out
with the instrument. In case the sharp spoon is used, it must be
handled with great care, pressing firmly against, but not too deeply
into, the uterine wall, and carried in {523} regular parallel strokes
from the fundus toward the internal os. After such manipulation the
cavity should be well washed out with hot water containing from 2 to 5
per cent. of carbolic acid, bichloride of mercury, borax, or
permanganate of potash, either with the ordinary syringe or Bozeman's
catheter; after this the entire inner surface of the uterus is touched
with carbolic acid, a little cotton wrapped upon the end of an
applicator and saturated with the solution answering the purpose very
well.

Hot water and carbolic acid usually suffice to thoroughly contract the
organ; should this not be the case, should a flabby, atonic condition
exist, it is well to place a tampon of iron cotton in the cavity. The
applicator is loosely wrapped with cotton of sufficient thickness to
fill the cavity; this is steeped in Monsel's solution or the
perchloride of iron, the superabundant fluid expressed, and then
introduced. Contraction is sure to follow, and the tampon is left in
place for three or four days, when it will either be expelled by the
action of the uterus or it will be found, coated with healthy pus,
barely held in the grasp of the muscle, and can be removed by the
slightest traction: no effort should be made, as it will remain firmly
fixed until a healthy granulating surface is established. It may be
kept in place by a tampon of cotton carbolated, or, better still,
prepared with iodoform, which is always a desirable application after
interference. Ergot should then invariably be given, either by
hypodermic injection or per os--if the stomach is in good condition, a
teaspoonful of the fluid extract every three hours during the first
day.

Putrid discharge and septic symptoms unquestionably indicate immediate
interference; the method, however, remains the same. In case of
beginning putrid discharge without constitutional symptoms, the dull
curette is greatly to be preferred to separate the sloughing tissue
from the healthy uterine structure without injuring the latter; whilst
if the uterine structure itself is affected, it is necessary to resort
to the sharp spoon to thoroughly remove all that is diseased.

Constitutional treatment must, of course, follow the local measures
above advocated. The danger of the sharp instrument, under these
circumstances, is in the possibility of lacerating healthy tissues and
opening new ways for infection. It can only be used if all diseased
tissue is thoroughly removed and the operation followed by
cauterization with pure carbolic acid and intra-uterine injection, that
all remaining particles, however small, may be washed away.

An active general treatment must accompany these local measures, but
upon this I will not dwell, as it is the same which must be followed in
all cases of septic poisoning. Quinine is the main stay, and in
addition to the remedies in general use ergot is here indicated to
further contraction and expulsion of offensive particles and close the
capillary and lymphatic canals to the possibility of infection.

AFTER-TREATMENT.--It cannot be too often repeated that the danger
resulting from abortion is not the immediate or primary one, but the
secondary, even in case of profuse hemorrhage; it is that of anæmia, of
general debility, a slow getting up. After abortion we have conditions
analogous to those of the puerperium, the dangers of infection, of
septicæmia, the greater liability of the system to surrounding
influences, {524} epidemic, infectious, malarial; but even greater than
after labor at term is that of incomplete involution with its chain of
insidious consequences. In the main, the danger of abortion lies in the
lightness of the affection and the indifference to after-treatment.
Involution is more questionable than after labor at term, and yet time
and opportunity are rarely given nature to accomplish this process of
restitution. If the abortion is passed easily, the patient rarely keeps
her bed, pays little or no attention to the occurrence, certainly none
to her getting up, and subinvolution, by far the most frequent sequence
to abortion, follows. Abortion is altogether the most prolific cause of
uterine disease, in consequence of the indifference with which it is
treated, not only by the patient, but by her physician. With the
expulsion of the ovum and the cessation of hemorrhage the case is
considered finished; even if a physician is called, proper time is not
given for restitution of the parts. Although by far less is to be
accomplished by the retrograde metamorphosis than after labor at full
term, the parts being not so fully developed, they are not so
thoroughly prepared for this restitution: retrograde metamorphosis has
not been initiated with the inauguration of the abortion, as it has
with the inauguration of labor at term. In the latter fatty
degeneration is in progress; the tissues are prepared for the
restorative process which is to follow: not so in case of abortion;
hence nature must be assisted, must be allowed to perform those
functions which are necessary to a healthy restoration of the sexual
organs.

In the great mass of cases it is not strictly medical attention which
is necessary, medical treatment, but mere ordinary care, precaution,
and cleanliness on the part of the patient herself, so as to assist the
efforts of nature: a week's rest in bed with healthy nutritious diet
should be accorded every woman who has aborted, and this must be
followed by at least one more week of quiet and confinement to the
room, and not until a month after the accident has occurred should the
patient resume her ordinary vocations.

I will not enter into the details of the after-treatment, as it is
identical with that after labor at term. No decided treatment is called
for unless demanded by symptoms peculiar to individual cases, yet
ergot, quinine, and tonics are in place, and the same antiseptic
precautions must be observed which are so highly appreciated in the
lying-in room.

The patient must be kept in a recumbent position, the room quiet, and
visitors excluded; a bed-pan must be used; the food must be easily
digestible and nutritious; prepared tow or salicylated or borated
cotton should be used in preference to the old-fashioned cloth to
receive the discharge, and this must be changed with sufficient
frequency: the parts must be washed with a lukewarm antiseptic wash,
and vaginal injections of the same given as cleanliness demands, at
least once a day; these should be hot (110°-120°) to further
contraction. Corrosive sublimate 1:2000, carbolic acid 2:100, or
boracic acid or borate of soda, serves a good purpose; intra-uterine
injections are called for only in case of putrid or offensive
discharge.

After the third or fourth day it is well to add an astringent, such as
alum or tannin, to the hot vaginal douche, a teaspoonful to the quart,
beginning with less, as some are very sensitive to these remedies, and
increasing the strength if desirable.

{525} Iron and chinine are serviceable in aiding the system to regain
its tone and in guarding against zymotic and malarial influences, to
which it is more subject in this weakened condition. Ergot is here in
its proper place: a three-grain pill of the aqueous extract should be
given, at least during the first week, three times a day; I prefer this
to the fluid extract in common use, which is nauseating to many. This
drug, so much abused during progressing abortion and in labor before
the contents of the uterus are expelled, answers an excellent purpose
at this stage, and, together with the hot, astringent douche, may be
relied upon to prevent subinvolution.

I can but repeat that the after-treatment should be that of the
lying-in room after labor at term, modified according to circumstances,
but never to be neglected, not even after the most simple cases. We
must remember that it is indifference under these circumstances,
under-estimation of the accident, which leads to years of suffering, by
which subinvolution so insidiously destroys a vigorous constitution.

Rest, peace of mind, and quiet of body should, together with antiseptic
precautions and tonic treatment, follow every abortion, intensified
according to the severity of the accident. The two most important, and
at the same time most neglected, features in the after-treatment of
abortion, both of which are called for in even the most ordinary cases,
are rest and cleanliness--rest, quiet of body and mind, to afford the
proper conditions for the efforts of nature toward restitution and
involution; cleanliness, antisepsis, to prevent external interference
with this process and to guard the lacerated cavity of the womb, which
offers so ready a receptacle for septic elements, against the dangers
which threaten from without and so frequently bring about the
rapidly-fatal termination of an apparently simple abortion.

{526}




{527}

DISEASES OF THE MUSCULAR SYSTEM.


MYALGIA.

PROGRESSIVE MUSCULAR ATROPHY.

PSEUDO-HYPERTROPHIC PARALYSIS.

{528}




{529}

MYALGIA.

BY JAMES C. WILSON, M.D.


DEFINITION.--An affection of the voluntary muscles, of which the chief,
and often the only, symptom is pain on movement.

SYNONYMS.--Myalgia as a general term has few synonyms. It is sometimes
called myodynia. This affection has no essential relation to rheumatism
or the rheumatic diathesis; therefore the common use of the term
muscular rheumatism as a synonym for myalgia is an error. This error
has occasioned much confusion of thought and mistaken medication, and
tends to maintain the obscurity which overhangs the subject of the
so-called and often miscalled rheumatic affections in general. That
true rheumatic processes may extend from serous or fibrous structures
to contiguous muscular masses has, in the absence of demonstration,
been assumed by many writers of authority, but that acute or subacute
rheumatism, with its recognized characters, ever manifests itself
primarily or exclusively as an inflammation of muscle-substance is an
assumption wholly without clinical or pathological support.

The term myo-rheumatism is as inapplicable as muscular rheumatism, and
lacks the sanction of usage. Myositis is a term used to describe (1) an
acute inflammation of muscle, often traumatic, and commonly attended by
suppuration, and (2) a chronic indurating inflammatory process, not
infrequently due to syphilis. Neither of these conditions resembles the
affection under consideration in its clinical aspects, nor is allied to
it pathologically.

As manifested in particular muscles or groups of muscles myalgia has
been described under the terms cephalodynia, torticollis (myalgia
cervicalis), pleurodynia (m. pectoralis seu intercostalis), lumbago (m.
lumbalis), dorsodynia, omodynia, scapulodynia (m. dorsalis), etc.

This affection must, in the present state of our knowledge, be
classified with the diseases of nutrition in the more narrow sense. It
is not a diathetic disease.

HISTORICAL CONSIDERATIONS.--To Inman[1] of Liverpool is due the credit
of having first pointed out the frequency of this malady and the ease
with which it may be mistaken for other and much more serious
diseases--an error in diagnosis which has been followed by serious
results, especially in the case of nervous and self-centred females and
other hypochondriacal persons. It cannot, however, be denied that this
author, carried away by his enthusiasm, exaggerated the importance of
this local {530} affection at the expense of undervaluing the frequency
and significance of other painful disorders which have their origin in
the nervous system. To Inman we also owe the term myalgia, which has
the positive merit of embodying the idea of pain as the chief symptom
of the disorder and the muscles as its seat, and the not inferior
negative merit of implying no erroneous theory as to its nature and
cause.

[Footnote 1: Thomas Inman, M.D., _Certain Painful Muscular Affections_,
1856; _Spinal Irritation Explained_, 1858; _On Myalgia, its Nature,
Causes, and Treatment_, 1860.]

This affection is described in few even among the recent textbooks; in
others it receives merely incidental mention; in the majority of them
it is passed over in silence. Yet it is obvious that the descriptions
of muscular rheumatism, which are rarely omitted, are based upon and
refer to cases of various kinds which for the most part are not
rheumatic at all, and very frequently are examples of true myalgia.

ETIOLOGY.--(_A_) Predisposing Influences.--Myalgia is "essentially pain
produced in a muscle which is obliged to work when its structure is
imperfectly nourished or impaired by disease." Hence all influences
which unfavorably affect the nutrition of the muscles, all diseases
which directly affect the integrity of their structure, predispose them
to this affection. The defect in nutrition may be only relative to the
amount of work the muscle is called upon to do, or there may be
absolute malnutrition, implicating the whole body. The muscle may be
impaired by a local disease which affects it alone, or it may share in
morbid processes which also involve other and distant structures.

Sedentary occupations, leading as they do to poor nutrition of the
muscular system from want of proper use and exercise; malnutrition from
a diet deficient in amount or defective in kind, or in childhood from
too rapid growth; the chronic wasting diseases; the state of
convalescence from acute maladies; and, finally, degenerative diseases
of the muscles themselves,--all favor the development of myalgia. Among
the acute diseases which by their derangement of nutritive processes
especially render those who have suffered from them liable to this
painful affection of the muscles during convalescence, is acute
articular rheumatism or rheumatic fever. It is this fact, taken
together with the use of a misnomer, that has given rise to the view
that the muscles share with the serous and fibrous structures in the
lesions of that disease, and that myalgia is rheumatism of the muscles.

There is, however, over and above these defects in nutrition, an
especial predisposition or idiosyncrasy, the nature of which is
unknown, which renders certain individuals far more liable to suffer
myalgic pain than others. This predisposition is encountered in those
who have an inherited or acquired gouty habit and in those who are free
from gout with perhaps equal frequency. It is not associated with a
special liability to true rheumatism.

(_B_) Exciting Causes.--Myalgia is a local affection, and depends for
its causation upon a derangement of the balance between the nutrition
of the affected muscles and the work they have been called upon to do.
Hence the most common exciting cause is (_a_) overwork pure and simple,
especially overwork which brings into excessive and prolonged exercise
unaccustomed muscles. Next in frequency is (_b_) exposure to cold, and
especially to damp cold, when overheated or overfatigued. Finally
(_c_), inevitable and incessant contractions, such as are physiological
and are performed without consciousness or sensation in a healthy state
of the {531} muscles, will, in muscles that are defectively nourished
or have undergone fatty, granular, or fibroid degeneration, cause more
or less distinct myalgia.

As examples of myalgia due to the first of this group of causes (_a_) I
may cite the pain in the adductors of the thighs after a hard ride when
out of practice; the epigastric pain in children suffering from measles
or other acute affection attended with persistent cough; and the pain
of spasm, in particular that which follows tonic spasm, such as occurs
from reflex causes in the calves of the legs at night and in bathers.
Many of the pains of childhood, which are classed in common parlance
together under the name of growing pains, are myalgic in their nature.

Examples of the second form (_b_) may be instanced in the pains of wry
neck or lumbago, such as often occur in those who, being very tired,
but otherwise healthy, fall asleep in a draught of air, or in those
who, coming home at evening in cold weather, find a leaking pipe in the
cellar, and stooping over to stop it, or in some other emergency of
every-day life, bring into excessive use unaccustomed muscles in an
atmosphere that is at once cold and damp.

Examples of the third group (_c_) are common enough in the flying or
fixed muscular pains and soreness that occur in wasting chronic
diseases and in the convalescence from acute maladies when prolonged
muscular effort is too early undertaken. Certain forms of præcordial
pain that occur in degenerative lesions of the muscular substance of
the heart are without doubt myalgic in character, and will, when the
clinical data of such conditions come to be more fully understood, be
recognized as having more or less diagnostic value.

SYMPTOMATOLOGY.--The chief symptom, the one symptom that is common to
all the cases, is pain. It is sometimes, especially in acute cases,
constant; more frequently it is very slight or wholly absent when the
patient is at rest, with the affected muscles in full extension, but it
is invariably present or aggravated when the muscles are called into
action. It is experienced throughout the muscular mass, but is most
intense at or near the point of tendinous insertion. Its character is
usually stabbing or stitch-like, but prolonged; sometimes it is acutely
dragging or tearing; in others it is like the soreness felt on moving a
contused or inflamed part. It is frequently in acute cases, almost
always in chronic cases, accompanied by a sensation of stiffness in the
affected muscles. The pain is essentially the same in all cases,
variations in its character and severity being determined by the
opportunities afforded the muscle for physiological rest. It is in
accordance with this statement that the most obstinate, and the most
severe form of myalgia is that which occurs in the intercostal muscles
and their fibrous aponeuroses--pleurodynia. Here the affected muscles
are constantly concerned in the movements of respiration, and have no
time for physiological rest except in the intervals of those movements.
Scarcely less stubborn and severe are the myalgias of the great
muscular masses, of which the principal function is to maintain by
their nicely-balanced and ever-varying contractions the erect position
of the head and trunk. Less painful and of shorter duration are the
myalgias of the limbs--less painful because prolonged intervals of
absolute rest may be voluntarily secured; of shorter duration, because
it is by rest that the balance of the nutrition is most speedily
restored.

{532} There is usually some degree of tenderness over the whole extent
of the myalgic area, becoming more marked in the regions of tendinous
insertion, to which it is, however, in many cases restricted. It is
elicited upon moderately firm pressure, and is not associated with
cutaneous hyperæsthesia.

Spasm is absent in the acute cases, except when the muscles are brought
into use. Its occurrence has much to do with the intensity of the
suffering then caused: in chronic cases a condition of tonic spasm or
spastic rigidity, with more or less persistent painfulness, comes on,
and finally in very chronic cases such tissue-changes take place as
result in great impairment or absolute loss of contractile power, with
or without atrophy.

Objective signs are absent, except that it is evident that the patient
assumes by preference an attitude of repose, and that he keeps the
involved structures as much at rest as possible. Pyrexia does not
occur; the appetite and digestion are not impaired; acid sweats are not
present; the urine shows no constant or characteristic alteration;
there is no tendency to endo- or pericardial inflammation. If
constitutional disturbance be present, it is trifling and due to
prolonged local suffering and want of sleep. In by far the greater
number of instances the patient remains in his usual health except the
local malady.

Myalgia may affect the voluntary, and perhaps also the involuntary,
muscles of any part of the body. Those most frequently involved are
those subjected to continuous and excessive work, and at the same time
liable to exposure to cold and damp. Single muscles or groups may be
affected. The most common and important varieties are--

(1) Cephalodynia, manifested as a superficial headache, increased by
movement of the scalp and attended by tenderness on pressure.

(2) Torticollis; wry neck, stiff neck--a very common form, involving
the muscles of the neck, especially the sterno-cleido-mastoid. The
affection is usually limited to one side, toward which the occiput is
more or less firmly rotated and flexed. Great pain is experienced in
attempting to turn the head in the opposite direction. The position is
extremely constrained and awkward; the head cannot be moved in any
direction without moving the whole body, and every effort at motion is
accompanied by pain which calls forth involuntary grimaces.

(3) Omodynia, Scapulodynia, Dorsodynia--forms in which the muscles of
the shoulders and upper part of the back are affected. They are very
common, especially among laboring men.

(4) Pleurodynia, Myalgia of the Chest-walls.--The intercostals,
pectorals, and serratus magnus may be involved. The pain is frequently
referred to the region of the interdigitations of the serratus magnus
with the external oblique. It is very often seated in the
infra-axillary region, and is much more common on the left side. It is
usually very severe, and is increased by all movements that bring the
affected muscles into play. The focus of pain is sometimes a very
limited spot, which is exquisitely tender upon pressure. Sometimes the
pain alters its position from time to time. It is increased by deep
inspiratory efforts and such acts as sneezing and coughing. Extreme
flexion of the trunk from side to side also aggravates the pain.
Pleurodynia sometimes comes on in consequence of severe and protracted
cough, as in patients suffering with phthisis. It is then apt to affect
both sides.

{533} This form of myalgia simulates pleurisy, from which it is to be
distinguished only by careful physical examination.

(5) Myalgia of the abdominal walls usually affects the recti muscles,
and often assumes the guise of an acute, agonizing pain in the
epigastric or pubic regions--occasionally so severe as to be mistaken
for peritonitis. It is sometimes due to cough, especially in measles,
but is more commonly met with in overworked and underfed tailors and
cobblers as a result of the excessive action of the recti muscles in
maintaining the bent posture assumed by such craftsmen at their toil.

(6) Lumbago, myalgia lumbalis.--The great muscular mass occupying the
lumbar region is peculiarly prone to attacks of myalgia. Lumbago is
very common in the middle and later periods of life. The attack is
usually sudden and severe. Both sides are, as a rule, affected, but not
to the same extent. There is constant pain across the loins, dull and
aching, rarely absent altogether, always sharply aggravated by such
movements as bring the affected muscles into play, and then becoming
stabbing in character and almost unbearable in intensity. The spine is
held stiffly, and the body is often bent slightly forward. Efforts to
stand erect, to rise from the sitting posture, or to recover from the
stooping position, such as is assumed in lacing one's shoes and the
like, greatly aggravate the pain. In the more severe cases the patient
cannot stir in his bed. There is usually tenderness upon pressure, and
palpation often discovers a distinct sense of abnormal tension and
resistance in the muscles.

(7) The aching, dragging pain in the back of the neck common in
poorly-nourished, nervous women and in other cases of neurasthenia, the
so-called pain of nervous exhaustion, is myalgia. It is felt chiefly
during fatigue, is present in the erect posture, and is almost always
relieved when the patient lies down. It is referred sometimes to the
base of the skull, sometimes to the whole of the back of the neck, but
more commonly to the spinal region just above the level of the upper
borders of the scapula, and constitutes a harassing symptom of the
cases in which it occurs. In this connection it must be pointed out
that many of the pains of that obscure condition to which the term
spinal irritation has been vaguely applied are myalgic.

Myalgia manifests itself furthermore in the limbs, in the diaphragm,
and occasionally in the muscles of the eyeballs.

The COURSE of the attack is in the simpler forms acute and transient;
it frequently, however, becomes chronic, and not uncommonly presents
the characters of the chronic form from the beginning. Again, it
sometimes attacks in succession several muscles or groups of muscles,
and in by far the greater number of individuals it shows a tendency to
recur from time to time.

DURATION.--The duration of acute attacks is usually brief, lasting from
a few hours to several days; that of the chronic form is indefinite,
tending to last years, sometimes, under unfavorable circumstances, a
lifetime, with varying periods of exacerbation and remission, which
are, after the disease is fully established, much influenced by the
phases of the weather.

The TERMINATION of acute myalgia is commonly in full recovery, but the
tendency to subsequent attacks is to be borne in mind, and guarded
{534} against by the exercise of wholesome precautions in the matter of
hygiene. Neglected cases of chronic myalgia not rarely terminate in
permanent alterations of the muscular structure, with loss of
contractile power and rigidity, with or without atrophy.

COMPLICATIONS.--In the acute forms there are no complications, properly
so called. In the more severe cases of the chronic form there is danger
of nutritive changes in the tissues entering into the formation of
joints, and loss of function from want of use.

SEQUELS.--There are no sequels other than those just pointed out.

PATHOLOGY AND MORBID ANATOMY.--As indicated by the various names by
which myalgia has been known, the principal theories advanced to
account for the morbid manifestations are three in number: (1) that the
malady is a rheumatism of the muscles; (2) a form of neuralgia; (3) an
inflammation.

(1) Muscular Rheumatism.--That this affection should be popularly
associated with rheumatism is not surprising when the character of the
pain is regarded, its aggravation on movement, and the temporary or
permanent crippling which it occasions; especially when we call to mind
the exceedingly vague and indefinite ideas which prevail in regard to
rheumatism. But that it should be looked upon, far and wide, among
physicians as a form of rheumatism, and described as such in the
systematic works--that it should be regarded as due to the same causes
as rheumatism and treated from that point of view--is certainly as
remarkable as it is misleading.

Let us look at the facts. Nothing is easier: the two affections are
under our daily observation side by side; in this climate and among
working people few maladies are more common.

On the one hand we behold a constitutional disease with widespread
manifestations--a special joint inflammation, which tends neither to
the deposit of urate of soda nor to suppuration; a peculiar acid
secretion from the skin; highly acid urine; a notable tendency to
inflammatory heart complications; marked pyrexia. We observe also a
marked disposition to recurrence and to the hereditary transmission of
the diathesis.

The phenomena of rheumatism may be ill defined; that is to say, the
attack may be subacute, but the features are the same; or they may
linger and assume the chronic form, in which fever is replaced by a
peculiar alteration in the fluids of the body, showing itself in a dull
anæmic complexion and a greasy skin; but in all cases the seat of the
disease-signs is in the joints; it is articular.

On the other hand, myalgia is not a general malady nor the expression
of one. It is scarcely a disease at all. It is purely local. A muscle
or a group of muscles, overworked, cry out, and this cry is interpreted
by the sensation of pain. It is to be borne in mind that the overwork
may be absolute, or merely relative to the healthfulness of the muscle
at the time. In either case there is a derangement between the balance
of work and nutrition in the muscle. The secretions are not altered;
there is no sweating; the urine presents no abnormal conditions.
Endo- and pericarditis never occur as complications; fever is absent.

The attack is often light, and quickly passes away. If it become
chronic, further nutritive changes take place. The muscle becomes
rigid, and often atrophies. According to Froriep and Virchow, as {535}
quoted by Jaccoud[2] and Niemeyer,[3] the fasciculi are beset here and
there with thickened connective tissue. Vogel observed in several
chronic cases the neurilemma of the nerves supplying the part to be
thickened, hardened, and adherent.

[Footnote 2: _Traité de Pathologie interne_, Paris, 1871.]

[Footnote 3: _Lehrbuch der Speciellen Pathologie und Therapie_, Berlin,
1871.]

In all cases the affection limits itself to the muscles. The joints
remain free. When they undergo changes it is after a long time and as a
result of want of use or of reflex disturbances of nutrition through
the nervous system. Nothing is known of hereditary predisposition to
myalgia. In the manifest tendency to recur in the same individual it
and rheumatism are alike. In all essential points their clinical
resemblance is of the most superficial kind. It is clear, then, that
the processes which give rise to the phenomena of rheumatism do not
directly affect the muscular system.

The credit of having first formulated this opinion, previously only
vaguely recognized, is due to Roche and Cruveilhier,[4] but Valleix,
Garrod, Flint, and other writers, who describe myalgia under the head
of muscular rheumatism, coincide in this view. Even the statement that
the two diseases are constantly associated is not borne out by the
results of extended clinical inquiries. My own observation has not
confirmed it. Of 7 cases[5] taken at random to illustrate a point of
treatment, 1 had followed an attack of rheumatic fever; 1 occurred in
an individual who had many years before suffered from rheumatism; and 5
gave no history whatever of that disease: 1 followed tonsillitis.
DaCosta[6] details 2 cases of myalgia--1 in the loins (lumbago),
associated with bronchitis or following it, the other occurring during
an attack of rheumatic fever and having its seat in the muscles of the
neck. In the latter case the constitutional disease yielded to
treatment which had no effect upon the local malady. Even were the
association much more frequent than it is found to be, the fact would
by no means establish a common causation, seeing that myalgia follows
other diseases which impair the nutrition of the body. It is worthy of
note that the groups of muscles most frequently involved in cases which
happen during or after acute diseases are those which must work
perforce--those which maintain the equilibrium of the body or carry on
respiration, etc. Hence we see wry neck, lumbago, pleurodynia
associated with other diseases; affections of the muscles of the
extremities after overwork pure and simple.

[Footnote 4: _Dict. de Méd. et de Chir. prat._, article "Arthrite."]

[Footnote 5: _Philada. Med. Times_, Nov. 7, 1874.]

[Footnote 6: _Penna. Hospital Reports_, vol. i.]

(2) Neuralgia.--Many observers have regarded myalgia as a neuralgia,
having its seat in the muscles. Valleix[7] wrote as follows: "Muscular
rheumatism and neuralgia have, in the correspondence of their symptoms,
their course, their exacerbations, in the absence of appreciable
anatomical lesions, the greatest resemblance to each other. These
affections often pass the one into the other.... The pain, which is the
capital symptom of neuralgia, expresses itself, according to our
observation, in three ways: If it remain concentrated in the nerves,
characteristic isolated painful points are found; here is neuralgia
properly so called. If the pain is diffused among the muscles, muscular
action is principally painful; we have muscular rheumatism. Finally, if
it be spread out upon the skin, an excessive sensibility of the
cutaneous surface results, and there exists {536} a dermalgia. These
three forms of an affection which is the same may all be present at the
same time, or two and two--neuralgia and dermalgia, neuralgia and
rheumatism, rheumatism and dermalgia." No wonder he found nothing more
difficult than to trace with exactitude the picture of this malady.

[Footnote 7: _Loc. cit._]

Flint[8] also regards myalgia as closely allied to neuralgia, and
states that, "being one of the neuroses, it has no anatomical
characters." It is not difficult to trace the results of this teaching
in the widespread confusion prevalent in regard to some very common
painful affections, as, for example, that painful form of stitch known
as pleurodynia, and the still more distressing gastrodynia. Even those
observers who refuse to class these affections as rheumatic are too
often at a loss as to whether they are neuralgic or purely muscular.
Anstie[9] has concisely contrasted the most important characters of
neuralgia and myalgia in a way that strongly urges the clinical
differences between them, as follows:

              NEURALGIA.          |            MYALGIA.
  Follows the distribution of a   | Attacks a limited patch or patches
  recognizable nerve or nerves.   | that can be identified with the
                                  | tendon or aponeurosis of a muscle,
                                  | which, on inquiry, will be found to
                                  | have been hardly worked.
                                  |
  Goes along with an inherited or | As often as not occurs in persons
  acquired nervous temperament,   | with no special tendency.
  which is obvious.               |
                                  |
  Is much less aggravated,        | Is inevitably and very severely
  usually, by movement than       | aggravated by every movement of the
  myalgia is.                     | part.
                                  |
  Is at first accompanied by no   | Distinguished from the first by
  local tenderness.               | localized tenderness on pressure
                                  | as well as on movement.
                                  |
  Points douloureux, when         | Tender points correspond to
  established at a later stage,   | tendinous origins and insertions of
  correspond to the emergence of  | muscles.
  nerves.                         |
                                  |
  Pain not materially relieved by | Pain usually completely, and always
  any change of posture.          | considerably, relieved by full
                                  | extension of the painful muscle or
                                  | muscles.

[Footnote 8: _Practice of Medicine_.]

[Footnote 9: _Neuralgia and Diseases that Resemble it_.]

(3) Inflammation.--That the muscular affection under consideration
should have been referred to morbid processes of an inflammatory kind
is very natural. The use of the term myositis embodies this view, which
is held, among others, by Garrod. This author defines muscular
rheumatism as "an affection of the voluntary muscles of an inflammatory
nature (?), but unaccompanied with swelling, heat, redness, or febrile
disturbance." He assigns the combined influence of cold and damp as a
cause, especially when associated with over-use of the muscles.

Though some of the gross characters of inflammation are wanting, and
the course of acute cases of myalgia is toward a speedy resolution,
there are several features of the affection which strongly suggest its
inflammatory origin. At all events, the view that the essential
pathological conditions consist in a hyperæmia with slight serous
exudation, or a partial paralysis of vaso-motor nerves with escape of
serum into the intimate tissues of the muscles, has, from a clinical
standpoint, much to support it. In the absence of knowledge derived
from the actual investigation of the morbid tissue-changes in all the
stages of the affection some {537} value is to be accorded to the
following facts as confirmatory of this opinion:

It is a local affection; the onset is usually sudden; there is often,
from the beginning, a slight but obvious fulness of the muscle;
tenderness is present as well as pain; in chronic cases inflammatory
increase of connective tissue occurs, with changes in the nerve-sheaths
and fatty degeneration of muscle-substance. Moreover, the permanent
contraction (contracture) which sometimes finally sets in is the same
as that which follows true inflammation of muscles after injuries
(traumatic myositis[10]).

[Footnote 10: Erb, _Ziemssen's Cyclopædia_, vol. ix.]

It is uncertain whether the nerves supplying the muscles are thrown
into morbid action by changes in the muscular fibres and in their
sarcolemma, or by simultaneous changes in their own neurilemma. However
it arise, irritation of sensory nerve-twigs is present, giving rise to
pain, along with irritation of motor filaments, which occasions spasm.

It is probable that the ultimate cause of the irritation within the
muscular mass, whatever it is, is common to all cases, and that when
myalgia occurs in a healthy man after extraordinary muscular effort or
exposure to cold damp when fatigued, or in a delicate child who has
played too long, or in a poorly-fed weaver working long hours over his
loom, or in the consumptive whose cough gives him no rest, or in
connection with any chronic disease or acute disease, whether
tonsillitis or bronchitis or fever or rheumatism, it is the same
thing--the expression of muscles or groups of muscles overworked. It is
not a disease; it is not a symptom of disease. It is an accident of
many diseases--of any disease that lowers nutrition. And it is not less
an accident of health when such muscular effort is demanded as is
beyond the capacity of health.

The essential pathology of myalgia is obscure. It is not an
inflammation, as that term is generally understood, but there is ground
for the opinion that the lesions are of the nature of a subinflammatory
process within the muscle. The not uncommon instances in which an
injury or contusion--in short, traumatism--has been followed shortly
after the recovery by severe myalgia are of further value as
illustrating this theory.

The obstacles in the way of precise histological investigation in cases
of acute myalgia are so great that it seems probable that further
knowledge is to be reached for the most part by way of clinical work.

DIAGNOSIS.--The fundamental question for consideration in this place is
whether we are dealing in any given case with local manifestations of a
constitutional disease or with purely local phenomena. That the latter
is the correct view seems to the writer to admit of no further
discussion in this article. This position being assumed, and due regard
having already been paid to the differential diagnosis between myalgia
and rheumatism, neuralgia and inflammatory myositis, it seems useless
to enter upon the consideration of the diagnosis between this and other
painful affections to which it bears but slight and superficial
resemblances. Spinal irritation, hypochondriasis, locomotor ataxia,
alcoholism, syphilis, gout, and lithiasis are on the one hand attended
by pains which are clearly not myalgic in character, and on the other
hand peculiarly predispose those subject to them to this affection of
poorly-nourished and easily-overworked muscles. Each of these diseases,
however, presents a complexus of {538} symptoms in which that which is
essential and characteristic is readily to be distinguished from that
which--as myalgia--is accidental.

A few words concerning the diagnosis of some of the varieties may not
be amiss.

In pleurodynia the ordinary physical signs of pleural, pulmonary, and
cardiac disease are absent, the painful points characteristic of
intercostal neuralgia are not found, and there is little or no
constitutional disturbance.

The diagnosis of myalgia lumbalis is, as a rule, unattended by
difficulty. The muscular pain in the loins is characteristic. It is
greatly increased by efforts to rise or to turn in bed, and is
associated with diffused slight tenderness upon pressure, but never
with the acute localized soreness of neuralgia or abscess. The
practitioner must, however, guard against the danger of mistaking the
back pains of more serious affections for lumbago by the careful
examination, in all cases, of the back and abdomen, and by the
investigation of the condition of the urine. The possibility that pain
in this region may be caused by spinal meningitis, lumbar abscess from
spinal caries, sciatica, inflammatory affections of the hip-joint,
renal calculus, perinephritis, abdominal aneurism, diseases of the
pelvic viscera, and the onset of certain of the acute infectious
diseases must not be overlooked.

PROGNOSIS.--Under satisfactory conditions as regards hygiene and
treatment the prognosis is always favorable. It becomes in chronic
cases unfavorable as regards complete recovery when by reason of
poverty, unhealthy occupations, unwholesome surroundings, or
established wasting diseases the nutrition of the muscles and their
physiological rest are permanently interfered with, and the balance
between their power and work permanently deranged.

TREATMENT.--The indications are threefold: (_a_) relief of pain; (_b_)
physiological rest for the affected muscles; (_c_) restoration of the
balance between the nutrition of the muscle and the work it has to do.

(_a_) Relief of pain is often secured by rest in a posture that permits
the complete relaxation of the muscles involved. In acute cases due to
overwork pure and simple, and where complete rest is attainable, little
other treatment is required. In the course of a few hours or days the
function of the muscles is fully restored and their contractions are
performed without pain. Where, however, complete muscular relaxation is
impracticable or fails to afford relief, anodynes are necessary.
Morphine hypodermically is very useful, but this altogether
independently of any local action. Continuous dry or moist heat by
means of flannels, flaxseed poultices, spongio-piline, etc. may be
applied. Various anodyne lotions are useful. Liniments containing
aconite, belladonna, chloroform, or chloral also afford relief. The
compound belladonna liniment of the British Pharmacopoeia is especially
to be recommended. So also are plasters of belladonna, conium, and
mustard. Galvanism occasionally gives prompt relief. The same statement
may be made of the use of static electricity. The pain sometimes
disappears under gentle and long-continued massage.

(_b_) Rest is usually enforced by the intensity of the pain attending
movement. In severe cases the bed is a necessity. In affections of the
respiratory muscles, as pleurodynia, firm support of the side, by means
of {539} overlapping strips of plaster drawn from the spine downward
and forward in the direction of the ribs to the median line in front,
is sometimes necessary and always comfortable.

(_c_) The balance of nutrition is restored by rest. Local means to
further this end are such as relieve pain--heat, anodyne and
stimulating frictions, massage, and galvanism. The parts must be
protected from sudden changes in temperature by extra thicknesses of
flannel or sheets of wool or cotton batting--if necessary covered with
a piece of oiled silk or fine gum-cloth. In old cases prolonged massage
with passive movements, shampooing, and the slowly interrupted galvanic
current, alternating with rapid faradic currents, are followed by good
results.

As a constitutional measure a Dover's powder at night, followed by mild
purgation in the morning, is often indicated. Purgation is especially
called for in plethoric or gouty persons, in whom also Turkish or vapor
baths are of great service, while poorly-nourished, anæmic subjects
demand quinine, iron, lime, and cod-liver oil. If the attack linger,
full doses of ammonium chloride, and in old cases potassium iodide in
moderate doses well diluted and long continued, are advocated; and in
stubborn cases Anstie recommends deep acupuncture of the muscle near
its tendinous attachment. In cases marked by a tendency to spastic
rigidity the repeated hypodermic injection of atropine may often be
relied upon as the speediest means of cure.

Where the general nutrition is poor the local trouble is apt to be
obstinate, and often yields only to measures that restore the general
health.




{540}

PROGRESSIVE MUSCULAR ATROPHY.[1]

BY JAMES TYSON, A.M., M.D.

[Footnote 1: From the view taken by the author as to the nature of the
disease under consideration, it is evident that its proper position
would be under affections of the nervous system. But as this view has
not been established to the satisfaction of all who have studied the
disease, it seems appropriate to place it in the intermediate position
selected for it by the Editor, between muscular and nervous diseases.]


SYNONYMS.--Chronic anterior poliomyelitis; Spinal form of progressive
muscular atrophy; Adult form of progressive muscular atrophy; Wasting
palsy (Roberts); Cruveilhier's atrophy; Amyotrophia spinalis
progressiva (Erb).

DEFINITION.--Progressive muscular atrophy is a gradually progressive
wasting of a group or groups of voluntary muscles, independent of
primary functional inactivity and of local lesion to nerve or muscle.

HISTORY.--We are indebted to William Roberts[2] for the best historical
account of this disease up to the date of publication of his monograph.
Van Swieten seems to have described the first case, in 1754, but
without comment. Cooke in his work _On Palsy_,[3] published 1822,
relates a case which had been under the care of Cline--that of an
officer, first attacked in 1795. Caleb H. Parry[4] reported another
case in 1825, and Sir Charles Bell[5] three cases in 1830. Abercrombie
described a marked case in 1828,[6] Dorwall[7] three striking cases in
1831, and Herbert Mayo[8] two evident cases in 1836. In 1849, Duchenne
presented to the Institute of France his memoir on _Atrophie musculaire
avec Transformation graisseuse_. In the next year Aran published his
essay entitled _Recherches sur une Maladie non encore décide du Système
musculaire_ (_Atrophie musculaire progressive_),[9] in which he claimed
priority in description. He reported in all eleven cases, and regarded
it as a primary muscular affection. Aran's researches were very
important, and have caused his name to be intimately associated with
the disease along with that of Duchenne.

[Footnote 2: _An Essay on Wasting Palsy_, London, 1858.]

[Footnote 3: London, 1822, p 31.]

[Footnote 4: _Collected Works_, London, 1825, p. 523.]

[Footnote 5: _The Nervous System of the Human Body_, London, 1830.]

[Footnote 6: _On the Brain and Spinal Cord_, 1828, p. 419.]

[Footnote 7: _London Medical Gazette_, vol. vii., 1830-31, p. 201.]

[Footnote 8: _Outlines of Human Pathology_, London, 1836.]

[Footnote 9: _Archives générales de Méd._, t. xxiv., Sept. and Oct.,
1850.]

Cruveilhier's studies were commenced as early as 1832, but his results
were not published until March, 1853,[10] when he read his memoir
before the Academy of Medicine of Paris. He seems to have made the
first autopsy, and was much surprised at the absence of any apparent
lesion of the {541} spinal cord. So enthusiastic and so exhaustive was
his study of the disease that his name, too, has become almost
inseparably associated with it, and the term Cruveilhier's atrophy is
one of those by which it is known. He concluded from his earlier
autopsies that the lesions were solely in the muscular system, which is
progressively destroyed, while the brain and spinal cord may remain
perfectly normal. In a later case (his third), terminating January,
1853, he found atrophy of the anterior roots of the spinal nerves, and
then concluded that the disease resided "not in the muscles themselves,
but in the anterior roots of the spinal nerves." But after the
termination of his fourth case, in which an autopsy was also secured,
he placed the primary lesion in the gray matter of the cord, whence he
considered the anterior roots take their origin.

[Footnote 10: _Ibid._, May, 1853, p. 561.]

Thouvenet,[11] an interne of Cruveilhier's, published in 1851 a thesis
based on some cases collected in the Charité, and was the first to
claim that the disease resides primarily in the peripheral nerves, and
that it must be classed among rheumatic affections.

[Footnote 11: _Gaz. des Hôp._, Nos. 143 and 145, 1851.]

In December, 1851, E. Meryon[12] read a paper before the
Medico-Chirurgical Society of London entitled "Granular and Fatty
Degeneration of the Voluntary Muscles." His observations appear to have
been made quite independently of any preceding researches. He argues
that the primary morbid change is a default of nutrition in the
muscular fibres.

[Footnote 12: _Med.-Chir. Trans._, vol. xxxv. p. 73.]

Subsequently, cases were published in 1853 by Bouvier, Landry, Burg,
and Niepce in France; in 1854 by Chambers in England, Guérin and Robin
in France, Cohn, Virchow, and Betz in Germany, and by Schneevogt in
Holland; in 1855 laborious essays were published by Oppenheimer,
Wachsmuth, and Eisenmann, and cases by Hasse, Valentiner, Virchow,
Meyer, and Diemer in Germany, and Gros in France. Duchenne's work on
_Local Application of Electricity_, also published in 1855, contains
much information on the subject.

Since 1855 the reports of cases and papers on the subject have been so
numerous as to make it unprofitable to enumerate them. Among the most
notable are those of Eisenmann, published in _Canstatt's Jahresbericht_
for 1856; Roberts's classic work on _Wasting Palsy_, in 1858; the
papers of Lockhart Clarke in 1866 and 1867,[13] and of Swarzenski in
1867;[14] Kussmaul's clinical lecture[15] and Friedreich's treatise[16]
in 1873; and Eulenburg's article on "Progressive Muscular Atrophy" in
_Ziemssen's Cyclopædia of Practical Medicine_, published in German in
1875 and in English in 1877. An important case, in consequence of the
careful post-mortem study of the nervous tissues, is one recently
reported by Wood and Dercam.[17]

[Footnote 13: _Med.-Chir. Transactions_, xlix., 1866, p. 171, and l.,
1867, p. 489.]

[Footnote 14: _Die Progressive Muskelatrophie_, Berlin.]

[Footnote 15: "Ueber die fortschreidende Bulbärparalyse und ihr
Verhältniss zur progressiven Muskelatrophie." _Sammlung klinische
Vorträge_, liv.]

[Footnote 16: _Ueber progressive Muskelatrophie, über wahre und falsche
Muskelhypertrophie_, Berlin, 1873.]

[Footnote 17: _Therapeutic Gazette_, March 16, 1885.]

ETIOLOGY.--The cause of this affection in a large number of cases is
quite unknown. That hereditation plays an important part seems well
determined by numerous observations, among which may be mentioned those
of Roberts, Friedreich, Hemptenmacher, Trousseau, Meryon, {542}
Eulenburg, Sr. and Jr., Naunyn,[18] Hammond, and Osler.[19] In the Farr
family, reported by Osler, 13 individuals in two generations have been
affected, 6 females and 7 males--a larger proportion of the former than
is common in this disease. Of these 9 had died at date of publication
of paper. With the exception of two, all occurred or proved fatal after
the age of forty. Of the 10 instances in the second generation, 5 are
the offspring of males and 5 the offspring of females. The disease has
not yet appeared in the third generation, which promises between forty
and fifty individuals, several of whom are over thirty years of age.

[Footnote 18: _Berliner med. Wochenschrift_, Nos. 42 and 43, 1873.]

[Footnote 19: _Archives of Medicine_, vol. iv., No. 3, Dec., 1880.]

The over-use of the muscles involved seems to be a well-determined
cause in certain cases of true muscular atrophy. The following
interesting illustrations are given by Eulenburg:[20] Betz observed
atrophy of the side three times in the cases of smiths and saddlers,
who had to do heavy work with the right hand; Gull, in a tailor after
excessive exertion; Hammond reports a case apparently due to excessive
use of one thumb and finger in playing faro; Friedreich, one of a
dragoon who may have exhausted his left hand in holding the bridle
while riding; another in a morocco-leather worker, who used to press
hard with his left hand; and a musician who played several hours a day
on the bass viol. Schneevogt names two cases of primary atrophy of the
shoulder-muscles, especially of the deltoid of the right side--one of a
sailor who had to pump for days together on a leaking ship, and the
other of the left side in a woman who always carried her child on the
left arm while suckling it. Continued threshing and the handling of a
musket have both been followed by it in the muscles called into play by
these exercises. Roberts was able to trace the effects of over-muscular
exertion in producing the disease in 35 out of 69 cases. As a
determining cause, at least, therefore, we must admit the over-use of
muscles.

[Footnote 20: _Op. cit._]

There is reason to believe, too, that this form of atrophy is one of
the consequences of senility--that the tendency to connective-tissue
overgrowth which characterizes old age operates to produce, in a way to
be presently explained, an atrophy of groups of muscles. In a woman
aged seventy, now under my care, the fingers of both hands are
clawed--became so inappreciably almost, and the condition is still
increasing.

In addition to the above-named causes, long-continued exposure to cold,
and especially to the action of very cold water, has been named.
Traumatic influences, such as injuries to nerve and muscle, have been
called upon to account for localized and progressive atrophy, but these
are excluded by our definition from the category of true progressive
muscular atrophy.

Cases have also occurred in the course of convalescence. Typhoid fever,
rheumatism, measles, scarlet fever, cold during salivation,
vaccination, childbed, excessive venery, syphilis,--have all been held
responsible for a certain number of cases.

AGE AND SEX.--In examining the literature of acute muscular atrophy it
is found that cases are reported at all ages. Thus, Wachsmuth, quoted
by Eulenburg, found among 49 cases 13 under the age of fifteen, 8 from
fifteen to twenty, 22 from twenty to fifty, and only 6 over fifty
years. On the other hand, Roberts--who, following Aran, divides the
disease into the general form and partial form--says the latter very
rarely falls on {543} individuals under adult age or over fifty, while
the average age of the instances of the partial form studied by him was
thirty-two years and four months. In 10 instances of the general form
the patients were under twelve, and 2 more are reported as children; 1
was said to be sixty-nine and another fifty-four, the average being
twenty-eight years and three months. Of Eulenburg's own cases, 7
acquired the disease before the age of ten, 6 before the twentieth
year, 2 before the thirtieth, 8 before the fortieth, 5 before the
fiftieth, and none later. The latter observer also finds that whenever
the disease is hereditary it occurs earlier, usually before the close
of the twentieth year. This was certainly not the case in the Farr
family, reported by Osler.

I am inclined to believe, especially in the light of Charcot's[21] and
of Erb's[22] recent studies, that the true spinal form of progressive
muscular atrophy is a disease of adult life, and that the majority of
cases reported as occurring in early life are instances either of what
Erb calls the juvenile form of progressive muscular atrophy or of
pseudo-hypertrophic paralysis.

[Footnote 21: "Revision nosographique des Atrophies musculaires
progressive," _Le Progrès méd._, No. 10, 1885, i. 314-335.]

[Footnote 22: "Ueber die Juvenile Form der Progressive Muskelatrophie
und ihre Beziehungen zur sogenannten Pseudohypertrophie," _Deutsches
Archiv für klin. Med._, xxxiv. 1884, S. 467.]

As to sex, males predominate. Thus, according to Friedreich's
statistics, out of 176 cases but 33 were females, or about 19 per cent.
Of Roberts's collection of 99, 84 were males and 15 females. Of 28
cases noted by Eulenburg, 17 were in men and 11 women. This is
doubtless owing to the fact that men are subjected to the causes of the
disease more than women. For Roberts early noted that women who engage
in needlework, washing, and household service are apparently not less
liable than men similarly employed, and he found that of those whose
labor did not press excessively on any particular sets of muscles
females formed even a majority of cases.

Some singular freaks of selection have presented themselves in the
matter of sex, particularly in the cases which have been ascribed to
hereditation. Thus it will sometimes attack only the male members of a
family. A remarkable instance of this was observed by Meryon, in which
four sons were attacked and six daughters remained unaffected; and,
again, two boys were attacked and two sisters escaped. This may occur
also independent of hereditation. Occasionally the reverse takes place,
the sisters only being attacked, while the brothers escape.

PATHOLOGICAL ANATOMY AND HISTOLOGY.--Two principal seats of change have
been found to exist in connection with progressive muscular atrophy.
The first and easiest recognized is, of course, the alteration in
muscles; the second, that in the nervous system.

The muscular change is simple, and affords a typical instance of what
is known as numerical atrophy. The muscular fasciculi one after another
undergo fatty metamorphosis, succeeded by absorption of the resulting
fat and substitution of connective tissue. The rate of atrophy varies,
but sooner or later the muscle is more or less substituted by fibrous
bands and cords, over which may be traced reddish lines which represent
muscular tissue in a normal state.

The rationale of these changes has not been always the same. The {544}
older observers regarded them as the result of a primary fatty
metamorphosis of muscular fasciculi, followed by absorption of the
resulting fat. Later it was asserted that the atrophy is secondary to a
myositis or inflammation of muscle, beginning as a hyperplasia of the
interstitial connective tissue in its finest ramifications between the
single primitive fibrils. Along with this are seen the results of
irritation in the primitive bundles themselves, shown by swelling and
multiplication of the muscular corpuscles, proliferation of their
nuclei, and sometimes cloudy swelling. Even hypertrophied muscular
fasciculi and dichotomous and trichotomous subdivision have been noted
by Friedreich.

It sometimes happens that the hyperplastic process in the intermuscular
connective tissue is succeeded by a fatty infiltration of the cells of
the connective tissue, and there results a lipomatosis which is
invariably outside of the muscular fasciculi and between them. This
gives rise to an appearance of hypertrophy which is only apparent, for
the muscular fasciculi are themselves wasted, and proportionally
paralytic. This is seen to occur particularly in the muscles of the
calves of the legs, in which is produced an appearance identical with
that in the disease known as pseudo-hypertrophic muscular paralysis,
with which, indeed, the condition under consideration is considered by
some identical. But although we must admit in certain cases a
complication of a certain degree of lipomatosis with progressive
muscular atrophy, the two diseases are essentially different; and it is
quite likely that in some instances pseudo-hypertrophic muscular
paralysis has been mistaken for progressive muscular atrophy.

The changes in the nervous system are not nearly so simple. They have
been noted in the peripheral nerves, both in their trunks and in their
intermuscular branches; in the anterior roots of the spinal nerves; and
in different parts of the spinal cord, including the central gray
matter, the antero-lateral and posterior columns; also in the
sympathetic system. These nerve-changes are not simultaneous, nor have
they been discovered in every case. It is a noteworthy fact, however,
that as methods of examination have improved and the manipulative skill
of observers has increased the number of negative cases has diminished.

First, as to alterations in peripheral nerves in their ultimate
distribution: The character of these is of a kind usually described as
irritative; that is, there is a hyperplastic process in the
connective-tissue sheaths (neurilemmæ) and their internal
prolongations, consisting in nuclear proliferation and thickening of
the tubular membrane or sheath of Schwann. Varicose distortion of the
medullary sheaths and their subsequent disappearance, together with
destruction of the axis-cylinders, also occurs.

The changes in the peripheral nerve-trunks, as studied in the median,
ulnar, radial, and musculo-spinal, are essentially the same, resulting
in thinning of the diameters of the nerves. These changes, however, are
by no means constant.

The anterior roots of the spinal nerves exhibit alterations in a large
number of instances. Cruveilhier called attention to them in the
celebrated case of the rope-dancer Lecomte. At the autopsy, the brain,
the cord, and posterior roots were found normal, but the anterior
roots, from the point of exit to where they unite with the posterior,
were greatly atrophied. In another case the anterior roots were to the
posterior in thickness, in the cervical region, in the ratio of 1:10,
while the normal ratio is 1:3; {545} in the dorsal region as 1:5, while
the normal is as 1:1½ or 2. The posterior roots, brain, and cord were
again unchanged. Up to 1876, Eulenburg had collected 26 cases in which
this alteration existed, and 19 in which it was absent. In the case of
Wood and Dercum, referred to, this atrophy of the anterior nerve-roots
existed, making 27 positive cases and 19 negative.

We come, finally, to the spinal cord as the seat of changes, and we are
met by Eulenburg's statistics, according to which, up to the date of
his article, there were 34 cases of positive disease and 15 negative.
To the former we have again to add the case of Wood and Dercum, making
35 against 15. These alterations are by no means constant as to seat
and character. Thus, Valentiner, who seems to have been the first after
Cruveilhier, in 1853, to record any, found in 1855, in the centre of
the cord, in the neighborhood of the three lowest cervical and upper
dorsal nerves, that the elements in the region of transition from gray
to white substance were obliterated, and the softened place contained
numerous compound granule-cells. Schneevogt also found a softening of
the cord from the fifth cervical to the second dorsal nerve, Frommann
described a red softening from the medulla oblongata downward,
involving chiefly the anterior and lateral columns, and especially the
commissures and the innermost parts of the anterior columns lying next
the commissure.

Luys found the gray matter in the neighborhood of the cervical
enlargement full of hyperæmic vessels, which were surrounded with
granular masses (compound granule-cells?). The same granular masses,
together with numerous corpora amylacea, were scattered throughout the
gray substance. The ganglion-cells of the anterior cornua had almost
disappeared in the part affected, and appeared to be replaced by the
granular masses. Here and there a few ganglion-cells could be
recognized in a state of retrograde metamorphosis, pigmented and bereft
of their polar prolongations. In this case the degeneration affected
principally the left anterior cornu, and it was the left side of the
body which was affected by the atrophy. The anterior roots of the
spinal nerves on the left side were also atrophied. Lockhart Clarke
found essentially the same changes in no less than six cases, and
Duménil, Schueppel, Hayem, Charcot (six or seven autopsies), Joffroy,
and lately Wood and Dercum,[23] have added others. The last two
observers found changes in the lower portion of the cervical
enlargement of the cord, and state in the report of their case that "in
the anterior cornua of the gray matter there is a marked diminution in
the number of nerve-cells. Of the three groups of these cells, the
anterior has almost entirely disappeared, the lateral group is
represented by but a few individual cells, while the internal group
seems to have undergone a less marked change. All of these cells, with
the exception of a few in the internal group, appear shrunken, and are
evidently much diminished in size. They have lost in great part their
polygonal shape, many of them being fusiform, and present but few
processes. Only in the internal group are these cells in any way
approaching the normal type, and these are few and seen in only a few
of the sections. They present the characteristic size and numerous
processes of the typical motor-cell, while they disclose a well-defined
nucleus and nucleolus. In the atrophied cells the nuclei can only be
distinguished with difficulty.

{546} "The neuroglia of the anterior cornua is increased in amount; the
vessels appear shrunken, with thickened walls and large perivascular
lymph-spaces.

"In the lumbar cord the cells in the anterior cornua appear normal: in
this respect the lumbar cord is in marked contrast with the cervical."

[Footnote 23: _Loc. cit._]

Another class of cases recorded by Gull,[24] Schueppel and Grimm,
Hallopeau and Westphal, consist in dilatation of the central spinal
canal with more or less complete destruction of the gray substance, and
in Grimm's case hyperplasia of the connective tissue in the white
substance along with increase of the axis-cylinders. The nerve-roots
were in a state of fatty degeneration, especially the finer fibres of
the anterior roots.

[Footnote 24: _Guy's Hospital Reports_, 1862.]

Still another set of observations discovers a degenerative atrophy of
the white columns only of the cord, sometimes the antero-lateral
columns and sometimes the posterior. Virchow, Friedreich, and
Swarzenski each found typical gray degeneration of the posterior
columns, in one instance recognizable by the naked eye. Atrophy of the
antero-lateral columns was noted by Frommann and Baudrimont; atrophy of
the antero-lateral columns, conjoined with inflammatory changes in the
gray substance and atrophy of ganglion-cells, by Duménil; changes in
the antero-lateral gray substance and posterior columns by Clarke.
Changes have even been found in the posterior cornua and posterior
nerve-roots in a few cases, although not confined to them.

Finally, the lesions of this singular disease have been sought also in
the sympathetic, and not without some success. Eulenburg's analysis
discovered 5 positive observations and 14 negative ones. To the
positive must be added the case of Wood and Dercum, who reported a
marked increase in the amount of connective tissue and a granular state
of the ganglion-cells without diminution in number. Among the changes
in the sympathetic were thinning of its trunk and of the two upper
ganglia observed by Swarzenski, and advanced fibrous fatty change of
the cervical and thoracic portion, with abundant hyperplasia of
connective tissue, disappearance of nerve-fibres and regressive
metamorphosis of ganglion-cells by Duménil.

PATHOGENY.--We come now to consider the relation of these changes to
the muscular atrophy which constitutes the conspicuous symptom of the
disease. There are three possible views of the pathology of this
affection. According to one, it is a muscular or myopathic disease in
the strict sense of the term. Such muscular disease may be primarily
inflammatory, a myositis--as Friedreich sought to prove in his great
work--followed by fatty metamorphosis of the sarcous substance and
subsequent absorption of the fat; or it may be a simple fatty
metamorphosis. According to a second view, it is primarily an affection
of peripheral nerves or of the anterior roots of the spinal nerves,
with secondary muscular atrophy. According to a third, it is a disease
of the spinal cord, and more particularly of the anterior cornua of the
gray matter--a poliomyelitis anterior.

A careful study of the morbid conditions as described in the various
cases reported leads me to adopt the last view. In the first place, the
number of instances of positive disease of the spinal cord exceed those
of any other seats of alteration, and although the changes do not
always involve the anterior cornua, yet it will be noted, from an
examination {547} of the foregoing paragraphs, that a decided majority
involve either the anterior cornua alone or these in connection with
the antero-lateral columns, the number of cases of disease of the
antero-lateral columns alone or of the posterior columns and posterior
nerve-roots being very limited. Again, the number of instances in which
lesions of the anterior cornua are found increases as our means of
accurate investigation improve.

If we add to these considerations the fact that the symptoms are best
explained by such a view, little more seems required to establish it.
Recalling the well-known observation of Waller, confirmed by Bernard
and others, that after section of the anterior root of a spinal nerve
the distal end wastes, while the central end remains intact, because it
is still connected with its own trophic centre, we have in this the
explanation why atrophy of the anterior roots is also so common a
symptom in progressive muscular atrophy. The fibres of the anterior
roots arise from the cells of the anterior cornua, and disease of the
latter must unfavorably influence the nutrition of the former; hence
their atrophy. This atrophy of motor nerve-filaments is continued into
the mixed nerves distributed to muscles, but is less easily
demonstrable by reason of the gradually diminishing size of the
nerve-trunks and by the fact that they are united in the mixed nerve
with the sensory fibres from the posterior roots, which do not suffer
atrophy. In consequence of the degeneration of these nerves follows
degeneration of the muscles to which they are distributed, so that the
alterations in the latter are altogether secondary.

From this point of view the disease in question is to be regarded as a
chronic form of poliomyelitis anterior, while the essential infantile
paralysis of Rilliet and Barthez would correspond to the acute form of
the disease.

The association of changes in the anterior roots with others in the
spinal cord may be explained either on the ground of extension by
continuity to adjacent parts, or on that of coincidence. In
illustration of the latter I may refer to a case recently reported from
Mendel's clinic[25] in Berlin, in which the symptoms of progressive
muscular atrophy were associated with those of tabes dorsalis or
progressive locomotor ataxia. Here it is not unlikely that the
coincidence is merely accidental; and this was Mendel's opinion in this
case. In other instances the involvement of other portions of the
spinal cord may be a result of an extension of the disease from its
true seat, while many cases described as progressive muscular atrophy
are not such at all, but are in part the result of other affections of
the spinal cord. It is evident, also, that this order may be reversed,
as in a case reported by Eulenburg[26] to the Berlin Medical Society.

[Footnote 25: _Philada. Medical News_, Sept. 12, 1885, p. 188.]

[Footnote 26: _Berliner klin. Wochenschr._, No. 15, April 13, 1885.]

SYMPTOMS.--The first distinctive symptom of the disease under
consideration is the muscular atrophy or wasting. However general it
may subsequently become, it is at first localized. The upper extremity
is by far the most frequently involved--7 out of 9 times in Aran's
cases. Sandahl out of 62 cases found the right upper extremity attacked
37 times, the left in 14 instances, and both in 11. In Friedreich's
statistics it occurred first in the upper 111 times out of 146, while
the lower was invaded 27 times, {548} and the lumbar muscles 8. Most
frequently it begins in some muscle or group of muscles in the right
hand, either the interossei or those of the ball of the thumb. Of the
interossei, the external interosseus is usually the first affected.
Thence it extends to the other interossei, and soon very striking
depressions make their appearance between the metacarpal bones, and the
extensor tendons on the dorsum, and the flexors in the palm become as
distinct as if dissected out. Succeeding this follows contraction of
the flexor tendons until the picture seen in Fig. 32 is produced, in
which 1 exhibits the anterior surface of the hand, and 2 the posterior.

[Illustration: FIG. 32. (1) HAND, PALMAR SURFACE. (2) DORSAL SURFACE
(after Duchenne).

_a_, Ends of the metacarpal bones; _b_, Tendons of the flexor sublimis;
_c_, Muscles of the ball of the thumb.]

Opinion is not unanimous as to whether the atrophy when beginning in
the hand involves first the thenar muscles or the interossei. Roberts,
Wachsmuth, and Friedreich say that it begins, as a rule, in the thumb;
Eulenburg, that it invariably begins in the interossei. From the
interossei it may creep up the forearm, and thence to the arm, or it
may skip the forearm and pass into the arm, although the triceps
extensor muscle is usually spared. It may come to a standstill in
either of those places, but may involve the muscle of the shoulder,
especially the deltoid. When the latter and the arm are involved, a
picture like that of Fig. 33 is produced.

[Illustration: FIG. 33. Showing Atrophy of the Right Deltoid and Arm,
and the Left Arm.]

[Illustration: FIG. 34. Showing Atrophy of the Deltoid, posterior
aspect, and the Scapular Muscles.]

Beginning most frequently in the right, both upper extremities become
sooner or later involved.

In other instances in which the upper extremities are previously
involved the atrophy begins in the shoulder, in the deltoid--here again
the right first. Succeeding the deltoid, the scapular and trapezius
muscles may be involved in any order, while a grotesqueness of effect
is often produced by reason of certain adjacent muscles retaining their
natural size or even being hypertrophied. This is particularly the case
with the anterior part of the trapezius, which is almost never
involved. With the shoulders first affected, the arm and forearm may
retain their usefulness and strength; but the power of lifting the arm
from the side, and especially of raising it above the head, is lost.
And if the patient wishes to lay hold of anything, he must swing his
arm forward with a jerk until it is brought in reach of his fingers,
and then it must often be caught up by the pathologically hooked
terminations of these.

The muscles of the trunk do, however, become at times involved--the
pectorales, the latissimi, serrati, and intercostales, and even the
{549} diaphragm and abdominal and lumbar muscles. Life is seriously
jeopardized when the intercostals and diaphragm are affected, in
consequence of interference with respiration. If the intercostals cease
to contract, the upper part of the thorax ceases to move, and if the
diaphragm is involved, the epigastric and hypogastric regions are drawn
in during inspiration, and talking and singing are interfered with.
Even a mild bronchitis is apt to be fatal in consequence of the
difficulty in expelling the secretions.

The muscular atrophy thus produced is generally accompanied by a
corresponding wasting and retraction of the skin, so that this
continues applied to the muscles in the usual manner. In some
instances, however, this is not the case, and in these a baggy
condition of the skin is added, which gives its subject an appearance
which has more than once rendered him valuable to the showman as the
elastic-skin man, etc. It sometimes happens, on the other hand, that
the atrophy is obscured by an accumulation between the muscle and skin
of adipose tissue, and an appearance of hypertrophy rather than atrophy
may be produced in consequence, analogous to the same state of affairs
in pseudo-hypertrophic paralysis, the relations of which disease to
progressive muscular atrophy will be considered under the head of
Diagnosis.

At almost any stage the disease may come to a standstill, and may
continue thus for many years. The time required to attain its various
degrees also varies greatly, but the spread is usually slow, requiring,
as a rule, years for its completion. A general involvement of the
voluntary muscles of the entire body is exceedingly rare.

As stated, the disease may begin in the lower extremity, but much more
rarely. It is very seldom that the same order of invasion pursued in
the upper extremity is followed in the lower--that is, beginning with
the interossei. It may begin in the thigh and involve it alone, or
extend to both {550} thighs, or both legs as well. Under these
circumstances weakness of the legs is a striking symptom, the patient
being unable to stand, often falling down or requiring a cane or
crutches to assist him. In illustration of this mode of invasion may be
related one of Roberts's cases, that of an adult woman thirty-eight
years old, a domestic servant, in whom at thirty-six was perceived a
weakness in the right thigh. She first noticed that it grew tired
sooner than the left. This gradually increased, until she was compelled
to sit much of the day, then to use a stick, and finally crutches. This
was accompanied by a gradual wasting of the thigh-muscles. Even in this
case the loss of power was greater than would have been expected from
the degree of atrophy, the loss of bulk incident to which Roberts
believed to have been in part replaced by fat. In other instances,
however, the extremest degree of atrophy has been noted where the
disease has commenced in the lower extremities.

The deformity produced by the wasting muscle is sometimes further
increased--more frequently in the earlier stages--by a painful swelling
of the joints, first mentioned by Remak, called by him neuro-paralytic
inflammation, and referred to the sympathetic. This may affect the
small (phalangeal) as well as the larger joints (shoulder and elbow).

Cases apparently beginning in the face are reported, when the distorted
expression resulting is very characteristic.

Aran first, and Roberts afterward, divided cases of the disease into
two groups, the partial and general. In the former are included those
involving the extremities only; in the latter become involved, sooner
or later, the muscles of the trunk, neck, face, mouth, pharynx (muscles
of deglutition), thorax (muscles of respiration), and even of the
abdomen. Even the tongue is reported as undergoing atrophy.

General wasting palsy, as was early observed by Roberts, is
unquestionably a rare disease, and in no case have all the muscles of
the body been found implicated in one individual, and a few seem
altogether exempted. Such are the muscles of mastication and of the
eyeball, including the levator palpebræ.

A second muscular symptom, more or less distinctive, is fibrillar
contraction. This consists in a wave-like contraction running along
small bundles of muscular fasciculi. The contractions occur
spontaneously or are excited by any slight stimulus, as a breath of air
or a dash of water, or by tapping the patient, or passing a galvanic
current through the parts, and at any stage of the disease, except that
they do not occur in muscles wholly destroyed. Sometimes they can be
felt by the patient. At other times he is wholly ignorant of them. They
are not invariably present, and often they have been observed in
muscles atrophied from other causes. They possess, however, a certain
amount of diagnostic value, especially when spontaneous.

More rare, and less destructive, are cramps, twitches, and clonic
contractions of groups of affected muscles. These, when present, are
sometimes exceedingly painful.

Coincident with the wasting of muscles is their loss of function. The
power of abducting and adducting the fingers gradually disappears, so
also that of flexion and extension, and everywhere the loss of function
goes pari passu with the atrophy. As Roberts graphically puts it, "The
tailor discovers that he cannot hold his needle; the shoemaker wonders
{551} he cannot thrust his awl; the mason finds his hammer, formerly a
plaything in his hand, now too heavy for his utmost strength; the
gentleman feels an awkwardness in handling his pen, in pulling out his
pocket handkerchief, or in putting on his hat. One man discovered his
ailment in thrusting on a horse's collar; another, a sportsman, in
bringing the fowling-piece to his shoulder."

Along with the atrophy of muscle and loss of power comes a gradually
diminishing response to electrical stimulus. Direct muscular
faradization fails first to excite contraction, and sometimes fails
completely even before voluntary mobility is lost. Indirect muscular
faradization continues longer to excite contraction, but it also
finally fails. Response to the constant current continues still longer,
but it also finally fails to elicit contractions, stronger and stronger
currents being required, until finally all fail. The galvanic
excitability of nerve-trunks is maintained for quite a long time, but
finally also disappears. Some irregularities present themselves in this
respect.

A singular electrical reaction, first described by Remak, and said by
him to be of frequent occurrence in muscular atrophy, was named by him
deplegic contraction. He describes it as follows: When the cathode or
negative pole is put below the fifth cervical vertebra, contractions
can be produced in the atrophied muscles of the arm when the anode or
positive pole is placed in an irritable zone, which extends from the
first to the fifth cervical vertebra, or, still better, in the carotid
fossa or the triangle between the lower jaw and the external ear. The
contractions always take place on the side opposite to that at which
the anode is placed, while when the electrodes are placed on the median
line they occur on both sides, although when the current is very weak
they are limited to the muscles most seriously involved. Meyer,
Drissen, and Erb confirmed Remak's statement, while Fieber, Benedikt,
and Eulenburg failed to do so. Remak interprets these contractions as
reflected from the superior cervical ganglion of the sympathetic. He
bases this view upon the fact that the patient perceived a sensation
behind the ball of the eye when the current was closed. Eulenburg, on
the other hand, regards them as genuine reflex contractions,
independent of the sympathetic, and caused either by excessive
irritability of the central reflex apparatus or by an abnormal
excitability of the muscles themselves.

Sensibility is, in many cases, unchanged, the tactile sense being as
delicate as ever, and pain, except accompanying the cramps above
described, is absent. At times, however, the atrophy is preceded by
paroxysms, which may or may not accompany the clonic contractions
referred to. It is sometimes in the course of nerve-trunks, but as
often diffuse, as though the muscles themselves were its seat. At other
times it is variously described as a soreness, an aching, or a
rheumatic pain. Accompanying advanced degrees of the atrophy, however,
there is very rarely--in 3 out of 105 cases, according to Roberts--a
slight diminution of sensibility, especially in the ends of the
fingers, while the faradic sensibility may be similarly diminished.

Modified sensations, as those of cold, numbness, and formication, may
be experienced, and reflex excitability may be increased, while the
knee-jerk is said to be absent. Unusual sensitiveness to cold is
sometimes noted, and a loss of muscular power under its influence,
which is again restored by artificial warmth.

{552} Among more inconstant symptoms, denominated vaso-motor, are, in
the early stages, fever and slight elevation in local temperature from
2° to 3° C. Fever is less frequently observed toward the termination of
the disease, and at this stage a fall of local temperature, as much as
4° C., has been noted. In the same category of vaso-motor symptoms are
classed the skin contractions already referred to, hyperidrosis or
excessive sweating, and certain very rare oculo-pupillary symptoms,
consisting mainly of contraction of the pupil and slow reaction, but
including also, in a case reported by Voisin, flattening of the cornea
on both sides and defective sight.

COMPLICATIONS.--Progressive muscular atrophy is not infrequently
associated with amyotrophic antero-lateral sclerosis and with
labio-glossal or progressive bulbar paralysis. Both affections may
result as an extension of the disease from the anterior cornua of gray
matter, the former into the antero-lateral columns, the latter into the
medulla oblongata, or the affection may be primary in either of these
two situations, and extend thence into the anterior cornua of gray
matter.

When there is also lateral sclerosis, there is rigidity of the lower
limbs in addition to the atrophy of the upper--at first temporary, but
afterward permanent. This may extend to the upper also, and the arms
become fixed in semipronation and semiflexion.

When there is bulbar paralysis there is difficulty in moving the
tongue, in speaking, and in swallowing. The mouth remains open, the
lower lip drops, the patient cannot whistle or kiss or blow out a
candle; he speaks through his nose. On the other hand, the upper part
of the face is natural, the orbicularis palpebrarum muscle and
occipito-frontalis acting well. As a consequence, the carrying of the
food back into the oesophagus is rendered difficult or impossible;
swallowing is imperfectly successful; the food sometimes enters the
larynx, and the patient dies of suffocation. The saliva dribbles from
the mouth. Later, respiration is embarrassed, and performed principally
by the diaphragm; there is difficulty in raising mucus, and if
bronchitis supervenes the patient dies of suffocation, because he
cannot raise the phlegm. Such was the death of Prosper Lecompte, the
historic patient of Cruveilhier.

DIAGNOSIS.--As our knowledge of progressive muscular atrophy increases
we realize more and more that there have heretofore been included under
this name many cases which must now be relegated to other categories.
If we confine the disease, as I think we must, to those cases in which
there are degenerative changes in the anterior cornua of the gray
matter of the cord, we must endeavor to associate with these lesions a
set of symptoms which are sufficiently constant, and exclude all other
similar combinations. Such a set of symptoms includes the following:
insidious and progressive atrophy of groups of muscles, beginning
usually in the hand or shoulder, from which, however, it may extend to
others in a diffuse and rarer form of the disease. The atrophy is
accompanied by a corresponding loss of power in the affected muscles
and partial or complete reaction of degeneration in the same, and by
fibrillar twitchings. Along with this, sensibility, the special senses,
the reflexes, as a rule, and sphincters always remain normal.

This complex of symptoms is to be distinguished from the so-called
{553} juvenile progressive muscular atrophy of Erb, and from
pseudo-hypertrophic muscular paralysis. In the first there is also
slow, symmetrical, but intermittent and often stationary, wasting and
weakness of certain groups of muscles, preferably those encircling the
shoulder and upper arm, the pelvis and upper thigh and back--"an
atrophy," says Erb, "which is very frequently combined with true or
false muscular hypertrophy, with a peculiar toughness of the atrophying
muscles, but without fibrillar contraction or any trace of the reaction
of degeneration or other lesion in the body, be it of the nervous
system, organs of sense, vegetative organs, or external
integuments."[27] The average age in the juvenile form is much less,
Erb's cases ranging from seven to forty-six, or an average of
twenty-six and a half, while in the spinal form, or true progressive
muscular atrophy, although the age is reduced by reason of the
admixture of other cases than those of true progressive muscular
atrophy, the average age is much greater. Of Roberts's cases, all of
which seem true cases, the youngest was twenty, while the age of the
remaining four was thirty-nine, forty-seven, sixty-seven, and
thirty-eight.

[Footnote 27: "Juvenile Form der Progressive Muskelatrophie,"
_Deutsches Archiv für klinische Medizin_, Bd. xxxiv., 1884, S. 471.]

There are certain symptoms in common in progressive muscular atrophy,
as heretofore described, and pseudo-hypertrophic paralysis; and I have
already said that Friedreich and others are disposed to consider them
one and the same disease; but such is not the case. First of all, while
there is wasting of muscle, although obscured in the lower extremities
by the fatty infiltration, and while there is loss of power, there are
in pseudo-hypertrophic paralysis absolutely no alterations in the
spinal cord. Pseudo-hypertrophic paralysis always begins in the lower
extremities, while progressive muscular atrophy begins for the most
part in the upper. Pseudo-hypertrophic paralysis is a disease of
childhood, and strikingly hereditary; and while progressive muscular
atrophy in its broadest application is also a disease of childhood and
hereditary, it is much less so than pseudo-hypertrophic paralysis; and
if, with Erb, we separate the juvenile form from muscular atrophy,
progressive muscular atrophy is not a disease of childhood, while
heredity is almost entirely removed from it.[28]

[Footnote 28: It cannot but help the reader to get a correct notion of
this interesting but still somewhat imperfectly understood disease to
be familiar with Erb's formulated conclusions (_loc. cit._, p. 510):

"There is a peculiar form of progressive muscular atrophy which is
characterized by a definite location, definite course, definite
behavior of affected muscles, and definite alteration in them, but
without alterations in the spinal cord--the condition named by me the
juvenile form. It begins in youth or childhood.

"This form agrees in its symptomatology--especially in its localization
in the upper half of the body, partly also in the lower--entirely with
the so-called pseudo-hypertrophy of muscles, only that in the former a
decided lipomatosis leading to an increase in volume is wanting; on the
other hand, true muscular hypertrophy is not infrequent in both forms
of the disease.

"If this juvenile form occurs in the earliest childhood, it may in all
its details be identical with pseudo-hypertrophy, except that the
lipomatosis is wanting.

"The anatomico-histological alterations of the muscles are exactly the
same in the juvenile form as in pseudo-hypertrophy.

"The juvenile form not infrequently occurs in entire groups in one
family, producing the so-called hereditary--better named
family-muscular--atrophy.

"If this juvenile-hereditary form occurs after puberty, it affects most
frequently, although not exclusively, the upper half of the body. If it
sets in, on the other hand, in {554} earliest childhood, it affects
preferably the lower extremities and the pelvis. Transitional forms,
however, occur also in family groups.

"In the latter form, that occurring in earliest life, we have that
which Leyden has proposed to designate as hereditary muscular atrophy.

"Thus, hereditary muscular atrophy is in all essential points identical
with pseudo-hypertrophy, and is distinguished from it only in the
slighter degree of lipomatosis of the muscles.

"All of these forms have probably nothing to do with spinal progressive
muscular atrophy; they differ from it in localization and course,
anatomical changes and clinical phenomena in the muscles, and
alterations in the spinal cord."]

Still another myopathic condition, which in the light of modern
knowledge has to be separated from progressive muscular atrophy, is
Duchenne's hereditary infantile atrophy. This is characterized by onset
at an early age and by its beginning in the facial muscles. Its
clinical features are thus described by Charcot[29] and his pupils
Marie and Guénon.[30] Although it mostly begins in infancy, it may not
come on until adolescence, or even until middle or advanced age; it is
often hereditary; the face-muscles are first involved, particularly the
orbicularis oris, and there is a peculiar expression of the
countenance; whistling is impossible, and the articulation of labials
difficult; the eyes cannot be completely closed or the eyebrows raised.
Subsequently other muscles become involved, particularly those of the
shoulder girdle, except the deltoid, the muscles of the arm, the long
supinators of the forearm, and in the lower extremities the muscles of
the buttocks, thighs, and of the anterior external aspect of the leg.
The muscles of the hands and fingers are spared. Fibrillar tremors are
not present, and there is no reaction of degeneration. The distribution
of the atrophy is almost identical with that of Erb's form, except that
it begins in the face. It is likewise an hereditary or family disease.

[Footnote 29: _Le Progrès médical_, No. 10, 1885.]

[Footnote 30: _Revue de Médecine_, October, 1885.]

PROGNOSIS.--The course of progressive muscular atrophy is never
rapid--essentially chronic. Recovery in a well-established case is not
to be expected, although it is rare for any one to die of the direct
effects of the disease. It is often arrested in its course, and remains
at a standstill for years. The wider its distribution and the more
numerous the foci of involvement, the more rapid is its course; and
when the muscles of deglutition and respiration are involved, and the
carrying back of food interfered with, death from asphyxia is liable to
be produced by the entrance of food into the larynx or from the
accumulation of mucus in what under ordinary circumstances would be a
slight catarrh of the respiratory passages.

TREATMENT.--Treatment directed specifically to the cure of the disease
is limited. Only where there is reason to believe that syphilis is
responsible for it do we find an opportunity to strike at the fons et
origo mali by mercurials and iodide of potassium. Yet in Cooke's case,
quoted by Roberts,[31] the disease after progressing continuously for
five years, during which a variety of modes of treatment was tried, had
its further progress stopped by a course of mercury, although no cause
of the disease could be assigned.

[Footnote 31: _Op. cit._, p. 1; also Cooke _On Palsy_, Lond., 1822, p.
31; also quoted by Graves in his _Clinical Lectures_, L. lxxxiii.]

In the majority of instances treatment must consist merely in efforts
to maintain the general health and strength of the patient and to
counteract {555} the obstinate tendency of the spinal disease to
produce wasting of the muscles by depressing their nutrition. The
former is accomplished by an abundance of nutritious food, fresh air,
and out-door life, by gymnastics, chalybeate and other tonics,
including arsenic, strychnine, and quinine. The second is attained by
electricity, frictions, and massage. Both forms of electricity are
useful, the induced current with rapid interruption with a view to
counter-irritate and to stimulate the circulation, or by slow
interruptions to stimulate individual muscles to contraction, and thus
maintain their nutrition. Duchenne recommended the application of
currents of moderate intensity, with not too frequent interruptions,
and for a few minutes only at a time, so as not to fatigue the fibres
undestroyed. He urged particularly the treatment of important muscles
like the diaphragm through the phrenic nerves, of the intercostals, and
of the deltoids before they were actually invaded by the disease. He
relates the case of a man named Bonnard who had lost many of his
trunk-muscles, and who was beginning to suffer with dyspnoea, on whom
faradization of the phrenic nerves, repeated three or four times a
week, was of great service, enabling him to walk considerable distances
and to go up stairs without fatigue. Another patient, whose arms were
much wasted, was so far restored that at the end of six months he was
again able to support his family.

The direct current--galvanism--is useful in advanced stages of the
disease, where even the strongest faradic currents fail to produce
response. Even where galvanic currents fail to exert contractions the
treatment ought to be persevered in for a long time. It may be
necessary to use very strong currents at the outset, which may be
gradually weakened as contractility returns.

Remak, who especially advocated the use of the continuous current,
advised to place the positive pole in front of one mastoid process and
the negative pole on the opposite side of the neck near the spinous
processes of the vertebræ, not higher than the fifth cervical, by which
he produced the contractions already described as diplegic in the
fingers and other paralyzed parts.

Galvanization of the sympathetic has been apparently useful in the
hands of some--viz. Roberts, Benedikt, M. Meyer, Guthzeit, Erb,
Neseman, and others, while the latter reports a case of complete cure
by this treatment. Eulenburg tells us, however, that a relapse is said
to have occurred in this case; also that neither he nor Rosenthal have
had any results from it.

Massage is equally important, and should be used at the same time with
electricity, but at a different time of day. Eulenburg refers to a case
which was said to have brought the disease to a standstill. There can
be no doubt of the value of the measure as an adjuvant to treatment.

In families in which an hereditary tendency exists prophylactic
treatment should be used. It should include hygienic measures of the
kind already referred to, and the avoidance of undue fatigue and
exposure; and in the selection of an occupation these matters should be
kept in view.

On the supposition that the disease is a purely local one, gymnastics,
involving the exercise of the groups of muscles prone to attack, would
{556} be indicated, but assume less importance from our standpoint that
it is a spinal disease. At the same time, the patient should have the
benefit of any existing uncertainty in the pathogeny of the affection;
and as gymnastics are eminently calculated to improve the general
health, and thus indirectly to avert the disease, their use is
indicated on these grounds.




{557}

PSEUDO-HYPERTROPHIC PARALYSIS.

BY MARY PUTNAM JACOBI, M.D.


SYNONYMS.--Hypertrophic paraplegia of infancy (Duchenne); Myo-sclerosic
paralysis (Duchenne); Progressive muscular sclerosis (Jaccoud);
Atrophia musculorum lipomatosa (Seidel); Lipomatous myo-atrophy
(Gowers); Muscular hypertrophy (Kaulich, Griesinger); Lipomatosis
musculorum luxurians progressiva (Heller); Myopachynsis lipomatosa
(Uhde); Pseudo-hypertrophic paralysis (Ross); Pseudo-hypertrophy of
muscles (Friedreich).

DEFINITION.--Pseudo-hypertrophic paralysis is a rare and predominantly
infantile disease, characterized by a considerable increase in the
volume of some or all the muscles of the lower extremities, associated
with progressive diminution in their functional energy, and accompanied
or followed by paresis and atrophy of the muscles of the trunk and
upper limbs. Many of the hypertrophied muscles subsequently atrophy;
many of the muscles in which atrophy is the most conspicuous lesion
pass through a preliminary period of hypertrophy. The proximate cause
of these alterations is a profound disturbance in the nutrition of the
muscles, attended by great increase of their connective tissue, by
wasting of the contractile substance, and by the ultimate replacement
of this by fat.

HISTORY.--The honors of the discovery of this remarkable disease may be
divided between Duchenne, Meryon, and Griesinger. In 1852[1] the
English physician published a series of six cases, four belonging to
one family, two to another; but these were described by him under the
name of progressive muscular atrophy; and it was left to Duchenne, who
in 1861[2] published as a new disease the first case observed by
himself, to demonstrate the identity of Meryon's cases with his own.[3]
In 1868, Duchenne had collected twelve additional cases, and published
an extensive monograph on the subject.[4] But in 1865, Griesinger[5]
had excised a portion of muscle from a patient suffering with the
disease, and made the first histological examination of its structure.
On this account several German writers habitually refer to Griesinger
as the earliest authority on the subject. Before Meryon, Partridge in
1847,[6] and Sir Charles Bell in 1830,[7] had described cases of
pseudo-hypertrophic paralysis, but without recognizing their separate
morbid entity. Bell's case is the following: {558} "A boy at eight
years of age began to experience difficulty in rising from a chair. The
disease gradually progressed, till at eighteen he had to twist and jerk
his body about to get upright. The muscles of the lower extremities,
hips, and abdomen were debilitated and wasted. The extensor quadriceps
femoris on both sides wasted, but the vasti externi had not suffered as
much; a firm body, remarkably prominent, just above the knee-joint,
marked the position of the vastus externus. No defect of sensibility or
affection of the sphincters. The upper part of the body, shoulders, and
arms were strong."[8]

[Footnote 1: _Lond. Med. Gaz._]

[Footnote 2: _De l'Électrisation localisée_.]

[Footnote 3: Duchenne at first doubted this identity.]

[Footnote 4: _Archives générales_, 1868.]

[Footnote 5: _Archiv der Heilkunde_.]

[Footnote 6: _Lond. Med. Gaz._, 1847.]

[Footnote 7: _Nervous System_, 2d ed., 1830, p. 163.]

[Footnote 8: _Loc. cit._ This case is quoted in an appendix to Gowers's
monograph.]

Autopsies.--The first was made by Meryon: the first which included
microscopic examination of the spinal cord was by Cohnheim on a patient
of Eulenburg's.[9] Since then autopsies have been made in 12 genuine
cases, and in 2 others frequently, though erroneously, ranked with
them.[10]

[Footnote 9: _Vhdlg. der Bul. Med. Ges._, 1866, Heft 2, p. 191, quoted
by Eulenburg in _Ziemssen's Handbuch_, Bd. xii. 2.]

[Footnote 10: Cases of Barth and Müller.]

Of cases without autopsies a collection of 80 was made by Friedreich in
the monograph on pseudo-hypertrophy which accompanies his longer
monograph on progressive muscular atrophy.[11] Mobius has increased
this list to 94;[12] Gowers describes 24 cases,[13] and refers in an
appendix to 20 more--18 observed by Adams, 2 by Clifford Albutt.[14]
Hammond in the sixth edition of his treatise on nervous diseases,
quotes 17 American cases, of which 6 were observed by himself.[15]
Gowers estimated that in 1879 about 220 cases had been reported,
divided up among a much smaller number of families.

[Footnote 11: _Ueber Progressiv Muskel Atrophie_.]

[Footnote 12: "Ueber Hereditare Nerven Krankheiten," _Volkmann's
Samml._, 171.]

[Footnote 13: _Clinical Lecture on Pseudo-hypertrophic Paralysis_,
Lond., 1879.]

[Footnote 14: Among Mobius's cases is that related by Pick in the
_Deutsches Archiv f. klin. Med._, Bd. vi., and really a case of
progressive muscular atrophy in an adult complicated by lipomatosis in
the calf-muscles. Of the other cases, 6 are quoted from the Swedish, 6
are hitherto unpublished, and have been collected by the author from
several clinics. There remain cases by Davidsohn, _Glasgow Med.
Journ._, 1872 (3 cases); Berger, _Schles. Gesellsch._, 1875; Uhde,
_Arch. f. klin. Chirurg._, 1873, Bd. xvi.; Huber, _Deutsches Arch. für
klin. Med._, 1874; Brieger, _ibid._, 1878, Bd. xxii.; Leyden, _Klinik
der Ruckenmark. Krank._, Bd. ii. S. 529; Schlesinger, _Wien. Med.
Presse_, 1873.

Many other cases have been published since, but without contributing
any special information on the disease. Of importance, however,
are--Cornil, accompanied by autopsy, _Bull. Soc. Méd. des Hôp._, 1880;
Donkin, followed by recovery, _Brit. Med. Journ._, 1882, i.; Albutt,
_Med. Times and Gaz._, 1882; Goodridge, _Brain_, 1882; Barthélemy,
_France méd._, 1880; Suckling, _Med. Times and Gaz._, 1885; Dowse and
Crocker, _Lancet_, 1881.]

[Footnote 15: These are reported by S. G. Webber, _Boston Medical and
Surg. Journ._, Nov. 17, 1870; Wm. Pepper, _Philada. Med. Times_, 1871;
S. Weir Mitchell, _Photographic Review_, 1871; C. H. Drake, _Philada.
Med. Times_, 1874; C. T. Poore, _New York Med. Journal_, 1875; Steele
and Kingsley of Missouri (4 cases), _Philada. Med. Times_, Oct., 1875;
George S. Gerhardt (2 cases), _Alienist and Neurologist_, Jan., 1880.

I have had an opportunity of observing 3 cases of the disease--1 at the
Mount Sinai Hospital; 2, brothers, in a private family.]

The material at present on hand is therefore sufficient, if not to
solve the problems of the disease, at least to make out a tolerably
complete clinical history.

SYMPTOMS.--The early appearance of the morbid symptoms is the first
striking peculiarity of the disease. Out of 88 cases whose records I
have analyzed, 35 must be considered congenital, since some degree of
paresis was observed from the time the child first began to walk;[16]
and the effort {559} at walking was unusually late, being deferred till
two, three, or even four years of age. In 21 other cases the first
symptoms of the disease declared themselves between the ages of three
and six[17]--at the age of seven 8 other cases began;[18] between nine
and ten, 7 cases;[19] between ten and sixteen were 8 cases;[20]
finally, in 7 cases, of which 2 are more than doubtful (cases Barth and
Müller), the disease seems to have begun in adult life.[21] Thus, 57
cases, or rather more than two-thirds of the whole number, began before
the age of six.

[Footnote 16: These cases are the following: Meryon, _Lond. Med. Gaz._,
1852 (5 cases); Partridge, _ibid._, 1847; Duchenne, _Électris. local._,
1861; Kaulich, _Prager Vierteljahr._, 1862, quoted by Friedreich;
Spielmann, _Gaz. méd. de Strasbourg_, 1862, quoted by Friedreich;
Duchenne fils, _Archives gén._, 1864 ("De la Paralysie atrophique
graisseuse"); Griesinger, _Archiv der Heilkunde_, 1864; Sigmund,
_Deutsches Archiv für klin. Med._, Bd. i. Heft 6; Wernich, _ibid._, Bd.
ii. Heft 2, 1866; Benedikt, _Elektrotherapie_, Wien, 1868; Balthazar
Foster, _Lancet_, 1869; Barth, _Archiv der Heilkunde_, xii. 2, 1871;
Chrostek, _Oesterreich Zeitschrift für prakt. Heilkunde_, No. 38, 1871,
quoted by Friedreich; Pekelharing, _Arch. Virch._, 1882, Bd. lxxxix.,
quoted by Friedreich; Knoll, _Wien. Medizin Jahrbuch._, 1872;
Friedreich, _Pseudo-hypertroph. der Musc._, 1878, p. 291; Duchenne,
_Archives gén._, 1868 (7 cases); Hammond, _Treatise Nerv. Dis._;
Gowers, _loc. cit._ (5 cases); Ross, _Treatise Nerv. Dis._, 2, 204.]

[Footnote 17: Cases by Eulenburg, _Allgemeine Med. Central Zeitung_,
Berlin, 1863, quoted by Friedreich; Rinecker, _Verhand. du Phys. Med.
Gesellsch. zu Wurzburg_, 1860, quoted by Friedreich; Heller, _Deutsches
Archiv f. klin. Med._, Bd. i. H. 6 (2 cases); Wernich, _ibid._, Bd.
ii., 1866; Lutz, _ibid._, Bd. iii., 1867; Benedikt, _loc. cit._ (5th
and 6th cases); Russel, _Med. Times and Gaz._, 1869 (3d case);
Duchenne, _loc. cit._ (2d, 3d, 6th, 12th, 13th cases); Hammond, _loc.
cit._; Gowers, _loc. cit._ (6 cases).]

[Footnote 18: Cases by Eulenburg and Cohnheim, _Beitr. klin. Woch._,
1865; Seidel, _Atrophia Musculorum Lipomatosa_, 1867; Heller, _loc.
cit._ (2d case); Wagner, _Berl. klin. Woch._, 1866 (8 cases); Benedikt,
_loc. cit._ (1st case); Duchenne, _loc. cit._ (9th case); Gowers, _loc.
cit._ (7th case).]

[Footnote 19: Seidel, _loc. cit._ (1st case); Coste and Gioja,
_Schmidt's Jahrb._, Bd. xxiv. S. 176; Spielmann, _Gaz. méd. de
Strasbourg_, 1862; Boquette, _Inaug. Dissert._, Berlin, 1868; Russel,
_loc. cit._ (2d case); Rakowac, _Wien. Mediz. Wochen._, 1872; Brieger,
_Deutsches Archiv f. klin. Med._, Bd. xxii., 1878; Pepper, _Philada.
Med. Times_, 1871.]

[Footnote 20: Lutz, _loc. cit._ (2d case); Ross, _loc. cit._, p. 190
(observed when adult); Hoffmann, _Inaug. Dissert._, Berlin, 1867;
Russel, _loc. cit._ (1st case); Gowers, _loc. cit._ (18th and 20th
cases).]

[Footnote 21: Benedikt, _loc. cit._ (2d and 3d cases); Dyce Brown,
_Edin. Med. Journ._, 1870; Eulenburg, _Archiv Virch._, Bd. xlix., 1870;
Martini, _Centralblatt für Med. Wissensch._, No. 41, 1871; Barth,
_Archiv der Heilkunde_, xii. 2, 1871; Müller, _Beit. zur path.
Ruckenmarkes_, 1871.]

The symptoms are of three kinds: 1st, those dependent on alterations in
the function of the affected muscles; 2d, changes in the appearance,
consistency, and electrical reaction of these same muscles; 3d,
deformities resulting from their structural alteration.

The first muscles invaded are invariably the gastrocnemii,[22] and
therefore uncertainty of gait is the first symptom observed. The child
is usually backward in learning how to walk, even when two, three, or
four years intervene between this acquisition and the first decided
appearance of the disease. In the unquestionably congenital disease the
act of walking is always imperfectly performed, and the original
imperfection gradually deepens into a noticeable uncertainty of gait,
and finally into real paresis. It is noticed that the child falls very
frequently--at first only when running, afterward even while standing.
He then begins to experience difficulty in going up stairs: pulls
himself up by the {560} bannisters, and usually drags one leg
completely. After a while it becomes quite impossible for him to go up
stairs except on his hands and knees.

[Footnote 22: Billroth relates an altogether exceptional case of a
limited pseudo-hypertrophy with lipomatous degeneration, localized in
the hamstring and adductor muscles of one thigh, in a girl seventeen
years old. The only generalized lesion was an immense development of
subcutaneous fat (_Archiv für klin. Chir._, Bd. xiii.).

Dyce Brown (_Edin. Med. Journal_, 1870) relates a case, also in an
adult of twenty-six years, where hypertrophy of the thigh-muscles is
said to have preceded by three weeks that of the calves.]

These symptoms all point to failure of power in the gastrocnemii
muscles, whose function it is to raise the heel from the ground in
running, to steady the heel by their tension during the act of
standing, and to raise the foot with considerable force during the act
of going up stairs. In descending a staircase or any inclined plane
great tension is required of these same muscles, and this act should
therefore be even more difficult than that of ascension. But it does
not seem to have been as carefully studied.

Attention is not often directed to the infirmity at this early stage,
especially if the child be very young, since the apparently excellent
development of the legs satisfies the parents that nothing serious can
be the matter, and the falling is explained by childish awkwardness.
Not infrequently, indeed, this is really due to a rachitis which has
preceded the degenerative lesion, and at the early stage of the latter
a diagnosis from the less severe disease is always required, and is
sometimes difficult to make.

The following test may be applied in doubtful cases: The child (if old
enough) is requested while standing to rise on the tips of his toes.
This act necessitates a powerful effort on the part of the sural
muscles, and of this, even at an early stage of degeneration, they are
generally incapable.

Functional weakness may precede for several years all visible
alteration of the muscles; the child may not learn to walk at all until
two or even three years of age; then walks badly until five or six,
when, for the first time, the calves begin to enlarge. More often the
paresis precedes the hypertrophy by only a few months or weeks, or the
symptoms occur simultaneously. A certain amount of hypertrophy will be
overlooked; but when the calves enlarge sufficiently to render the
child's stockings too tight, attention is forcibly called to the
change. The enlargement is more marked at the upper part of the calf,
so that the symmetry of the leg is deranged by it. Often, however, the
impression of vigor conveyed by the appearance of the child's legs is
with difficulty dispelled by the discovery of their functional
weakness.

Eulenburg[23] affirms that the consistency of the muscle is soft and
doughy, recalling, when grasped in the hand, a lipomatous tumor. This
description, however, does not apply to the early stage of the disease;
for then the hypertrophied muscles feel extremely hard to the touch;
there is even a stony hardness (Duchenne fils); somewhat later, the
hypertrophy continuing, these muscles "seem to make hernial protrusions
through the skin" (Duchenne). This appearance is most marked when the
subcutaneous fat is atrophied; when, as happens especially in the adult
cases,[24] the diseased muscles are covered by a thick layer of
subcutaneous fat, their protrusion is concealed. A rapid exchange of
the hardness characterizing the first stage of the lesions for a
lipomatous softening is of bad omen, as indicating a more rapid and
irresistible march in the disease (Mobius).

[Footnote 23: _Ziemssen's Handbuch_, Bd. xii.]

[Footnote 24: See case by Billroth, quoted p. 853, note.]

At this early stage the electrical reactions of the enlarging muscles
are all intact. Disturbances of sensibility, however, are not uncommon.
Especially frequent are pains in the back and loins and stabbing pains
in the lower limbs. These pains sometimes follow the track of the {561}
crural or sciatic nerves; at other times they appear in the joints;
sometimes are limited to the affected muscles. The pains are diminished
by repose and a recumbent position, but are greatly aggravated by
movement. Paræsthesias, or a feeling of cold and formication, are also
observed--never anæsthesia. Seidel[25] has found the cutaneous
sensibility to be intact, as also the sense of space and pressure. The
temperature sensibility has not been tested. The temperature of the
affected part is, according to Eulenburg, often lowered several
degrees. This statement probably refers to the advanced degree of
degeneration. At an earlier stage Ord[26] found the temperature of the
calves to be increased.

[Footnote 25: _Loc. cit._, p. 32.]

[Footnote 26: _Med.-Chir. Trans._, 1874, 1877.]

Reflex excitability is maintained, not only in this, but in the second
stage of the disease, except in the patellar tendon, where it is
abolished after the quadriceps extensor has been invaded. This fact may
be of importance in diagnosticating paresis depending on incipient
pseudo-hypertrophy from that which would be caused by a mild anterior
poliomyelitis.

No symptoms of the third kind (deformity) appear in the first period of
the disease. The second is ushered in either by the first perceptible
degree of hypertrophy in the calves (Duchenne) or by increase of the
hypertrophy, which may have already begun during the first period of
paresis, and by extension of this to other muscles.

This extension of the lesion is indicated by further derangement in the
functions of station and locomotion. To steady himself the child
instinctively widens his base of support by placing the feet far apart,
and thus straddles while walking in a manner that is highly
characteristic. A second peculiarity is an oscillating movement of the
trunk from side to side. The trunk is carried over to the side of the
foot planted on the ground, the so-called active limb, and while the
passive limb is being swung forward. A third peculiarity of attitude,
already exhibited in station, but exaggerated by the act of walking, is
lordosis. The lumbar portion of the spine, with the abdomen, is carried
forward; the shoulders are carried backward, so that a plumb-line
dropped from them falls behind the sacrum. Thus, the walk of the
patient becomes highly characteristic--the feet planted so far apart;
the lumbar portion of the trunk projecting forward; the body
oscillating at each step from side to side.

At this stage the act of rising from a sitting or recumbent position
becomes more difficult than walking. If near a support, the child
always tries to draw himself up by his arms; if a fixed support be
lacking, he first gets on his hands and knees, and then, grasping each
thigh alternately with one hand, is enabled to get first one foot and
then the other on the floor. He then seizes the thighs by successive
grasps, each higher than the other, pressing back the flexed hip- and
knee-joint as he does so. By this method of apparently climbing up his
own thighs the patient is finally enabled to extend his body and arrive
at an upright position.

This attitude of the hands, on the knees, and subsequently on the
thighs, during the act of rising, is pathognomonic of
pseudo-hypertrophy, for it is observed in no other disease.

Corresponding with this increased disturbance in function is the
increased visible alteration in the muscles of the lower extremities.
The muscles on the anterior part of the legs are not always attacked,
but often {562} become hypertrophied and paretic contemporaneously with
the gastrocnemii. After these, hypertrophy of the glutæi comes next in
frequency. The quadriceps extensor of the thighs may become paretic,
and even perfectly paralyzed, without showing any sign of enlargement.
In many cases, however, hypertrophy proceeds regularly up the limbs,
and invades the thighs simultaneously with the buttocks.[27] The exact
proportion of cases is difficult to ascertain, because the history is
often imperfect, and at the time of observation the quadriceps extensor
is frequently atrophied, even when it has been hypertrophied at an
earlier date. The thinness of the thighs is then all the more
conspicuous from the hypertrophy of the calves below and of the
buttocks above. The sacro-lumbales and quadratus lumborum muscles are
also frequently enlarged, next in order to the quadriceps extensor
femoris, which, as seen, is rather less often hypertrophied than are
the gluteal muscles.

[Footnote 27: Cases in which the calves and thighs are alone described
as hypertrophied: those by Kaulich, Griesinger, Sigmund, Wagner,
Wernich (2d), Lutz (1st and 2d), Foster, Stoffella, Eulenburg (2d).

Cases of hypertrophy of calves with atrophy of thighs: those by
Eulenburg (1st), Lutz (3d), Adams, Barth (2d), Knoll, Friedreich,
Gowers (1st, 4th, 5th, 9th, 10th, 11th, 12th, 14th). In Rakowac's case,
as also Barth's, the glutæi were also hypertrophied.

Cases of hypertrophy, calves, thighs, glutæi, and sacro-lumbales
muscles: Duchenne (1st, 5th, 6th, 7th, 8th, 12th, the last being the
miniature Hercules, in which all the muscles were hypertrophied except
the pectorals), Heller (2 cases), Benedikt (1st, 2d, 3d, 4th; in the
5th the sacro-lumbales atrophied), Gowers (13th, 20th), Pekelharing.

Cases with hypertrophy of the calves and glutæi, with atrophy of the
thighs: Berend, Duchenne fils (hypert. sacro-lumbales), Duchenne (3d,
4th, 10th).

Cases of atrophy of all but calves: Spielmann, Gowers (7th), Hammond (2
cases).

Cases of hypertrophy of calves and deltoids, atrophy of all other
muscles: Ross (2 cases).]

The flexor muscles of the leg are much less often affected than these;
the adductors and the ileo-psoas rather more frequently. Paresis and
moderate hypertrophy of the abdominal muscles, though relatively rare,
are observed. Thus, from the foot up to the spinal column the morbid
imminence is pronounced on the side of the extensor muscles. The
liability to invasion on the part of the flexors is greatest at the
foot, where dorsal flexion is early impeded, and diminishes upward
toward the abdomen.

Most important for the theory of the disease is the fact that the
hypertrophic appearance of the muscles is never accompanied by even a
transitory period of increased strength.[28] Some degree of paresis
usually precedes the hypertrophy, and becomes intensified when this
sets in. The two symptoms, however, are by no means proportioned to one
another.

[Footnote 28: In Auerbach's case of true muscular hypertrophy the same
paresis was observed.]

There is another anatomical change in the muscles no less
characteristic of the disease than is their hypertrophy, which
contributes at least as much to the loss of muscular power. This is
atrophy of the muscles, which in the lower extremities is almost
invariably secondary to a stage of hypertrophy, but which occasionally
in the quadriceps extensor constitutes the primary lesion. On the other
hand, the calf-muscles, though occasionally retroceding from a state of
exaggerated hypertrophy, never atrophy below the normal dimensions.[29]

[Footnote 29: Hammond relates a remarkable case where the muscles of
the calves and thighs, having enlarged progressively during about two
years, then began to waste, and continued to do so for three years.
Then a second stage of hypertrophy set in, and continued at the time of
writing (_Treatise on Nervous Diseases_, 6th ed., p. 508).]

It not unfrequently happens that the atrophic and hypertrophic {563}
processes go on simultaneously in the same muscle, and so compensate
each other that the muscle varies little or nothing from the normal
size. This is especially apt to be the case with the pelvic and
lumbo-spinal muscles; and thus functional disturbances will develop for
which the mere appearance of the involved muscles seems to furnish no
sufficient explanation.

The peculiarities which have been described in station, locomotion, and
the act of rising to a vertical position nevertheless all depend on
such anatomical lesions of the muscles of the back and lower
extremities as render the adequate performance of their functions
impossible. Thus, the widening of the base of support by straddling the
legs is necessitated by weakness in all the extensor muscles of the
limbs--the glutæi, quadriceps, and gastrocnemii--which by their tension
should normally provide solid columns for the support of the trunk. The
lordosis begins with the first difficulty experienced in steadying the
heels, but is increased when the gluteals become incapable of extending
the pelvis on the femurs and when the sacro-lumbales are unable to
extend the vertebral column on the pelvis. The backward projection of
the shoulders, effected by the extensors of the upper portion of the
spine, is an instinctive compensation for the lordosis, to prevent the
trunk from falling altogether forward in front of the base of support.

The lateral oscillations of the trunk have been variously explained.
Duchenne attributed them to weakness of the gluteus medius. This
muscle, he asserted, is normally designed to restrain the tendency of
the pelvis at each step to incline toward the leg which is off the
ground.[30] But, in reality, during the act of walking, the pelvis, and
the trunk with it, are inclined toward the leg which is fixed, rotating
upon the head of the femur on that side, and being slightly elevated on
the opposite side, where the leg is being swung forward. This elevation
assists in enabling the swinging leg to clear the ground (Ross,
Hueter). The rotation is accomplished by the gluteal abductors on the
active or fixed side, the femoral extremity of these muscles being
fixed. Weakness of the gluteals must interfere with this rotation, and
should therefore diminish lateral oscillation did this depend on the
rotary movement.

[Footnote 30: _Archives gén._, 1868, p. 28.]

In a case examined by Ross, in which the lateral oscillation was much
marked, contractions of the gluteus medius were distinctly perceptible
to the hand placed just above the great trochanter. In another case,
where the gluteals were entirely destroyed, the oscillation, on the
contrary, was barely perceptible. Ross himself explains the phenomenon
more plausibly as a simple exaggeration of what occurs in normal
locomotion. In this the centre of gravity is necessarily shifted at
each step from the movable to the fixed leg by the inclination of the
trunk and shoulders to the side of the latter. When the legs are placed
far apart the body must incline farther in order to bring the weight in
the same relative position. Moreover, from the weakness of the anterior
tibial muscles the dorsal flexion of the foot, which should take place
at the moment the leg is lifted off the ground, is impeded or rendered
impossible; and the inclination of the pelvis on one side, which
necessitates its increased elevation on the other, thus favors the
swinging of the leg by leaving more room between the trunk and the
ground (Ross).

The curious manner in which pseudo-hypertrophic patients rise from a
{564} sitting or recumbent position has been carefully studied by
Gowers, and minutely analyzed by Ross in an adult case. The act to be
accomplished demands a series of extensions of the leg and pelvis on
the thigh and of the vertebral column on the pelvis. As the extensor
muscles are all paretic, this can only be effected by means of the
muscles of the upper extremities and of the weight of the body, which
the arms compel to serve as a motor force. Thus, from a recumbent
position the patient rolls upon his hands and knees: then, grasping the
knee, he lifts the leg upright with the foot planted on the ground. The
thighs remain strongly flexed, the trunk bent forward over the thighs.
The action of grasping the thighs above the knees, which is so
characteristic, serves to extend them by a double mechanism. In the
first place, the knee-joints are pressed slowly but directly backward.
In the second place, by the intermediary of the arms the weight of the
body is transferred from the upper end of the femur, above the power of
the quadriceps extensor, to the lower end of the lever, near the
fulcrum at the knee. Thus a lever of the third order, with the power
between the fulcrum and the weight, is partly transformed into a lever
of the second order, with the weight between the fulcrum and the power;
and thus the enfeebled quadriceps is able to act to more advantage.
Moreover, when the body inclines so far forward that the centre of
gravity is carried in front of the knees, it then becomes a force
applied to the upper end of the femur capable of extending the knees
without any action of the quadriceps.

When extension of the knee-joints is nearly complete, extension of the
pelvis on the femurs is effected by grasping the thighs alternately
higher and higher. By this manoeuvre the femur is pushed back and the
trunk is pushed up; and thus is compensated the incapacity of the
glutæi to perform their normal action of pulling up the pelvis flexed
on the femurs. Enough power remains in these muscles, however, for a
long time to complete the extension when, by the pushing movement, this
has been nearly effected.

During these actions the patient constantly oscillates the trunk from
side to side as he transfers the centre of gravity from one foot to the
other. In this, the second stage of the disease, and where the same
functional disturbances may arise with very various combinations of
hypertrophy and atrophy in the muscles of the lower extremities, a
third set of symptoms appears--certain deformities, namely, depending
on muscular shrinkage. The earliest, and often the most marked, of
these is talipes equinus. The patient becomes unable to plant his heels
firmly on the ground, and these are gradually drawn up higher and
higher, the patient resting first on the toes, then on the anterior
surfaces of the phalanges; ultimately is unable to stand at all, the
foot being drawn into a line with the leg, and the astragalus not
unfrequently luxated. Some authors explain this deformity by the
preponderating action of the gastrocnemius. The paralysis of this
muscle, which coincides with its hypertrophy, even when not quite
proportioned to it, renders such an explanation highly improbable. The
elevation of the heel is due to the gradual shrinkage of the muscular
tissue which accompanies the pseudo-hypertrophy; and on this account
the talipes is at every stage of its development irreducible.

The other possible deformities in the lower extremities are permanent
{565} flexions at the knee- or hip-joints. Both existed in the case
recently described by Pekelharing.[31] Before the disease has reached
its maximum degree of development in the lower extremities, its
progress has usually been marked in another manner--namely, by the
invasion of the trunk and arms. In cases 19-22 of Gowers's remarkable
series, where four boys out of a family of ten children were affected
by the disease, the hypertrophy first involved all the muscles of the
lower extremities, and then passed to the trunk and arms.[32]

[Footnote 31: _Loc. cit._]

[Footnote 32: Three other boys in this family, and three girls,
remained healthy.]

The description of the disease in the upper half of the body may be
distinctly separated from that in the lower half, on account of the
remarkable differences observed in the mode of the muscular
degeneration. In the lower extremities and pelvis primary
pseudo-hypertrophy is the rule; atrophy is almost invariably secondary,
and below the hips is rarely excessive.[33] In the upper part of the
body primary atrophy is the rule for certain muscles, and succeeds
rather early to the pseudo-hypertrophy which affects others. Only a few
muscles habitually hypertrophy, and remain enlarged until a somewhat
advanced period of the disease. The first in this group is the deltoid,
which not unfrequently enlarges simultaneously with the
gastrocnemii.[34] In one case the triceps humeri, and after that the
biceps, are the next most frequently hypertrophied,[35] in some cases
even together with atrophy of the deltoids (2d case Seidel). In
exceptional cases all the muscles surrounding the shoulder-joint,
especially those covering the scapula, are hypertrophied. Thus in the
early case of Coste and Gioga[36] the latissimus dorsi and trapezius
were hypertrophied, together with the deltoids, and even the muscles of
mastication and the tongue. In this case not only the quadratus
lumborum, but also the recti abdominis muscles, were hypertrophied. In
Chrostek's case the tongue was hypertrophied, although all the
shoulder-muscles, and also the sterno-cleido-mastoids, were
atrophied.[37] In Duchenne's third case the temporal and masseter
muscles were hypertrophied, while no alteration of size in any
direction was observed in the arms or shoulders. In Duchenne's twelfth
case all the muscles of the body, including the face, were
hypertrophied, with the single exception of the pectorals. In Barth's
second case, the left sterno-mastoid, the supra and infra spinali,
together with the left deltoid, were hypertrophied.

[Footnote 33: The quadricipites femoris, as already noticed, are not
unfrequently wasted.]

[Footnote 34: See cases of Kaulich, hypertrophy of calves, thighs,
deltoids; Heller, hypertrophy of all muscles of lower limbs, also of
abdomen with deltoids; Benedikt (4th and 6th cases); Friedreich (1st
case); Adams; Gowers (4th and 11th); Ross (2 cases); Brieger. In a case
by Clarke (_Med.-Chir. Trans._, vol. lvii.) the deltoids were observed
to be large seven years after the beginning of the disease. In a case
by Duchenne the enlargement of the deltoids, by great exception,
preceded that of the gastrocnemii by several months.]

[Footnote 35: Cases of hypertrophy triceps or biceps: Seidel (2d),
Rinecker, Griesinger, Wagner (2d, triceps without deltoid), Knoll,
Rakowac, Pekelharing, Spielmann (atrophy deltoid).]

[Footnote 36: _Schmidt's Jahrb._, Bd. xxiv. S. 196. Other cases are
given by Wernich (hypertrophy of rhomboids), Barth, Gowers (11th).]

[Footnote 37: _Oesterreich Zeitschrift f. prakt. Heilk._, 1871.]

In the majority of cases, however, at the time the patient came under
observation all the muscles above the quadratus lumborum were
atrophied, except the deltoids. In the pectoral, which has never been
found hypertrophied, the wasting process always sets in the earliest,
and advances to the greatest extent. The pectoral muscle is thus the
exact antithesis of the gastrocnemius, while the deltoid more nearly
resembles {566} the gastrocnemius than any other muscle of the upper
extremity. After the pectoral the latissimus dorsi, then the trapezius
scapular muscles (including the serratus magnus), those of the arm and
fore arm, the muscles of the neck, are found more or less wasted by the
time the disease is fully developed. The wasting is sometimes extreme,
as in a case described by Gowers, where the patient maintained a
permanently crouching attitude, the spinal column being in extreme
cyphosis, all its processes projecting, from the extreme emaciation of
the trunk.

In Eulenburg's adult case[38] the atrophy began in the hands, and was
regarded by him as a combination of true progressive muscular atrophy
in the upper, with lipomatosis musculorum luxurians in the lower
extremities.[39]

[Footnote 38: _Virch. Arch._, Bd. xlix., 1870.]

[Footnote 39: Cases of atrophy (often excepting deltoids): 1st case by
Seidel, "simultaneous paresis in upper and lower extremities in four
years; atrophy of arms and thighs, with hypertrophy of calves and fore
arms; in six years, primary atrophy sterno-cleido-mastoids and
pectorals; secondary atrophy of deltoids."

Further: case of Kaulich (atrophy of shoulder-muscles, including
deltoid, while triceps and biceps hypertrophied); Duchenne fils;
Eulenburg and Cohnheim; Heller (2 cases); Wagner (2d case); Wernich
(1st case); Lutz (a girl, case much resembling Eulenburg's adult case);
Roquette (atrophy of thighs as well); Hoffmann; Russel; Foster (atrophy
of muscles of forearm); Chrostek (notwithstanding hypertrophy of
tongue); Friedreich (2 cases); Duchenne (2d); Wagner (2d and 3d);
Gowers (9 cases); Ross (2 cases).]

Gowers attaches diagnostic importance to the early signs of atrophy in
the latissimus dorsi and great pectoral muscles. The time of their
invasion contrasts with that in progressive muscular atrophy, where the
process usually begins in the hands and creeps upward to the
shoulder-joint.

Neither the atrophic nor the hypertrophic process is necessarily
symmetrical on the two sides of the body, but an approximate symmetry
is usually observed. The same muscles are usually affected, and in the
same way, but not often precisely to the same degree. Fibrillary
contractions often occur in the wasting muscles, but not in those which
are hypertrophied. The electrical reactions, however, do not differ
greatly in the two states. The faradic contractility diminishes in
proportion to the diminution in the contractile mass of the muscle,
whether this be concealed by the growth of fat and connective tissue or
rendered obvious by the general wasting of the whole. But even when
contractions can be obtained, these are often abnormally feeble, and by
continual diminution in the number of contractile fibres, and increase
in the lipomatous masses overlying them, the electrical irritability is
ultimately lost. The excitability of the nerves remains intact, and
therefore response may be obtained by an indirect excitation after
direct excitation of the muscle fails to elicit one.

Eulenburg has occasionally observed one curious phenomenon in the
galvanic reaction of nerves. The anode opening contraction grows weaker
or even disappears with a progressively stronger current, and then with
a still stronger current reappears. This is due to a cross action of
the current on the excitability and on the conductibility of the nerve.
At a certain moment the increased excitability is compensated by a
corresponding increase in the resistance to conduction, and therefore
all electrical response ceases. Later, the resistance remaining the
same, the excitability is increased and the reaction reappears.

{567} The symptoms of the first order (disturbance of muscular
function) and of the third (deformity) are for a long time less
conspicuous in the upper than in the lower extremities. When the arms
begin to be paretic the patient is crippled in the characteristic
manoeuvres by which, during the earlier period of the disease, he
palliates the inefficiency of the lower limbs. When he can no longer
push up the trunk by means of his arms, he becomes unable to rise from
a sitting position at all. Further progress in the atrophy of the
erectores spinæ muscles renders even the act of sitting impossible: the
patient can only crouch, and ultimately must remain altogether
recumbent. The functions of the hands usually remain unimpaired to the
last, so that the unfortunate patient is able to amuse himself with
knitting and other light work.

Besides the paralytic cyphosis, scoliosis of a high grade is sometimes,
though infrequently, developed. It is due to the lateral oscillations
with excessive inclination of the upper portion of the trunk.[40]

[Footnote 40: Cases of scoliosis from such cause, where inequality of
muscular action cannot be invoked as a cause, help to throw light on
the real etiology of the idiopathic deformity so often attributed to
irregular muscular action.]

It is rare that any researches have been made on the nutritive
functions in pseudo-hypertrophic paralysis. Seidel[41] has analyzed the
urine in the two cases (brothers) which form the basis of his memoir.
He expected to find a marked diminution in the urea, corresponding to
the diminution in the mass and in the functional activity of the
muscles. This expectation was based on the assumption, at present
considered incorrect, that the elimination of urea is modified by
muscular contractions. In the cases examined the actual amount of urea
was considerable, rising on several occasions to 40, 43, and 69 grammes
in twenty-four hours, and offering, in the first boy, a daily average
of 41 grammes. But Scherer estimates that the average elimination of
urea in children is, per kilogramme, double that in adults; and on the
basis of this calculation the amount of urea eliminated by the patient
in question should have been 51 grammes. There was therefore a
diminution of about one-fifth.

[Footnote 41: _Atrophia Musculorum Lipomatosa_, Jena, 1867.]

Seidel has also examined the temperature of the diseased muscles during
their contraction either under the influence of the will or of the
faradic current. The hypertrophied gastrocnemius muscle showed a rise
of 1.5° to 2° less than a healthy gastrocnemius similarly excited. The
rise of temperature never occurred during the contraction, but during
the ten or fifteen minutes which followed it. The duration of this rise
of temperature was always longer than in the control experiment
performed on a healthy subject. The observation was the same in
hypertrophied and in atrophied muscles, and indicated a notable
diminution of heat-production in both.[42]

[Footnote 42: _Loc. cit._, p. 54.]

The mental functions are not unfrequently impaired. The defective
intelligence exhibited by several of his first patients led Duchenne to
attribute a cerebral origin to the disease. The internal hydrocephalus
discovered at the autopsy of the case so recently published by
Pekelharing suggests that this hypothesis may have been too hastily
abandoned, and that it may really prove to be correct for certain
cases. In many, however, the intelligence is intact or even precocious,
and all suspicion of cerebral lesion must be excluded.

{568} COURSE OF THE DISEASE.--As already stated, a period of paresis
may precede all signs of hypertrophy for several weeks, months, or even
years. From the time that the enlargement of the calves has once begun
about a year and a half is required before the maximum of hypertrophy
is attained. Then the disease usually remains stationary for two or
three years before the third period is ushered in by aggravation of
paralysis in the lower and by extension of paralysis, together with
hypertrophy or atrophy, to the upper limbs.

When, from complete loss of muscular power, the patient has become
permanently condemned to a recumbent position, life may nevertheless be
prolonged for ten or twelve years, with integrity of all the vegetative
functions. Death finally takes place, in all recorded cases, from some
acute pulmonary disease, whose effects are intensified by the atrophy
of the external respiratory muscles, which often extends even to the
intercostals.

The course of the disease, and consequent prognosis, is much modified
in the rare cases in which it attacks girls. Two of Duchenne's thirteen
cases were girls: in one the disease was spontaneously arrested, in the
other apparently cured. Lutz[43] relates the altogether exceptional
history of a family in which five female members were affected--two
sisters, also one step-sister, daughter of the mother by an earlier
marriage, a sister and niece of the mother, of whom a brother also was
diseased. The step-sister and niece both died at six years of age, but
the aunt lived to be forty-three (the brother to be forty-two), and one
of the girls observed by Lutz, who began to suffer at the age of six,
was twenty-eight at the time of observation: paresis had only become
marked at seventeen, and locomotion impossible at twenty-two. In the
other girl the first symptoms appeared at seventeen, and at twenty-two
were still moderate and confined to the lower extremities.

[Footnote 43: _Deutsches Archiv f. klin. Med._, Bd. iii., 1867.]

In Roquette's female case[44] the disease began at ten; in
Hoffman's,[45] at eleven and a half. These cases, with one of
Benedikt's, are the only female cases among the 88 I have analyzed.[46]
Gowers estimates 30 female cases out of a total of 220, or only 13 per
cent. of the whole.

[Footnote 44: _Inaug. Dissert._, Berlin, 1868, quoted by Friedreich.]

[Footnote 45: _Ibid._, 1867.]

[Footnote 46: This excludes the adult cases of Eulenburg, where
"progressive atrophy of the upper extremities combined with
pseudo-hypertrophy of the lower;" the case of Barth, an amyotrophic
lateral sclerosis; the case of Müller, a dementia paralytica; and the
case of Billroth, where the lesion was localized in the hamstring
muscles of one thigh.]

This great preponderance in the male sex is the first of three striking
peculiarities which distinguish the clinical history of the disease.
The second is its strangely-marked hereditary character. This is not,
and indeed hardly could be, shown in a direct line, since the patients
are incapable of marriage, or even die before arriving at maturity. But
several brothers in a family are usually afflicted. There was, it is
true, no trace of heredity in Duchenne's 13 cases, but this author
himself recognizes the frequency of hereditary influence in those
observed by others. Out of 81 cases analyzed by Friedreich, two or more
members of one family were attacked thirty-five times. Thus, the first
clinical report, that made by Meryon, described four brothers in one
family and two in another. Coste, Griesinger, Wernich, Benedikt, Adams,
Russel, Gowers, each relate cases of two members in one family; Heller,
Wagner, Billroth, {569} Seidel, have seen three: Moore[47] describes
three cases out of a family of seven, consisting of five boys and two
girls. Two of the cases I myself have seen were brothers. Gowers[48]
relates five cases in the families of two sisters who married two
brothers. This same writer refers to three other families in which two
brothers were affected; to a fourth family described by Clifford
Albutt, where two brothers were paralyzed, the third child dying of
Hodgkin's disease; finally, to the family of a clergyman, himself
living to the age of seventy-four, having always had large calves, and
out of whose eight children two boys and one girl were affected.

[Footnote 47: _Lancet_, 1880.]

[Footnote 48: _Loc. cit._, Appendix.]

The families invaded by this singular disease are often remarkably
large, and even where several children are affected, many others, even
boys, escape. The morbid inheritance is always through the mother,
"thus through the ovum--a condition unknown in diseases of the nervous
system" (Gowers). This peculiarity belongs to only one other disease,
hæmophilia, also almost limited to males. The third fact, which from
its all but universality is shown to be of fundamental importance, is
that the disease begins during infancy or early childhood. It has been
shown that more than two-thirds of all cases began before the age of
six. Whether there is ever an intra-uterine origin is still doubtful
(Friedreich). This early invasion, often coinciding with the first
efforts to walk or to use the muscles which are first attacked,
distinctly separates pseudo-hypertrophic paralysis from all diseases
which can be traced to definite accidents or to perversion of
functions. It implies a profound perversion of nutrition, or rather a
misdirection of developmental force.

PATHOLOGICAL ANATOMY.--The anatomical lesions of pseudo-hypertrophic
paralysis are to be sought first in the muscles, afterward in the
spinal cord, upon which so many peripheric lesions of the
nervo-muscular system have recently been shown to depend. The argument
from analogy, therefore, has of itself almost sufficed to create a
conviction that some disease of the central nervous organs must exist
as the real basis of pseudo-muscular hypertrophy.[49] Nevertheless, as
will presently be shown, the present evidence in favor of such
hypothesis is extremely small.

[Footnote 49: This conviction is fully expressed by Hammond, _loc.
cit._]

Muscular Lesions.--In the muscles, however, the anatomical changes are
profound and varied. They may be divided into three kinds--those
affecting the muscular fibre itself; those touching the connective
tissue; and, finally, the fat deposited in this.

The lesions of these different elements are variously combined with
each other in different muscles, and also at different stages of the
disease. Thus, in the muscles of the trunk and upper extremities
affected with primary atrophy the increase of fat is always moderate
and quite insufficient to compensate the wasting of the contractile
mass, while in the gastrocnemii and gluteal muscles the hypertrophied
masses are often found to consist entirely of fat, traversed by bands
of connective tissue, and indistinguishable from a lipoma.

The muscles have been examined in two ways--in the course of a general
post-mortem examination, and also during life by means of excision or
extraction by various instruments. Griesinger in 1864[50] excised a
piece {570} of the deltoid in a boy of thirteen,[51] and made on it,
with Billroth, the first microscopic examination of the diseased
muscles. Duchenne, to avoid an operation not devoid of danger for the
patient, devised his harpoon, by means of which small fragments of
muscles could be torn away. As this instrument is liable to change the
relations of the parts separated by tearing, Leech has contrived
another, in which the fragment is removed by cutting. By one method or
another of harpooning the muscular lesions have been studied during
life by Duchenne, Heller, Wernich, Russel, Eulenburg, Martini, Knoll,
Rakowac, Friedreich, Ross, Gowers, Auerbach, Hammond, Pepper, in the
cases already quoted.

[Footnote 50: _Archiv der Heilkunde_.]

[Footnote 51: The wound suppurated for a long time.]

Muscular Fibre.--There are contradictory opinions in regard to the
first stage of alteration in the muscular fibres. According to most
observers, the fibres are seen to directly atrophy; the transverse
striæ become dim and gradually disappear, and the primitive bundles
shrink in diameter from loss of some of their fibrillæ (Brieger,
Hammond, Pepper). Friedreich[52] adds that the complete collapse of the
contractile substance in the primitive bundles often leaves empty or
shrunken sarcolemma sheaths, which swell the mass of the connective
tissue. Friedreich, however, denies that the striation is modified; and
its extreme fineness, commented upon by Duchenne, is considered by
Ollivier[53] and Ranvier as devoid of pathological significance.

[Footnote 52: _Loc. cit._, p. 300.]

[Footnote 53: _Des Atrophies musculaires_, Thèse d'Agrégation.]

The real size of the primitive fibres is best estimated by the method
of Cohnheim, who isolated the fibres by boiling the muscular fragment
from four to six hours in a mixture containing 100 c.c. of 90 per cent.
alcohol and ¾ c.c. of concentrated muriatic acid. Many were found
reduced to one-fifteenth or one-sixteenth their normal size.[54]
Between atrophied fibres lay a peculiar striped tissue, probably
composed of empty sarcolemma sheaths. Side by side with these atrophied
fibres were many normal, and others grossly hypertrophied to two or
even three times the normal calibre. These were only found in the
hyper-voluminous muscles. Some of these exceeded the largest
frog-muscle fibres. They lay in bundles of four to six between the
small fibres, and seemed to be about equally distributed through the
hypertrophied gastrocnemius and atrophied biceps.[55]

[Footnote 54: _Berlin. klin. Wochensch._, 1865, No. 56.]

[Footnote 55: Hypertrophied fibres have also been seen by Knoll
(_Medizin Jahrbuch._, Wien, 1872), Müller, and Eulenburg.]

Another alteration observed in the muscular fibres was their
dichotomous and even trichotomous division. This same lesion has been
seen by Friedreich in progressive muscular atrophy.

The presence of hypertrophied fibres in wasting muscles lends a special
significance to the cases of true muscular hypertrophy described by
Auerbach[56] and Hitzig.[57] Auerbach's observation related to a
soldier aged twenty-one, whose upper arm became rather rapidly
hypertrophied and paretic. In a fragment excised from the enlarged
biceps the fibres were seen to have a diameter of from 96 to 180 µ.
(the normal diameter being 33 to 67 µ.). The other arm was not
enlarged, and yet examination of fibres obtained by means of a similar
excision found them also enlarged. Auerbach suggests that this
hypertrophy constituted a preliminary stage {571} in the general
process of pseudo-hypertrophic paralysis. In it, as when the excessive
volume is known to depend upon the presence of non-contractile tissue,
the arm, far from increasing in strength, was paretic.[58]

[Footnote 56: _Virch. Arch._, Bd. liii., 1871.]

[Footnote 57: _Berlin. klin. Wochen._, Dec. 2, 1872.]

[Footnote 58: Mobius (_loc. cit._) declares that neither of these cases
bears any relation to pseudo-hypertrophy.]

Connective Tissue.--Far more conspicuous than the alterations in the
contractile fibre of the muscles are those of its connective tissue.
The perimysium internum, between the primitive bundles, proliferates
abundantly, and the hyperplasia gradually extends correlatively with
the wasting of the muscular fibres, until the hypertrophied mass is
mainly composed of connective tissue. Broad bands replace the thin
lamellæ normally present between the primitive bundles; the parenchyma
of the muscle seems stifled in a sclerosis. It is then that it offers
the feeling of stony hardness so often noticed in the clinical history.

Charcot, Knoll, Müller, and Barth describe a rich development of nuclei
and of spindle-shaped cells in this new connective tissue, this being
especially abundant in the neighborhood of the small vessels and in
their adventitia. Eulenburg and Leyden, however, affirm that the
connective tissue is unusually poor in nuclei, and thence infer that
the hyperplasia is compensatory, and not due to inflammation.

In some cases, as in those of Duchenne examined by Ordonez, the
sclerosis and atrophy of contractile tissue constitute the entire
lesion of the muscle. Only a few fat-cells are interspersed among the
bands of connective tissue or penetrate between the primitive bundles.
The fatty infiltration tends constantly to increase, apparently by the
same process as governs the growth of normal adipose tissue--namely,
the deposit of fat in connective-tissue cells; and ultimately not only
muscular fibre, but the hyperplastic connective tissue, is concealed in
a yellowish glistening mass indistinguishable from a lipoma.[59]

[Footnote 59: See case of Billroth.]

The growth of fat contributes to the apparent hypertrophy of the
diseased muscles, but much less so than does the hyperplasia of
connective tissue which invariably precedes it. Great rapidity of fatty
infiltration marks a more rapid and irresistible progress in the
disease, a lower stage of nutritive degradation. Fat-cells are found
penetrating between the primitive bundles of fibres in the atrophied as
well as in the hypertrophied muscles; but there the fatty substitution
is always much less complete.

In contrast with this fatty infiltration true fatty degeneration of the
muscular fibre is as rare in pseudo-hypertrophy as in progressive
muscular atrophy. This fact is emphasized by Pepper from observation of
the harpooned fragment examined by him,[60] also by Cohnheim.[61] In
Meryon's first case,[62] however, the post-mortem examination of the
muscular fibres found them "totally degenerated, their substance
changed into a mass of granules and oil-globules, while the sarcolemma
was destroyed." In Brieger's case[63] the fibres were filled with
fat-globules.

[Footnote 60: _Philada. Med. Times_, 1871.]

[Footnote 61: _Loc. cit._]

[Footnote 62: _Med.-Chir. Trans._, vol. xv., 1852.]

[Footnote 63: _Deutsches Archiv_, Bd. xxii.]

The sclerotic process which precedes the stage of fatty infiltration is
far from being completed when this latter begins. Both processes,
initiated nearly at the same time, continue together, and at the death
of the patient may be found existing in about equal proportion, or the
one {572} markedly predominating over the other. In cases of long
duration the hypertrophied muscles, as already stated, are found
converted into masses of fat, divided by stripes and bands of
connective tissue. With death earlier in the disease the enlargement is
found to be due to masses of connective tissue englobing muscular
fibres and interspersed with fat-cells.

In the wasted whitish-red muscles the proliferation of connective
tissue is sometimes more, sometimes less, marked; in the pale-yellowish
muscles fat accumulates by interstitial deposit, but does not overlay
and conceal the remnant of muscular fibre.

Central Nervous Organs.--While the examinations of the diseased muscles
have been frequent, post-mortem examinations are still relatively few,
although their records are rapidly increasing. The first was made by
Meryon[64] on the first of his series of six cases. Charcot has
examined a case for Duchenne; Cohnheim has made a celebrated autopsy
for Eulenburg;[65] Gowers and Clarke have together published a
fourth.[66] The cases by Müller and Barth are still habitually--though,
as we shall see, erroneously--included among the autopsies of
pseudo-hypertrophic paralysis. Ross[67] and Leach have, however, a
fifth indubitable case with autopsy; and more recently Cornil,[68]
Brieger,[69] Bay,[70] Schultze,[71] Pekelharing,[72] and possibly Goetz
and Drummond,[73] have all described post-mortem examinations. The data
for discussion, therefore, are to be derived from 14 cases. Of these,
the spinal cord was found perfectly healthy in 7, those related by
Meryon, Cohnheim, Charcot, Cornil, Brieger, Bay, Schultze--all most
competent observers. The cases by Barth and Müller require some special
consideration, for, although rejected as irrelevant by most authors,
Hammond still adduces them in proof of the central origin of
pseudo-hypertrophic paralysis.

[Footnote 64: _Loc. cit._]

[Footnote 65: _Loc. cit._]

[Footnote 66: _Med.-Chir. Trans._, 1874; also monograph by Gowers.]

[Footnote 67: _Loc. cit._]

[Footnote 68: _Union méd._, 1880.]

[Footnote 69: _Deutsches Archiv f. klin. Med._, Bd. xxii. H. 2.]

[Footnote 70: _Virch. Jahresb._, 1877.]

[Footnote 71: _Virch. Arch._, 1879, Bd. lxxv.]

[Footnote 72: _Arch. Virch._, Bd. lxxxix., 11, 2, 1882.]

[Footnote 73: Quoted by Pekelharing--the first from the _Aerztliches
Intelligenz Blattmünchen_, 1879; the second from the _Lancet_, 1881,
vol. ii., No. 16.]

Müller's case[74] is that of a woman thirty-four years of age who at
the age of four fell out of bed, and from that time began to walk with
difficulty, and ultimately acquired a double talipes equinus. The right
leg atrophied, the left remained of tolerable thickness. At the age of
thirty-four she was admitted to an insane asylum during the incipient
stage of dementia paralytica, and death occurred two years later of
pneumonia. The autopsy showed--1st. That the calf-muscles on both sides
were converted into masses of fat, streaked with whitish-red remnants
of muscular tissue. The short muscles of the feet were atrophied; all
the other muscles of the body normal. 2d. In the brain the
blood-vessels showed a thickening of the adventitia by delicate
connective-tissue fibrillæ, between whose meshes nucleated cells were
strewed. The ependyma of the ventricles was thickened and granular, and
their cavity was filled with serous effusion. 3d. In the cord was found
diffused degeneration, especially of the lateral columns, consisting in
thickening of the interstitial connective tissue, with proliferation of
its cells; atrophy of a part of the primitive nerve-fibres with
granular degeneration of the {573} medullary sheath, and occasionally
atrophy of the axis cylinder. The adventitia of the blood-vessels was
thickened, the perivascular spaces dilated. In the central gray
substance the ganglion-cells were everywhere intact, but the
intercellular substance was thicker, and seemingly composed of a thick
net of stout, finely-granular fibres. Traces of an infantile
polio-myelitis were found in the lower part of the lumbar enlargement
(atrophy of the anterior cornua, especially the right, together with
their ganglion-cells).

[Footnote 74: _Beiträge zur pathol. des Ruckenmarkes_, 1871.]

The final lesion of importance was the obliteration of the central
canal, which was moreover surrounded by a dense ring of connective
tissue. In this case the suddenness of the original paresis, the
atrophy of the right leg, and the lesions of the lumbar cord found at
the autopsy prove that the initial disease was an acute anterior
polio-myelitis. Upon this a very localized pseudo-hypertrophy seems to
have been grafted during childhood, while in adult life a chronic
lepto-meningitis and internal hydrocephalus were certainly the cause of
the symptoms, and probably of the lesions in the cord.

That such lesions in the cord may be the consequence of chronic
hydrocephalus is well argued by Pekelharing in regard to his own
recently published case, which in some respects closely resembles that
by Müller. The patient was a boy in whom muscular paresis was
congenital, and who from birth had exhibited deficient intelligence
with an abnormally large head. At the autopsy, made at fourteen,
ventricular effusion was found in the brain, and in the cord irregular
dilatation of the central canal and great dilatation of blood-vessels
and accumulation of leucocytes in its immediate neighborhood. Some
ganglion-cells in the inner and anterior groups of the anterior cornua
were shrunken and deprived of their prolongations. The author suggests
that in this case the cerebral hydrocephalus was the primary disease;
that the central canal in the spinal cord was dilated by extension of
the effusion from the brain; that a partial reabsorption of such
effusion had caused hyperæmia ex vacuo in the tissue immediately
surrounding the canal; and that the emigration of leucocytes and
partial alteration of the ganglion-cells both resulted from this
hyperæmia.

In Müller's case the central canal and adjacent tissue were also the
part of the cord most diseased; but the canal was obliterated by
proliferation of the ependyma, not dilated. In Barth's case also[75]
the central canal of the cord was found obliterated. The patient was a
man of forty-four, who since the age of forty had suffered from
stiffness in the left ankle and difficulty of walking. After a year the
stiffness extended to the right ankle; in two years the paresis had
mounted to the thighs, and was accompanied by severe pains. Paresis and
pain then appeared in the upper extremities, which gradually atrophied.
After two years the patient was entirely confined to bed, and two years
later was unable even to sit up. Later, the muscles of the neck became
hypertrophied. No mention is made of perceptible hypertrophy in other
muscles, nor of contractions or tremors other than fibrillary. But at
the autopsy was discovered a lateral sclerosis extending the entire
length of the cord, associated with partial atrophy of the
ganglion-cells in the anterior cornua. In both the gray and white
substances the blood-vessels were dilated, and, {574} as already
stated, the central canal was obliterated. The brain was healthy. The
supinators of the upper extremities, the gastrocnemii at the lower,
were richly infiltrated with fat streaked with long bands of connective
tissue; the remaining muscles were atrophied.

[Footnote 75: _Archiv der Heilkunde_, xii. 2, 1871.]

The anatomical lesions in this case are identical with those of the
special symptom-complex described by Charcot as amyotrophic lateral
sclerosis. Certain symptoms of lateral sclerosis are wanting to
complete the clinical history, but at least as many are lacking for a
typical history of pseudo-hypertrophic paralysis. Only the muscles of
the neck hypertrophied: the gastrocnemii and adductors, primarily
atrophied, later regained some of their original size. The fatty
infiltration of the calf and muscles was unattended by
pseudo-enlargement or by retraction: it resembled a fatty substitution
due to nerve-paralysis, rather than the hyperplastic process of
pseudo-hypertrophy.

Setting aside the three foregoing cases, three remain which, together
with an unimpeachable history of pseudo-hypertrophic paralysis, show
positive lesions in the spinal cord. The first and the most famous was
made upon a patient of Gowers by Lockhart Clarke.[76] Changes were
found scattered through the entire length of the cord. "In the upper
cervical region were patches of incipient disintegration in the gray
network of the lateral portion of the cord, the lateral white columns
being healthy. Here and there in the gray substance of the anterior and
posterior cornua the intercellular matrix was wasted and disintegrated,
especially in the neighborhood of the blood-vessels and at the bottom
of the anterior median fissure. Here were accumulated globules of
myeline and other débris of nerve-tissue. The blood-vessels were
distended, their perivascular spaces enlarged. Patches of
disintegration of nerve-fibres of the lateral and posterior columns
were seen in the lower cervical and in the dorsal regions. Globules of
myeline and masses of fatty matter were at some points accumulated at
the entrance of the posterior nerve-roots, and even, to a much less
extent, adjacent to the anterior roots. The most extensive lesion
existed in the lowest part of the dorsal region. In the lateral gray
substance on each side was an area of softening containing an actual
cavity just outside each posterior vesicular column. The latter
remained undamaged.

"The anterior cornua throughout the cord were perfectly normal, though
the processes of the cells were perhaps less distinct than elsewhere.
Further, notwithstanding the spots of disintegration in the lateral
columns there was in them no change comparable to that of lateral
sclerosis."[77]

[Footnote 76: _Med.-Chir. Trans._, 1874.]

[Footnote 77: This autopsy was made on a boy of fifteen, in whom the
calves began to hypertrophy at three, and reached their maximum size at
five.]

The second post-mortem was made by Ross on a patient belonging to
Leech: "In the lumbar region of the cord the normal loose and spongy
texture of the central column was replaced by a somewhat dense and
fibrillated tissue, in which no trace of ganglion-cells could be found.
The blood-vessels were enlarged and their walls thickened. In the
anterior cornua the ganglion-cells had completely disappeared from the
median area, the anterior group, and from the margins of all the other
groups. This atrophic process extended into the dorsal and cervical
{575} region, and in the latter the central column was changed in the
manner already described."[78]

[Footnote 78: _Loc. cit._, p. 207. Patient was nine years old at time
of death; the disease had begun with paresis at two; was well developed
at nine.]

The third autopsy is recorded by Drummond in the _Lancet_ for 1881
(vol. ii.): The subject was a boy of fourteen, who never walked after
the age of six. There was found, as the author shows by some good
drawings, disintegration in the lateral gray network of fibres halfway
between the anterior and posterior horns, extending more or less
throughout the cord. In the left lumbar region the tissue had broken
down, and a cavity existed filled with serum, which bulged out the wall
of the cord, forming an apparent tumor.

Several circumstances are common to all the foregoing five cases. In
all, the patients during life had exhibited paresis and atrophy of a
large number of muscles (in Barth's case nearly all), with
pseudo-hypertrophy of some muscles of the lower extremities. In all,
the post-mortem found fatty substitution for muscular fibre in both the
atrophied and the hypertrophied muscles. Finally, in all, the lesions
found in the cord were principally grouped about the central canal.
This was dilated (Pekelharing) or obliterated (Müller, Barth); the
hyperæmia was always most intense in its vicinity; and it was in the
lateral gray substance adjoining, or in the gray network between it and
the lateral white columns, that patches of disintegration were
principally noted (Clarke, Ross). Negatively, the absence of any
extensive lesion of the anterior cornua is noteworthy in all the cases
but one; and here this lesion was evidently secondary to the lateral
sclerosis (Barth). On the other hand, the differences between these
cases were as numerous as the resemblances. Two resembled each other in
the presence of cerebral symptoms and of an internal hydrocephalus to
account for them (Pekelharing, Müller); in one alone was there lateral
sclerosis (Barth); in one, cavities in the lateral portion of the
central gray column (Clarke); in one, traces of an acute polio-myelitis
(Müller), Finally, in only three cases (Clarke, Ross, Drummond) was the
clinical history perfectly characteristic of the disease.

Comparing these facts with the others, equally significant, where the
autopsy in cases of pseudo-muscular hypertrophy has shown the central
nervous organs to be perfectly healthy, we should be led to
conclude--1st. That if fatty substitution in the muscles is ever to be
associated with lesions of the spinal cord, these are to be sought in
the central gray substance surrounding the central canal. 2d. That,
nevertheless, muscular lesions similar, if not in all respects
identical, can develop as the result of an idiopathic process depending
on causes at present unknown. 3d. That atrophy of muscular fibre and
replacement of it by lipomatous fat are probably determined in several
different ways, and must often be regarded as merely secondary
processes;[79] but that the muscular lesion characteristic of
pseudo-hypertrophy, considered as an idiopathic disease, is the
hyperplasia of connective tissue which originates in the perimysium
interum of the muscles. This lesion was well marked in the Ross-Leech
case, much less distinct in the three we have noted as doubtful
(Gowers).

[Footnote 79: See Leyden's remarks in his essay "Ueber Polio-myelitis
und Neuritis," _Zeitschrift für klin. Med._, 1880.]

{576} PATHOGENY.--These last conclusions, if valid, supersede the
necessity for prolonged discussion of the question whether
pseudo-hypertrophic paralysis be a peripheric disease or central
disease. By the latter term authors almost invariably mean a disease
dependent on morbid processes in the spinal cord. Hammond is almost
alone in affirming that these exist, and bases his opinion on only
three autopsies, of which two are the doubtful cases of Müller and
Barth. Mobius,[80] recognizing the frequent absence of spinal lesions,
nevertheless claims that the hereditary, frequently congenital, nature
of the disease proves that it inheres in the nervous system. Gowers,
however, points out that the exclusive inheritance through the
mother--that is, from the ovum--is a circumstance unknown in nervous
diseases. This mode of inheritance is observed in hæmophilia, which
also resembles pseudo-hypertrophy in being almost confined to males.

[Footnote 80: _Volkmann's Sammlung_, No. 171.]

The pseudo-muscular hypertrophy of children so strikingly resembles in
many particulars the progressive muscular atrophy of adults that the
theory of their essential identity could not fail to suggest itself.
Friedreich unhesitatingly advocates this theory. Many of the facts
which support it become for him additional confirmation of the
peripheric nature of the adult disease, where, nevertheless, the
anterior ganglion-cells of the cord are habitually found atrophied.[81]

[Footnote 81: According to the Friedreich theory, the lesion of the
anterior cornua is coincident with or consecutive to degeneration of
the other extremity of the nervo-muscular motor apparatus.

Lichtheim, _Arch. f. Psych._, viii., quoted in _Brain_, 1879, vol. ii.,
No. 1, quotes a case of progressive muscular atrophy with typical
changes in the muscles, but unaccompanied by the slightest change in
the nerves or nerve-roots, large ganglion-cells of the anterior cornua,
or other part of the spinal cord. The author agrees in regarding the
nearly allied pseudo-hypertrophic paralysis as a peripheric affection.
See also Hayem.]

Eulenburg thus sums up the relations between progressive muscular
atrophy and pseudo-hypertrophic paralysis: In both diseases the
fundamental muscular lesion consists in a chronic irritative process,
which starts from the interstitial connective tissue, and secondarily
affects the muscular fibre. In children, pseudo-hypertrophy of the
muscles of the lower extremities is regularly followed by primary
atrophy of many of the muscles in the upper half of the body, and
secondary atrophy in almost all. In a case of Eulenburg's the two
typical diseases seemed to coexist in the same patient, an adult woman.
More frequently they coexist in the same family, as in the observation
by Russel, where two brothers suffered from progressive atrophy, a
third from pseudo-hypertrophic paralysis.

Pick[82] relates a case where a typical atrophy of the upper
extremities and of the trunk was accompanied by moderate hypertrophy of
the calves, with proliferation in the calf-muscles of the interstitial
fat and connective tissue. Charcot admits a special form of atrophia
musculorum lipomatosa which complicates progressive muscular atrophy,
and is associated, therefore, with atrophy of the anterior
ganglion-cells; with which, however, it has no direct connection.

[Footnote 82: "Ueber einen Fall von progressive muskel atrophie,"
_Archiv für Psych._, Bd. vi., 1876.]

The adult and infantile muscular diseases differ by the remarkable, and
sometimes even colossal, apparent development of the calf-muscles
through the excessive development in them of fat and connective {577}
tissue--by the fact that the latter disease invariably begins in the
lower extremities, and is almost peculiar to childhood, while the
progressive atrophy begins in the upper half of the body, and usually
the hands, and is as nearly exclusively limited to adult life. For both
diseases may be admitted, with Friedreich, "a congenital nutritive and
formative weakness of the striated muscle-substance" (Gowers). But, we
may add, in progressive atrophy this does not become manifest until the
muscles have been for many years subjected to the strain of constant
employment: in pseudo-hypertrophy the nutritive failure appears early
in the flagging of the developmental forces at the moment that these
are strained in muscular growth.

It would perhaps be more correct to ascribe the error of development to
a perversion of nutritive forces rather than to their weakness. For
there is no arrest in the general development of the limbs, such as
occurs after infantile spinal paralysis: the bones grow normally; the
initial lesion is hyperplasia of the connective tissue--possibly, also,
true hypertrophy of the muscular fibre. The wasting is secondary.
Perhaps the terminal nerve-plates, or else the capillary network on the
outside of the primitive bundles of muscle-fibre, does not grow in
proportion to the increasing mass, and therefore becomes insufficient
for its nutrition (Auerbach).

The question arises whether the primitive error of development does not
lie in the capillary network. Ranvier has shown that the capillaries of
muscles are specially adapted to them, being disposed in quadrangles,
at whose corners the vascular canal dilates into little pouches. It is
surmised that these pouches serve as reservoirs to hold an extra supply
of blood for the moment of contraction.[83] If such specialty of
structure be necessary for the proper accomplishment of the muscular
contraction, it is evident that any congenital defect in the
arrangement of the blood-vessels might disturb in many ways the balance
of muscular nutrition. The absence of vascular reservoirs, for
instance, would render the supply of blood during the contraction
insufficient: the contraction must then be inadequate or exhausting,
and the physiological stimulus to the growth of the muscle wanting. On
the other hand, the capillaries being, by the hypothesis, adapted to
the lower type which nourishes connective tissue, this would become
nourished at the expense of the contractile fibre, and the known
hyperplasia would result.

[Footnote 83: _Cours d'Anatomie au Collège de France_, 1880.]

That morbid vascularization exists, is shown by the peculiar mottled
appearance of the skin, which has often been interpreted as a proof of
vaso-motor paralysis (Duchenne). On such an hypothesis, further, the
curious and otherwise inexplicable relations between pseudo-hypertrophy
and hæmophilia[84] would be explained. The one or the other hereditary
disease would be due to imperfection in the blood-vessels--here of
structure, there of architecture. This imperfection could be directly
traced to the mesoblast in the embryo, in which the vascular tissues
exclusively originate. Whether we should admit the bold speculation of
His[85] that the tissues of the mesoblast are exclusively derived from
the ovum, while {578} the archiblastic tissues--the nervous, muscular,
epithelial, and glandular--come from the substance of the spermatozoa
fused with it, is beyond the scope of this paper to discuss. But were
this speculation well founded, the independent morbid tendencies of the
mesoblast would be rendered by so much the more plausible.

[Footnote 84: Part of which do not exist between pseudo-hypertrophy and
progressive atrophy, since the latter disease is not exclusively
inherited through the mother.]

[Footnote 85: _Unsere Körper Form_.]

The fact that the disease begins in the extensor muscles of the lower
extremities is probably to be explained by the rapid development of
these muscles during early childhood, and by the functional strain
imposed on them during the effort of learning to walk. It is thus
really analogous to the début of progressive atrophy in the muscles of
the hands of adults--the muscles whose functional activity is the most
incessant and the most complex during adult life.

The preponderance of the disease in males remains unexplained, unless
it be that the greater extent of muscular development in the male
necessitates a greater intensity of developmental force for the
muscles, whose deficiency, therefore, would earlier be made manifest.

DIAGNOSIS.--The diagnosis of pseudo-hypertrophic paralysis can never be
difficult in typical cases and at an advanced period of the disease.
During the early period the diagnosis rests on the gradual diminution
of force in the lower extremities, without atrophy or with apparently
excellent development of their muscles; the straddling of the legs,
lordosis, and lateral oscillation, all at first slight, but constantly
becoming more and more emphasized; the peculiar method of rising by
placing the hands on the knees and then gradually climbing up the
thighs. In the second period the enlargement of the calf or other
muscles of the lower limbs, in the third the extension of the paresis
to the upper extremities, associated with wasting of the pectorals and
usually some of the extensors of the back, confirm beyond question the
diagnosis. This may be further established by examination of small
fragments of muscular fibre removed by means of the harpoon or trocar,
and the repeated examinations, which serve, moreover, to mark the
progress of the disease.

Few diseases require to be differentiated. One very rare disease that
might be confounded with pseudo-hypertrophy is the infantile form of
progressive muscular atrophy. This is distinguished from the ordinary
form of atrophy by beginning in the muscles of the face,[86] especially
the orbicularis oris, from whose defective contractility the lips
become thick and motionless. The morbid process then progresses
downward, and is thus in notable contrast with that of
pseudo-hypertrophy, which invariably begins in the lower limbs and
extends upward, invading the face only by exception.

[Footnote 86: Duchenne has seen seventeen cases of this disease.]

It is probably after the establishment of talipes equinus and of
flexions at the knee- or hip-joint that pseudo-hypertrophy would be
most liable to be confounded with infantile atrophic paralysis. In the
latter, however, the talipes is much more rarely double, and, if
existing, is usually complicated with varus. At an advanced stage of
pseudo-hypertrophy the enlargement of the calf is apt to be confined to
its upper part, and the retraction of the lower half simulates atrophy,
even when this has not really set in. At this stage, moreover, the
thighs and gluteal regions are usually atrophied, so that the
resemblance to an atrophic paralysis may be considerable. This may be
still further increased in those rare {579} cases of extensive
polio-myelitis, where paralysis of one or more of the upper extremities
coincides with lumbar paraplegia. It is extremely rare, however, that
both arms are paralyzed and atrophied,[87] while this is the rule, with
approximative symmetry, in pseudo-hypertrophy. In the latter disease,
moreover, there are paralysis and atrophy of the muscles of the trunk
and abdomen, which is scarcely ever seen, and never to the same extent,
in atrophic paralysis. The reflex excitability is lost in the latter
disease, as also the faradic; the latter, often intact in
pseudo-hypertrophy, rarely is quite abolished. Finally, the history of
the case is generally decisive: gradual development in the one, sudden
onset, with immediate maximum intensity of paralysis, in the other;
primitive wasting of the paralyzed muscles in the spinal paralysis,
enlargement preceding the atrophy in the pseudo-hypertrophic paralysis.

[Footnote 87: A patient described by Eulenburg was affected by such
general paralysis, but recovered after five months' treatment.]

Rachitis, with its frequent polysarcia and paretic gait, might
sometimes lead to a suspicion of muscular pseudo-hypertrophy, as,
conversely, the earlier symptoms of the latter disease may be
erroneously referred to rachitis. The error is all the more facile
because children afflicted with pseudo-hypertrophy are not unfrequently
rachitic, and the symptoms of specific paralysis and muscular sclerosis
may easily seem to deepen out of those of muscular inertia and
subcutaneous fat which are due to the nutritive diathesis. The
consistency of the enlarged limbs is, however, different--soft and
flabby in rachitis, hard, even stony, in pseudo-hypertrophy. When in
the latter the subcutaneous fat is atrophied instead of increased, the
muscles seem to make hernial protrusions through the emaciated skin.

Congenital cerebral disease, due to intra-uterine lesion, causes
imperfect walking, and even contraction of the calf-muscles, which may
simulate the analogous symptoms of pseudo-hypertrophic paralysis. But
the trunk is bent straight forward, and not bent in lordosis; the lower
extremities tend to cross in spastic paraplegia; there is no lateral
oscillation of the trunk, and the faradic contractility is always
preserved. The progress of the diseases suffices to decide all doubts.

TREATMENT.--The excessively bad prognosis of pseudo-hypertrophic
paralysis may be inferred from the foregoing description. Duchenne
claims to have had two cases brought to him at the early stage of the
disease. The first (Obs. 9) was a boy attacked at the age of seven and
a half with paresis of the lower extremities. He soon began to walk
with a straddling gait, lordosis, and lateral oscillation. Thirty-four
months later some enlargement of the calves was noticed, but the
disease remained stationary for six months, when the patient was
brought to Duchenne. He was treated by hydro-therapeutics, massage, and
faradization of the affected muscles. Cure was complete in six months.

The second case, (Obs. 13) was a little girl six and a half years old.
Paresis of the lower limbs began at the age of four and a half, and
rapidly increased. The legs and thighs began to enlarge shortly after
the first appearance of the paresis. Treatment began in about a year,
and was conducted as in the first case, but in addition cod-liver oil
and bitters were administered internally. Cure after a few months'
treatment.

Duchenne refers the beneficial effect of the faradic current to a {580}
stimulating action on the vaso-motor nerves and capillary circulation,
which he assumes to be paralyzed in this disease. The important point
is to exert this stimulus before the hyperplasia of the connective
tissue is far advanced.

Benedikt claims to have improved five cases by galvanization of the
sympathetic. But the treatment was certainly based on an erroneous
theory of the disease, and the alleged results must be received with
caution.

Uhde[88] claims to have arrested the progress of the disease in the
gastrocnemii muscles by a double tenotomy operation performed for the
relief of pes equinus. The patient was a boy of eleven, in whom the
disease had begun at the age of five. At the time of observation all
the muscles of the legs, as also the glutæi and sacro-lumbales, were
hypertrophied. The feet could not be brought to the ground, owing to
retraction of the calf-muscles: standing and walking were entirely
impossible, and even the power to move the limbs in a recumbent
position was very much limited. Faradization during a fortnight
produced no effect. Then the tendons were cut, and faradization
continued. In a month the patient could execute slight movements in
bed; three weeks later he could walk along the ward; and four months
after the operation he could walk alone and with the soles of the feet
flat on the ground. The calves were softer than before, and diminished
in circumference. But as the history stops here, it is possible that
the two latter changes depended on a substitution of fatty infiltration
for sclerosis. By this, moreover, the muscular fibre would be less
compressed, and in its temporary liberation would for a while seem to
regain part of its force. The last case of alleged recovery that we
have seen is by Donkin.[89]

[Footnote 88: _Langenbeck's Archiv für Chir._, Bd. xvi., 1874.]

[Footnote 89: _Brit. Med. Journ._, 1882, vol. i.]

Gowers remarks[90] that treatment must be directed rather against the
effects of the morbid process than against the morbid process itself,
which, as a primary error of development,[91] must be, to a large
extent, beyond our influence. As internal remedies, Gowers recommends
arsenic, phosphorus, and cod-liver oil, noting that iron and strychnine
seem to have no effect.

[Footnote 90: _Loc. cit._, p. 52.]

[Footnote 91: Gowers says, "of the muscular tissue," but we have shown
reasons why this should rather be sought in the blood-vessels of the
part.]

Faradization also, which is nearly always used, must have nearly always
disappointed expectation, or more cures would be recorded. Systematic
muscular exercises are recommended as the appropriate physiological
stimulus to muscular growth. But in view of the fact that precisely
those muscles are earliest and most profoundly affected which are
exposed to the most strenuous influence of this stimulus, it is
theoretically doubtful whether this advice be valuable.




{581}

DISEASES OF THE SKIN.




{582}

{583}

DISEASES OF THE SKIN.[1]

BY LOUIS A. DUHRING, M.D., AND HENRY W. STELWAGON, M.D.

[Footnote 1: In the general arrangement and order of diseases the
classification adopted by the American Dermatological Association has
been followed.

For obvious reasons, personal references are almost entirely omitted in
the text, but the authors desire to acknowledge valuable suggestions
derived from the writings of J. C. White, R. W. Taylor, L. D. Bulkley,
J. N. Hyde, W. A. Hardaway, A. R. Robinson, H. G. Piffard, A. Van
Harlingen, G. H. Fox, and others.]


CLASS I.--DISORDERS OF SECRETION.


Hyperidrosis.

Hyperidrosis, or excessive sweating, is a functional disturbance of the
sweat-glands characterized by an increased flow of sweat. It may be
local or general, slight or excessive. As a local affection, the form
which mainly interests the dermatologist, it occurs usually about the
hands and feet, especially the palmar and plantar surfaces, and also
about the axillæ and genitalia. If the secretion is excessive,
maceration of the epidermis results, with tenderness, and even
inflammation, of the parts as a consequence: this is not infrequently
the result when the feet are involved, a sodden appearance of the parts
being not unusual. The affection may be acute or chronic, the latter
usually being the case. It is purely a functional disorder, no
anatomical changes taking place in the glands or surrounding tissues.
There is no change in the nature of the secretion. Debility is usually
the fault in general hyperidrosis. The causes of the local varieties
are in many cases obscure. Faulty innervation is doubtless frequently
an important factor. The nervous system possesses a powerful control
over this secretion. The diagnosis presents no difficulties, as there
is no other affection with which it could be confounded. Prickly heat
and oily seborrhoea are considered to bear some resemblance, but
confusion is not likely to occur. Although some cases are readily
relieved, the majority prove obstinate. The duration, locality, and
extent of the affection, as well as the condition of the general
health, are to be considered in pronouncing a prognosis. The disease is
liable to relapse.

Concerning treatment, in addition to quinine and the ordinary tonic
remedies, belladonna and ergot may be referred to as being useful,
particularly the former. Local treatment is always demanded.
Dusting-powders are useful, such as starch or lycopodium powder, to
which from ten to thirty grains of salicylic acid to the ounce may be
added with {584} benefit. They are to be applied freely, so as to
absorb the secretions. Astringent lotions are also of value, and
constitute the most agreeable method of treatment. One drachm of tannic
acid to six ounces of alcohol will be found of service. Solutions of
alum and of zinc sulphate may also be employed. Boric acid, either in
powder or in the form of a saturated solution, and tincture of
belladonna as a lotion, full strength or diluted with alcohol, are both
useful. A successful plan of treatment is that by diachylon ointment
(unguentum diachyli) as recommended by Hebra. The parts are first
cleansed and dried, and then the ointment applied on strips of muslin
as a plaster. It is to be renewed twice daily, the parts on each
occasion being rubbed dry with lint or a soft towel and lycopodium or
starch powder. Water is not to be employed. The treatment must be
continued one or two weeks, and then the ointment omitted, and a
dusting-powder used night and morning for several weeks. In many cases
relief results from one such course; others may require several
repetitions. If a good diachylon ointment is not procurable, the same
plan may be followed out with an ointment made by melting together
equal parts of lead plaster and cosmoline, or with an ointment of
tannic acid, a drachm to the ounce.


Anidrosis.

Anidrosis is a functional disorder of the sweat-glands characterized by
a diminution or suppression of the secretion. It is the opposite
condition of hyperidrosis, and occurs to a slight extent in certain
general diseases, and also in some affections of the skin, as
ichthyosis. It sometimes occurs as an idiopathic disorder, and may
cause much discomfort. Occasionally in nerve-injury localized areas of
diminished or suppressed secretion occur. The treatment should be
conducted upon general principles, including warm or vapor baths and
friction.


Bromidrosis.

Bromidrosis is a functional disorder of the sweat-glands in which the
secretion, which may be either normal or excessive in quantity, is of
an offensive odor. The quantity is usually excessive, as in
hyperidrosis, but occasionally it is normal in amount, while the odor
is heavy, strong-smelling, offensive, and disgusting. It may be
universal or local in character, more frequently the latter; in either
case the odor is rendered more marked by heat and increased
perspiration. In smallpox, measles, typhus and relapsing fevers, and in
some nervous affections peculiar odors are noticed. Certain drugs, as
sulphur, asafoetida, and like substances, taken internally, may be
detected in the odor of the sweat. It is as a localized disorder,
however, that the affection usually comes under observation, the
axillæ, genitalia, and feet being favored localities, the last named
being the most common region affected. It occurs about the soles and
between the toes, and is generally symmetrical. The sweating, if
excessive, causes after a time more or less maceration, and sometimes
hyperæmia or inflammation; the skin becomes {585} whitish and sodden,
the affected area having a pinkish margin. Both Hebra and Thin consider
the socks and soles of the shoes--which become thoroughly permeated by
the secretion--and not the feet, the source of the odor. The latter
observer states that he has found innumerable bacteria (Bacterium
foetidum) in the fluid in which the sock is soaked. The etiology of the
disease is not well understood, but it is without doubt due to some
nervous derangement.

The treatment is about the same as that advised for hyperidrosis. In
addition, however, to the remedies named for that disorder, there are
several other local remedies that have been found useful in this
disease, among which may be mentioned a wash of potassium permanganate,
two or three grains to the ounce, and chloral, twenty or thirty grains
to the ounce of water or dilute alcohol. Thin recommends the use of
cork soles, which (and also the socks) are first to be soaked in a
boric-acid solution and dried.


Chromidrosis.

Chromidrosis is a functional disorder of the sweat-glands, the
secretion being variously colored and generally increased in quantity.
The color may be blackish, bluish, reddish, greenish or yellowish,
bluish and reddish being the most common. The affection is usually
local, occurring in the form of patches, the face, neck, arms, backs of
the hands and feet, chest, and abdomen being the favorite localities.
The disease is rare. Ferrocyanide of iron, copper, and other substances
have been detected in the secretion, to the presence of which doubtless
the colors are due. It is generally observed in nervous and excitable
persons, chiefly in unmarried women; but it has also been noted in
strong men. It tends to recur, and may appear on different parts of the
body with each manifestation. The treatment should be directed against
the suspected cause, with especial reference to the nervous system.


Uridrosis.

Uridrosis, or urinous sweat, is a functional disorder of the
sweat-glands, the secretion containing the elements of the urine,
especially urea. This latter is occasionally detected in the sweat of
persons apparently in good health. In some cases, however, it exists in
such quantity as to be noticeable on the skin, appearing usually on the
face and hands as a colorless or whitish saline crystalline deposit or
coating. In most of the marked cases reported partial or complete
suppression of the renal function has preceded or accompanied the
condition.


Phosphoridrosis.

Phosphoridrosis is the rare condition in which sweat is phosphorescent.
It is sometimes seen in the later stages of phthisis, also in miliaria,
and occasionally in persons who have eaten of putrid fish.


{586} Sudamen.

Sudamen (syn. miliaria crystallina) is a non-inflammatory disorder of
the sweat-glands characterized by pinpoint- to pinhead-sized, isolated,
superficial, translucent, whitish vesicles. The lesions make their
appearance on any portion of the body, but have a predilection for
certain regions of the trunk, especially where the epidermis is thin.
They show themselves as numerous, closely-crowded, discrete, whitish or
pearl-colored minute elevations, in appearance not unlike dew-drops.
They form rapidly, remaining discrete, never becoming puriform, and
evince no tendency to rupture. They are non-inflammatory, never reddish
in color, and are without areolæ. The fluid disappears by absorption
and the epidermal covering by subsequent desquamation. The lesions may
appear in successive crops or new vesicles may show themselves
irregularly from time to time. On the other hand, the first outbreak
may disappear rapidly, and no further manifestation show itself.
Sudamina occupying the face are usually seen in middle-aged females.
The vesicles here are larger, deeper-seated, and more persistent.

Constitutional debility is a predisposing cause of the disease.
Diseases accompanied with a high temperature--such, for example, as
typhus and typhoid fevers, tuberculosis, and acute articular
rheumatism--are frequently responsible for the eruption. The vesicles
are produced by the collection of sweat in some part of the sweat-duct
or epidermis, usually the latter. As ordinarily seen, the vesicles are
situated between the lamellæ of the horny layer, the sweat having made
its way from a rupture in an obstructed duct. In those exceptional
cases of deep-seated and more persistent sudamina occurring about the
face, the vesicles are situated in the corium, and are caused by a
dilatation of the duct. The affection is to be distinguished from
miliaria by the absence of inflammatory symptoms.

The course and duration of the disease depend upon the cause. In the
treatment, removal of the etiological factor is of first importance.
For external use some simple dusting-powder, such as equal parts of
starch and lycopodium, or frequent bathing of the parts with an
evaporating lotion, such as alcohol and water or vinegar and water, may
be employed.


Seborrhoea.

Seborrhoea is a disease of the sebaceous glands characterized by an
excessive and abnormal secretion of sebaceous matter, appearing on the
skin as an oily coating, crusts, or scales. Although most commonly
seated on the scalp and face, other parts of the general surface may
also be attacked. Upon the trunk the sternal and intrascapular regions
are the parts most frequently affected. It may occur at any period of
life, although more common in adolescent and early adult age. In
newly-born infants it constitutes the vernix caseosa, in which case,
however, it is physiological rather than pathological. The course of
the disease varies, at times disappearing spontaneously or with simple
remedies, and in other cases being rebellious even to judicious
treatment. It is in most cases influenced by the tone of the general
health. In the majority of {587} instances the disease is
non-inflammatory; some cases, on the other hand, show intense hyperæmia
and even inflammatory signs, while not infrequently the disease varies
from time to time in the activity of the process. Itching and burning
in a varying degree are sometimes present; the subjective symptoms are,
however, rarely marked. The disease is usually better in warm than in
cold weather.

There are two clinical varieties of the disease, depending upon the
character of the secretion--seborrhoea oleosa and seborrhoea sicca.
Seborrhoea oleosa appears as an oily, greasy coating upon the skin, and
is seen most frequently about the nose and forehead. The oiliness may
be slight or excessive. Seborrhoea sicca is the more common form of the
disease, and is seen usually on the scalp and face, and occasionally on
other parts of the body. It consists in the formation of dry sebaceous
crusts, usually of a grayish-yellow color, which are slightly adherent.
Frequently both varieties are seen together, and present products of a
mixed character.

Occurring upon the scalp, constituting seborrhea capitis, popularly
known as dandruff, the disease is commonly of the dry or mixed variety,
and usually involves the whole of that region. Sometimes it occurs in
disseminate patches. It appears as small, dry, and pulverulent scales,
detached and loose, or as thin or thick, greasy, crust-like, adherent
masses. In the latter condition the hairs may be matted or pasted to
the scalp. The hair sooner or later becomes affected, and in
consequence is dry and lustreless, and gradually falls out. The
disease, if neglected, finally causes more or less structural change in
the follicles, with permanent alopecia as a result. The skin beneath
the crusts in chronic cases is often of a dull, grayish or bluish-gray
color; sometimes, however, it is hyperæmic. Occurring on other hairy
parts, as the bearded region and eyebrows, the same characters are
presented, but ordinarily they are less marked. At times a condition is
seen on the scalp in which there is a mild degree of inflammation, with
the formation of fine, dry epithelial scales, with slight or marked
itching and burning.

Seborrhoea when occurring about the nose and face--seborrhoea
faciei--is characterized by more or less redness, oiliness, and
sometimes with a moderate amount of scaling and crusting. The
follicular openings are enlarged and patulous, and are either free or
contain sebaceous plugs. On the trunk--seborrhoea corporis--the disease
tends to form circular and confluent scaly patches on a pale or
hyperæmic base, with the sebaceous covering extending into the
follicles in the form of projections. Or the skin may be slightly
reddened, the follicles open and enlarged, the scales having been
detached by the rubbing of the clothing. Seborrhoea when involving the
genital region--seborrhoea genitalium--presents characters somewhat
different. The inner surface of the prepuce, the glans penis, and the
sulcus in the male, and the labia and clitoris of the female, are the
parts commonly affected. A soft, cheesy mass collects about the parts,
which, unless frequently removed, rapidly undergoes decomposition. If
neglected or if the disease is marked, inflammatory symptoms may arise.

The disease is functional in character, the increased and usually
changed oily secretion, with the epithelial scales from the glands and
ducts, forming its products. There is no alteration in the gland
structure except in {588} long-continued cases, in which there may be
slight atrophy. The affection depends usually upon an impairment of the
general health. Chlorosis and anæmia are frequently the predisposing
causes. Stomachic, intestinal, and uterine derangements are also, not
infrequently, factors. Persons of light complexion are more prone to
the dry form, while those of a dark complexion usually show the oily
variety. It is also to be noted that the affection is not infrequently
seen in persons apparently in perfect health, yielding, however, in
such cases to simple external treatment.

Seborrhoea occurring on the scalp must be distinguished from eczema and
from psoriasis. In eczema the skin is somewhat infiltrated, thickened,
and reddened, and rarely involves the whole scalp; there is less
scaliness, and at times more or less of the characteristic gummy
exudation and marked itching of that disease. Psoriasis occurs usually
in well-defined, circumscribed inflammatory patches, and in most cases
shows signs of the disease upon other regions. These same points are of
value in differentiating when the disease is upon non-hairy parts. From
lupus erythematosus, which it may at times, on the face, closely
resemble, it is to be distinguished by the absence of infiltration and
thickening, of the sharply-defined border and violaceous or reddish
color of that disease, as well as by the absence of atrophic scarring.
Seborrhoea differs from ringworm, which it occasionally resembles,
especially on the trunk, by its history, slow course, and by the
greasiness of the scales. In obscure cases the microscope will
determine the question.

TREATMENT.--It is a curable disease, but in the majority of cases
proves obstinate. The rapidity of the cure depends in a great measure
upon the removal of the predisposing causes. In seborrhoea of the
scalp, if the process be allowed to continue through a long period,
more or less marked permanent alopecia, especially of the vertex, may
result. Even in unfavorable cases, however, much may be done toward
promoting a regrowth of hair.

Treatment consists in both constitutional and local measures. The
former is frequently of importance, with a view of securing, if
possible, permanent relief. Iron, quinine, cod-liver oil, and arsenic
are useful. In some cases one-tenth to one-quarter grain doses of calx
sulphurata, three or four times daily, will prove of benefit.
Dyspepsia, if present, is to be relieved. Fresh air and healthful
exercise will sometimes aid considerably in effecting a cure.

External treatment is demanded in every case. The crusts and scales are
to be removed. If in abundance, oily applications, such as olive or
almond oil, are to be made to the parts, and after remaining on for six
or twelve hours to be washed off with soap and hot water. In severe
cases several repetitions may be found necessary. On the other hand, in
mild cases simply washing with castile or ordinary toilet soap and warm
water, or with a decoction of soap-bark, will suffice. If scaling and
crusting are marked, instead of the plain soap sapo viridis should be
used, either alone or in the form of the spiritus saponatus kalinus,
consisting of two parts of sapo viridis in one of alcohol, perfumed
with an essential oil. A tablespoonful of this poured on the scalp, and
then a small quantity of hot water added and the parts rubbed briskly,
wall produce considerable lather; the scalp is then to be rinsed with
warm water, the hair {589} dried, and an oily or fatty substance
applied. If after a removal of the crusts the skin is found to be
irritated, a bland ointment, such as petroleum ointment, will be the
best application. Glycerin and alcohol, one to four, will be of service
if the skin is dry and hyperæmic. Subsequently more stimulating
applications may be made; in the greater number of cases these are
indicated from the start. Chloral, as in the following prescription,
may sometimes be used with benefit:

  Rx. Chloralis, scruple ij;
      Glycerinæ, minim xx;
      Aquæ rosæ, fluidounce iv.  M.

Gentle friction should be employed in making the application. If the
lotion is too drying, more glycerin may be added. An excellent
application in many cases is the following:

  Rx. Acidi carbolici, minim xxx;
      Olei ricini,     fluidrachm ij;
      Alcoholis,       fluidounce j drachm vj.  M.

This may be perfumed with a few drops of any essential oil. If greater
stimulation is required, then to this last combination one to three
drachms each of tincture of cantharides and tincture of capsicum may be
added. Liquid applications may be made as follows: An eye-dropper is
filled and introduced between the hairs at different points of the
scalp, and a few drops pressed out, and subsequently rubbed in by means
of a piece of flannel rag; in this manner the application is brought
into intimate association with the skin without to any extent soiling
the hair.

Ointments are also useful. Sulphur, one or two drachms to the ounce, is
one of the best. Ammoniated mercury, twenty to sixty grains to the
ounce, red precipitate, five to twenty grains to the ounce, are both
valuable. In some cases tannic acid, one or two drachms to the ounce,
acts well; also a naphthol ointment, twenty or thirty grains to the
ounce. Tar is also of decided value, and may be added to any of the
above ointments or be prescribed alone in ointment, one or two drachms
to the ounce. The tarry oils, as oil of white birch and oil of cade,
used pure or in the form of tincture, one or two drachms to the ounce
of alcohol, are also valuable. They may also be used with ointments.
The treatment of seborrhoea of other parts of the body than the scalp
is essentially the same, but the applications should be somewhat
weaker. The sulphur preparations are the most useful.

The frequency of applications in seborrhoea will depend upon the
activity of the process. Once or twice daily in the beginning may
gradually be changed to once every other day, or later even less
frequently. The soap-and-water washing is to be regulated in the same
manner. It is advisable to intermit external treatment occasionally to
see if the disease is entirely removed or merely in abeyance.


Comedo.

Comedo is a disorder of the sebaceous glands, consisting of retention
of sebaceous matter, characterized by yellowish or blackish
pinpoint- to pinhead-sized elevations corresponding to the orifices of
the glands. The affection is seated, for the most part, about the face,
neck, and upper part {590} of the trunk; it may occur, however,
wherever there are sebaceous glands. Each lesion is pinpoint to pinhead
in size, whitish or yellowish, and usually with a central blackish
point. There is very little elevation unless the amount of retained
sebaceous matter is excessive. They may exist sparsely or in great
numbers. Not infrequently the regions of the forehead, nose, and chin
are studded with the lesions, other parts of the face and the shoulders
showing them in smaller numbers. They may be disseminated or grouped.
If they exist in profusion they give the face a soiled, greasy look, as
if dirty and unwashed. Lateral pressure forces out the sebaceous matter
in a thread-like form closely resembling a worm, hence the popular
terms flesh-worms and grub-worms. From collection of dust and from
other causes the outer ends of the sebaceous plugs become blackened,
and this appearance has given rise to the term black-heads. This
coloring may possibly, to some extent at least, as has been suggested,
be dependent upon a chemical change caused by the action of the air on
the exposed portion of the sebaceous collection. According to Unna, it
is due to pigment matter, either free or contained within epidermal
cells. Krause states that the bluish granules described by Unna are
from extraneous sources. Seborrhoea oleosa is often seen to coexist. At
times the retained secretion, either as a result of pressure or in
consequence of chemical changes in the mass, excites inflammation, and
acne results. It is not uncommon to find comedones and acne lesions
associated together.

The affection is seen most frequently between the ages of fifteen and
thirty. The lesions are sluggish, and are apt to disappear and reappear
from time to time, depending upon the activity of the predisposing
cause. As the patient advances in age the affection tends to
spontaneous disappearance. The causes of the disorder are essentially
the same as give rise to acne, a disease to which it is, as may be
inferred, closely allied. Thus, disorders of digestion, constipation,
chlorosis, scrofulous conditions and menstrual disturbances are often
predisposing causes. In addition, the unstriped muscular fibres of the
skin lack tone and contract sluggishly. The infrequent use of soap,
especially in those with oily skins (seborrhoea oleosa), favors their
formation. Working in a dirty or dusty atmosphere may cause mechanical
obstruction of the ducts, and in consequence the formation of
comedones.

Pathologically, the affection has its seat in the sebaceous glands and
ducts, consisting essentially of retained secretion and epithelial
cells within either the gland or duct or both. The accumulation gives
rise to more or less dilatation, which usually increases the longer the
comedo exists. The mass consists of epidermic cells, sebaceous matter,
and sometimes cholesterin crystals, and one or more lanugo hairs. At
times, also, the parasite Demodex folliculorum is found within the
mass, but is not responsible in any way for the production of the
lesion; it is also often found in healthy follicles. The dark points
which usually mark the lesions are due to the accumulation of dirt. The
process is an inactive one, occasioning usually no disturbance. The
accumulation may increase until a papule is formed, or, on the other
hand, may gradually relieve itself. The affection is to be
distinguished from acne punctata and milium. Acne is a closely-allied
disease, but is inflammatory in its nature; comedo is functional in
character: the presence or absence of {591} inflammation, therefore, is
a decisive differential point between the two diseases. Milium differs
from comedo in the facts that it has no open duct, no black point, and
the contents cannot be squeezed out.

The result of treatment is usually favorable, several months sufficing
for its removal. On the other hand, occasionally cases are met with
which prove rebellious. The aim of constitutional treatment should be
to remove the predisposing condition. For this purpose cod-liver oil,
iron, quinine, arsenic, and various other tonics, and ergot in full
doses, are variously prescribed. At times, small doses (about a tenth
to a fourth of a grain) of calx sulphurata have a good effect. Saline
aperients are often valuable. An aperient tonic pill of iron, aloes,
and strychnia is sometimes serviceable. Open-air exercise and other
hygienic measures are to be advised.

External treatment is of great importance,--is in fact indispensable.
The condition may in many cases be relieved by local applications
alone. Removal of the plugs by mechanical means is to be advised.
Lateral pressure with the finger-ends, or perpendicular pressure with a
watch-key or similar instrument, will be found effectual. Washing the
parts with sapo viridis and hot water, with considerable friction and a
kneading motion, will aid in dislodging the sebaceous collections.
Instead of the sapo viridis its solution in alcohol, two parts of the
soap to one of alcohol (spiritus saponatus kalinus), may be employed.
Steaming the face or the application of hot water from ten to twenty
minutes will aid in softening the secretion, and with friction and
kneading will often have a good effect. Friction with sand soap is also
valuable. A soap made of equal parts of green soap (sapo viridis) and
finely-pulverized marble may also be used. The use of the dermal
curette is at times of service, scraping off the tops of the comedones,
rendering their expulsion more easy. After the soap-washing and
hot-water application ointments or lotions containing sulphur, such as
prescribed in acne, may be applied. The following lotion is often
valuable:

  Rx. Sulphuris præcipitati, drachm ij;
      Ætheris,               fluidounce ss;
      Alcoholis,             fluidounce iijss.  M.

S. Shake before using: dab on with a mop for several minutes, allowing
it to dry on.

Alkaline lotions containing borax or sodium bicarbonate, ten to twenty
grains to the ounce, are often useful. The following paste has been
highly spoken of for loosening and dislodging the sebaceous plugs:

  Rx. Aceti,     drachm ij;
      Glycerinæ, drachm iij;
      Kaolini,   drachm iv.  M.

S. Apply over the surface at night. If applied near the eyes, the lids
should be kept closed for a few moments, on account of the pungent
fumes of the vinegar. The lotion containing zinc sulphate and potassium
sulphide, the formula of which is given in the treatment of acne, is of
value. Corrosive-sublimate lotions, one-half to two grains to the
ounce, are useful in some cases. In changing from a sulphur to a
mercurial application, treatment should be suspended for several days,
so that the formation of the black sulphuret of mercury, which may
darken the skin and comedo plugs to an annoying degree, may be {592}
avoided. If treatment brings about considerable irritation of the
parts, a result often desirable, it should be omitted temporarily and
soothing applications made.


Milium.

Milium, described also as grutum and strophulus albidus, consists in
the formation of small, whitish, roundish, pearly, non-inflammatory
elevations situated in the upper part of the corium. The lesions are
usually pinhead in size, whitish or yellowish, seemingly more or less
translucent, rounded or acuminated, without aperture or duct, and
appear for the most part about the face, especially about the eyelids,
and occasionally elsewhere. One, several, or great numbers may be
present; ordinarily, however, but several are to be seen, usually near
the eyes. In our experience the affection is observed most frequently
in middle-aged women. The lesions develop slowly, and after a certain
size is reached may remain stationary for years. Their presence causes
no disturbance, and unless large and numerous the affection is but
slightly noticeable. Acne and comedo are often found associated with
it. The cutaneous calculi occasionally met with are milia which have
undergone calcareous metamorphosis. The etiology of the disease, in a
great majority of cases, is not known. In some cases, however, the same
causes as are operative in the production of comedo and acne seem to
have an influence.

Anatomically, the affection is found to have its seat in the sebaceous
glands. The duct from some cause is obliterated and the secretion
cannot escape. The retained mass consists of sebaceous matter which
tends to become inspissated and calcareous, and, as the lesion is
without aperture, it cannot be squeezed out. The epidermis constitutes
the external covering. It has also been shown by several authorities
that the covering proper is either the gland itself or the wall of the
hair-follicle, and that in the larger lesions connective-tissue septa
are found. According to the investigations of Robinson, two different
conditions have been described as milia--one which evidently has its
origin in the sebaceous glands or ducts, and the other in which there
is no connection whatever with these structures. The lesions are
characteristic and the diagnosis easy. The absence of the duct-opening
and black point of comedo serves to distinguish it from that disease.
The small lesions of xanthoma--a disease which usually has its seat
about the eyelids--may resemble it, but can scarcely be confounded with
it, as its nature is entirely different.

As regards treatment, it is usually necessary in all cases to incise
the lesions and squeeze out or scrape out their contents; in some,
touching the base of the excavation with a minute drop of iodine
tincture or nitrate of silver may be required to prevent a
reappearance. Electrolysis has also been recommended.


Steatoma.

Steatoma--or, as commonly called, sebaceous cyst, sebaceous tumor, or
wen--appears as a variously-sized, elevated, roundish, or semi-globular
firm or soft tumor having its seat in the corium or subcutaneous
tissue. {593} One or several may be present. They are cysts of the
sebaceous glands, and may exist wherever these structures occur, but
are seen most frequently about the scalp, face, back, and scrotum. They
develop slowly, are variable as to size, and may exist indefinitely
without causing any inconvenience except disfigurement. The overlying
skin is either normal in color or whitish from stretching; on the scalp
it is usually devoid of hair. Cysts are usually firm, but may be doughy
or soft. As a rule, they are freely movable and painless. In some a
gland-duct orifice can be seen; in the majority it is absent.
Spontaneous suppuration and ulceration may occasionally take place in
enormously distended tumors. Anatomically, steatoma is a cyst of the
sebaceous gland and duct, produced by retention of secretion. It is in
fact an enormously distended duct and gland whose walls have become
thickened into a tough sac. The contents vary, in some being hard and
friable, in others soft and cheesy or even fluid, with or without a
fetid odor, and of a grayish, whitish or yellowish color. The mass
consists of fat-drops, epidermic cells, cholesterin, and sometimes
hairs. As a rule, the diagnosis is made without difficulty. Gummata,
which may have some resemblance, grow more rapidly, are usually painful
to the touch, are not freely movable, and tend to break down and
ulcerate. Sebaceous cysts can scarcely be mistaken for fatty tumors and
osteomata.

In the treatment excision is radical and most satisfactory. A linear
incision is made, and the mass and enveloping sac dissected out. A
removal of the sac is necessary, or a reproduction usually takes place.
As the scalp wound especially should be treated on antiseptic
principles, injecting the tumor with a small quantity of tincture of
iodine or other irritant has been successfully employed.


CLASS II.--INFLAMMATIONS.


Erythema Simplex.

Erythema simplex is a hyperæmic disorder characterized by redness,
occurring in the form of variously sized and shaped, diffused or
circumscribed, non-elevated patches. The affection is due to various
causes, which may be external or internal. Hence it is usual to divide
the affection into two classes--idiopathic and symptomatic. Under the
head of idiopathic erythema are described the erythemas due to cold,
heat, traumatism, poison, etc. Erythema caloricum arises from the
action of heat or cold. If the degree of heat or cold is sufficient, a
dermatitis, or even gangrene, may result. In a mild degree, however,
simple congestion of the skin--erythema--is produced. It is usually
bright red in color, later becoming somewhat darker, and at times is
followed by slight desquamation. If produced by the action of the
sun--erythema solare--the uncovered parts only are affected. Erythema
traumaticum is usually seen {594} as a result of the pressure of
tightly-fitting clothes, corsets, bandages, etc. It disappears rapidly
upon removal of the cause, without scaling. If the cause is long
continued, a dermatitis may be produced. Erythema venenatum is a term
applied to the form of hyperæmia resulting from the action of
substances poisonous to the skin: such are all irritating chemicals,
the ordinary rubefacients, various dyestuffs, acids, alkalies, and the
like. The symptomatic erythemas are the more important. The rashes
often preceding or accompanying certain of the systemic diseases, such
as smallpox, diphtheria, and vaccinia, belong to this class. Disorders
of the digestive tract, especially in children, are responsible for
many cases. Roseola is a term sometimes applied to the symptomatic
rashes. The division-line between simple erythema and dermatitis is
often ill-defined.

The indications for treatment in the various erythemata are usually
self-evident. A removal of the cause in idiopathic rashes is all that
is needed. The same may be stated of the symptomatic erythemata; but
here there is at times difficulty in recognizing the etiological
factor. Local treatment is rarely necessary. Dusting-powders, mild
lotions, or ointments such as used in acute eczema may be prescribed.

       *       *       *       *       *

ERYTHEMA INTERTRIGO.--Erythema intertrigo--known popularly as
chafing--is a hyperæmic disorder occurring on parts where the natural
folds of the skin come in contact, characterized by redness and at
times an abraded surface and maceration of the epidermis. The causes
are usually local. Thus it appears chiefly about the folds of the neck
in fat subjects, the nates, groin, perineum, and axillæ. It is seen
usually in hot weather in infants and others whose skin is tender. The
skin becomes red from chafing, and if long continued or untreated the
perspiration of the parts causes more or less maceration of the epiderm
and a mucoid discharge. If the condition continues, actual inflammation
may be developed. The affection may pass away in a few days or last
several weeks. There is a feeling of heat and soreness about the
affected parts. Occurring between the nates in infants, a favorite
locality, from the friction of the parts, and the action of the feces
and urine, it is often persistent. As a rule, it yields readily to
treatment. The predisposition to its development, and its continuance
are often due in children to derangement of the stomach or intestinal
canal.

In the treatment undue moisture and friction of the parts are to be
prevented or counteracted. Washing with castile soap and cool water,
and cleanliness, should be advised. The folds or parts are to be
separated or kept apart with lint, cloth, or absorbent cotton.
Dusting-powders are to be used freely, as they constitute the best
method of treatment. The following is a good formula:

  Rx. Pulv. zinci oxidi,  drachm ij;
      Pulv. talci Veneti, drachm ij;
      Pulv. amyli,        drachm iv.  M.

Simple starch and lycopodium powder, alone or together, will both prove
efficacious. If the affection prove rebellious to this plan of
treatment, astringent and alcoholic lotions may be used. Black wash,
diluted, dabbed on the parts several times daily, followed by
oxide-of-zinc ointment or a dusting-powder, will be found useful in
obstinate cases. A weak {595} solution of corrosive sublimate, a
fraction of a grain to the ounce, may also prove valuable in some
instances. Lotions of zinc sulphate or of acetate of lead, two or three
grains to the ounce, and a weak solution of alum, may also be
mentioned. A lotion we have often found of service is the following:

  Rx. Pulv. calaminæ,
      Pulv. zinci oxidi, aa. drachm iss;
      Alcoholis,             fluidrachm ij;
      Aquæ rosæ,             fluidounce iv.  M.

Sig. Shake before using. Apply several times daily. The local treatment
of rebellious cases is, in fact, that which is found efficacious in
acute erythematous eczema.


Erythema Multiforme.

Erythema multiforme is an acute inflammatory disease characterized by
reddish, more or less variegated macules, papules, and tubercles,
occurring discretely or in patches of various size and shape. Certain
regions of the body, such as the backs of the hands and feet and the
arms and legs, are the parts mainly invaded. The eruption, as the name
signifies, is usually marked by the multiformity of its lesions,
although, as a rule, one of the forms is generally predominant.
Peculiarities which the lesions assume have given rise to the
qualifying terms annulare, iris, and marginatum, etc. Thus, when the
erythematous patch is circular, fading in the centre, it is called
erythema annulare. At times concentric rings, presenting variegated
colors, are formed, giving rise to the term erythema iris. When the
eruption consists of sharply-defined marginate patches, it is
designated erythema marginatum. Most commonly, the eruption appears in
the form of papules and tubercles. Erythema papulosum is the form of
the disease usually met with. It consists of discrete or aggregated
patches of flat papules, variable as to size and shape. In color they
are bright red, violaceous, or purplish, disappearing partly under
pressure. They fade rapidly, rarely lasting longer than a few weeks.
Erythema tuberculosum is a form of the disease occasionally encountered
in which the lesions are larger, but of the same general character as
in the papular variety.

Erythema multiforme varies as regards duration, averaging about two
weeks. During its course new lesions are apt to develop as the older
eruption fades away. As the lesions disappear slight pigmentation and
desquamation are noticeable. In addition to the parts already named as
commonly invaded, the face is sometimes the seat of the eruption. It
may, moreover, attack the mucous membranes. The subjective symptoms are
rarely marked: usually slight burning and itching are complained of.
There may be evidences of constitutional disturbance, such as malaise,
headache, rheumatic pains, and gastric derangement, especially at the
beginning; as a rule, however, general symptoms are not observed.
Relapses, especially from year to year, are not uncommon. The causes of
the disease are in most cases obscure. It is most frequent in early
adult age. Spring and autumn seem to be predisposing factors, although
it is also seen at other periods of the year. Gastric disturbance may
give {596} rise to the eruption in some instances. Rheumatism is
occasionally associated with it. The affection is more common in the
female.

Anatomically, the affection is an exudative disease, resembling
urticaria. It is generally regarded as a vaso-motor disturbance. It is
closely related to herpes iris and erythema nodosum, and by some these
are looked upon as varieties. In regard to the diagnosis, it is to be
differentiated from urticaria. In the latter affection itching and
burning are prominent and constant symptoms, the lesions are fugacious,
and the duration of the disease shorter. It can scarcely be confounded
with eczema, in which disease the lesions are smaller and intensely
itchy, and the eruption does not assume the different shapes seen in
erythema multiforme. Erythema nodosum and herpes iris are also to be
differentiated. The prognosis is always favorable, as the affection
runs a definite course, usually disappearing at the end of a few weeks.
It is rarely influenced by treatment.

Saline laxatives, alkalies, and the bromides may be given and the diet
regulated. In the beginning of the attack large doses of quinine may be
useful. Locally, applications of alcohol or vinegar and water, or a
lotion of carbolic acid, five or ten grains to the ounce of water, will
be found of advantage if itching or burning is present. As a rule,
active external treatment is not required.


Erythema Nodosum.

Erythema nodosum (syn., dermatitis contusiformis) is an acute
inflammatory affection characterized by the formation of
variously-sized, roundish or ovalish, more or less elevated
erythematous nodes. Febrile disturbance usually ushers in the eruption,
often accompanied with gastric derangement, malaise, and rheumatic
pains. The efflorescence appears rapidly, having special predilection
for the arms and legs, particularly the tibial surfaces. The lesions
vary in size, being rarely smaller than a cherry and often as large as
an egg, and are ovalish or roundish in shape. They are reddish in
color, with a bluish or purplish tinge, which becomes more decided as
they grow older. Later, as they are disappearing, yellowish, greenish,
and bluish coloration manifests itself, as in the case of a bruise. Not
infrequently the lesions are hemorrhagic. When at its height a node has
a shining, tense appearance, indicative apparently of beginning
suppuration; this latter process, however, does not occur, absorption
invariably taking place. Firm and hard at first, as they begin to
decline they become softer. They are apt to appear in crops. The
lesions are rarely present in large numbers, from five to twenty being
the average; occasionally, however, they are much more numerous. The
mucous membranes may, as in erythema multiforme, be invaded. They are
tender and more or less painful, and are usually accompanied with a
sense of burning. Lymphangitis is at times observed. At the end of two
or three weeks the affection has usually run its course.

The causes of the disease are not known. It is closely allied to
erythema multiforme, and by many observers is regarded as merely a
manifestation of that disease. It is generally encountered in the
spring and autumn months, and occurs most frequently in children and
young {597} persons. It is usually associated with rheumatic pains, and
not infrequently with digestive derangement. It is not a common
disease. It is regarded by Lewin as an angio-neurosis. According to
Hebra, in most cases it is essentially an inflammation of the
lymphatics. Bohn regards it as due to embolism of the cutaneous vessels
giving rise to inflammatory infarctions. The process is an inflammatory
oedema. There is considerable serous transudation, with some
blood-corpuscles, and not infrequently with more or less hemorrhage.
The lesions usually bear resemblance to bruises, abscesses, and
gummata. The rosy hue, the apparently violent character of the process,
the number, course, and situation of the lesions, will serve to
distinguish it. The prognosis is favorable, as the affection tends to
disappear in a few weeks, rarely lasting more than a month.

As spontaneous recovery results, treatment should be conservative.
Rest, the more complete the better, sedative applications, as of
lead-water and laudanum or of carbolic acid, with the use of saline
laxatives and full doses of quinia, are the measures indicated. The
diet should be regulated according to the case.


Urticaria.

Urticaria, hives, or nettlerash, is an erythematous affection
characterized by the development of wheals of a whitish, pinkish, or
reddish color, accompanied by stinging, pricking, and tingling
sensations. The advent of the efflorescence is usually sudden; not
infrequently symptoms of gastric derangement precede its appearance.
The wheals are of variable size, shape, and color. Ordinarily they are
of the size of a coffee-grain or bean, rounded or ovoidal in shape, and
whitish, pinkish, or reddish in color. They occur isolated or in the
form of patches caused by a coalescence of several lesions, and vary in
elevation from half a line to several lines. Instead of the ovoidal or
rounded form, the eruption may appear in streaks or irregularly-shaped
patches. To the touch the lesions may be soft or firm.

The efflorescence disappears, as a rule, without leaving a trace.
Pigment-stains are in some cases left which may be slow to disappear.
Burning, tingling, stinging, and itching are prominent subjective
symptoms. The individual lesions are fugacious, inclining to disappear
at one part and to show themselves at another. They are more apt to
appear on parts subjected to pressure by contact of clothes, although
no region is exempt. No age is spared, but the disease, especially in
its acute form, is more common in the young. Ordinarily, urticaria is
an acute disorder, lasting a few hours to several days, in which time
frequent exacerbations may take place. On the other hand, it may be
chronic in the sense that relapses occur successively, the skin, in
fact, rarely being entirely free of the lesions.

At times the wheals are peculiar as to formation or are complicated
with another condition, and hence arise the so-called varieties of the
disease. The most common of these is urticaria papulosa, which was
formerly known as lichen urticatus. The lesions have the form of a
papule with most of the characteristics of a wheal. They appear, as a
rule, suddenly, and after a few hours or days gradually disappear; they
rarely {598} occur in numbers, and are generally scattered over the
trunk and limbs, especially over the latter. They are intensely itchy,
and hence their apices are usually excoriated and covered with
blood-crusts. The itching usually becomes more marked toward night.
This form of the affection is observed particularly in badly-nourished
or in ill-cared-for young children. The occurrence of the disease in
association with purpura, or as a complication of the latter, has given
rise to the names urticaria hæmorrhagica and purpura urticans or
urticata. The lesion is of a mixed character--purpuric and urticarial.
Sometimes the wheal formation is of such a nature as to give rise to
fluid exudation, producing a bulla; hence the name urticaria bullosa.
In rare instances large walnut- or even egg-sized nodes or tumors are
formed, constituting urticaria tuberosa, or giant urticaria.

The causes of urticaria are numerous. Two that are well known may be
classed under the heads of external and internal irritants. Under the
former may be mentioned stinging nettle, jelly-fish, caterpillars,
fleas, bedbugs, and mosquitoes; among the latter, whatever produces
gastric and intestinal derangements. These latter are responsible for
most instances of acute urticaria. With some persons indulgence in
certain articles of food, as fish, oysters, clams, crabs, lobsters,
pork, strawberries, and similar articles, almost invariably calls forth
the efflorescence. A number of medicinal substances, such as copaiba,
cubebs, turpentine, valerian, chloral, salicylic acid, iodide of
potassium, quinine, and others, taken internally, may provoke an
attack. Malaria, functional and organic diseases of the uterus, a weak
or irritable state of the nervous system, and impaired digestion are
common causes of both the acute and chronic forms of the disease.
Various nervous, hemorrhagic, and rheumatic diseases are also sometimes
associated with urticaria. In fact, an irritation from disease of any
internal organ, functional or organic in character, may give rise to
the eruption.

Anatomically, a wheal is seen to be a more or less firm elevation,
consisting of a circumscribed collection of semi-fluid material exuded
into the upper layers of the skin. It has its seat for the most part in
the papillary layer. The vaso-motor nervous system is probably the main
factor in the production of the wheal. Dilatation following a spasm of
the vessels results in effusion; in consequence, the overfilled vessels
of the wheal are emptied by the pressure of the exudation, and the
central paleness produced, while the pressed-back blood gives rise to
the red border.

The features of the disease are so characteristic that there is, as a
rule, no difficulty in distinguishing it from other affections.
Erythema simplex, erythema multiforme, erythema nodosum, and erysipelas
are to be differentiated. Erythema simplex is a simple hyperæmia, while
urticaria is a peculiar inflammatory exudation--a point sufficient to
distinguish the two. The papular and tubercular forms of erythema
multiforme are to be differentiated by their more persistent character,
the locality affected, and the absence usually of marked itching and
burning. Erythema nodosum may resemble urticaria tuberosa, but the
nodes in the former are usually encountered upon the tibial surfaces,
are of much longer duration, and are free from itching. It is only when
several wheals coalesce, causing swelling and burning, and then only
when occurring about the face, that it may be mistaken for erysipelas;
but the evanescent {599} character of the eruption in urticaria, its
rapid formation, the itching, and the absence of constitutional
symptoms usual in erysipelas, are points of difference.

TREATMENT.--Most cases of acute urticaria may be speedily relieved.
Relapses may occur, however, upon repeated exposure to the exciting
cause. The prognosis of chronic urticaria, on the other hand, is not
always so favorable, and will depend in a great measure upon the
ability to remove or modify the predisposing condition. The first
essential in the management of a case, therefore, is an investigation
into its etiological cause.

In the acute disease, where, as in the majority of cases, gastric
disturbance is the exciting factor, a purgative--preferably a
saline--should be given. In severe cases, if food is still in the
stomach, an emetic will be of service, sulphate of zinc, ipecacuanha,
and mustard being the best. The diet should be of the simplest kind.
Aperients are generally indicated until recovery takes place. In
chronic urticaria, where faulty digestion is the exciting cause,
remedies appropriate to that condition are to be prescribed. In all
cases attention is to be directed to the state of the general health.
If there is a suspicion of malaria, quinine and arsenic may be
administered. Functional and organic affections should receive proper
management, as they may prove to be the active cause of the disorder.
If diuretics are called for, acetate of potassium will often best serve
the purpose. The alkaline and laxative natural mineral waters are
sometimes useful. In obstinate cases, especially in those in which no
assignable cause can be detected, pilocarpine, atropia, tincture of
belladonna, chloride of ammonium, bromide of potassium, and arsenic may
be tried. Change of climate is at times advisable.

On account of the great distress usually attending the affection, local
treatment is demanded in almost all cases. Baths and lotions are the
most serviceable methods of applying external remedies. Sponging the
surface with vinegar or alcohol, pure or diluted, may afford relief. A
lotion of carbolic acid, two to four drachms to the pint of water, will
frequently give prompt ease. The latter lotion may be improved by the
addition of two or three ounces of alcohol and a small quantity (one to
two drachms) of glycerin to the pint. A lotion of thymol, one grain to
the ounce of alcohol and water, is likewise of value. Benzoic acid and
borax, each five to ten grains to the ounce of water; chloral, ten to
twenty grains to the ounce; dilute hydrocyanic acid, one to three
drachms to the pint; and diluted ammonia-water,--may also be mentioned.
Alkaline baths made with carbonate of sodium or potassium, three or six
ounces to the bath, are sometimes serviceable. Starch, gelatin, and
bran baths may in like manner be used; and acid baths, half an ounce of
hydrochloric or nitric acid to the bath, have been recommended.
Dusting-powders, especially when applied after baths, will in some
cases prove acceptable.

       *       *       *       *       *

URTICARIA PIGMENTOSA, called also zanthelasmoidea, is an unusual form
of the disease, cases of which during the past few years have been
reported. It begins usually in infancy, and may continue for a period
of months or years. The wheals are intensely itchy, are more or less
persistent, and leave yellowish, orange-colored, greenish, or brownish
{600} stains. Its nature is obscure: by some observers it is regarded
as an urticaria; by others it is claimed that there is a new-growth
element in the lesions. Most cases certainly show urticarial lesions
and run the course of this affection. It is more than probable that the
different cases reported are not examples of one disease. Treatment is,
as a rule, unsatisfactory.


Dermatitis.

Dermatitis, although in its general meaning signifying any inflammation
of the skin from whatever cause or character, is a term usually applied
to those forms which are directly traceable to the action of irritants.
Such irritants may act from without, as cold, heat, caustics, etc., or
through the medium of the blood, as in the eruptions following the
ingestion of certain drugs. The intensity of the inflammation varies
from a simple erythematous condition to actual gangrene. Redness, heat,
pain, swelling, and at times itching, the common clinical signs of
inflammation, are present, but are variable as to degree. The
inflammation may be confined to a small area or may be diffused,
depending usually upon the cause. The forms of dermatitis are
designated according to the causes which produce them.

DERMATITIS TRAUMATICA.--Under this head are included all those
inflammations of the skin which are due to traumatism. Contusions and
similar injuries, abrasions and inflammation from the pressure of
tight-fitting garments, bandages, etc., excoriations, and the like, are
common examples of this form. The excoriations from scratching in
pediculosis, scabies, pruritus, eczema, and other itchy diseases are to
the dermatologist the most frequent examples of traumatic dermatitis.
They subside on removal of the cause, leaving often, especially if the
scratching has been at all violent and the cause long continued,
thickening of the skin and pigmentation, both of which, notably the
latter, may be more or less permanent.

DERMATITIS VENENATA.--All inflammatory conditions of the skin due to
contact with deleterious substances are classified in this group. Apart
from chemical irritants, certain plants, notably those of the rhus
family, are capable in some individuals of producing inflammation of
the skin. The two well-known plants of this group are the poison ivy or
oak and the poison sumach or dogwood. The majority of persons are not
affected by these plants, but in many contact, or in some mere
proximity to the plant, will be followed by a dermatitis, variable as
to degree. The inflammation may simply be of an erythematous character
with slight swelling, or, on the other hand, it may be vesicular,
pustular, or bullous, with marked hyperæmia, oedema, and swelling. As a
rule, the inflammation appears soon after exposure or contact,
sometimes within a few hours; not infrequently, however, several days
will elapse before the symptoms present themselves. Itching is commonly
a prominent symptom, as also heat and burning.

The eruption usually begins as an erythema with heat, swelling, oedema,
and itching, remaining for several days, and then subsiding, or, as is
frequently the case, vesicles or even blebs are developed, and the
affection then is, as a rule, slower in disappearing. Oedema and
swelling may be {601} slight, or, as often occurs, so great as to cause
marked temporary disfigurement. The face, hands, and genitalia are the
parts generally involved, although the disease may extend to other
regions, at times involving large areas or even the greater portion of
the whole surface. The lesions, either spontaneously or through
violence, rupture, and dry to crusts, and subsequently fall off,
leaving erythematous spots, which in turn gradually fade. The affection
runs an acute course, lasting from one to six weeks. In some cases,
especially in those with a tendency to eczema, its duration may be
prolonged. The poisonous principle has been found to be toxicodendric
acid, and is exceedingly volatile in character.

The eruption is influenced by treatment. Bland astringent lotions or
ointments are most serviceable. The fluid extract of grindelia robusta,
two to four drachms to the pint of water, dabbed on frequently, or
cloths wet with it kept constantly applied, will usually have a
remarkably beneficial effect. Black wash, either alone or followed by
the oxide-of-zinc ointment, as in acute eczema, and lead-water, are
both serviceable. A saturated solution of sodium hyposulphite, a lotion
of sodium bicarbonate, one of carbolic acid, one or two drachms to the
pint of water, a weak ammonia lotion, and other applications of a
similar nature, may also be advised, frequently with good result.

Other substances which at times act on the skin somewhat similarly to
the rhus plants are the aniline dyes, mezereon, arnica, and certain
other drugs, as savin, croton oil, tartar emetic, mercurials, etc.

DERMATITIS CALORICA.--Both heat and cold are capable of producing
serious disturbances of the skin. The condition varies from a simple
erythematous inflammation to a state of actual gangrene, depending upon
the degree and duration of the cause, and to some extent upon the
recuperative power of the exposed parts. Whether due to heat
(dermatitis combustionis, combustio, burns) or to cold (dermatitis
congelationis, congelatio, frost-bite, chilblain), the clinical
symptoms are about the same. Treatment is generally of a soothing
character.

In cases of dermatitis due to cold which are seen immediately after
exposure, the parts should gradually be brought back to a normal
temperature, at first being rubbed with snow or cold water applied. In
ordinary chilblains stimulating applications are most serviceable, such
as tincture of iodine and frictions with oil of turpentine. Balsam of
Peru, camphor, lead plaster, carbolic acid, twenty to sixty grains to
the ounce of ointment, camphor, and similar remedies may also be
mentioned.

In burns where the inflammation is of a mild degree, sodium
bicarbonate, either as a powder or in saturated solution, is effective;
while in those of a more severe grade a solution of 2 to 5 per cent.
will be of greater advantage. In burns or frost-bites in which the
inflammation is vesicular, bullous, pustular, or escharotic the
measures advisable in ordinary inflammation are to be employed.

DERMATITIS MEDICAMENTOSA.--Medicinal eruptions are due to the ingestion
of certain drugs, some of which produce in a large proportion of
individuals, sooner or later, well-defined cutaneous manifestations; on
the other hand, many drugs are only exceptionally noted as giving rise
to cutaneous disturbance. Of the former, the iodides and the bromides
stand conspicuous; while of the latter class, arsenic and quinine may
be cited. The glandular structures of the skin are frequently involved,
{602} especially in the iodide and bromide eruptions, and apparently
the inflammation and resulting pustules are due to the effort at
elimination through these structures. In other instances, especially
the erythematous and urticarial eruptions, the effects of the drug seem
to be due to some action upon the nervous system.

Arsenic.--Exceptionally eruptions are seen to follow the continued
administration of arsenic. They are of an erythematous type, resembling
the macular syphiloderm and measles; or papular, somewhat similar to
the papular manifestation of erythema multiforme. Vesicles, herpetic in
character, and pustules have also been observed. An urticarial-like
eruption has occasionally been noted. In several instances arsenic has
seemed to hold a causative relationship to an attack of herpes zoster.
Arsenical dermatitis is most frequently seen about the face, neck, and
hands, and lasts usually from a few days to two weeks. Workmen in
arsenic-works are occasionally observed to have a pustular, ulcerative,
and even gangrenous eruption, due to the local action of the drug.

Atropia or Belladonna.--A scarlatinoid rash is a frequent result of
ingestion of belladonna, even a small dose at times sufficing to
provoke the eruption. It is seen most frequently in children, face,
neck, and chest being usually involved. Dryness of the throat and
general malaise may be present. Usually there is no febrile
disturbance, and desquamation seldom if ever follows, the rash usually
passing away within a few hours or days after the drug has been
discontinued.

Bromides.--The eruption from the bromides is usually pustular in type,
occasionally furuncular, and at times giving rise to purulent
accumulations of a carbuncular character. In some individuals a single
dose suffices to call out the eruption; usually, however, it is only
after a few weeks' administration that the cutaneous lesions are
observed. In rare instances even its prolonged use is unaccompanied by
any disturbance of the skin. The face, neck, shoulders, and back are
most prone to its effects. The pustules have their seat in and about
the sebaceous glands. A small dose of arsenic or bitartrate of
potassium with each dose of the bromide will sometimes prevent the
eruption caused by the latter.

Cannabis Indica.--An eruption of a vesico-papular type, the lesions
pinpoint- to pea-sized, scattered over the entire surface, accompanied
with considerable pruritus, has been recorded, following within twelve
hours after a full dose of the drug, and disappearing in a few days.

Chloral.--A scarlatinoid or urticarial eruption, dusky-red in color,
somewhat itchy, occurring especially about the face, neck, and
extremities, occasionally follows the administration of chloral. In
some instances, if the drug is long continued, glandular enlargement,
vesicles, petechiæ, ulceration, and sloughing, and rarely death with
symptoms of purpura hæmorrhagica, result. In a few cases the drug has
produced simple purpuric lesions.

Copaiba.--The copaiba eruption is well known. It may follow a single
dose, or, as is more often the case, after several days' or a few
weeks' use of the drug. It is maculo-papular or papular in type, itchy,
and resembles urticaria and erythema multiforme. The extremities are
usually invaded, although not infrequently the whole surface is
attacked. A {603} scarlatinoid rash has also been observed. The
disturbance usually disappears in a few days.

Cubebs.--A diffused erythematous eruption, with milletseed-sized
papules, coalescent here and there, occurring over the face and trunk,
and to a less extent the extremities, disappearing with furfuraceous
desquamation, is occasionally observed.

Digitalis.--A few cases of scarlatinoid and papular eruptions have been
recorded as following the administration of digitalis.

Iodides.--Eruptions from the ingestion of the preparations of iodine
are not uncommon. They may be erythematous, papular, vesicular,
pustular, bullous, or purpuric in character. The erythematous type is
not uncommon, appearing in patches chiefly about the forearms, face,
and neck. The papular and vesicular forms are rarer, the latter
occurring usually about the chest, limbs, scalp, and scrotum. A
markedly eczematous eruption, occupying the greater portion of the
entire surface, with copious secretion, has been occasionally noted. A
pustular eruption, acne-like in character, resembling that seen
following the bromides, is the most frequent. It is seen commonly about
the face, shoulders, back, and arms. Iodine has been found in the
contents of the lesions. A bullous eruption, occurring chiefly about
the head and neck, has also been noted. This form is rare. The lesions
usually begin as small vesicles or vesico-papules, and develop to
blebs, containing a serous, puriform, or sanguinolent fluid. In some
cases the eruption does not go beyond the vesicular or vesico-papular
formation. Purpura has also, although rarely, been observed, the
lesions being small, simple in character, and occurring mainly about
the legs; or exceptionally assuming a grave hemorrhagic type, which may
terminate fatally. All of the eruptions of the iodides disappear
rapidly after the drug has been discontinued.

Mercury.--An eruption of an erysipelatous character, beginning about
the face and extending to other parts, has been occasionally noted to
follow this drug. The skin is smooth, shining, red, dry, and itchy.

Opium, Morphia.--An erythematous eruption, scarlatinoid in type,
favoring the chest and flexor surfaces of the limbs, with or without
itching, is in some individuals caused by even the smallest dose of
opium or its alkaloid morphia. It may disappear in a few days or be
prolonged and followed by marked desquamation. In some persons one or
two doses will give rise to intense itching without any eruption, or if
the drug is continued the erythematous condition described is
developed. Opium has also rarely caused profuse sweating and sudamina.

Phosphoric Acid.--An instance of a bullous eruption has been recorded
as following the administration of this drug.

Quinine.--Quinine rashes are not infrequent, appearing usually first on
the face and neck, and then invading other parts. The eruption may be
patchy or confluent. The type is generally erythematous. Chill, nausea,
and other symptoms of malaise precede its development. There may be
oedema and injection of the conjunctivæ, and redness and dryness of the
naso-pharyngeal passages. Itching and burning are almost constant
symptoms. Desquamation, furfuraceous or lamellar, follows. Eruptions
resembling urticaria and erythema multiforme have been observed. A
purpuric type has also been noted.

Salicylic Acid.--Dermatitis of an erythematous and urticarial type,
{604} with symptoms of general disturbance, is sometimes seen in
patients taking salicylic acid or its salts. An efflorescence of
vesicles and pustules about the hands and feet, with profuse sweating,
has been recorded. A case in which ecchymotic patches about the back
and neighboring regions appeared from the use of this drug has been
reported.

Santonine.--An instance of an urticarial outbreak with oedema of the
eyelids and swelling of the face has been observed following the
ingestion of this drug.

Stramonium,--An erythematous efflorescence has been recorded as
following this drug.

Strychnia.--A case is on record in which a rash of a scarlatinoid type
followed a dose of one-twenty-fourth of a grain of strychnia.

Turpentine.--Both erythematous and papular eruptions, usually itchy,
have appeared as the result of large doses of turpentine, occurring
principally about the face and upper trunk, the papules being minute in
character. A vesicular eruption has also been noticed somewhat similar
to vesicular eczema.

DERMATITIS FACTITIA.--Feigned diseases of the skin are not uncommon.
Erythema, vesicles, bullæ, and gangrene have been brought about,
chiefly in hysterical females, to gain sympathy, or, as also in other
individuals, for the purpose of deception, by the action of friction,
acids, or strong alkalies.


Dermatitis Gangrænosa.

Dermatitis gangrænosa, or gangrene of the skin, is a rare affection. It
may be idiopathic or symptomatic. As an idiopathic disease it begins
usually as circular, erythematous, dark-red spots, tending to appear
symmetrically, either painful and hyperæsthetic or without sensation.
Malaise, fever, and symptoms of debility usually precede and accompany
its development. The lesions go on to gangrene and sloughing, recovery
taking place or a fatal termination gradually resulting. There may be
several or as many as thirty or forty patches. The progress of the
disease, whether terminating fatally or in recovery, is slow, usually
of several months' duration. Gangrene of the skin as a symptomatic
affection is occasionally seen in grave cerebral and spinal diseases,
and also in diabetes.


Furunculus.

Furunculus, or boil, is a deep-seated, inflammatory disease,
characterized by one or more variously-sized, circumscribed, rounded,
more or less acuminated, firm, painful formations, usually terminating
in central suppuration.

In the beginning the lesion appears as a reddish spot, small, rounded,
imperfectly defined, inflammatory, and painful to the touch, having its
seat in the corium; it gradually becomes larger, raised, and with
marked tendency to central suppuration, usually maturing in from one to
two weeks, when it appears as a painful, deep-red, rounded, pointed,
inflammatory formation, varying in size from a pea to a walnut,
exhibiting central suppuration, the so-called core. In some cases there
is no {605} tendency to core-formation, such lesions being popularly
designated blind boils.

A furuncle is usually painful, of a throbbing nature, which persists
until suppuration has taken place and the contents discharged. The
intensity of the inflammation gives rise to considerable areolar
swelling and hyperæmia. There may be but one lesion present, or, as
more frequently happens, several may exist at the same time scattered
over different regions. In the latter case, after a partial or complete
disappearance of the first crop, a second outbreak frequently occurs,
to be followed later by a third, and so on, constituting furunculosis.
The lesions are usually isolated. No region of the body is exempt; the
face, neck, back, and buttocks are favorite localities. Sympathetic
constitutional disturbance, more or less marked in severe cases, is
usually present. Boils sometimes occur in association with eczema. In
general, they are the result of a depressed state of the system.
Friction, a contusion, or similar local irritation is often the
exciting cause. They are met with in association with diabetes, pyæmia,
uræmia, chlorosis, fevers, and like conditions. Although observed at
all periods of life, they are more common during adolescence and in old
age. The view has been advanced that a furuncle is due to the presence
of a microbe (Torula pyogenica). According to Pasteur, this bacterium
is identical with that of abscesses of the soft parts, etc.

The lesion usually has its starting-point in a sebaceous gland in the
upper part of the corium, or, deeper, in a sweat-gland or
hair-follicle. Beginning in a sweat-gland in the deeper structures it
constitutes the so-called connective-tissue furuncle, or hydroadenitis
of some authors. The core, or central suppuration, is usually made up
of the tissue of the gland in which the boil had its origin, and pus,
and when cast off appears as a whitish, tough, pultaceous mass. A more
or less permanent cicatrix usually results. There is only one affection
with which a furuncle is likely to be confounded--namely, carbuncle. In
this latter, however, the lesion is considerably larger, flattened
instead of rounded and pointed, the pain of an intense character and in
a measure independent of touch or injury. Moreover, a carbuncle has
several points of suppuration, the boil having but one, and the former,
moreover, is rarely multiple.

When occurring in crops, the affection is often rebellious to
treatment. Both constitutional and local measures, especially the
former, are demanded. Functional disorders are to be regulated, and any
faulty condition of the general health corrected. Tonics, such as
quinine, iron, strychnia, mineral acids, and arsenic, are not
infrequently of service. The last remedy usually proves of most value
in those cases in which the lesions appear in crops. The preparations
of sulphur are of positive service in many cases of the disease;
hyposulphite of sodium, ten or fifteen grains three or four times
daily, is one of the most valuable remedies we possess, and with the
same view calx sulphurata, one-tenth to one-half grain five or six
times daily, may be prescribed. Alkalies, especially liquor potassæ in
ten or fifteen minim doses, are not infrequently beneficial. The
compound syrup of the hypophosphites may also be employed with the hope
of obtaining relief. In regard to the diet, the most nutritious food,
liberally partaken of, is, as a rule, to be advised. At times change of
air and scene will act most happily.

{606} Concerning the local treatment, the lesion in the first stage may
possibly be aborted, or at least modified in its course, by the
application to the forming core of a strong solution or of a crystal of
carbolic acid. This procedure is preferable to the actual cautery. If
the lesion be farther advanced, a drop of carbolic acid and glycerin,
equal parts, will often give instantaneous relief and arrest the
progress of the boil. A few drops of a 5 per cent. carbolic-acid
solution may also be injected into the apex of the boil with good
results. For the same purpose painting the parts with tincture of
camphor or tincture of iodine is advised. An ointment of carbolic
acid--as, for example, resin cerate an ounce, carbolic acid from
fifteen to thirty grains--applied as a plaster will be found useful.
The application of poultices affords ease in some cases. As soon as
suppuration has been fully established evacuation of the contents will
shorten the course of the process. If the boil is open and discharging,
boric acid in powder, freely applied, has been recommended.

       *       *       *       *       *

ALEPPO BOUTON, BOIL, OR EVIL, DELHI BOIL, AND BISKRA BOUTON.--The first
of these diseases, the Aleppo bouton, boil, or evil, is observed at
Aleppo, Bagdad, and the neighboring regions. Delhi boil is not uncommon
in India, and the Biskra bouton is found in Algeria and elsewhere along
the African coast. In fact, these diseases are more or less epidemic in
these countries. They have been considered as allied to furuncle, but
their true nature is somewhat obscure. The three affections are
probably examples of the same disease, modified, it may be, by climate,
habits, etc. They begin as a papule or tubercle, soon becoming a
pustule, and then ulcerate, leaving a cicatrix.


Carbunculus.

Carbunculus (anthrax, carbuncle) is a firm, more or less circumscribed,
painful, deep-seated inflammation of the skin and subcutaneous
structures, variable as to size, terminating in a slough. General
malaise, slight fever, and chilliness precede and usher in the disease.
Locally, there appears at first a more or less circumscribed, circular
redness, with swelling, tenderness, and pain. Soon a phlegmonous
inflammation develops, the surface at times showing vesiculation, the
lesion involving an area several inches in diameter and of considerable
depth. The progress of the disease is not uniform. At the end of a week
or two suppuration is fully established, the first signs of this
process appearing about the hair-follicles. The tissues are now soft
and boggy; the skin becomes gangrenous, breaking down at numerous
points, disclosing centres of suppuration, giving the lesion a
cribriform appearance. Finally, the whole mass sloughs away either as
an entirety or in portions, and results in an open, deep ulcer with
hard and raised edges, which gradually granulates and heals, leaving a
pigmented cicatrix. The area involved varies, and may be extensive,
sometimes as much as six or eight inches in diameter. The favorite
localities for its development are the nape of the neck, shoulders,
back, and buttocks. As a rule, the process ends in three to six weeks.
Usually only one lesion exists. When there are several or where they
follow each other in succession, the general condition is apt to {607}
become markedly depressed, and even a fatal result is not at all
uncommon.

The causes which give rise to the affection are similar to those which
predispose to furuncle. It is generally observed in those whose health
is impaired or broken down. It is more common in men, and is usually
encountered in those past middle age. The inflammation starts
simultaneously at numerous points, usually from the hair-follicles,
sweat and sebaceous glands, extends in all directions, and eventually
terminates in gangrene of the whole area. The inflammatory centres
break down rapidly, from each of which the collected pus finds its way
to the surface, thus producing the cribriform appearance. According to
Warren, the pus ascends by way of the columnæ adiposæ to the
hair-follicles, and thence to the surface. The process may involve
fascia, muscles, and even periosteum and bone. The disease is to be
distinguished from furuncle by its greater size, flatness, and the
multiple points of suppuration. From erysipelas, to which in the
beginning it may have some resemblance, it is to be differentiated by
the hardness, painfulness, and circumscribed character of the lesion.
It is also to be distinguished from malignant pustule. It is always to
be looked upon as a serious affection, especially when occurring in
those past the age of fifty or sixty and in those in a debilitated
condition. Carbuncle when occurring about the face terminates in a
large proportion of the cases fatally.

The treatment is both local and general. The local measures are in the
main the same as advised for furuncle. In the early stages the actual
cautery may arrest the process. Injections of from eight to twelve
drops of a 5 or 10 per cent. solution of carbolic acid will be found
valuable, often affording speedy relief. Frequently-repeated paintings
with tincture of iodine in the early stage may prove of service.
Poultices are of value, and will often diminish the tension and the
pain. A dressing of white lead, laid on thick, is highly spoken of by
Milton and other English observers. When the purulent collections have
broken through the skin the application of a cupping-glass to draw out
the pus has been advised. The wound should be dressed with carbolized
oil. The use of the moist-sponge dressing, with the view of absorbing
the pus, as recommended by McClellan, may be advised. Compression may
also be resorted to with good results. The weight of authority is
against the practice of incision, although in some cases it is to be
recommended, the operation being preceded by hypodermic injections of
cocaine. The general treatment should be of a tonic character.
Iron--preferably the tincture of the chloride--and quinine in large
doses are to be advised. A liberal diet of nourishing food, with a
moderate amount of stimulants, is indicated in almost every case.


Herpes Simplex.

Herpes simplex is an acute, non-contagious, inflammatory disease,
characterized by the formation of pinhead- to pea-sized vesicles
arranged in groups and occurring for the most part about the face and
genitalia. Malaise and pyrexia in severe cases may precede the
eruption. Usually, however, the efflorescence appears without any
systemic disturbance. The lesions {608} are rarely numerous, and appear
in the form of one or more clusters. Sense of heat in the part usually
signalizes the outbreak. The vesicles show no tendency to rupture. The
contents are at first clear, but later become cloudy or puriform, and
dry to yellowish or brownish crusts, which subsequently fall off,
leaving the skin normal. If broken or rubbed, a superficial excoriation
results. The affection is acute, ordinarily running its course, if
unirritated, in a week or ten days. It is liable to recur from time to
time. Occurring about the face, it is designated herpes facialis. It is
usually seen about the lips (herpes labialis), frequently about the alæ
of the nose, and occasionally on other regions of the face. The mucous
membrane of the mouth may also be invaded. The lesions may remain
discrete or may coalesce, forming small blebs.

When the affection shows itself upon the genitalia, it is termed herpes
progenitalis; and when on the prepuce, a common site, herpes
præputialis. In the female, in whom it occurs here much less
frequently, the labia majora and labia minora, as well as the skin
about the vulva, are the parts usually invaded. It is seen most
commonly in the young and middle-aged. Burning, slight itching,
sometimes darting pain, and more or less oedema, may be present. As a
rule, the lesions are not numerous, the average number being five or
six. They incline to group, and ordinarily but one group is seen.
Unless irritated they run the same favorable course as when on other
regions. If, however, as often happens, especially when occurring about
the inner surface of the prepuce or the glans, or on the inner surface
of the labia, the vesicles break down and excoriations resembling
ulcers result. The disease is even more prone to recur than when on
other parts.

Herpes of the face is often observed in association with lung and
febrile diseases. Malaria is sometimes the cause, and digestive and
nervous disorders frequently predispose to it. Herpes of the genitalia,
it is stated, is seen most frequently in those who have previously had
gonorrhoea, chancroid, or chancre, especially the first. It may be
that, occurring in such persons, it excites solicitude, and hence
medical relief is sought, and the relative frequency of such causes
unduly increased. A long prepuce is a predisposing factor.

The characters of the eruption, as it occurs about the face, are so
well marked as to preclude an error in diagnosis. About the genitalia,
however, the lesions may become abraded or irritated, and may simulate
chancroids. The history, course, and character of the two affections
should in doubtful cases be carefully considered before expressing a
positive opinion.

In herpes facialis, flexible collodion, camphorated cold cream, or the
lotion of zinc sulphate and potassium sulphide (see treatment of acne
for formula) may be prescribed. In herpes progenitalis cleanliness is
of great importance. Liquor gutta-perchæ, a paste composed of equal
parts of mucilage of acacia, glycerin, and oxide of zinc, lotions of
sulphate of zinc, a few grains to the ounce, and of ammonia-water, may
be prescribed. A saturated solution of boric acid and a dressing of
borated absorbent cotton are likewise useful, while in some cases
dusting the parts with calomel will prove beneficial. Where the
affection recurs, if the prepuce is long, circumcision may afford
future immunity.


{609} Herpes Iris.

Herpes iris is an acute non-contagious disease, consisting of one or
more groups of inflammatory vesicles or blebs, arranged usually in the
form of more or less complete concentric rings, the whole efflorescence
being somewhat variegated in color.

The eruption most frequently appears on the backs of the hands and
feet, especially the former. It begins as a simple papule or vesicle,
which soon disappears, a ring of discrete or confluent vesicles now
appearing around the periphery. The process may be arrested at this
stage, the lesions soon undergoing involution, or still another ring
may form. The vesicles may be discrete or confluent, but usually they
coalesce, forming small or large blebs. The number of groups or patches
in most cases is not large, three or four usually being present at one
period; but sometimes as many as a dozen or more exist. The eruption is
usually symmetrical. The difference in the age of the several rings
that go to form a single patch gives rise to the variegated colors
which characterize the disease. In size the vesicles vary from a
pinhead to a pea, and the patches from a fraction of an inch to several
inches in diameter. They contain a yellowish, clear, or puriform fluid
which rapidly dries to crusts. New patches, as a rule, continue to
appear in crops for a few weeks, when the process gradually subsides,
leaving slight pigmentation, which soon fades away. Variations in the
type of the efflorescence are not uncommon. In some instances the
lesions barely reach vesiculation, being rather papulo-vesicular, while
in others blebs may appear at the beginning in the place of vesicles.
The subjective symptoms of itching and burning are either lacking or
are not marked. Malaise or slight febrile action may usher in the
disease, or, as is usually the case, constitutional disturbance is not
observed. The affection is comparatively rare. Recurrences may take
place, usually at intervals of a year or more.

It is seen chiefly in spring and autumn, and is met with in both sexes,
but is more common in children and young persons. Its nature is
obscure. It is probably due to the same causes that are responsible for
erythema multiforme, a disease to which it is very closely allied. The
process also is intimately identical with that affection, it being,
apparently, merely an advanced stage or modification of that disease.
It is to be distinguished from ringworm, erythema multiforme, herpes
zoster, pemphigus, and dermatitis herpetiformis. In ringworm the
process is more superficial, and usually is less inflammatory, the
papules or vesico-papules being scarcely distinguishable; in doubtful
cases the microscope will decide. Vesiculation will serve to
differentiate from erythema multiforme. The absence of neuralgic pain,
the distribution, location, and arrangement of the vesicles, are
sufficient to exclude herpes zoster. In pemphigus the size,
distribution, arrangement, mode of formation, and course of the lesions
are different from herpes iris.

The affection tends to spontaneous disappearance in the course of a
week or two; nor does treatment seem to influence materially its
course. The bowels should be opened with saline laxatives, and other
symptoms treated on general principles. Tonics, especially quinine, are
in some cases of value. Locally, dusting-powders, such as oxide of
zinc, starch, and lycopodium, may be frequently applied. Cooling,
antipruritic, or {610} astringent lotions--such, for example, as those
used in acute vesicular eczema--will generally prove grateful.


Herpes Zoster.

Herpes zoster, or zoster, popularly known as shingles, is an acute,
self-limited, inflammatory disease, characterized by groups of vesicles
with inflammatory bases situated along or over a nerve-tract, and
accompanied by more or less neuralgic pain.

As a rule, the cutaneous lesions are preceded, usually for several
days, by neuralgic or burning pains in the part, and in some cases mild
febrile disturbance. An inflamed state of the skin, in the form of one
or several patches, is seen, which is soon followed by the formation of
vesico-papules, which rapidly become distinct vesicles. They vary in
size from a pinhead to a pea, are situated on inflamed bases, and are
irregularly grouped. They may occur in small numbers, or, as is usual,
be numerous, in which case they are crowded together. In the latter
event they may coalesce here and there, forming larger lesions or
irregular patches. They continue to appear for five or six days, remain
stationary a short time, and then begin to subside. One or more groups
may be present; usually a half dozen or more are seen in the one case.
The vesicles contain a clear yellowish liquid, which gradually becomes
puriform; those that appear last rarely reach full development. They
show no tendency to rupture, are distended, subsequently becoming
slightly umbilicated, and by the end of two weeks have gradually dried
to thin yellowish or brownish crusts, which soon drop off. Except in
severe cases, especially the hemorrhagic form, scarring rarely results.
A tendency to group is characteristic of the eruption. The disease is
acute, and runs its course usually in from ten to twenty days.

In some instances the lesions run an abortive course, barely arriving
at the point of vesiculation. On the other hand, small blebs and
pustules may be formed. In severe cases the vesicles may become
hemorrhagic. The neuralgic pain may accompany the disease, and in
severe cases, especially in persons advanced in years, may persist long
after the eruption has subsided. In some cases burning is the only
subjective symptom complained of. The disease is not confined to any
age or sex. It is more common in the winter season. As a rule, it is
limited to one side of the body. Moreover, it is rarely seen in the
same individual twice. The intercostal and lumbar regions show the
eruption most frequently. In zoster of the orbital region the eye
becomes involved, and the disease may in some instances terminate in
loss of sight, and even in destruction of the eyeball. Any nerve-tract
or part of the body may be the seat of the eruption, hence the names
zoster capitis, facialis, brachialis, pectoralis, etc. The disease is
not uncommon.

The eruption is dependent upon an irritable and inflamed state of the
ganglia or nerves--a neuritis. Hence any agent that may bring about
this condition is capable of producing the eruption. Among such may be
included atmospheric changes, sudden checking of the perspiration,
compression, nerve-injuries, operations, and similar influences. In
some instances the eruption is noted to follow the administration of
arsenic. {611} The primary seat of the affection is usually in the
spinal ganglia; they are found softened and altered in structure and
the nerves inflamed and thickened. It may, however, have its beginning
along the tract of a nerve or in the peripheral branches. In fact, it
may be spinal, ganglionic, or peripheral in origin. The vesicles are
found to have their seat in the lower strata of the rete. The
surrounding corium and papillæ show more or less round-cell
infiltration, with dilatation of the papillary blood-vessels. A
perineuritis, with cell-infiltration in and about the neurilemma, is
also usually observed. The vesicles contain rete-cells, pus-corpuscles,
and serum.

The diagnosis is usually unattended with difficulty. The premonitory
pain, the appearance of grouped vesicles upon inflammatory bases, with
no tendency to rupture, and the limitation of the eruption to one side
of the body, are sufficiently characteristic. The vesicles are larger
than those of eczema, and lack the well-known tendency of the latter to
break and discharge a gummy fluid which rapidly forms to crusts. In
erysipelas the line of demarcation, the deep-reddish color, and the
constitutional symptoms will serve to differentiate the diseases. It is
to be distinguished from simple herpes by its location, number of
groups, unilateral distribution, and absence of relapses. The prognosis
is favorable, as the eruption usually disappears at the end of two or
three weeks; severe cases, however, may last a month or more. When
involving the eye, the possibility of its destroying the same, and even
of a fatal result, is to be kept in mind. In elderly subjects the
neuralgic symptoms are apt to prove persistent.

Treatment is mainly expectant. The disease is self-limited, and hence
severe measures are to be avoided. Internal treatment has, so far as
experience shows, very little influence upon its course. Phosphide of
zinc, in one-third grain doses every three hours, at times seems to
have a beneficial effect. Morphia, hypodermically or by the mouth, is
required if the neuralgia is severe. The galvanic current, applied once
or twice daily, will sometimes quiet the pain and favorably influence
the course of the disease. Locally, the parts are to be protected from
irritation. For this purpose dusting-powders, to which a small quantity
of morphia and camphor may be added, may be employed. The parts should
be further protected with a bandage. Oxide-of-zinc ointment, and
anodyne ointments containing powdered opium or belladonna, may also be
used. Painting the efflorescence with oil of peppermint or with
solutions of menthol, thymol, or carbolic acid will be found to relieve
the burning and pain; so also, flexible collodion, containing ten
grains of morphia to the ounce, will sometimes afford relief. The parts
subsequently may be covered with a layer of cotton batting.


Dermatitis Herpetiformis.

This disease is multiform and protean in character, consisting in the
formation of herpetic, erythematous, vesicular, pustular, and bullous
lesions, occurring separately or in various combinations, accompanied
with itching and burning sensations and pursuing usually a chronic
course with relapses.

This affection, which until recently has been confounded with other
{612} cutaneous diseases, is rare, although as its peculiar features
become belter known numerous cases will doubtless be reported. It was
first described by one of us (Duhring) in a paper read before the
American Medical Association in 1884. It is an inflammatory disease of
an herpetic character, the various lesions showing more or less
tendency to group. In some of its forms it bears likeness to erythema
multiforme and herpes iris, while in other cases it is allied to
pemphigus. It varies greatly in the degree of development. The causes
are varied, though in many cases they are neurotic in their nature;
thus, the disease may follow shock to the nervous system. It is also
met with accompanying the parturient state. In some cases it is
septicæmic in origin. It is also at times due to irregular
menstruation. As to sex, while more frequent in women, it is also
encountered in men. In severe cases there is more or less
constitutional disturbance, consisting of malaise, slight fever, and
constipation, accompanying the onset of the disease or its relapses and
exacerbations. Increased heat of skin, itching, and burning are also
prominent symptoms at such periods.

The disease manifests itself in the erythematous, vesicular, bullous,
pustular, and multiform varieties. The erythematous variety is
characterized by patches or a diffuse efflorescence of an urticarial or
erythema-multiforme-like nature, the similarity to the latter process
being sometimes marked. The disease may remain in this form, or, as is
usually the case, may pass into other varieties, especially the
vesicular. This latter is the usual form of the disease. It is
characterized by variously-sized, flat or raised, irregularly-shaped or
stellate, glistening vesicles, as a rule without marked areolæ. They
are usually firm and distended, are often difficult to detect, and have
an herpetic look, being grouped into clusters of two, three, or more.
Here and there they are aggregated into patches. When in close
proximity they tend to coalesce, forming large irregularly-shaped,
oblong, or lobulated vesicles, or even blebs. The eruption is usually
profuse. The most striking symptom is the itching, which in most cases
is severe or even intense. The vesicles make their appearance, as a
rule, slowly, several days or a week being required for their complete
development. This variety of dermatitis herpetiformis (formerly
described with the name herpes gestationis) is liable to be confounded
with vesicular eczema, but the irregularity in the size and shape of
the vesicles; their angular or stellate outline, giving them a puckered
look; their firm, tense walls, showing no disposition to spontaneous
rupture,--will all serve in the diagnosis. In some cases the
constitutional disturbance and the magnitude of the eruption, as
regards profusion, distribution, and multiformity, will also be
apparent.

In the bullous variety the lesions are more or less typical blebs,
variable as to size and shape, seated upon a slightly inflamed or
non-inflammatory base. They tend to group into small clusters, in which
case the skin between them will be red, as occurs in herpes zoster.
Together with the blebs, vesicles and small or even minute whitish
pustules will usually be found, the combination of these varied lesions
being sometimes remarkable. The blebs generally rupture or are broken
by injury, and become the seat of yellowish or brownish crusts. This
variety of the disease is liable to be confounded with pemphigus, but
differs in its marked herpetic and more inflammatory aspect.

{613} The pustular variety is generally less clearly defined than the
vesicular, because the lesions are usually intermingled with vesicles,
vesico-pustules, and blebs. The pustules are acuminate, rounded, or
flat, are variable as to size, and are whitish or yellowish in color.
The smallest are generally flat, sometimes being no larger than a
pinpoint or pinhead, while those that attain the size of a pea are
rounded or acuminate, and are surrounded with a marked red areola. The
largest are flat, and incline to spread out and to run together,
forming patches which later become covered with greenish crusts.
Grouping occurs here as in the other varieties, and is sometimes
peculiar in that a central pustule may be surrounded by a variable
number of smaller pustules in a circinate form, as in herpes iris. This
variety of the disease is the same condition described by Hebra with
the title impetigo herpetiformis.

The papular manifestation is an ill-defined form of disease, consisting
of small reddish, firm, more or less grouped papules, resembling in
general appearance the papular lesions sometimes met with in abortive
herpes zoster. They resemble at times also certain phases of relapsing
chronic papular eczema. Owing to itching and scratching they are
generally excoriated.

Finally, there remains to be described the multiform variety, which
consists of several of the foregoing varieties occurring in
combination, a phase of the disease which is not infrequent. It
comprises erythematous, sometimes slightly raised, urticarial patches
of variable size and shape, often marginate or confluent, and of a
reddish, yellowish, or variegated color. In addition, there may be
present more or less well-defined irregularly-shaped or rounded
maculo-papules and flat patches of infiltration, papules, and
papulo-vesicles in various stages of evolution. Vesicles, blebs, and
pustules may also exist, together with pigmentation. Thus it will be
noted there exists a mixture or combination of lesions, calling to mind
the peculiarities of eczema, although the process is both more
capricious and varied in its behavior.

It must also be stated that the disease may at any period change its
type; thus the vesicular variety may exist for weeks or months, to be
followed by a crop of blebs or of pustules. The mingling of several
varieties at one or another period in the course of the affection is
usually a marked feature. It is variable in its course, but is in most
cases chronic, and not infrequently is of many years' duration. It
inclines to persist and to show itself in distinct crops or attacks at
irregular intervals, the patient in the mean time being comparatively
free of eruption. Relapses are common. It is in most cases very
rebellious to treatment. The prognosis should be guarded. The pustular
and bullous varieties are the most grave, and at times may prove fatal,
especially in connection with the parturient state.

Concerning the treatment, with the knowledge now at hand but little
encouragement can be given. The general state of the patient should
receive attention, and the cause inquired into and modified or remedied
if possible. The therapeutics must be conducted on general principles.
Arsenic and its preparations do not seem to be of value, at least in
the cases that have fallen under our observation. Locally, the remedies
most useful are those usually employed in chronic eczema and in
pemphigus.


{614} Psoriasis.

Psoriasis may be defined as a chronic disease of the skin,
characterized by reddish, dry, inflammatory, infiltrated patches,
variable as to size, shape, and number, covered usually with abundant
whitish, mother-of-pearl-colored, imbricated scales. It varies
considerably in the degree of its development, but as a rule the
lesions are numerous and their features clearly defined. It is the most
uniform in its symptoms of all the diseases of the skin. It is
therefore easy to recognize. In the first stage it appears as a small
reddish spot, as large as a pinhead or a pea; it grows rapidly or
slowly, and from the beginning shows signs of scaling, the scales being
whitish, imbricated, and easily detached by scraping. They are
reproduced readily, so that the lesion is usually well covered. In
their early stages the lesions usually develop rapidly until their
determinate size has been attained. The usual course is for the lesion
to begin as a pinhead-sized spot, and grow to the size of a small or
large coin. Several may appear side by side in close proximity, in
which event they tend to coalesce, and to form larger, rounded,
ovoidal, or figure-of-eight-shaped patches. Thus in time large surfaces
of disease, the size of a hand or larger, may result. In other cases
the lesions remain small, but through their great number may involve a
considerable portion of the whole integument.

When typically developed, the lesions are of a bright- or dull-red
color, and are covered with whitish, grayish, or pale-yellowish scales.
The degree of inflammation varies with the case; at times it is slight,
causing the lesions to assume merely a pale-pinkish, slightly
inflammatory look; at other times it is more active, producing a
decidedly inflammatory, strawberry- or raspberry-red hue. The majority
of cases show a well-defined dull pinkish-red color of a cold
inflammatory hue. The scaling, while usually active and abundant, is
likewise variable; where the lesions are numerous and large it is
constant, the scales being formed and shed rapidly from day to day;
where the process is active, they are large, laminated, of a whitish,
silvery, or mother-of-pearl-colored or slightly yellowish hue, varying
somewhat with the locality involved. Sometimes they are heaped up. They
are, moreover, easily detached, and can be readily picked or scraped
off, leaving beneath a dry or very little excoriated, reddish surface.
When deeply scratched, minute drops or points of blood, sometimes
appear. They never exude serum. The lesions are, as a rule,
circumscribed and sharply defined from the surrounding healthy
integument, differing in this respect from similar patches of eczema.
The skin between the lesions is perfectly healthy. In markedly
inflammatory cases they occasionally possess a slightly raised border,
and sometimes, especially in certain localities, as the hands, fissures
form, as in eczema and syphilis.

The disease pursues an eminently chronic course, often lasting years or
even throughout life, disappearing and recurring from time to time.
Relapses at intervals of months or years are the rule, sometimes
slight, at other times severe. It is a capricious disease. Usually it
is better in summer than in winter, and in some cases it makes its
appearance only during the latter season. It is generally unaccompanied
by marked subjective symptoms, although this depends largely upon the
degree of {615} inflammatory action. In most chronic cases the itching
and burning are either absent or slight, and when present are generally
most annoying during the period that new lesions are appearing or old
ones spreading. On the other hand, where the affection is highly
inflammatory and running an acute, rapid course, both sensations,
especially burning, may exist to an annoying degree. The disease is not
contagious.

The eruption takes on different appearances according to the size and
outline of the lesions, some of which require mention. They constitute
the so-called varieties of the disease, but, strictly speaking, are
forms rather than varieties. Thus, when the lesions are pinhead in size
the form is termed punctata; when larger, the size of peas, guttata,
from their resemblance to a drop of mortar; when still larger, the size
of coins, they are designated nummularis, this being the form generally
encountered. Sometimes the last-named lesions become more or less clear
in the centre, and spread on their circumference after the manner of
ringworm of the general surface, the condition being called circinata;
at other times, more rarely, they assume a figured or ribbon-like form,
causing them to have a serpentine, gyrate, or festooned appearance,
termed gyrata. Commonly, however, when they grow to a large size they
form, by the coalition of two or more lesions, irregularly-rounded
patches, covering, it may be, a considerable area, the condition being
called diffusa. The disease shows preference for certain regions, among
which may be mentioned the extensor surfaces of the limbs, the elbows
and knees, the scalp, and the trunk. The palms and soles and nails may
also be invaded alone, or, as is usually the case, in connection with
the disease upon other regions. It is usually symmetrical.

The causes of the disease seem to be varied, and are by no means well
understood. It is met with, as a rule, in subjects whose general health
is of the best, and who have hearty and strong constitutions, with no
other ailment than the cutaneous manifestation. But cases are also
encountered where the general condition is at fault: sometimes the
system is below standard, as during lactation; in other cases the
nervous system is depressed, as from some long-continued cause like
mental worry. It occurs in both sexes, and usually makes its appearance
in early adult life. It is seldom met with before the age of eight, and
does not show itself in infants. In some cases it is inherited, but
more frequently such is not the case. It occurs in all walks of life,
being found among the rich and the poor in about like proportions.
Statistics show it to be one of the most common diseases of the skin.
It is of more frequent occurrence in some countries than in others.
According to White's report of 5000 consecutive cases of skin disease
observed in Boston, 152 cases of psoriasis were recorded, while
Anderson in Glasgow reports 725 cases among 10,000 cases of skin
disease, the difference being more than two to one in favor of
Scotland. Diet in the majority of cases possesses but little influence
over the disease.

The pathological process is one of the most defined and constant in
cutaneous medicine. It is well marked throughout its course, and is
subject to little variation. According to the most recent and reliable
observations, it is held to be an inflammation induced by a hyperplasia
of the rete mucosum. The views put forth by Auspitz and by Tilbury Fox
have been substantiated by more recent observers. A. R. Robinson, {616}
and later Jamieson and Thin, have investigated the pathological anatomy
of the disease with care, and have shown that the disease consists
essentially of a hyperplasia of the rete mucosum, the increase taking
place in the interpapillary portion of the layer. The growth extends
downward, pressing upon the papillæ and corium, and setting up a
variable degree of inflammation. In the later stages the superficial
blood-vessels become dilated, more or less emigration of corpuscular
elements occurring, the connective tissue especially in the
neighborhood of the vessels becoming the seat of a round-cell
infiltration. Effusion of serum, moreover, takes place, separating the
connective-tissue bundles and fibres into an open meshwork. As the
disease is vanishing there is a gradual return to the normal state, the
hyperplasia, dilatation, and infiltration disappearing without traces.
The hair is affected from the beginning in the form of hyperplasia of
the external root-sheath, but the sebaceous and sweat glands are not
found to be involved.

DIAGNOSIS.--The diagnosis, as a rule, offers no difficulties. The
characteristic features are so constant and are usually so well marked
that in ordinary cases errors are not likely to occur. When localized,
as upon the scalp or upon the hands, it may be, however, readily
confounded with other diseases. The general aspect of the eruption, the
form of the lesions, the peculiar character of the scaling, the
localities invaded, and the course of the process must be kept in view.
It may be confounded with squamous eczema, especially where only one or
two lesions are present, but the scales are usually more abundant,
larger, and whiter than in eczema. The patches of psoriasis, moreover,
are circumscribed, often sharply defined, and are always dry. In eczema
there is not infrequently a history of moisture; itching is also
generally an annoying symptom, much more marked than in psoriasis.

The papulo-squamous syphiloderm at times closely resembles psoriasis,
especially as it occurs upon the palms and soles. Symmetry usually
exists in psoriasis, but in syphilis it is often lacking, even in
connection with disease of the palms and soles. Apart from the question
of a history of syphilis, it will be found that psoriasis generally
involves more surface, and in a more disseminate form, than the
syphilitic eruption; also, that the scales are whiter, larger, and more
copious than in syphilis. The color of the lesions in both diseases is
similar, but in psoriasis it is pinker or redder, and free from the
yellowish, brownish, ham-colored tint that generally characterizes the
later syphilitic eruptions. The infiltration and thickening of the skin
in a psoriatic patch are less than in syphilis, this observation being
a valuable point in the diagnosis. The character of the inflammatory
product in the diseases is different, that of psoriasis being simpler
and less dense and firm. Finally, the course of psoriasis is peculiar,
the lesions always manifesting the same general characters, often
disappearing spontaneously and again reappearing.

Seborrhoea, especially of the scalp, sometimes simulates psoriasis, but
the patches in the former disease are ill defined, are not so
marginate, and are covered with finer, looser, and fatty scales. The
lesions of psoriasis are redder and more infiltrated, and will usually
be found to exist also in other localities. The disease may also be
mistaken for lupus erythematosus in its early stage. The involvement of
the sebaceous glands in {617} almost all cases in the latter affection,
the character of the scaling, and the fact that the face is the usual
locality attacked, will aid in the diagnosis. Ringworm of the general
surface may also bear resemblance to psoriasis, especially to the
circular form, but the parasitic disease is more superficial and more
marginate, is less scaly, and runs a more acute course. In doubtful
cases the microscope should always be employed to determine the
question.

TREATMENT.--The disease is rebellious to treatment, sometimes even
where the lesions are few and small. It must be regarded as one of the
most stubborn and persistent of the inflammatory diseases of the skin,
for, while many cases yield readily to either internal or external
remedies, the majority will often resist the best-directed therapeutics
looking toward a permanent cure. It may often be happily dissipated for
the time being, but immunity from relapses is a difficult task. To
relieve the patient of the lesions, and, secondly, to prevent, if
possible, relapses, should be the aim. To accomplish this demands
usually both external and internal treatment. Before entering upon
therapeutic measures the case should be viewed from a general
standpoint. The condition of the general health should be inquired
into, and the cause, if possible, determined. The history of the
disease in chronic cases should be learned, and, if a relapse, the
behavior of the lesions on former occasions. The influence of the
several well-known remedies, such as arsenic internally, and tar,
chrysarobin, and the mercurials locally, should also be ascertained.
Finally, the acuteness or chronicity of the attack, the activity of the
process, the amount of disease present, the locality invaded, and the
general circumstances of the patient and the time that can be devoted
to the treatment, should all receive consideration.

Among internal remedies, arsenic and its preparations occupy the most
prominent position. For the majority of cases this remedy will be found
valuable, and, if administered when indicated and in suitable doses for
sufficient length of time, good results may be expected. It is not
indicated in every case, as is shown by the fact that sometimes,
instead of relieving, it aggravates the disease. It should be used
tentatively at first, with the view of determining its tolerance and
effect, not only upon the skin, but on the general system and
alimentary canal. It is a powerful remedy, and should always be
employed with due caution. At the same time, there need be no
hesitation in prescribing it, or even in employing it for a long
period, if attention be directed to its effects. Toxic symptoms should
never be permitted to occur. In acute stages, whether in first attacks
or in relapses, where the process is active, characterized by marked
redness, inflammation, and heat, it should be withheld. At these
periods it usually aggravates the disease. The more chronic the
process, the more useful will the remedy probably prove.

The drug is generally administered in the form of arsenious acid,
liquor potassii arsenitis, and liquor sodii arsenitis. A dose of
arsenious acid varies from one-fortieth to one-fifteenth of a grain
thrice daily, administered in pill form. The dose of the liquor
potassii arsenitis--or Fowler's solution of arsenic, as it is generally
termed--varies from one to five minims three times a day, the average
dose being two or three minims. It is best to begin with a small dose
and gradually to increase the quantity until the maximum dose is
ascertained; {618} after which the regular dose may be instituted.
Patients, it will be found, vary as to the amount they can safely and
beneficially take: in most cases two or three minims continued for a
length of time will prove a full dose, while in others four or five
minims will be tolerated. It may be given with water, elixir of
calisaya, or wine of iron. The practice of prescribing it pure,
directing a certain number of drops to be taken at each dose, is
objectionable; it does not ensure an accurate quantity or proper
dilution, and, moreover, gives the patient unnecessary trouble. A
prescription such as the following possesses practical advantages:

  Rx. Liq. potassii arsenitis, fluidrachm iss;
      Elix. calisayæ,          fluidounce iv.

M.--Sig. One teaspoonful with a wineglassful of water thrice daily,
after meals. The dose here is three minims; should it prove too strong,
a half teaspoonful of the mixture may be ordered. The toxic effects of
arsenic should be borne in mind. Some persons are very susceptible to
the remedy, half-minim or one-minim doses sometimes causing unpleasant
symptoms. The usual ill effects consist of erythema of the fauces,
oedema of the eyelids, injection of the conjunctivæ, watering of the
eyes, pains in the head, nausea, sharp pains in the bowels, and
diarrhoea, coming on within a few days or a fortnight after beginning
treatment. As a rule, they pass away in a few days after ceasing the
use of the remedy.

The length of time that arsenic should be given will depend upon its
effects upon the general system and upon the disease. In most cases
improvement is noticeable within a fortnight, though its use from one
to three months is generally necessary to bring about complete
recovery; and it is best to continue the medicine in small doses for a
month or two longer. Arsenic is a nervine tonic. It acts as a stimulant
to the skin, exerting a decided impression upon the cells of the rete
mucosum; doing this, without doubt, directly through the nerves, which,
as is well known, are abundantly supplied to this structure.

Phosphorus has been used by several dermatologists, but with varying
results. It is liable to produce gastric disturbance, and is a
disagreeable remedy. Tar, in capsule or pill form, will sometimes prove
of value where arsenic and other remedies have failed. From one to
three capsules, containing from three to five grains each, may be given
for a dose. Carbolic acid has also been extolled by some, especially in
chronic cases with slight infiltration. Anderson speaks well of it, and
gives the following formula for its administration:

  Rx. Acidi carbolici, drachm iij;
      Glycerinæ,       fluidounce j;
      Aquæ,            fluidounce v.

M.--Sig. One teaspoonful in a large wineglassful of water before meals.

In some cases, more particularly in strong, hearty, plethoric persons,
and in those having a rheumatic or gouty habit, the free use of
alkalies proves of great value. In these cases arsenic often aggravates
rather than improves the condition, whereas the alkali acts most
happily. It may be recommended in acute stages of the disease when the
lesions are red, heated, and growing. Liquor potassæ, in from ten to
twenty drop doses, diluted with a large wineglassful of water, thrice
daily, is the form generally prescribed. Improvement is sometimes noted
within a few days. Anderson calls attention also to the value of
carbonate of ammonium, in {619} from ten to thirty grain doses, in like
cases. The acetate of potassium, in thirty-grain doses, may also be
referred to as being sometimes useful.

Local treatment may now be considered. This is of great value, and
should be instituted in all cases, either alone or in conjunction with
internal remedies, according to the case. Sometimes it may be directed
alone with good results, more particularly in chronic, sluggish cases
where the lesions undergo but little change from time to time and are
unaccompanied by subjective symptoms. Before prescribing certain points
should be ascertained. The duration of the disease; the extent of the
eruption, including the number and size of the lesions, and their
acuteness or chronicity; the locality involved; the circumstances and
the age of the patient; and the time that can be given to the
treatment,--should all be taken into consideration. In this connection
it should be remembered that whatever plan of treatment is adopted, the
remedies should be applied thoroughly. The disease at best yields
stubbornly, and to secure satisfactory results the importance of
employing the agents properly should be insisted upon. This requires in
most instances considerable time once, and, in some cases, twice a day.
The scales are to be removed first. Where they are thick and adherent,
inunction with some simple oil, as olive oil, followed by the use of
soap and water, may be employed. Ordinarily, soft soap alone, well
rubbed into the lesions with a piece of wet flannel and rinsed off with
water, will be found sufficient. A 5 or 8 per cent. alcoholic solution
of salicylic acid may be employed for the same purpose. The bath,
simple or alkaline--the latter containing, for example, borax--is also
frequently of service.

In acute, highly inflammatory cases, where the skin is red, hot,
scaling profusely, and the lesions spreading from day to day, soothing
applications, as of olive oil, will generally prove most valuable.
Instances are sometimes encountered where the use of the simple bath,
followed by inunctions of olive oil or one of the petroleum ointments,
will prove to be the only treatment tolerated. The majority of cases,
however, seeking advice show the disease already well developed and in
the chronic stage, and here stimulating remedies are demanded.

One of the most valuable and generally useful remedies is tar, employed
in the form of ointment or tincture or in combination with other
substances, as, for example, the mercurials or sulphur. The tarry
products in common use are pix liquida, or common tar, oil of tar, oil
of cade, and oleum rusci (oil of white birch). The chief objection to
their employment is the penetrating odor, which is almost impossible to
banish. The oil of birch is probably the least objectionable in the
list. Officinal tar ointment, full strength or weakened, will be found
serviceable. It should be applied with a piece of cloth or stiff brush,
well rubbed into the skin, and should be used twice daily, the scales
having been previously removed by one or another of the methods
indicated. Similar ointments, one or two drachms to the ounce, may in
like manner be prepared from any of the other preparations of tar, as,
for instance, the oil of white birch. Where an ointment is not desired,
the oil of tar, oil of cade, or oil of white birch may be employed, the
remedy being thoroughly rubbed or worked into the skin. Attention to
the mode of application should always be insisted upon.

Other tarry preparations, such as liq. picis alkalinus, liq. carbonis
{620} detergens (the formulæ for which have been given in speaking of
the treatment of eczema), diluted, may also be prescribed in some cases
with benefit. Hebra's modification of Wilkinson's ointment may be
referred to as an energetic and useful compound:

  Rx. Sulphuris sublimati,
      Ol. cadini,      aa. drachm iv;
      Saponis viridis,
      Adipis,          aa. ounce j;
      Cretæ præparatæ,     drachm ijss.
  M. Ft. ugt.

Another method of using tar consists in the so-called tar bath: the
patches are deprived of scales by means of soft soap, after which tar
ointment or one of the tarry oils is rubbed in, and the patient then
placed in a warm bath for several hours. A stimulating tarry mixture,
especially useful in circumscribed, infiltrated, obstinate patches, is
composed of equal parts of tar, soft soap, and alcohol. Tar should not
be applied over extensive surfaces without cautioning the patient that
systemic disturbance, produced by absorption, may possibly occur. In
ordinary cases, however, such an accident is very rarely noted.
Creasote, turpentine, and acetic acid, remedies similar to tar in their
action on the skin, may also be mentioned. The first-named may be used
in the form of an ointment, from one to four drachms to the ounce.
Turpentine may be applied pure or with oil, one to two or three parts.
In some cases thymol in the form of an ointment, from five to thirty
grains to the ounce, proves of service. The mercurials may also be
referred to, but it may be stated that they are not as valuable in this
disease as they are in eczema. The most useful is white precipitate in
the form of ointment, from forty to eighty grains to the ounce, which
is especially valuable in psoriasis of the scalp and of the face.
Lotions of corrosive sublimate will also sometimes be found of service.

The treatment of psoriasis by chrysarobin--or chrysophanic acid, as it
was originally termed--may now be referred to. It is a very valuable
method of treatment. Care should be exercised in the selection of a
reliable preparation, there being considerable difference in the
strength, and therefore in the results obtained, of the remedy as found
in the shops. Its disadvantages must be mentioned: It is liable to
irritate and inflame the skin, causing sometimes an acute dermatitis or
a follicular or furuncular inflammation and a variegated purplish or
mahogany-colored staining of the skin. The hair, nails, and the linen
of the patient also become stained. It may be prescribed in the form of
an ointment, from ten grains to one drachm to the ounce of lard or
petroleum ointment. The most desirable mode of application, that which
is least objectionable, is in the form of a pigment, with flexible
collodion or liquor gutta-perchæ, in the same strength as the ointment
mentioned. It should be applied with a brush daily or every other day.
The following formula, suggested by G. H. Fox, may be given:
Chrysarobin and salicylic acid, each ten parts; ether, fifteen parts;
collodion, enough to make one hundred parts. Another valuable remedy,
having a similar action, to be used in the same manner as chrysarobin,
is pyrogallic acid. Like chrysarobin, it stains the skin (a brownish
hue), but it possesses the advantage over that substance in not being
so irritating. Neither of these remedies, {621} especially the
pyrogallic acid, should be applied over extensive surfaces, on account
of liability to absorption and systemic poisoning.

Where the patches are not numerous a solution of sulphide of lime may
sometimes be used with excellent results, as according to the following
formula, known as Vleminckx's solution:

  Rx. Calcis,              ounce ss;
      Sulphuris sublimati, ounce j;
      Aquæ,                fluidounce x.
  Coque ad fluidounce vj, deinde filtra.

This may be perfumed with oil of anise, five or ten drops to the ounce.
It may be applied diluted with two or four parts of water or full
strength, and is to be rubbed into the skin with a flannel rag, after
which the parts are to be bathed with water and some emollient oil or
ointment applied.

Treatment is usually effective in removing the lesions, but,
unfortunately, in the majority of cases, relapses sooner or later
occur. It may be said relapses are the rule. The prognosis will depend
upon the case.


Pityriasis Rosea.

Pityriasis rosea, known also as pityriasis maculata et circinata, is an
inflammatory disease, occupying chiefly the trunk, characterized by
discrete or confluent pinkish or reddish macular or slightly raised
lesions varying in size from a small to a large coin. They are rounded
in form, but by coalescence may assume irregular shapes and
considerable size, as in the case of psoriasis. They are circumscribed,
usually clearly defined, superficially seated, of a bright rosy,
pinkish, or reddish hue, which sooner or later fades and is followed by
yellowish, salmon-colored, or rusty tints. The surface of the lesions
is from the beginning dry, and as the process advances furfuraceous or
flaky scaling sets in, similar to that observed in tinea versicolor and
in tinea circinata. This feature is more marked about the border, the
process inclining to recover in the centre and to spread on the
periphery, after the manner of tinea circinata. The skin is only
slightly, if at all, thickened. At times there is slight burning or
itching, but more frequently subjective symptoms are altogether
wanting.

The course of the affection is variable, in many instances lasting from
one to several months, while in exceptional cases it is more acute. It
tends to spontaneous recovery, and is to be viewed as a mild disease,
notwithstanding that the lesions at times, by their redness and size,
indicate considerable cutaneous disturbance. It is met with in all
ages, in our own experience more frequently in adults than in children,
and occurs in both sexes and in those possessing average general
health. It is one of the rarer cutaneous diseases, and is not
contagious.

It is to be distinguished from ringworm of the body, from tinea
versicolor, and from the macular syphiloderm, all three of which
diseases it at times closely resembles. It possesses some of the
peculiar features which characterize the vegetable parasitic diseases,
but in some respects it differs from them in its behavior. The
microscope fails to reveal fungus. Concerning treatment there is but
little to be said, as the process inclines in most cases to spontaneous
disappearance. Mildly stimulating ointments or {622} baths, as in
eczema, may be prescribed. When involution sets in recovery usually
takes place rapidly.


Pityriasis Rubra.

Pityriasis rubra is an inflammatory disease, usually pursuing a chronic
course, characterized by redness and abundant and continuous epidermic
exfoliation. It usually develops rapidly, beginning as small, red,
scaly patches. It may make its appearance on one or more regions, the
spots increasing in size rapidly, and coalescing to form large patches.
In a variable time the whole or a large portion of the entire surface
is involved, the skin being of a pale or violaceous red color and
covered with thin whitish or grayish lamellar scales. These are
abundant, and are rapidly formed, cast off and replaced by new, the
exfoliation being, as a rule, in the form of flakes. Thickening of the
skin seldom occurs. The surface when deprived of the scales is
hyperæmic and shining in appearance. The disease usually involves the
whole surface. Oedema, especially of the limbs, and stiffness of the
joints are sometimes observed. The disease is superficial in character,
rarely involving more than the upper cutaneous layers, and is always
dry. Fissuring is only exceptionally seen.

As a rule, the subjective symptoms are slight, burning and itching, if
present, seldom being violent. Symptoms of constitutional disturbance
may or may not be present, but chilliness is often complained of. The
disease generally occurs in adults, is acute or chronic, usually the
latter, with a tendency to relapses. Being a rare affection, the
etiology is obscure. Anatomically, there is found more or less marked
cell-infiltration of the cutaneous tissues, especially noticeable in
the rete and upper layer of the corium. In severe cases the papillæ are
not distinguishable; the same may be said of the sweat and sebaceous
glands.

Erythematous and squamous eczema and psoriasis bear resemblance to the
disease. Its superficial nature, wide or universal distribution,
absence of infiltration, character and rapid formation of the scales,
and the slight itching or burning will serve to differentiate it from
eczema. In psoriasis the whole surface is rarely if ever involved,
while there is more or less thickening of the corium, and the scales
are thicker and imbricated. It can scarcely be confounded with lichen
ruber or with pemphigus foliaceus.

The disease pursues a variable course. It may last for years, with
exacerbations, or outbreaks may occur from time to time. Treatment is,
as a rule, unsatisfactory. For external treatment applications of a
bland or soothing character afford the most relief. Vaseline, cold
cream, and oily substances are generally of most service. Stimulating
applications seldom prove useful--in fact, will in most cases give rise
to discomfort and positive aggravation. In regard to constitutional
remedies general indications are to be followed. There is no drug that
seems to exert a specific influence.


{623} Dermatitis Exfoliativa.

This term is employed to designate certain cases in which more or less
exfoliation is the prominent characteristic, and which cannot be
classified under the head of any of the other diseases in which this
symptom is noted. These cases have been variously described under the
names of general exfoliative dermatitis, recurring exfoliative
dermatitis, desquamative scarlatiniform erythema, recurrent acute
eczema, acute general dermatitis, and recurrent exfoliative erythema.
The affection is characterized by an erythematous inflammation, rarely
vesicular or bullous, acute in type, with desquamation or exfoliation
of the epidermis accompanying or following its development. There is
also usually more or less marked constitutional disturbance, in some
instances of a serious nature, and a tendency to relapse and
recurrence. It is possible that in some instances the disease could be
properly classified under the head of eczema, psoriasis, pityriasis
rubra or pemphigus foliaceus.


Lichen Ruber.

Lichen ruber is an inflammatory disease, characterized by small flat
and angular or acuminated, smooth and shining or scaly, discrete or
confluent red papules, having a distinctly papular or papulo-squamous
course, attended with a variable degree of itching. Two varieties are
met with--the plane (lichen ruber planus) and the acuminate (lichen
ruber acuminatus), the first of which occurs much the more frequently
in this country. The acuminate variety is met with chiefly in Austria,
where it was first described by Hebra: it is very rare in the United
States, only a few authentic cases being on record. In lichen ruber
planus the papules vary in size from a pinhead to a pea, and are
peculiar in that they are not rounded, but are quadrangular or
polygonal in shape. In their early stage they have a smooth, glazed
surface, and are free of scales, but later they become papulo-squamous.
They are more or less flattened on their summits, and show slight
umbilication with whitish puncta. They are of a dull pinkish, reddish
or violaceous color, the hue varying with the individual, age, and
locality. As a rule, they are numerous, and occur in variously-sized
aggregations, the distribution scarcely amounting to grouping. They
tend to coalesce and form patches, which are slightly elevated,
flattened, and uneven, the lesions when crowded together having a
mosaic pattern. In lichen ruber acuminatus the papules are smaller,
pointed, scaly, and disseminated, showing no disposition to group. This
variety of the disease spreads rapidly, pursues a chronic course, and
is a more serious affection, sometimes terminating fatally.

Lichen ruber planus usually presents itself upon the extremities,
especially upon the flexor surfaces, the forearms and wrists and backs
of the feet being favorite localities. Not infrequently it appears in
the form of short or long narrow bands, following the natural lines of
the skin, and sometimes nerve-tracts. The course of the disease is
generally slow, extending over months. Occasionally, however,
especially where the lesions are acute and very numerous, it is
comparatively rapid. New {624} papules continue to show themselves from
to time, the older ones disappearing by absorption, leaving persistent
marked reddish or brownish pigmentation, which is to be regarded as a
characteristic symptom.

The etiology of the disease is at times obscure, although, according to
our experience, patients usually show signs of impaired nutrition or
nervous depression, arising from varied causes, as, for example,
overwork or shock. It occurs at all periods of life, but is usually met
with at middle age, and is more common in women than in men.
Pathologically, the process is considered an inflammation of a chronic
character, accompanied by more or less alterative changes in the
structure of the skin, involving the several layers as well as the
follicles. The lesion is always of a papular type. Later investigations
(Robinson) into the anatomy of the lesions of lichen ruber acuminatus
and lichen ruber planus are apparently indicative of the distinct
nature of the two varieties, the former being considered a paratypical
keratosis, leading to retrograde changes and atrophy, and the latter an
inflammatory process occurring in and about the papillæ and upper part
of the corium.

In the diagnosis of lichen ruber the papular syphiloderm, lichen
scrofulosus, psoriasis, and papular eczema are to be excluded. The
irregular and angular outlines of the lesions of the plane variety,
taken with their flattened, slightly umbilicated, smooth, or scaly
summits and the dull-red or violaceous hue, are sufficiently
characteristic. The evolution of a patch of psoriasis is entirely
different from that of this disease, the former appearing as small
spots and enlarging by peripheral growth, the patches of the latter
resulting from aggregations of lesions. In papular eczema the papules
are rounded, bright-red in color, intensely itchy, and have a different
history and course. The prognosis of lichen ruber planus is generally
favorable, although some cases are exceedingly rebellious. According to
Hebra, in the severe forms of lichen ruber acuminatus, if neglected or
improperly treated, a fatal result may ensue.

A general tonic plan of treatment is almost always indicated, such
remedies as iron, quinia, strychnia, and the mineral acids proving of
benefit. Arsenic exercises in many cases a specific influence. When the
general health is much reduced arsenic fails, as a rule, to benefit
until the patient's condition is brought back to its normal tone. The
remedy should be given in tolerably large doses, and continued until
the lesions have entirely disappeared. On account of the itching and
discomfort experienced, external applications are demanded. The various
antipruritic remedies mentioned in the treatment of eczema may be
employed. Alkaline baths are useful. Unna has reported a few instances
of cure of well-developed cases of the disease by the use of an
ointment composed of two ounces of oxide-of-zinc ointment, forty grains
of carbolic acid, and from one to two grains of corrosive sublimate.
Tarry applications, especially in the form of lotions, often prove of
service, the liquor picis alkalinus and the liquor carbonis detergens
being the preparations commonly employed.


Lichen Scrofulosus.

Lichen scrofulosus is a chronic disease characterized by
milletseed-sized, flat, reddish or yellowish, more or less grouped,
desquamating papules, {625} unaccompanied by itching and occurring in
those of a scrofulous disposition. The lesions, of a pale red or
yellowish color, are usually numerous, are seated about the
hair-follicles, and show a decided tendency to group, giving rise to
patches of variable size and of a rounded or crescentic shape, which
sooner or later become covered with minute scales. They are always
small; are seen usually about the abdomen and chest, and exceptionally
about the limbs; are chronic in character; and as a rule, are
unaccompanied by itching. Pit-like, atrophic depressions may or may not
follow the disappearance of the lesions.

The affection is not uncommon in Austria, but in this country it is
practically unknown. It was first described by Hebra. It is more common
in males, and is seen chiefly in children and young people. Symptoms of
a scrofulous habit, such as glandular enlargements, ulcers, bone
disease, or lung complaint, are found associated in almost all cases.
According to Kaposi, the process is an inflammation and
cell-infiltration in and about the hair-follicles, the sebaceous
glands, and papillæ around the apertures of the follicles. Each papule,
as may be seen on close examination, has its seat about the opening of
a follicle, the inflammation beginning around the vessels and at the
bases of the follicles and glands, and subsequently the cellular
infiltration invading the interior of these structures to such an
extent as to give rise to distension and elevation into papules.

It is to be differentiated from papular eczema, lichen ruber, the
miliary papular syphiloderm, and keratosis pilaris. According to Hebra,
cod-liver oil, employed internally and externally, is the remedy to
which the disease readily yields.


Eczema.

SYMPTOMS.--Eczema, known popularly as tetter, is the most important and
the commonest of the diseases of the skin. It may be defined as an
inflammatory, non-contagious disease of the skin, characterized in the
beginning by erythema, papules, vesicles or pustules, or a combination
of these lesions, pursuing an acute or chronic course, accompanied by
infiltration and itching, terminating either in discharge with the
formation of crusts, in absorption, or in desquamation. The disease is
multiform in character, and is capable of manifesting itself in a great
variety of forms; and for this reason any definition that is attempted
must be broad enough to comprise all of its essential features. It may
begin as a circumscribed or diffuse small or large erythematous patch,
which may remain dry and become scaly, or may pass into a state of
moist exudation with crusting. It may also begin with vesicles or
pustules, which soon rupture, giving rise to a red, moist, oozing,
weeping, excoriated surface pouring forth a scanty or abundant fluid,
gummy discharge, which rapidly dries to crusts. Instead of a moist
discharging surface the skin may become dry, scaly, thickened, and more
or less fissured. In other cases small papules, discrete or confluent,
in patches or disseminated, form, constituting papular eczema. Finally,
several or all of these lesions may occur together or in the course of
the process. Thus, it will be observed, the disease is markedly
multiform and protean. Not {626} infrequently it is capricious in its
manifestations both as to the nature of the lesions and as to the
evolution. Several varieties of the disease may appear simultaneously
on one or on different regions.

Infiltration is one of the most marked features, and is present in
varying degree. In the discharging varieties the fluid exuded is
generally considerable and often excessive, giving rise to abundant
crusting. In the papular variety the exudation is plastic in character,
causing thickening of the skin, followed by more or less induration.
Scaling is also frequently a prominent symptom, giving to the condition
known as squamous eczema its peculiar features. Itching, usually
marked, is an almost constant symptom, varying in degree. As a rule, it
is an annoying feature of the disease, causing the patient to scratch
in spite of good resolutions. In some cases, as in the erythematous
variety, the sensation is of burning rather than itching, or it may be
a combination of the two. Occasionally the locality affected is the
seat of pain. The course of the disease is extremely variable. As a
rule, it inclines to chronicity. Relapses are common, especially in
adults and elderly persons. There are many cases on record, however,
where, recovery having taken place, the individual remains free of the
disease. The several varieties may now be considered.

Eczema Erythematosum.--This begins as an erythematous spot or macule,
or as a patch, variable as to color, size and outline. It is most
frequently met with upon the face, occupying a portion or the greater
part of this region, usually in the form of several discrete or
confluent patches. It generally begins as a coin-sized, ill-defined
lesion, rounded or irregular in outline, of a pale-red hue, accompanied
by itching and burning. The patch at first may be insignificant, but
from time to time it spreads and becomes redder, thicker, and the
surface slightly scaly. When fully developed, as is perhaps most
frequently encountered upon the forehead, it consists of a more or less
broken-up patch of considerably thickened somewhat swollen skin of a
mottled or streaked pale-reddish, yellowish-red or violaceous hue. The
surface is dry or excoriated and very slightly moist in places, and is
covered with a thin film of dried, ragged epidermis or with thin
adherent scales. The disease varies from time to time, being paler and
less marked one week than another. Scratch-marks and excoriations,
punctate or linear, are generally present, indicative of the scratching
and rubbing to which the skin has been subjected. As stated, several
patches generally exist, the disease tending to symmetry. The forehead,
sides of the nose, and cheeks are the localities most frequently
invaded, but other regions, as the back of the neck, axillæ, and
flexures, are all common seats.

Its course is variable. As a rule, it inclines to assume chronicity,
varying in intensity from time to time, or even disappearing and
reappearing at irregular intervals. It is exceedingly liable to
relapse, perhaps more so than any other variety. Having established
itself, it may remain erythematous in character or may pass into other
varieties of the disease. Thus, a moist or weeping surface may take the
place of the erythema, followed by crusting, giving rise to eczema
madidans, or eczema rubrum. Not infrequently the patch becomes markedly
scaly, and continues in this form, producing eczema squamosum. When it
occurs in regions where two opposing surfaces come in contact, as under
the mammæ, between the {627} nates, and about the genitalia, an
excoriated moist condition is produced known as eczema intertrigo, or
eczema mucosum.

Eczema Vesiculosum.--This may be regarded as the typical and perfect
expression of the disease. It is characterized in the beginning by a
diffuse redness with puncta, which rapidly become small pinpoint- to
pinhead-sized, more or less perfect vesicles, accompanied with heat and
usually intense itching. As a rule, the lesions are small and are
discrete or confluent. They soon mature and burst, the fluid oozing
forth on and over the surface, forming yellowish honeycomb-like scanty
or abundant crusts. The skin of such a patch is generally slightly
swollen, and at times considerably infiltrated with serum (eczema
oedematosum). The disease may thus develop upon a small surface, or, as
is oftener the case, over an extensive area, as, for example, the
flexor surface of the forearm. There is no disposition for the lesions
to group, but they incline to appear in areas, a large patch being
usually composed of several smaller patches. The amount of serous fluid
poured forth is often great, large bulky crusts forming which in time
completely mask the skin beneath. The exudation may take place rapidly
in the course of a few days and cease, or it may continue, oozing
slowly from day to day or with intermissions from time to time
indefinitely, constituting acute, subacute or chronic vesicular eczema.
The amount will, moreover, depend somewhat upon the locality involved
and whether the disease be properly treated or irritated.

Vesicular eczema may show itself typically, the whole of the affected
skin taking on vesicular formation, or, as frequently happens, it may
be associated with other varieties of the disease, more particularly
pustules and papules. Abortive vesicles and vesico-pustules and
vesico-papules are common, occurring here and there mixed with the
vesicles and about the circumference of the patch. The amount of
surface invaded varies. The disease often manifests itself in different
regions simultaneously, as, for example, upon the neck and flexor
surfaces of the forearms or upon the trunk and the thighs. In infants
the face is the locality usually attacked, constituting the so-called
crusta lactea, or milk-crust, of former writers. While the disease
tends to manifest itself upon the thin skin of the flexor surfaces of
the extremities and upon the face, such is not always the case, for the
hands and fingers are also often invaded.

Eczema Pustulosum.--This variety of the disease (designated by some
writers eczema impetiginosum) is closely allied to the preceding
variety. The lesions may develop as pustules or may become pustular
from pre-existing vesicles; both lesions are not infrequently found
together, although one of the two will usually predominate. In pustular
eczema the swelling, heat, and itching are seldom so marked as in the
vesicular variety, and the lesions are generally larger and firmer. As
in the case of the vesicles, they rupture and dry, forming yellowish or
greenish bulky crusts. This variety is most frequently encountered
about the face and scalp, and in those--especially young people--who
are strumous, ill-nourished, or in a depraved state of health.

Eczema Papulosum.--Eczema papulosum is characterized by small, rounded
or acuminated papules about the size of a pinhead. Sometimes they are
well defined and circumscribed, but more frequently they possess no
sharply-marked outline or form. They are reddish in color, the tint
varying with the individual and with other circumstances, and are
usually {628} discrete, although not infrequently they are so numerous
and so crowded together as to coalesce and form patches or aggregations
of disease, which often show considerable infiltration. They begin as
papules, and usually preserve this character throughout their course.
Vesicles or vesico-papules not infrequently coexist. Sooner or later
the lesions disappear, but are usually replaced by others, the process
in this manner continuing its course for weeks or months. The itching
is in almost all cases severe and persistent, the patient generally
scratching himself to the extent of producing excoriations and
blood-crusts. Papular eczema shows a preference for certain regions,
notably the extremities, especially the flexor surfaces. The face is
seldom attacked. It is one of the most obstinate varieties of the
disease.

       *       *       *       *       *

In addition to the principal varieties of eczema, just described, there
are other forms of the disease which on account of their peculiar
features require mention. Of these eczema rubrum, or eczema madidans,
may first be spoken of. It is to be viewed as a secondary condition
resulting from one or another of the primary varieties. Thus it usually
follows eczema vesiculosum or pustulosum. It is characterized by a
reddish, moist or discharging surface, the serum, sometimes bloody,
usually exuding freely and forming thick yellowish or brownish crusts,
together with more or less thickening of the skin and other secondary
changes. In other cases discharge is wanting. The condition varies with
the stage of the process and with other circumstances: at one time the
red, inflammatory dry or oozing skin is the most striking feature,
while in other cases this is completely obscured by large, diffuse
masses of crust. It may occur upon any region, but it is most
frequently met with on the legs, especially in adults, and more
particularly in elderly people. It is usually chronic in its course,
and may continue for years, better and worse from time to time, but
usually evincing no disposition to spontaneous recovery.

Another clinical form of the disease is known as eczema squamosum,
which frequently has been preceded by the erythematous variety, and in
many cases is to be viewed as a stage of that variety. It may also
follow other varieties. It appears in the form of reddish, dry, more or
less infiltrated, scaly patches, the amount of scaling being variable.
The scales are usually small or fine, and as a rule are scanty. The
condition is generally chronic, and is often met with on the scalp.

Fissures, superficial or deep, are not infrequently met with in eczema,
usually in the chronic or recurrent forms of the disease, and may be so
pronounced as to give rise to the so-called eczema fissum. This is
often seen about the fingers and hands, especially the palms. In
localized infiltrated patches of chronic eczema a peculiar warty
condition is occasionally met with, which is known as eczema
verrucosum; or if simply hard, rather than wart-like, eczema sclerosum.

Eczema is divided into acute and chronic, the several forms of the
disease being so different in their clinical pictures as to demand such
a division, which relates rather to the pathological changes than to
time. Thus the disease may show acute symptoms throughout its course,
or, on the other hand, may in the beginning take on a chronic action.
As a rule, it tends to chronicity, secondary changes in the skin
usually manifesting themselves early in the course of the process.

{629} ETIOLOGY.--Eczema is the commonest of the cutaneous diseases, and
seems to be of more frequent occurrence in this country than in Europe.
It is met with among all classes of society and at all ages.
Individuals with light hair and florid complexions are more often
subjects of the disease than those of the opposite temperament. Not
infrequently the disease is hereditary, although examples are very
common in which no such history obtains. So-called eczematous subjects,
in which at longer or shorter intervals throughout life and under
variable conditions the disease manifests itself, are of frequent
occurrence in practice. The state, though well known clinically, is
difficult to define, consisting of a peculiar inherent condition of the
system at large and of the skin itself which under favorable
circumstances permits the disease to assert itself from time to time.
The association in some cases of chronic bronchitis and allied
affections of the respiratory tract with eczema, and the clinical
observation that as one disease improves the other becomes worse, has
led some dermatologists to regard eczema as being catarrhal in its
nature.

The constitutional causes which may produce the disease are numerous,
and are worthy of careful study as bearing directly upon the treatment.
Disorders of the digestive tract, including dyspepsia in its many forms
and constipation, are not infrequently found to be the exciting cause
of an attack, while faulty excretion through the several emunctories,
and the existence of a gouty or rheumatic disposition, may all prove
potent factors. Deterioration in the tone of the system, arising from
varied causes, with impaired nutrition--as seen, for example, during
pregnancy and lactation--is sometimes accompanied with an outbreak of
the disease, while nervous exhaustion and other neurotic states, as is
now well established, are not infrequently active causes.

In some cases excitants, external or internal--as, for example,
cutaneous irritants and intestinal worms--may determine an outbreak. In
like manner, dentition and vaccination may call forth the disease.
Among the local causes producing the so-called artificial eczemas the
preparations of mercury, sulphur, croton oil and tincture of arnica are
most notable. Contact with the several varieties of the rhus plant,
though usually producing a peculiar dermatitis, may in eczematous
subjects provoke a genuine eczema. Heat and cold, especially the rays
of the sun, are also factors to be considered, while it is well known
that the disease in many instances is influenced by the seasons, being,
as a rule, worse in winter than in summer. There are many subjects who
suffer only in winter. In sensitive skins water, soap, alkalies and
acids, all prove more or less injurious, giving rise to harshness or
chapping of the skin, and sometimes to eczema. In the same manner the
presence of parasites and the consequent scratching are productive of
more or less simple dermatitis, and in eczematous subjects the disease
under discussion. Eczema is not contagious, a question which is
frequently asked by the patient.

PATHOLOGY.--The changes which occur in the skin in the various
eczematous conditions are somewhat different as the process is of short
or long duration and mild or intense in character. In all cases
hyperæmia and exudation, constant symptoms of all inflammations, are
present, varying according to the activity and duration of the process.
The rete mucosum is also involved in all cases, being oedematous and
infiltrated. In {630} the erythematous form the blood-vessels of the
papillary layer are dilated, exudation and congestion as well as
increasing activity of the rete taking place. In the papular variety
the process is mainly limited, primarily at least, to the follicles.
The exudation is confined to small circumscribed areas and gives rise
to papular elevations. In the vesicular variety fluid exudation occurs
in the upper strata of the corium and in the rete, and the formation of
vesicles results. The contents of the vesicles consist of a clear
liquid containing a few rete-cells and later some pus-corpuscles. In
the pustular form the process is more intense in character, and the
cell-emigration and multiplication increased. In the chronic forms of
the disease the infiltration involves the deeper parts of the corium
and even the subcutaneous tissues, which, in addition to the new
connective-tissue formation sometimes taking place, gives rise to
considerable thickening. The papillæ are enlarged, and at times are
considerably hypertrophied, as exemplified by the so-called verrucous
eczema. The exudation and cell-infiltration are especially marked along
the blood-vessels. In squamous eczema the blood-vessels of the corium
and papillæ are dilated, and these parts infiltrated with round cells
and changed connective-tissue corpuscles. Pigmentation may take place
in the deeper layers of the rete and in the corium, especially about
the vessels. The pathological process in eczema seems to have its
starting-point in disturbance of the capillary circulation, the origin
and nature of which it is difficult to determine.

DIAGNOSIS.--It must be remembered that the disease is capable of
appearing in a multitude of forms, some of which are so dissimilar in
their clinical features as sometimes to occasion embarrassment in the
diagnosis. No other disease except syphilis manifests itself in such a
variety of forms. In all cases where the lesions are varied or where
they are ill defined the eruption should be viewed as a whole, when the
characters of the process will usually be apparent. Thus a variable
amount of infiltration, with swelling or thickening, is almost always
present, the skin being more or less red and inflammatory. Moisture or
positive discharge, with slight or extensive crusting, is a frequent
though by no means a constant symptom, and when present is
characteristic. Itching is experienced in almost all cases, and is
generally a marked symptom. In some cases heat and burning are
complained of.

Cases are occasionally met with in which the eruption bears some
resemblance to erysipelas and scarlatina, but the absence of systemic
symptoms in eczema would prevent an error in diagnosis. Papular eczema
may at times simulate the papular manifestations of urticaria,
especially in children, but in ordinary cases there is no likelihood of
confounding the diseases. Herpes zoster in its early stage may bear a
resemblance to a patch of vesicular or papular eczema, but the grouping
of the lesions and the burning or pain in the former disease will
generally prove sufficient to distinguish them. Seborrhoea, especially
as it occurs upon the scalp, may be mistaken for squamous eczema, but
in seborrhoea the scales are greasy, containing more or less sebaceous
matter, and the distribution of the disease is usually more uniform
than in eczema; and, finally, in the latter affection the skin is
reddish, inflamed, often thickened, and usually itchy.

Psoriasis and squamous eczema frequently simulate each other, and in
{631} some instances the resemblance is so close that error in
diagnosis may readily occur. Both diseases are common, and are liable
to invade all regions. In eczema the patches usually fade away into the
healthy skin, whereas in psoriasis their margins are generally sharply
defined. In eczema the scales are usually scanty, thin and small; in
psoriasis they are abundant, whitish or silvery, large and imbricated.
These points, taken in connection with the history of the case, will
serve to aid in the diagnosis.

The rare disease pityriasis rubra may be confounded with squamous
eczema, but the peculiar abundant, thin, papery scaling of this
affection is not met with in eczema. Sometimes papular eczema resembles
lichen ruber, but with attention to the characteristics of the lesions
in the latter disease the diagnosis in most cases offers no difficulty.
The resemblance of tinea circinata to eczema in some cases is to be
borne in mind, but in the latter disease there is wanting the tendency
to circular and marginate forms so characteristic of the parasitic
disease. The microscope should always be employed in doubtful cases.
Both tinea sycosis and sycosis may be confounded with eczema of the
hairy portion of the face, but the follicular involvement in the former
affections is the diagnostic point to be remembered. Scabies in its
early stages often looks much like papular, vesicular, or pustular
eczema, and care should in all cases be taken to make a correct
diagnosis. The history of scabies, the regions involved, the
distribution and multiformity of the lesions, and the presence of the
parasite, as shown by the extraction of the mite or by the burrow, are
all points to be duly inquired into. Eczema seldom simulates syphilis.
They are most likely to be confounded one with the other when occurring
in chronic forms about the scalp and the hands and feet.

PROGNOSIS.--Under favorable circumstances eczema is always a curable
disease. In the prognosis of the affection as regards the probable
length of time required to remove it an opinion should be guardedly
expressed. It depends upon the extent of the disease, the duration, the
attention the patient can give to the treatment, and the ease with
which the exciting causes can be removed. Where the disease is the
result of nervous prostration, as seen in those who have been mentally
overworked from whatever cause, the cure will take place slowly, and
many relapses will probably occur before positive recovery sets in.

Where the exciting causes cannot be entirely removed recovery is slow,
and a complete or permanent cure is sometimes impossible. Thus in
eczema about the hands in those who are obliged to wet or wash the
parts frequently, to handle chemicals, dyestuffs, or otherwise expose
the parts to the action of deleterious substances, a cure of the
affection is exceedingly difficult. The same may be said in regard to
eczema of the scrotum and neighboring regions, where the natural heat
and moisture are constant and exciting, and to a certain extent
irremovable, causes. In eczema of the lower limbs depending upon a
condition of varicose veins the disease is obstinate. On the other
hand, there are many cases of acute eczema met with which run a rapid
course and end favorably. Eczema of the face, lips, and other exposed
parts is, for evident reasons, apt to prove rebellious. In each case,
then, all these points are to be taken into consideration in rendering
an opinion upon the probable duration and termination of the disease.

{632} TREATMENT.--There is no other disease of the skin which requires
so thorough a knowledge of general medicine for its successful
management as does eczema. The exciting cause of the affection is to be
ascertained and to be properly treated. It is the specialist who has as
the groundwork a comprehensive knowledge of general medicine who is
best able to cope successfully with the disease under consideration. In
the management of eczema both constitutional and local treatment will
be necessary. It is true that some authorities depend upon external
applications alone, but, judging from our own experience, a combination
of external and internal treatment promises decidedly better results.
In those cases in which the exciting cause has disappeared and the
eczema persists from habit, as it were, the simplest local treatment
may bring about a cure. But these are, unfortunately, exceptional
instances. In almost all cases external treatment is indispensable.

Constitutional Treatment.--There are no specific remedies for eczema.
Arsenic, it is true, acts in some cases admirably, but these instances
are rather exceptional; the proportion of cases in which it may be
prescribed with the hope of advantage is not very large. It not
infrequently proves positively injurious. It is in the dry, scaly, and
papular forms of the disease, and especially those in which the
inflammation is of a low grade, that it acts most happily. The drug is
to be given in sufficiently large doses to obtain slight evidences of
its physiological action; toxic effects are to be avoided. It should
never be given in acute cases. In small doses (one or two minims of
Fowler's solution) arsenic is frequently of value as a tonic, acting
then in the same manner as other tonics. When the physiological effects
of the drug are desirable the dose should be gauged accordingly,
beginning with two or three minims three times daily, and increasing
gradually up to five or six or even more minims; as soon as the action
of the drug becomes evident, as shown by a slight conjunctival
injection and puffiness about the eyelids, the dose should be
diminished and its administration continued for an extended period.

In the management of eczema attention should be given to the subject of
diet. The food should be nutritious but plain, avoiding such articles
as pork, salted meats, pastry, cabbage, gravies and sauces, pickles,
cheese, condiments, beer and wine, etc. In anæmic and debilitated
individuals a moderate use of stimulants may prove useful. Fresh air
and exercise are often of aid in the treatment. The various remedies to
be employed internally will depend upon the cause or causes which have
brought about the attack. In robust persons and those of full habit
laxatives or purgatives will prove of positive service. A useful
formula for such cases, and also for those in whom constipation is
present, is the following:

  Rx. Magnesii sulphatis,        ounce iss;
      Potassii bitartratis,      drachm iv;
      Sulphuris præcip.,         drachm ij;
      Glycerinæ,                 fluidrachm ij;
      Aquæ menthæ pip., q. s. ad fluidounce iv.

M.--S. A tablespoonful in a tumblerful of water a half hour before
breakfast. If this dose of the mixture fails to produce one or two free
evacuations daily, then as much as double the quantity may be taken or
a dose may be taken morning and evening. In many cases an aperient
combined with a tonic is indicated. This is the case in those who are
{633} dyspeptic and debilitated, and in whom there is more or less
constipation present. The following formula is available for such
cases:

  Rx. Magnesii sulphatis,      ounce iss;
      Ferri sulphatis,         gr. iv;
      Acidi sulphurici dilut., fluidrachm ij;
      Aquæ menthæ pip.,        fluidounce iv.

M.--S. A tablespoonful in a tumblerful of water a half hour before the
morning meal. In some cases the acid is contraindicated, and then the
mixture may be prescribed without this ingredient. Although this
formula is found to agree with most individuals, there are some who are
either not able to take it or in whom it is found to aggravate the
dyspepsia or to cause more or less gastric disturbance. In these cases
the following formula has proved of value:

  Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
      Acidi muriatici dilut.,   fluidrachm ij;
      Elix. calisayæ,           fluidounce iij drachm ij.

M.--S. A teaspoonful in a large wineglassful of water before or after
meals. The laxative effect of the mixture is more marked when it is
taken twenty or thirty minutes before meals. In some cases it will be
found necessary to increase the proportion of the cascara sagrada,
while, on the other hand, not infrequently a less quantity may be
sufficiently active. In acute eczema laxatives, especially the salines,
are of great service. The various mineral-spring waters may also be
mentioned as useful. Of these Friedrichshall, Hunyadi Janos, the
Hathorn and Geyser Springs of Saratoga, are the most serviceable. A
tonic aperient where there is only slight constipation is the
following:

  Rx. Sodii phosphatis,         drachm vj;
      Acidi phosphorici dilut., fluidrachm iij;
      Syr. zingiberis,          fluidounce j;
      Infus. gentianæ comp.,    fluidounce iiss.

M.--S. A tablespoonful in a wineglassful of water three times daily.

The following aperient mixtures may be prescribed for children:

  Rx. Syr. rhei aromat.,
      Olei ricini,       aa. fluidounce ij.

M.--S. A teaspoonful two or three times daily, according to the effect.

  Rx. Ext. cascaræ sagradæ fl., fluidrachm ij;
      Syr. aurantii cort.,      fluidrachm vj.

M.--S. A teaspoonful in water at bed-time.

Occasional laxative doses of calomel are often valuable both in
children and adults. Dyspepsia, if present, should receive appropriate
treatment. The bitter tonics, mineral acids, alkalies, and the various
artificial aids to digestion may be employed as seem indicated. Where
malaria is suspected, full doses of quinine and small doses of arsenic
should be prescribed. In these cases, as also in those in which there
may be anæmia or chlorosis, the preparations of iron may be prescribed.
If a gouty diathesis appears to be at the foundation of the attack,
purgatives, the alkalies, and colchicum are to be advised. In these
cases, if of an acute or subacute type, the following formula is
serviceable:

  Rx. Potassii acetatis, ounce j;
      Liquor, potassæ,   fluidrachm vj;
      Aquæ menthæ pip.,  fluidounce iij drachm ij.

{634} M.--S. A teaspoonful in a half gobletful of water an hour before
meals. In cases of a chronic type the following may sometimes prove of
benefit:

  Rx. Potassii iodidi,           drachm v gr. xx;
      Liquor. potassii arsenit., fluidrachm iss;
      Liquor. potassæ,           fluidrachm vss;
      Aquæ,                      fluidounce iij.

M.--S. A teaspoonful in a half gobletful of water after meals.

In some gouty and rheumatic cases wine of colchicum may be added to the
above two prescriptions with advantage. Where a scrofulous tendency
exists cod-liver oil is a valuable remedy; also in all cases of
impaired nutrition, in moderate doses, long continued, it will often
prove useful, especially in children.

External Treatment.--The local treatment of eczema is based upon the
pathological conditions present. The acute disease requires entirely
different management from that employed in chronic cases. The stage of
the disease and the amount of skin involved, whether in the form of a
circumscribed patch or as a diffuse eruption, are points to be taken
into consideration in the selection of a remedy and the mode of its
application. The several varieties, the erythematous, papular,
vesicular, pustular and squamous, and also the secondary forms rubrum,
fissum and verrucosum, all demand applications appropriate to the
condition. In acute erythematous or vesicular eczema caution is to be
exercised in the selection of remedies. Only the milder applications,
as a rule, are tolerated. That which will agree with one may not agree
with another. It is advisable to try the remedy upon a small portion of
the diseased surface to see if it is acceptable to the skin. In these
varieties also soap and water should, as much as possible, be avoided.

For the average case, especially of the vesicular variety, the most
successful plan of treatment is with lotio nigra and oxide-of-zinc
ointment. The lotion is to be dabbed on by means of a sponge or cloth
every three or four hours, ten or fifteen minutes at a time; as soon as
dry a small quantity of oxide-of-zinc ointment is to be gently smeared
over. In many instances this method furnishes immediate relief to the
itching, and under its use the inflammation is soon relieved. Powdering
the surface with dusting-powder will sometimes afford ease, starch or
lycopodium powder, either alone or together, equal parts, being useful.
Subnitrate of bismuth is also of value, proving a more stimulating
powder. In some cases a half drachm of finely-powdered camphor to the
ounce may be advantageously added to one or another of the simple
powders. Powdered Venetian talc is also sometimes useful alone or in
combination with starch, a drachm or two of the former to the ounce of
the latter. Dusting-powders should in all cases be used freely and
often, their chief object being to afford protection to the inflamed
surfaces.

Another lotion frequently employed in acute cases of vesicular eczema
with free discharge, especially in cases where there is oedema or where
the skin is irritable, is one containing calamine and zinc oxide; for
example,

  Rx. Pulv. zinci oxidi,
      Pulv. calaminæ,    aa. drachm iiss;
      Glycerinæ,             fluidrachm j;
      Liq. calcis,
      Aquæ rosæ,         aa. fluidounce iij.

{635} The following may also be mentioned as being useful in similar
cases:

  Rx. Pulv. calaminæ,
      Cretæ præparatæ,       aa. drachm j;
      Acidi hydrocyanici dilut., fluidrachm ss;
      Glycerinæ,                 fluidrachm ij;
      Aquæ,
      Liq. calcis,           aa. fluidounce iij.

These lotions, as will be seen, contain more or less insoluble powder,
and they are to be applied in the same manner as advised when speaking
of the use of black wash.

There are other lotions which are often of service. Carbolic acid, one
or two drachms to the pint of water, to which may be added a like
quantity of glycerin, is in many cases of value, especially in those in
which itching is marked. A saturated solution of boric acid, with or
without the addition of glycerin, may also be employed in these cases,
especially in erythematous eczema. It is one of the most useful of the
milder remedies. In this variety, particularly when confined to the
flexures, constituting eczema intertrigo, the following formula
containing acetate of lead may be prescribed in some cases with
benefit:

  Rx. Plumbi acetatis,    drachm ss;
      Acidi acetici dil., fluidrachm ij;
      Glycerinæ,          fluidrachm iv;
      Aquæ,      q. s. ad fluidounce vi.  M.

In those cases where lotions do not seem to act happily a mild ointment
of salicylated suet (2 or 3 per cent. strength) will often relieve the
condition. The fluid extract of grindelia robusta, one or two drachms
to six ounces of water, seems to suit some cases, but it should be
applied cautiously, as in some instances it tends to aggravate. Weak
alkaline lotions, a drachm of the bicarbonate of sodium or borate of
sodium to the pint of water, and a drachm of the solution of subacetate
of lead to the pint, may be also mentioned. Tarry lotions of weak
strength are sometimes useful. A drachm of the liquor carbonis
detergens to two or four ounces of water, or the liquor picis
alkalinus, a drachm to the half pint of water, may afford relief. The
former tarry preparation is made by mixing together nine ounces of
tincture of soap-bark[2] and four ounces of coal-tar, allowing to
digest for eight days and filtering. The formula for the liquor picis
alkalinus, the other tarry preparation referred to, is as follows:

  Rx. Potassæ,       drachm j;
      Picis liquidæ, drachm ij;
      Aquæ,          fluidrachm v.  M.

A lotion made up of two drachms of zinc oxide, two drachms of glycerin,
six drachms of lead-water, and three ounces of infusion of tar is
sometimes valuable in the erythematous form.

[Footnote 2: Tincture of soap-bark is made by digesting for eight days
one pound of soap-bark in one gallon of alcohol.]

As a rule, ointments are not so well borne in acute eczema as lotions,
but as soon as the more acute symptoms have subsided, and in some
instances even during the acute stage, they may be used with benefit.
The oxide-of-zinc ointment is well known, and is one of the most
soothing; sometimes it is well to reduce the proportion of zinc oxide.
{636} Oleate of zinc, in the proportion of one or two drachms to the
ounce of vaseline or lard, is somewhat similar to oxide-of-zinc
ointment, but is more astringent and stimulating. The oleate of
bismuth, pure or with an equal part of vaseline or other fatty base, is
also at times of service. The same may be said of the oleate of lead
melted with an equal part of lard or vaseline, in this form
constituting a soothing and astringent application similar to the
well-known diachylon ointment. The latter ointment, if properly
prepared, is in the subacute stage often exceedingly valuable. The same
objection to this holds as with the different oleates named--that is,
the difficulty of securing properly-made preparations. Many are vaunted
as such, but our experience is that good preparations are exceptional,
and those furnished, instead of acting as expected, often give rise to
irritation or marked aggravation. For the acute and subacute stages of
the disease the ordinary cold-cream ointment may be in some cases
advantageously prescribed. An ointment of equal parts of diachylon
plaster and one of the petroleum ointments, as vaseline, constitutes an
elegant preparation, useful when a mild, soothing application is called
for.

A paste made up as follows may also be recommended for the subacute
condition, and at times suits even during the active inflammatory
stage:

  Rx. Pulv. zinci oxidi, ounce ss;
      Mucilag. acaciæ,
      Glycerinæ,     aa. fluidounce j.

M.--S. Apply with a brush two or three times daily. To this formula, if
there is considerable itching present, carbolic acid or salicylic acid
in the proportion of 2 per cent. may be added. Glycerite of tannic acid
sometimes proves of value, especially in the erythematous varieties of
the disease, more particularly when occurring about the face. In like
cases glycerite of subacetate of lead may be prescribed. The following
is Squire's formula: Acetate of lead, 5 parts; litharge, 3½ parts;
glycerin, 20 parts, by weight. Mix and expose to a temperature of 350°
F., and filter through a hot-water funnel. The fluid resultant contains
129 grains of the subacetate of lead to the ounce, which is to be
diluted with from two to six parts of glycerin or with water. This
preparation may sometimes be used with benefit in chronic eczema of the
legs applied on strips bound on with a bandage. In these cases the
following paste, suggested by Unna, proves useful:

  Rx. Kaolini,
      Ol. lini,           aa. drachm vj;
      Zinci oxidi,            ounce ss;
      Liq. plumbi subacetat., fluidounce ss.  M.

This is painted on and allowed to dry, and then bandaged for
twenty-four hours. In some skins, however, glycerin invariably
irritates.

In the papular form the tarry lotions named and carbolic-acid lotion
are of most benefit. These cases are from the beginning inclined to
take on the chronic type, and the more stimulating applications are
well borne. Thymol, one or two grains to the ounce of alcohol and
water, is also useful.

In chronic eczema, and, in fact, in all cases of eczema, after the
active inflammatory symptoms have more or less subsided--which usually
takes place soon after the beginning of the outbreak--stimulating
applications are to be resorted to. In fact, the {637} dividing-line
between acute and chronic eczema is difficult to define. The products
of the disease, be they crusts or scales, must be removed in order that
the remedial application may be brought in contact with the diseased
surface. Thoroughly saturating the part with oil, and subsequently
washing with warm water and soap, will usually suffice to remove the
accumulations. On the non-hairy surface a bland oil, lard, or a
non-irritating ointment thickly spread on the parts, will soon be
followed by softening and removal of the crusts or scales. If these
more simple measures are not sufficient, washings with sapo viridis and
warm water are to be advised for this purpose, immediately afterward
applying a mild unguent. On the scalp, instead of the pure green soap,
the spiritus saponatus kalinus is more satisfactory. In patches which
are covered with thickened epidermic masses, as in eczema of the palms,
strong applications are necessary to remove the accumulations. For this
purpose green soap or salicylic acid may be used. Of these, salicylic
acid is in most cases to be preferred. It may be applied as an
alcoholic solution, 5 or 8 per cent. strength, or in ointment form,
fifteen to forty grains to the ounce.

After a removal of the products of the disease the remedies proper are
to be applied. The various ointments already named for the treatment of
the acute and subacute types may also be employed in the chronic cases.
In some instances they may prove sufficient, but in the majority it
will be found necessary to have immediate recourse to the stronger
ointments and lotions. In small patches washing the parts with green
soap and hot water and following with unguentum diachlyi or a similar
ointment will be sufficient.

The mercurials are of great value in the treatment of eczema, used
either alone or in combination with various other remedies. An ointment
of the mild chloride of mercury, twenty to eighty grains to the ounce,
is valuable in many cases. Citrine ointment, weakened, and ammoniated
mercury, in the same proportion as calomel, are also well-known and
very useful preparations, likewise acceptable in many cases. To these
ointments tar may often be advantageously added, in the strength of one
or two drachms to the ounce. Carbolic acid in ointment, ten to twenty
grains to the ounce, may also be mentioned as often proving
serviceable. A compound ointment, prized in the Blackfriars Hospital
for Skin Diseases, London, is composed of acetate of lead, ten grains;
oxide of zinc, twenty grains; calomel, ten grains; citrine ointment,
twenty grains; palm oil, half an ounce; benzoated lard, enough to make
one ounce. Another mildly stimulating preparation is composed of
bisulphide of mercury and red precipitate, each six grains; lard, one
ounce.

Tarry preparations constitute the most generally efficacious
applications in the treatment of all forms of chronic eczema, where
this remedy is at all tolerated by the skin, especially in the squamous
variety of the disease. A good formula, and one that is often of
service even in the subacute variety, is the following:

  Rx. Picis liquidæ,
      Zinci oxidi,    aa. drachm j;
      Ugt. aquæ rosæ,     drachm vj.

M. Ft. ugt.--This is to be gently but thoroughly rubbed into the {638}
diseased skin. There are three preparations of tar that may be
interchangeably employed: these are the ordinary pix liquida, oleum
cadinum, and oleum rusci. The oleum rusci is the least unpleasant. They
may be employed in the strength of 10 to 50 per cent., either in
ointment form or with alcohol. If used upon the scalp, the lotion form,
with alcohol, is to be preferred. In the use of a tarry preparation, to
be efficient it is to be gently but thoroughly worked into the patches,
so that it permeates the skin; the excess may be wiped off. The liquor
picis alkalinus, already mentioned in speaking of the treatment of
acute eczema, may be used either in the form of an ointment, in the
strength of one or two drachms to the ounce, or in the form of a
lotion, in the strength of two to eight drachms to the half pint. This
tarry preparation may even be employed in full strength to small and
thickened patches, applying carefully and using no other treatment, or
following the application immediately with a simple or tarry ointment.
In cases of verrucous eczema or in patches of thickened papular or
squamous eczema, used in the manner described, it is often curative. It
is a strong remedy, and is to be employed with caution. The liquor
carbonis detergens, in the strength of one or two drachms to the ounce
of water, is also valuable in these chronic cases. It is a safe plan in
the use of these tarry preparations to begin with a mild strength and
then increase if advisable. An equally efficacious formula for the
thick, leathery patches of chronic eczema is the following:

  Rx. Saponis viridis,
      Picis liquidæ,
      Alcoholis,       aa. drachm iv.

M.--S. Rub in twice daily. There is another mildly alkaline tarry
preparation, the goudron de Guyot, somewhat similar in composition to
the liquor picis alkalinus, which at times seems to suit when the other
tarry applications fail to benefit.

In the treatment of eczema rubrum of the legs Hebra was in the habit of
employing the following method: A small quantity of the green soap is
to be rubbed into the parts with a flannel rag, employing considerable
friction, until all the soap has apparently disappeared; then warm or
hot water is to be added and rubbed in in the same manner, an abundant
lather being the result. The parts after being rubbed for from five to
fifteen minutes, according to the effect, are to be thoroughly rinsed
off with simple warm water, and a mild ointment, spread upon cloths,
applied. The best ointment for this purpose is the unguentum diachyli,
but any mild ointment may be employed. This treatment is to be repeated
once or twice daily. In most cases improvement sets in after a few
applications. It is an excellent method of treatment, and can be
recommended. It requires considerable time and trouble, however, and is
therefore not suitable in all cases, for unless the details are
properly carried out it may fail.

Salicylic acid is another remedy that is often useful. In thick,
leathery patches, an ointment of the strength of thirty to sixty grains
to the ounce, applied on cloths or rubbed in, will often produce marked
benefit. In the form of a paste it may be used in many cases of
subacute and chronic eczema with good effects: {639}

  Rx. Acidi salicylici,     gr. xx;
      Ugt. petrolei,        drachm iv;
      Amyli,
      Zinci oxidi,      aa. drachm ij.

M.--S. Apply once or twice daily. If it is used upon the scalp, it
should be used with petroleum ointment or lard, the starch and zinc
oxide being omitted. Boric acid in the form of a saturated solution, as
advised in acute eczema, or in ointment of the strength of a drachm to
the ounce, will prove useful in some instances. Sulphur in the form of
ointment may also be mentioned as being frequently of value in cases of
chronic eczema, especially of the leg. In some cases of subacute and
chronic eczema the lotion containing zinc sulphate and potassium
sulphide, diluted, mentioned in acne, will be found serviceable. In
circumscribed and chronic patches blistering with cantharides is
sometimes advisable. In these cases tincture of iodine is also
employed. In thickened patches, rebellious to the usual remedies,
chrysarobin or pyrogallic acid, as used in psoriasis, may sometimes be
applied with benefit.

Mention may here be made of vulcanized india-rubber, used in the form
of bandages, the method proving of most value in eczema of the lower
extremities, especially in those cases which are due to a condition of
varicose veins. It is not suitable in all cases, as in some the disease
is aggravated. Reference may also be made to the use of the so-called
gelatin dressing. The medicinal substance is incorporated with the
gelatin basis, which is made by melting together over a water-bath two
parts of water and one of gelatin; and when the application is made the
gelatin compound is melted over a water-bath and applied while in the
fluid condition; it rapidly hardens and forms an impermeable coating to
the diseased part. The dressing is liable to crack, to avoid which, in
a measure, a small quantity of glycerin is mixed with the gelatin and
water. Another plan is, after the dressing has dried, to brush over the
surface a few minims of glycerin. It has, however, cleanliness in its
favor, and it is undoubtedly of service in many instances. A good basis
formula for the gelatin dressing consists of eight parts of water, four
of gelatin, and one of glycerin.

Another form of fixed dressing for scaly patches is with collodion.
This may often be made use of when tar is employed, the addition of one
or two drachms of pix liquida or one of the tar oils to enough
collodion to make an ounce. Such a preparation may be applied to dry
and scaly patches, and constitutes an excellent method of application;
but tar so applied is not as efficient as when used in solution or in
ointment. The gutta-percha and muslin plasters[3] constitute excellent
methods of applying remedies; they are cleanly, easily applied,
comfortable to the patient, and efficacious.

[Footnote 3: These plasters were devised by Unna, and are made by
Beiersdorf, an apothecary of Hamburg, Germany. The muslin plasters
consist of muslin incorporated with a layer of stiff ointment; the
gutta-percha plasters consist of muslin faced with a thin layer of
india-rubber, the medication being spread upon the rubber coating.]


Prurigo.

Prurigo is a chronic inflammatory disease, characterized by discrete
pinhead- to small pea-sized, solid, firmly-seated papules, slightly
raised, {640} of a pale-red color, accompanied by general thickening of
the skin and itching. The disease manifests itself by the development
of small firm elevations, which at first are scarcely perceptible; but
they may be distinctly felt by passing the hand over the surface.
Later, they may be seen as slightly-raised papules, varying in size
from a milletseed to a small pea, of the same color as the surrounding
skin or of a pinkish hue, and to the touch are found to be well-defined
inflammatory deposits. The lesions are discrete, may be present in
great numbers and in close proximity, and show no tendency to group,
being irregularly distributed. There is rarely distinct
scale-formation, but the papules are usually covered with roughened,
dry epidermis, and are frequently perforated with hairs.

Itching, usually intense, is a constant symptom, giving rise to
scratching, and as a consequence many of the lesions are covered with
blood-crusts and the skin is markedly excoriated. In course of time,
either as a symptom of the disease or as a result of the scratching and
consequent hyperæmia, or more probably resulting from both, the skin
becomes thickened and the surface harsh or rough. The extensor surfaces
of the legs, especially the tibial regions, and later the forearms and
arms, and in marked cases the trunk, are the regions usually invaded.
The palms and soles escape, and only in rare cases is the head
involved. As a result of strong local remedies or scratching, or of
both, a simple dermatitis or an eczema may develop as a complication.
In consequence also of the cutaneous irritation the lymphatic glands,
especially the inguinal, may become engorged--prurigo buboes (Hebra).

The causes of the disease are obscure. It is common in Austria, and is
occasionally met with in France and England, but it is almost unknown
in the United States. It is met with, as Hebra states, almost
exclusively in poor subjects and those ill nourished in childhood, and
so most often in foundlings and beggars' children. The disease is not
hereditary. It usually develops, however, in early childhood, and is
worse in winter than in summer. Anatomically, the lesions differ but
slightly from those of papular eczema. The papillæ and rete show a
moderate amount of cell and serous infiltration. Later, as a result of
the chronic inflammation, thickening, increased cell-infiltration,
atrophied sweat and sebaceous glands, and pigmentation are observed.
The process, according to various authorities, begins in the papillary
layer.

Prurigo has been, and is still, erroneously confounded with pruritus
and pediculosis, diseases which have nothing in common with that
affection except the itching and resulting excoriations--symptoms, as
is well known, common to many diseases. In pruritus there is no
structural change in the skin except that produced by scratching, a
point of difference that is diagnostic. The thickening of the skin and
the harsh, rough surface encountered in prurigo are absent in pruritus.
The latter disease is usually one of middle or old age; prurigo, on the
other hand, dates from childhood. In pediculosis the lesions, punctate
or papular in form, are consequent upon the wounds of the pediculus,
and are most numerous about the trunk, especially the shoulders and
hips. Between simple eczema and prurigo the diagnosis is not difficult.
It is to be remembered, however, that eczema may exist as a
complication, in which case, after its disappearance, the
characteristics of prurigo become evident.

{641} Severe cases are said to be incurable, according to Hebra and
others, but in the milder forms of the disease a cure may be effected.
Good food, hygiene, and tonic remedies, and systematic local treatment
similar to that generally employed in chronic eczema, are the measures
indicated. Naphthol, in the form of a 5 per cent. ointment for adults
and a ½ per cent. ointment for children, has been found by Kaposi to be
of value.


Acne.

Acne, or acne vulgaris, is an inflammatory, usually chronic, disease of
the sebaceous glands, characterized by papules, tubercles or pustules,
or a combination of these lesions, occurring for the most part about
the face. There are several so-called varieties of acne, although
examples of all these forms may be seen usually in an individual case,
and instances in which all the lesions are of the same type or
character are practically not encountered. Other disorders of the
sebaceous glands, as comedo and seborrhoea, are often seen associated
with this affection. In fact, hypersecretion or retention of the
sebaceous matter is the exciting cause of the inflammation.

If the retained sebaceous mass causes a moderate degree of hyperæmia or
inflammation, a slight elevation with a central whitish or blackish
point results, constituting the lesion of acne punctata. If the
inflammation is of a higher grade, the elevation is more marked,
reddened, and papular, the lesion being known as acne papulosa. If the
process is still more active, the central portion of the papule
suppurates and acne pustulosa results. The surrounding inflammation of
this form is often of a violent type, and the lesion may be situated
upon a hard and inflamed base, and then is designated acne indurata. In
some cases of acne the disappearing lesions leave more or less atrophy
about the gland-ducts in the form of pit-like depressions--acne
atrophica. On the other hand, at times there results connective-tissue
hypertrophy about the glands--acne hypertrophica. In strumous,
cachectic individuals the lesions, which are usually pustular in type,
or at times furuncular, almost of the nature of dermic abscesses, may
be more general in distribution, and are, moreover, usually of a more
sluggish character, constituting the so-called acne cachecticorum. The
efflorescence which follows the prolonged ingestion of the iodides and
bromides is usually of a more inflammatory type, the glands and
follicles being sometimes seriously and irreparably involved. This form
of acne, as well as that resulting from the external action of tar,
characterized by the formation of all kinds of lesions with a minute
central blackish deposit of tar and more or less inflammation of the
surrounding skin, constitutes acne artificialis.

The most common form of acne is that in which the pustule predominates.
The lesions, in all the varieties, are usually confined to the face,
the forehead, cheeks, and chin being favorite localities; not
infrequently, however, the eruption also involves the shoulders and
upper part of the back. They are irregularly distributed and tend to
appear in crops. Sometimes the face and shoulders are spared, and the
lesions, being confined to the back, extend as far down as the lumbar
region or even to the thighs. In these cases the lesions are usually
{642} of a papulo-pustular character and are sluggish in their
evolution. As a rule, an acne papule or pustule runs an acute course,
disappearing in the course of one or two weeks, and a new lesion
appearing at another point to supply its place. The disease is
essentially chronic, in the sense that the parts are never or seldom
free, new lesions forming and old ones disappearing from time to time,
in some cases indefinitely. As a rule, there are no subjective
symptoms, but in some markedly inflammatory cases the lesions are
painful; in other exceptional instances there is slight itching.

The disease is common about the age of puberty, and occurs in both
sexes. Chronic derangement of the digestive apparatus is a frequent
factor. Those of a light complexion are more liable to its development,
while menstrual difficulties, chlorosis, scrofulosis, and general
debility may all predispose to the disease. Medicinal substances, such
as the iodides and bromides, and tar externally, are also prone to
produce acne-form lesions. The retention of the secretion within the
sebaceous gland is the first step in the formation of an acne lesion,
and its presence--or it may be its decomposition--gives rise to
inflammation, which usually involves the gland-structure and the
surrounding tissue. Primarily, it is a folliculitis, the tissue
immediately about the follicle subsequently becoming involved,
constituting a perifolliculitis. As a result of this latter process, or
from inflammation and changes within the gland without much surrounding
inflammation, the destruction of the sebaceous follicles may ensue. The
hair-follicles at times are also involved in the process. The degree of
inflammation determines the character of the lesion; if mild in
character, the simple papule or pustule results; if of a severe grade,
the lesion of the indurated and hypertrophied forms follows.

Acne resembles at times the papular and pustular syphiloderms. In
syphilis the distribution of the eruption, the history of the case, the
color, the duration of the individual lesions, the tendency of the
papules or pustules to group, and usually the presence of other
evidence of the disease, will serve to distinguish it from acne. Tar
acne may be recognized by the history, the black points at the
follicular openings, and usually evidence of the presence of tar about
the patient. Acne resulting from the ingestion of the bromides and
iodides is almost always of an acute and markedly inflammatory type,
the lesions being scattered over the general surface, and are usually
larger and more virulent in character than those of acne vulgaris. From
acne rosacea it may be known by the characters referred to in speaking
of that disease.

TREATMENT.--Cases of acne vary considerably as to their course and
curability. There is in almost every case a natural inclination toward
disappearance of the eruption at the age of twenty or thirty. Although
the lesions are at any age of the patient generally easily removable by
treatment, relapses are the rule; but the older the patient the less
probability is there of a recurrence. Even in young subjects, however,
the cure may be permanent, depending upon the ability to discover and
remove the cause. The disease requires both constitutional and local
treatment. For the removal of the existing eruption local applications
alone are usually sufficient, but the disposition to the development of
new lesions in most cases yields only to appropriate internal
treatment.

Each case of acne for its successful management demands careful {643}
investigation with a view of discovering the etiological factors. If
these can be ascertained and removed, a successful result is assured.
As already intimated, disorders of digestion play a most important part
in the etiology of this disease, and in a large proportion of cases
remedies appropriate to such conditions are required. The diet is to be
strictly regulated: all indigestible articles of food, such as pork,
salt meats, pastry, cheese, pickles, etc., should be interdicted. If
constipation exists, laxatives are to be prescribed. As a rule, salines
are more serviceable than vegetable preparations for plethoric
individuals, while for others the latter, especially for long-continued
administration, are to be preferred. A change from one to the other is
often advisable. The dose should be sufficient to produce a free
evacuation daily. An excellent tonic aperient mixture is the following:

  Rx. Magnesii sulphatis,      ounce iss;
      Ferri sulphatis,         gr. viij;
      Acidi sulphurici diluti, fluidrachm ij;
      Aquæ menthæ piperitæ,    fluidounce iij drachm vi.

M.--S. A tablespoonful in a tumblerful of water a half hour before
breakfast. The tonic effect of such a mixture is best obtained by
prescribing one or two teaspoonfuls in a large wineglassful of water
before each meal: as a rule, however, when thus given its laxative
property is not so well marked. The mint-water may be replaced by a
bitter infusion, such as quassia, but the mixture, unpalatable at the
best, is not improved by such a substitution. In some cases the acid in
the above mixture is contraindicated, and the following, also a
valuable formula, may be prescribed:

  Rx. Magnesii sulphatis, ounce iss;
      Potassii bitart.,   drachm iv;
      Sulphuris præcip.,  drachm ij;
      Glycerinæ,          fluidrachm ij;
      Aquæ menthæ pip.,   fluidounce iv.

M.--S. Tablespoonful in a tumblerful of water a half hour before
breakfast. Hunyadi Janos water, in the dose of a large wineglassful
thirty or forty minutes before the morning meal, is a useful saline,
and is not especially disagreeable. Friedrichshall water is an
efficient laxative and cathartic, but has a nauseous taste and odor.
The ordinary mixture of rhubarb and soda is of value, not only for its
laxative effect, but also for its antacid property where such is
indicated. The following formula, containing cascara sagrada, is of
service:

  Rx. Ext. cascaræ sagradæ fl., fluidrachm iv;
      Acidi muriatici diluti,   fluidrachm ij;
      Tincturæ gentianæ comp.,  fluidounce iij drachm ij.

M.--S. Teaspoonful in a large wineglassful of water before meals. At
times this proportion of cascara sagrada is too large, and, on the
other hand, in some cases it must be increased. A laxative pill, as the
following, containing aloin, belladonna, and strychnia, may be given:

  Rx. Aloin,               gr. iij;
      Ext. belladonnæ,     gr. ij;
      Strychniæ sulphatis, gr. ¼.

M. Ft. pilul. No. xv.--S. One or two at night. If there is torpor of
the liver, an occasional dose of blue mass or calomel may be
prescribed. {644} When there is flatulence or other symptoms of
fermentative indigestion, a mixture such as the following will be found
useful:

  Rx. Sodii hyposulphitis,  drachm ijss-ounce j;
      Ext. nucis vomicæ fl. fluidrachm ij;
      Aquæ menthæ piperitæ, fluidounce iv.

M.--S. Teaspoonful in a large wineglassful of water a half hour before
meals. The hyposulphite of sodium contained in the mixture may have a
laxative effect in addition to its antifermentative action.

If there is anæmia or chlorosis, a preparation of iron, combined with
aloes if there is tendency to constipation, is to be prescribed, the
wine of iron being one of the most eligible ferruginous preparations.
Ergot in the dose of a half drachm of the fluid extract has been
recommended in the acne of females, especially where it seems probable
that uterine disturbance is the exciting cause. Possibly its effect is,
as has been suggested, due to its action on the unstriped muscular
fibres of the skin. After one or two weeks' administration it is apt to
cause gastric disturbance and, directly or indirectly, vertiginous
symptoms. Calx sulphurata in the dose of one-tenth to one-half grain
every three or four hours is of value in some cases, usually proving of
most service in the pustular type. In strumous individuals, and in
those whose nutrition is below the average, cod-liver oil is a valuable
remedy. In like cases glycerin in similar doses may be prescribed,
although its action is not so certain.

Arsenic is of decided value in some cases, but proves powerless in
others. The sluggish papular forms are often influenced favorably by
its continued administration. The alterative effect of mercury is
sometimes beneficial, corrosive sublimate in small doses being the most
available preparation. Where the inflammation is of a high grade,
potassium acetate and other alkalies may be prescribed, as in the
following formula:

  Rx. Potassii acetatis,     drachm v gr. xx;
      Liq. potassæ,          fluidrachm ijss;
      Liq. ammonii acetatis, fluidounce iij drachm v.

M.--Sig. Teaspoonful in a large wineglassful of water one hour before
meals.

Local Treatment.--This is of great importance and is demanded in every
case. In acute acne, rarely encountered, mildly astringent applications
are to be advised. The disease, as generally met with, however, is of a
subacute or chronic character, requiring stimulating measures. External
treatment in these cases has for its object the production of hyperæmia
and the removal of the superficial layers of the epidermis, thus
stimulating the glands and circulation and assisting in the excretion
of the sebaceous matter. For this purpose washing the parts
energetically with sapo viridis and hot water every night, using a
sponge or preferably a piece of flannel, may be advised. After the
soap-washing the parts are to be sponged with hot water for several
minutes, or the face held over a basin containing steaming hot water.
Subsequently, the comedones are to be pressed out by means of pressure
with the fingers, or, better, by a watch-key with rounded edges so as
not to injure the skin. An application of a simple emollient, such as
cold cream or vaseline, may then be made and allowed to remain on over
night. This plan of treatment is to be repeated nightly or every other
night.

In many simple cases of acne the above method of external treatment,
{645} combined with appropriate constitutional medication, will bring
about marked improvement and sometimes permanent relief. In the
majority of cases, however, a more stimulating plan of treatment is
called for. In almost all cases the soap-washing, either with the sapo
viridis or a milder soap, and the sponging with hot water, are to
precede the nightly remedial applications. Among the external remedies
for acne sulphur preparations stand first. Properly managed, they
rarely fail to benefit, and often prove curative. Precipitated sulphur
is the preparation generally employed, and in many cases the most
suitable. It may be prescribed as a powder, in ointment, or in lotion.
As a powder it may be applied pure or mixed with starch, and as an
ointment the following formula can be recommended:

  Rx. Sulphuris præcipitati, drachm iss;
      Adipis benzoati,       drachm iv;
      Ugt. petrolei,         drachm ijss;
      Olei rosæ,             gtt. iij.

M. Ft. ugt.--Sig. To be rubbed thoroughly into the skin at night. Or,
instead of the precipitated sulphur in the above ointment, the sulphur
hypochloride may be substituted. As a mild stimulant sulphur soap may
often be ordered with advantage in connection with other remedies.

In sluggish, non-inflammatory cases the following may be used:

  Rx. Sulphuris præcipitati,
      Potassii carbonatis,
      Glycerinæ,
      Ugt. petrolei,         aa. drachm ij.

M. Ft. ugt.--Sig. Apply at night, rubbing it into the skin. In the
above formula the petroleum ointment may be replaced with the same
quantity of alcohol. In the form of a lotion precipitated sulphur at
times acts more decidedly than as an ointment. There are several useful
formulæ which, as a rule, answer equally well, although in some cases
differing in their beneficial effects. In the average case the
following seems most certain in its results:

  Rx. Sulphuris præcipitati,   drachm ij;
      Pulv. camphoræ,          gr. xx;
      Pulv. tragacanthæ,       gr. xxx;
      Aquæ aurantii flor.,
      Liq. calcis,         aa. fluidounce ij.

M.--S. Dab on with a mop or rag; shake before using.

A similar mixture in the form of a paste may be made with equal parts
of mucilage of acacia, glycerin, and sulphur, and is to be applied with
a brush, being allowed to remain on the skin over night.

Another sulphur lotion is the following:

  Rx. Sulphuris præcipitati, drachm ij;
      Glycerinæ,             fluidrachm j;
      Alcoholis,             fluidounce j;
      Liq. calcis,           fluidounce ij;
      Aquæ aurantii flor.,   fluidounce j.

M.--Sig. Apply with a sponge or rag, shaking well before using.

The annexed is also a good stimulating lotion: {646}

  Rx. Sulphuris præcipitati, drachm ij;
      Ætheris,               fluidrachm iv;
      Aquæ cologniensis,     fluidrachm iv;
      Alcoholis,             fluidounce iij.

M.--Sig. Shake well and dab on with a rag.

Potassium sulphide is a preparation of sulphur which often acts
admirably in this disease. It may be employed as an ointment, or,
preferably, as a lotion. An excellent formula, containing the sulphide,
which can be prescribed with advantage in many cases, is the following:

  Rx. Potassii sulphidi,
      Zinci sulphatis,   aa. drachm j;
      Aquæ rosæ,             fluidounce iv.

M.--S. Apply with a sponge or rag. The resulting lotion from this
mixture is a complex one, a double reaction taking place. The salts
should be separately dissolved, and then mixed. If properly made, the
lotion when shaken is of a milky color and free from odor; upon
standing the particles sink and form a white sediment, the liquid above
being clear. If improperly prepared, as is often the case, it is of a
yellowish tinge with a decided odor of the potassium sulphide, and has
an entirely different effect. Vleminckx's solution,[4] perfumed with an
essential oil, is often of service; it is to be diluted with three to
six parts of water and dabbed on every night, the strength gradually
increased if necessary.

[Footnote 4: See treatment of Psoriasis for formula.]

Another class of external remedies found of service in the treatment of
this disease are the mercurials. They are not so valuable as the
sulphur preparations. Corrosive sublimate, white precipitate, and
calomel are the mercurials commonly used. If sulphur has been
previously employed, several days should intervene and the parts be
repeatedly cleansed before using a mercurial, otherwise the skin is
darkened temporarily by the formation of the black sulphuret of
mercury. Corrosive sublimate is prescribed in the form of a lotion,
from one-half to two grains to the ounce of alcohol and water, or as in
the following formula:

  Rx. Hydrargyri chloridi corros., gr. ij;
      Zinci sulphatis,             gr. xv;
      Alcoholis,                   fluidounce ij;
      Aquæ rosæ,                   fluidounce ij.

M.--S. Apply with a rag. The zinc sulphate renders the lotion
astringent, and is often a valuable addition. Ammoniated mercury,
thirty to sixty grains to the ounce of benzoated lard or cold cream,
will frequently prove serviceable. If the lesions are numerous and are
seated close together, the application is to be made to the entire
surface of the part; on the other hand, if they are sparse, it may be
made to the spots only. The same may be said also in regard to the
sulphur preparations. A 5 or 10 per cent. ointment of oleate of
mercury, rubbed thoroughly into sluggish and indurated lesions, will
often shorten their course by promoting suppuration. In many cases
puncturing the lesions with a sharp knife or scraping with a curette
before applying the hot water will be of assistance in the treatment.
In obstinate indurated lesions, in addition to puncturing the lesions,
the apices may be treated with carbolic acid. The protiodide of
mercury, in the strength of five to fifteen grains to the ounce of
ointment, is well spoken of by some authorities; it is to be used {647}
with care, as it is actively stimulant. In some cases rubbing
energetically over the parts a mixture of sapo viridis and sulphur,
adding enough hot water to make a lather, and allowing it to remain on
over night, will, if repeated nightly until the skin becomes slightly
inflamed and then followed subsequently by a mild ointment, produce a
decided effect.


Acne Rosacea.

Acne rosacea, or rosacea, is a chronic, hyperæmic or inflammatory
disease of the face, invading especially the nose and cheeks,
characterized by redness, dilatation and enlargement of the
blood-vessels, more or less acne, and hypertrophy. The course of the
disease divides itself naturally into three stages. There is at first
simply a hyperæmia, due to passive congestion. In young subjects the
affection is seen in this stage, and rarely passes beyond it. In other
cases, however, sooner or later, dilatation and enlargement of the
vessels (telangiectasis) take place, and acne papules and pustules are
scattered over the parts, constituting the second stage of the disease.
This stage is frequently met with, and illustrates the acne rosacea
usually seen. Exceptionally, however, the disease progresses, the
vessels increase in calibre, the glands are enlarged, and there is more
less hypertrophy of the connective tissue and the third stage is
developed. The nose may become much enlarged, even lobulated, and in
some portions pendulous (rhinophyma). The nose and its immediate
neighborhood are the favorite localities for the development of acne
rosacea, but it is not infrequently confined to the cheeks, and
sometimes is localized upon the forehead, while all these parts are not
infrequently affected simultaneously. As a rule, there are no marked
subjective symptoms, although in some instances burning or a sense of
fulness is complained of.

It is seen in both sexes, but is more frequent in males; in women it
rarely, if ever, reaches the same degree of development as in men. It
is most common about middle life. The causes are varied. Chronic
stomachic and intestinal derangements, anæmia, and chlorosis are common
causes. The habitual use of spirituous liquors is not infrequently a
source of the disease. Long-continued exposure to excessive cold or
heat is in some cases a causative agent. In women, menstrual and
uterine difficulties are often the responsible factors; hence in this
sex it is much more common at the climacteric period. When occurring in
the young about the period of adolescence, it is frequently associated
with seborrhoea, and rarely advances beyond a condition of hyperæmia.
Pathologically, in the first stage of the disease there is simply a
hyperæmia--a stasis; in the second, hypertrophy and dilatation of the
vessels are superadded, together with acne and slight hypertrophy of
the sebaceous glands; in the third stage there is, in addition,
hypertrophy of the connective tissue of the corium.

Acne rosacea is to be distinguished from the tubercular syphiloderm,
lupus vulgaris, and acne vulgaris, to which affections it at times
bears resemblance. The tubercular syphiloderm is comparatively more
rapid in its course; does not necessarily involve the sebaceous glands;
has frequently as a consequence ulceration and crusting; is usually
confined to a part of the nose; and is unaccompanied with dilatation
and enlargement of the blood-vessels. Its history, the firmer
consistence, and the more {648} dusky color of the tubercles, and
frequently the presence of other evidences of syphilis, are also points
of difference. In lupus vulgaris the characteristic soft, yellowish-red
papules, the absence of the hypertrophied blood-vessels, the
degeneration, ulceration, and cicatricial-tissue formation, the more or
less limited character of the eruption, and the history of the case,
will serve to distinguish it. A simple case of acne vulgaris can
scarcely be confounded with acne rosacea: in many cases, however, the
dividing-line is far from being marked; in fact, the disease under
consideration is often acne with hyperæmia and dilated blood-vessels
superadded.

TREATMENT.--The affection may in all cases be more or less favorably
influenced by treatment. The milder cases, although at times obstinate,
are curable; but when the disease has advanced to marked dilatation and
hypertrophy of the blood-vessels and connective tissue, the prognosis
is not so favorable. In all stages of the affection, however, as
stated, a great deal can be accomplished by appropriate remedies.
External and internal treatment are required in the majority of cases.
The former usually proves the more valuable.

Concerning internal remedies, there is no drug that exerts a specific
influence. The guide to constitutional treatment should be a study of
the etiological causes of the disease. Constipation is frequently
present, and hence laxatives, especially the salines, are indicated.
Chlorosis in the female is often the predisposing cause, and such
remedies as iron, quinine, and strychnia will be found useful.
Dyspepsia is one of the most frequent causes, and treatment directed
toward a removal of that condition will often be of considerable aid in
curing the disease. Menstrual irregularities should be inquired into
and the appropriate remedies employed.

There are mainly two classes of external remedies which are used in the
treatment--namely, the mercurials and the sulphur preparations. The
latter are by far the more valuable, precipitated and sublimed sulphur,
the hypochloride of sulphur, and the sulphuret of potassium being the
most serviceable. They are prescribed either in the form of lotions or
ointments. The officinal sulphur ointment, an ointment of the
precipitated sulphur and of the hypochloride of sulphur, of the
strength of one or two drachms to the ounce, may be referred to as
valuable applications. Sulphur may also be used as a dusting-powder or
in the form of a paste, as in the following formula:

  Rx. Mucilag. acaciæ,  fluidrachm ij;
      Glycerinæ,        fluidrachm ij;
      Sulphur, præcip., drachm iij.

M.--Sig. Use with a brush as a paint.

A lotion containing one to four drachms of precipitated sulphur, twenty
or thirty grains of camphor, thirty to sixty grains of tragacanth, in
two ounces each of lime-water and orange-flower water, or one of the
same quantity of sulphur, two or three drachms of ether, and three and
a half ounces of alcohol, will in many cases prove serviceable. A
lotion of one or two drachms each of sulphide of potassium and sulphate
of zinc, in four ounces of water, is one of great value.

Concerning the mercurials, corrosive sublimate, calomel, and white
precipitate are in some cases of service. Corrosive sublimate is
prescribed {649} as a lotion of the strength of one-half to four grains
to the ounce of water or water and alcohol. Calomel and white
precipitate are prescribed in ointment, twenty grains to two drachms of
either to the ounce, or they may be used in the form of a powder, full
strength or weakened with starch powder, dusted over the surface.

To a great extent, the treatment of acne rosacea is the same as simple
acne, and for other formulæ and for the method of applying the various
remedies the reader is referred to that disease. When dilated
blood-vessels are present, however, other measures, in addition to
those advised above, are to be adopted. There are two methods of
destroying the blood-vessels. One plan is by the knife, cutting across
the vessels at several points or slitting their whole length,
permitting them to bleed; subsequently cold water may be applied. The
other method is by means of electrolysis, according to the procedure
fully described in the treatment of hypertrichosis. If the vessel is
long, inserting the needle at several points along its length will be
necessary; if short, insertion at one or two points will suffice. While
either of these methods will, if properly managed, destroy the vessels,
neither will prevent the growth of new vessels. In those cases,
however, in which the cause has long ceased to operate destruction of
the existing vessels may not be followed by new growth. Excessive
connective-tissue hypertrophy may require ablation by the knife.


Sycosis.

Sycosis (syn., sycosis non-parasitica, folliculitis barbæ) is a chronic
inflammatory, non-contagious affection, involving the hair-follicles,
appearing generally upon the bearded region, and characterized by
papules, tubercles and pustules perforated by hairs. The disease is
seen, as a rule, only on the bearded part of the face, either about the
cheeks, chin, or upper lip, involving a small portion or the whole of
these parts. The hairy portion of the neck may also be invaded. The
disease may begin by the formation of papules and pustules about the
hair-follicles on previously healthy skin, or chronic hyperæmia, or
even eczema, may have preceded. The lesions generally occur in numbers,
in close proximity, and, together with the accompanying inflammation,
make up a patch of disease involving a greater or less area. The
pustules are discrete, flat or acuminated, small in size, yellowish in
color, perforated by hairs, show no disposition to rupture, and are, as
a rule, apt to appear in crops. They dry to thin yellowish-brown
crusts. There is more or less swelling and infiltration. Papules and
tubercles may usually be seen intermingled with the pustules, or the
former may constitute the greater part of the eruption. At first the
hairs are firmly seated, but later, when suppuration has involved the
follicles, they may be easily extracted. Not infrequently the
hair-follicles are completely destroyed, in which case scarring and
alopecia result. The process is chronic, it being of a subacute or
chronic character, with, usually, acute exacerbations. Burning
sensations, and at times pain or itching, accompany the disease.

According to Robinson, the affection is primarily a perifolliculitis,
{650} the first changes, which are those usually observed in vascular
connective-tissue inflammations, taking place around the follicle.
Later, the follicle and its sheath become involved, the pus and
transuded serum finding their way into these structures. At times pus
does not enter within the follicle, the changes observed therein being
due to the transuded serum. The pus reaches the surface by forcing its
way through the epidermis close to the hair. The causes of the disease
are not understood. It is usually seen in those between the ages of
twenty-five and fifty, in all classes of society, and in those in good
or bad health. Persons with eczematous skin and those having thick and
stiff hair are especially predisposed to the disease. Local irritation
may serve as the exciting cause. The affection is not common. It is not
contagious.

The disease is to be distinguished from tinea sycosis and eczema. Tinea
sycosis usually begins as a circular scaly patch--in fact, as simple
ringworm--later invading the hairs and follicles and giving rise to
papules and tubercles. These lesions are larger than in simple sycosis,
and appear and feel like lumps and nodules. Moreover, the changes in
the hairs in the parasitic disease are characteristic: they become
opaque, brittle, loose, and can be readily extracted. If necessary, a
microscopical examination of the hairs may be resorted to. In eczema
there is either an oozing, red, crusted surface, or it is dry and
scaly; the lesions, as a rule, do not remain discrete, are not
perforated by hairs, and the eruption is apt to involve other parts of
the face. It is scarcely possible to confound the disease with
syphilis.

The disease is essentially a chronic one, and under the best management
is often rebellious. Relapses are not uncommon. The treatment consists
mainly of external measures. Suitable internal remedies are, however,
in some cases, as in plethoric or in broken-down subjects, of value.
The digestive apparatus is to be looked after. The extremes of heat and
cold are to be, as far as possible, avoided. Clipping the hair, or
shaving if not too painful, will permit a more thorough application of
remedies. If the disease be of an acute type, soothing applications are
at first to be advised. If there is crusting, it should be removed by
poultices or oily applications. The use of lotio nigra, and
subsequently a cloth spread with oxide-of-zinc ointment, as in acute
vesicular eczema, may be advised to allay inflammation. Cold cream,
vaseline, or applications of lead-water and like remedies, will also be
found useful in the acute stage. As a rule, however, astringent and
stimulating ointments may be prescribed when the case first comes under
observation. As an astringent ointment there is in the average case
nothing superior to a good unguentum diachyli. It should be spread
thickly on muslin and bound down to the parts, renewing every six or
twelve hours. If stimulation is permissible, twenty grains to a drachm
of ammoniated mercury or calomel to the ounce of ointment may be
prescribed.

If the process be chronic in character, the parts may be washed with
sapo viridis and water, and then diachylon ointment applied, repeating
the washing every day and the application of the ointment twice or
thrice daily. Sulphur, one to three drachms to the ounce of ointment,
is a valuable stimulating remedy, and should be applied thoroughly
twice daily; citrine ointment, two or three drachms to the ounce of
lard or cold cream, will sometimes have a good effect. Shaving will be
found useful in many cases. In {651} some instances epilation proves a
valuable adjunct to the treatment. In acute stages the hairs should be
extracted from the pustules only--in the chronic stage both from
papules and pustules. The operation will be rendered less painful by
previously steaming or applying hot water to the parts. After the
operation the surface should be dressed with a mild ointment. Epilation
at the proper time will often save follicles from irreparable
destruction; if for any reason it is not advisable, the pustules should
be incised, so that free egress may be given to the pus.


Impetigo.

Impetigo is an acute inflammatory disease, characterized by the
formation of one or more pea- or finger-nail-sized, rounded and
elevated, usually firm, discrete pustules, seated upon an inflammatory
base. The affection is at times preceded by slight malaise. The lesion
is pustular from the beginning, and when well advanced may be of the
size of a pea or finger-nail, is rounded, or semiglobular, markedly
elevated, yellowish or whitish in color, with at first a more or less
pronounced areola, which as the lesion matures becomes less and less
marked, and finally almost entirely subsides. The pustule is usually
distended, shows no disposition to rupture nor to umbilication, and is
characterized by but little surrounding infiltration, and even where
several exist close together they show no tendency to coalesce. Ten,
twenty, or more lesions are usually present, and are most common about
the face, hands, feet, and lower extremities. They dry to crusts of a
yellowish or brownish color, which are usually thin and drop off, no
pigmentation or scar remaining. The process is of brief duration, is
benign in character, and is rarely attended with subjective symptoms.
It is commonly seen in children under the age of ten.

The disease, apparently, is not related to eczema; occurs, as a rule,
in well-nourished subjects, and is not contagious. The lesion is a
typical pustule, the process being distinctly circumscribed. The walls
are somewhat thick, and are probably made up of both the horny and
mucous layers. There is no inflammatory base. Microscopically, the
contents are found to be composed of pus-corpuscles, a few red
blood-corpuscles, epithelial cells, and cellular débris. The disease is
to be distinguished from pustular eczema, impetigo contagiosa, and
erythema. The pustules of eczema are numerous, closely crowded
together, small in size, tend to coalesce, with a decided disposition
to rupture, and are accompanied by itching. The lesions of impetigo
contagiosa are vesicular or vesico-pustular, flattened, superficial,
thin-walled, often umbilicated; if close together they tend to
coalesce, and dry to lamellar crusts of a yellowish color, and the
affection is distinctly contagious. The pustules of ecthyma are flat,
with an inflammatory base and areola; the crusts are brownish or
blackish, and seated upon a deep excoriation; and the affection is,
moreover, usually seen in adults and in those whose general health is
markedly below the standard.

The affection rarely calls for treatment, as it tends to spontaneous
recovery. Incision and evacuation of the matured lesions and a simple
protective dressing of a mild ointment, such as oxide-of-zinc ointment,
{652} may be advised. If slight stimulation is desirable, ten or twenty
grains of ammoniated mercury may be added to the ounce of the ointment.


Impetigo Contagiosa.

Impetigo contagiosa is an acute, inflammatory, contagious disease,
characterized by the formation of discrete, superficial, flat, rounded
or ovalish vesicles or blebs, which soon become vesico-pustular and
pass into crusts. Precursory febrile symptoms, especially in young
children, frequently usher in the eruption. The lesions begin as
discrete vesicles, small in size, becoming vesico-pustular and
increasing by extension peripherally, reaching the size of a pea or
developing into blebs as large as a dime or silver quarter dollar. They
are flat, slightly or markedly umbilicated, the umbilication being more
marked in the older lesions. Several or a few dozen such vesicles or
blebs may be present, and if situated close together may coalesce and
form patches. There is very little areola, and the covering of the
lesion is thin and withered-looking. The superficial character of the
process is a striking feature. In a few days the lesions dry to crusts,
thin, granular, wafer-like in character, light-yellowish or
straw-colored, and but slightly adherent. If the vesicular or bleb wall
or the crust is removed, a slightly excoriated surface is disclosed,
resembling a superficial burn, secreting a thin fluid. The lesions are
seen most commonly about the face and hands, although they frequently
occur on other parts. In some cases one or two dozen lesions are
scattered over the general surface. In these instances the resemblance
of the whole process to an acute contagious systemic disease with
cutaneous manifestations is striking. The lesions of the affection as
ordinarily encountered appear simultaneously or in crops. As a rule,
there is very little itching, and when it exists is usually present
only in the beginning of the disease or at night. The affection is
contagious and auto-inoculable, and at times apparently epidemic; is
seen most frequently in the warm months, and is confined almost
exclusively to children. When occurring in adults it is usually of an
abortive type. In addition to the cutaneous covering, the mucous
membranes of the mouth and conjunctiva are sometimes affected. As a
rule, it runs an acute course, lasting ten days or two weeks. In
exceptional instances the disease is anomalous, as regards not only its
course, but the character and type of the individual lesions.

The causes of the disease are not understood. Some authorities consider
it due to the presence of a parasite,--a view in which we are not
prepared to coincide. A fungus--in fact, several varieties--may be
found in microscopic examinations of the crusts, but the same may be
found in crusts of other diseases, and their presence may be considered
as accidental. There seem to be two varieties of the disease, in one of
which the lesions are for the most part confined to the face and hands,
and in the other the lesions are scattered over the general surface.
The affection is encountered most frequently among the poor and
ill-cared-for. A relationship to vaccination has at times been noted.

In the diagnosis eczema and simple impetigo are to be excluded. The
history, course, and characters of the lesions of contagious impetigo
are {653} entirely different from those of these two diseases. The
size, growth, isolated character, the non-inclination to rupture, and
the comparative absence of itching will serve to distinguish it from
eczema. The pustule of simple impetigo is prominently raised; that of
contagious impetigo is flat and usually umbilicated; the contents of
the former are distinctly pustular, and the crusts thicker, smaller,
and usually yellowish-brown; of the latter the contents are rarely more
than vesico-pustular, the crust thin, light-yellowish or straw-colored,
and has the appearance of being stuck on. Those cases which resemble an
exanthem may in the early stages be confounded with varicella, but
later the lesions are much larger than seen in that disease. In
exceptional instances the resemblance to the blebs of pemphigus is more
or less pronounced.

As a rule, but little treatment is necessary, as the affection tends to
spontaneous disappearance. In some cases, however, in which there is
more or less itching, auto-inoculation at the excoriated points takes
place, and in this manner the affection may persist. An ointment of
ammoniated mercury, ten or fifteen grains to the ounce, rubbed in the
lesions, will have a curative effect; likewise an ointment or lotion of
carbolic acid, ten grains to the ounce.


Ecthyma.

Ecthyma is characterized by the formation of one or more discrete
finger-nail-sized, flat, inflammatory pustules. The pustules are
usually few in number, vary in size from that of a pea to a large
finger-nail, roundish or ovalish in shape, and are situated on an
inflammatory base, with a marked areola of a bright-red color. In the
beginning they are yellowish, but later, from an admixture of more or
less blood, they become reddish, subsequently drying to brownish but
slightly adherent crusts. If the crust is removed, a superficial
excoriation, secreting a yellowish fluid, is disclosed. The lesions
pursue an acute course, but new pustules are apt to form from time to
time. The lower extremities, shoulders and back are favorite
localities. The subjective symptoms are usually slight, but burning and
pain may be complained of. More or less pigmentation is left to mark
the site of the lesions, which sooner or later disappears. The
affection is seen in both sexes and at all ages, but is more frequently
met with in men.

It is a disease of the poorly-nourished and debilitated; hence it is
chiefly seen in the lower walks of life. All causes that tend to reduce
the tone of the general health are indirectly responsible for the
disease. In such persons external irritants, such as pediculi,
bed-bugs, and similar parasites, may provoke the formation of
ecthymatous lesions. The affection is not contagious. The process is of
a markedly inflammatory type, and tends rapidly to pus-formation. The
lesion is a typical pustule, and the excoriation does not extend deeper
than the papillary layer. Permanent scarring never results. In the
negro, instead of increased pigmentation, loss of pigment results.

The disease is to be distinguished from simple impetigo, contagious
impetigo, and the flat pustular syphiloderm. It differs from impetigo
in the flat form of the lesion and the character of its crust, and in
the more {654} inflammatory nature of the process. The
non-contagiousness of the affection, the character and color of the
crust, the regions involved, and the course will serve to differentiate
it from impetigo contagiosa. In exceptional cases of this latter
disease some of the lesions bear considerable resemblance to ecthyma. A
striking similarity to the large flat pustule of syphilis is often
noticed in ecthyma, and it is here that difficulty in the diagnosis is
most likely to be experienced. The local disturbance, such as pain and
heat, is generally more marked in ecthyma. The syphiloderm is usually
of slower development and runs a more chronic course; moreover,
positive ulceration beneath the crusts does not occur in ecthyma. The
crusts of syphilis are darker in color, and usually have a greenish
hue. Concomitant symptoms of syphilis are almost always present, and
are valuable in the diagnosis. Ecthyma can scarcely be confounded with
pustular eczema, as the size and discrete character of the pustules and
the absence of marked itching are sufficiently distinctive.

Where it is possible for the patient to follow out treatment the result
is always favorable. The importance of good food and proper hygiene
cannot be overestimated. Tonics may be prescribed as efficient
adjuvants. Iron, quinine, nux vomica, and the mineral acids are
valuable. As a rule, simple measures are sufficient in the external
treatment. If the lesions are numerous and are markedly inflammatory,
alkaline baths, six ounces of sodium bicarbonate or of a similar
alkaline salt to the bath, will be of service. The crusts are to be
removed by poultices or hot-water applications, and the excoriations
dressed with an ointment of ten to twenty grains of ammoniated mercury
in an ounce of oxide-of-zinc ointment. In some cases a more stimulating
ointment is required. Where active stimulation is demanded, touching
the parts with nitrate of silver, diluted carbolic acid or a similar
agent will prove serviceable.


Miliaria.

Miliaria--popularly known as prickly heat or heat-rash--is an acute
inflammatory disorder of the sweat-glands, characterized by pinpoint to
milletseed-sized papules or vesicles, attended usually by sensations of
pricking, tingling, or burning. In some cases the eruption is almost
entirely made up of papular lesions, and constitutes the form of the
affection known as miliaria papulosa. In other cases the lesions are
vesicular in nature, and miliaria vesiculosa is typified. It is chiefly
the papular form to which the name of prickly heat has been applied.
This variety begins with the formation of minute elevated, acuminated,
bright-red papules, occurring usually in great numbers, more or less
crowded together; the individual lesions, however, remain discrete. The
affection may be localized, or, as is usually the case, may involve
considerable surface. In miliaria vesiculosa the lesions are in the
form of vesicles the same in size as the papules, and appear as whitish
or yellowish points surrounded with inflammatory areolæ. They are
usually crowded so closely together as to give the skin a bright-red
look (miliaria rubra). At first the vesicles are transparent and
contain a clear fluid, but as they become older they appear opaque and
yellowish-white (miliaria alba), and instead of the bright-red
appearance the eruption has then a yellowish cast. As in the {655}
papular form of the eruption, small areas may be involved or the
greater part of the entire surface. The trunk is a favorite locality.
The vesicles dry up in a few days, showing no tendency to rupture, and
terminate in slight desquamation. In the majority of cases the eruption
consists of papular, vesico-papular, and vesicular lesions
interspersed. They make their appearance suddenly, usually accompanied
with considerable sweating, and if the cause has ceased to act
terminate in the course of a few days. As a rule, the subjective
symptoms are mild in character, nothing more than slight tingling,
burning, being noted; in others, however, these may be so marked as to
give rise to considerable annoyance. Individuals who are debilitated
seem most prone to an outbreak. Hot weather predisposes to it; in fact,
excessive heat from whatever cause is apt to provoke an attack. It is
especially common in children. The affection as usually met with is
essentially an inflammatory disorder of the sweat-glands, congestion
and exudation taking place about the ducts, giving rise to papules or
vesicles, according to the intensity of the process.

It is to be distinguished from eczema and sudamen. The papules of
eczema are larger, more elevated, firmer, make their appearance more
slowly, and are of much longer duration; moreover, the itching of
papular eczema is usually marked. Vesicular eczema differs from
miliaria vesiculosa by the larger size of the lesions, their
disposition to rupture, their tendency to become confluent, and their
greater itchiness, and by the general features of the eruption both as
regards its appearance and duration. It is to be noted that miliaria
occurring in children from the conjoint effects of warm weather and
superfluous clothing may, if the exciting causes are continued, result
in eczema. Sudamen may be differentiated by the absence of inflammatory
symptoms.

The affection under favorable circumstances runs a rapid course,
disappearing in a few days or weeks. A removal of the exciting cause
will in all cases have a favorable effect. Too active treatment is to
be avoided, not only as being useless but prejudicial. Undue
perspiration should be guarded against. The patient is for the time to
avoid exercise and to be properly clad. Refrigerating diuretics, as
citrate or the acetate of potassium or simple lemon-juice diluted, may
be prescribed. When the eruption is kept up or frequently recurs as a
result of impaired health, tonics, as quinine, iron, and the mineral
acids, will be useful. In the majority of cases local treatment alone
is necessary. Dusting-powders and cooling or astringent lotions are of
most value. Starch and lycopodium powder, equal quantities or with 20
to 30 per cent. of oxide of zinc added, may be used; the surface is to
be kept freely powdered. Astringent lotions may be employed in place of
the dusting-powder, or, what is often advisable, may immediately
precede the latter, the lotion being first applied, allowed to dry on
the surface, and then the powder freely dusted over. A lotion of
alcohol and water and sponging with vinegar and water may be
prescribed.


Pompholyx.

Under this head (and also that of Dysidrosis) a rare disease of the
skin has been described, characterized by peculiar vesicles and blebs
and an excoriated state of the skin, with subsequent exfoliation of the
{656} epidermis. It consists at first of deep-seated vesicular lesions,
which resemble small boiled sago-grains implanted in the skin,
accompanied by a variable degree of inflammation. As the lesions grow
they incline to coalesce, thus forming small or large blebs showing but
little if any disposition to rupture. Sooner or later the fluid is
reabsorbed or exudes, the epidermis peeling off, usually in large
flakes or pieces, sometimes in the form of a cast of the fingers or
hand. In most cases burning sensations, tenderness, and soreness are
complained of. The disease pursues a variable course. Ordinarily, the
process lasts from two to eight weeks. Relapses as well as recurrences
of the disease may take place. It attacks by preference the hands, more
especially the palms and the sides of the fingers, from which
circumstance it was originally designated cheiro-pompholyx; but it may
invade the feet and also other regions.

The same disease has been described with the two names given, some
observers regarding it as being due to a disordered state of the sweat
apparatus, others as being an inflammatory affection. We incline to the
latter view, looking upon true dysidrosis as a form of miliaria. The
disease under consideration is without question neurotic in origin. It
occurs chiefly in those suffering from nervous debility or prostration
arising from varied causes. It is due to impaired, faulty innervation.
It is most liable to be mistaken for vesicular eczema or pemphigus. The
treatment should be general, consisting of such remedies as quinine and
arsenic, together with good food and proper hygiene. Local treatment
may be prescribed as in the case of eczema, but the result in most
cases is not as satisfactory as in that disease.


Pemphigus.

Pemphigus is an acute or chronic bullous disease, characterized by the
successive formation of variously sized and shaped blebs. Two varieties
are met with--pemphigus vulgaris and pemphigus foliaceus--the symptoms
of which differ considerably. Pemphigus vulgaris, the usual form of the
disease, appears with or without precursory symptoms. In marked cases
headache and fever may precede the cutaneous outbreak. All portions of
the body may suffer, but the extremities are more commonly the seat of
the eruption. The mucous membrane of the mouth and vagina may also be
involved. The lesions, as a rule, are rarely seen in large numbers, a
dozen or so usually being present at one time. They vary in size from a
pea to a large egg, and are generally rounded or ovalish, fully
distended, and according to the size are elevated from a few lines to
an inch above the surrounding skin. There is but little inflammation
attending their formation. In some cases the blebs arise from
erythematous spots or wheals, but generally from apparently normal
skin. The fluid is yellowish, later often becoming cloudy or puriform.
At times slight hemorrhage occurs, giving the lesions a reddish or
purplish color. Spontaneous rupture of the lesions seldom occurs, the
contents usually disappearing by absorption. Each bleb runs its course
in from two to eight days. Itching and burning are rarely prominent
symptoms, in some cases being scarcely noticeable or absent, in others
present to a marked degree, constituting pemphigus pruriginosus. In
children pemphigus vulgaris is {657} usually attended with systemic
disturbance; in adults, as a rule, only in severe cases. The disease
may be acute or chronic. Acute pemphigus is rare, and occurs, as a
rule, only in children. It usually runs a favorable course, except in
ill-nourished children, in whom it may take on a malignant type and
have a fatal termination. Chronic pemphigus may be benign or malignant.
In the benign form the eruption may persist several months by
successive outbreaks, and then disappear, or the blebs may form
irregularly and indefinitely. In the former case there may be but the
one attack, or, as commonly occurs, relapses may follow after months or
years. In the malignant form the disease is more violent, with marked
systemic depression and ulcerative action, and may frequently have an
unfavorable termination.

Pemphigus foliaceus, the other variety of the disease, is rare. The
blebs are loose and flaccid, with milky or puriform contents, rupture,
and the oozing liquid dries to crusts, which are cast off, disclosing
the reddened corium beneath. The blebs may coalesce and involve
considerable surface, and may appear in rapid succession on other
regions and on the sites of disappearing or half-ruptured lesions; even
the whole surface may become involved, the process continuing for
years, undermining the general health and eventually destroying the
patient.

Pemphigus is a rare disease, and seems to be of even less frequent
occurrence in this country than abroad. It is not contagious, nor is it
due to syphilis, the so-called syphilitic pemphigus being a bullous
syphiloderm and not a true pemphigus. General debility, overwork,
shock, and nervous prostration are influential in producing the
disease. Occasionally an hereditary tendency is traceable.

The contents of blebs are at first colorless or yellowish, consisting
of serum,--later containing blood-corpuscles, pus, fatty-acid crystals,
and epithelial cells, and occasionally uric-acid crystals and free
ammonia. The reaction is alkaline, becoming more markedly so as the
contents grow older. The lesions are superficially seated, between the
horny layer and upper part of the rete and the lengthened cells of the
rete and the corium. The papillæ and subcutaneous tissues show
round-cell infiltration and dilated blood-vessels.

Herpes iris and the bullous syphiloderm are to be excluded in the
diagnosis. In herpes iris the acute course, small lesions, variegated
colors, the usually marked areola, the decided tendency to concentric
arrangement of the lesions, the seat of the disease,--all tend to
distinguish it from pemphigus. The thick, bulky, greenish crusts of the
bullous syphilide, with the underlying ulceration, its course, and the
presence of concomitant symptoms of that disease, taken with the
history of the case, are points of difference. Impetigo contagiosa may
at times strikingly resemble pemphigus, but the history of the case,
its distribution, the contagious and auto-inoculable properties of the
contents of the lesions, and the characteristic crusting of the former
disease,--are all available in the differential diagnosis. The blebs of
pemphigus are to be distinguished also from the accidental blebs of
urticaria and of erythema multiforme. It is to be remembered also that
cases sometimes come under observation in which blebs are, for the sake
of feigning disease, produced artificially, the subjects being usually
hysterical women.

Pemphigus is in most cases a grave disease. The unfavorable {658}
symptoms are the presence of numerous bullæ, the rapid and successive
development of new lesions, flabby walls, frequent febrile attacks,
loss of strength, and marasmus. It is injudicious, even in mild cases,
to express an opinion as to the probable duration of the disease. Both
constitutional and local treatment, especially the former, are
demanded. The general health should receive careful study and faulty
conditions corrected. Good food, milk, wine, or ale, eggs and meat are
in most cases to be advised. Suitable hygienic regulations should also
receive attention. Arsenic in appropriate doses, long continued, has in
some cases almost a specific action: on the whole, it must be regarded
as our most valuable remedy. Quinine in full doses, cod-liver oil,
iron, and the mineral acids are also of service. External treatment is
of importance, and is in many cases demanded for the comfort of the
patient. The blebs are to be opened as soon as developed, and the parts
anointed with oxide-of-zinc ointment. Lotio nigra, used as in eczema,
will sometimes be found soothing, as also lotions containing liquor
carbonis detergens or liquor picis alkalinus. Dusting-powders of zinc
oxide with talc and starch are likewise useful. Baths containing bran,
starch, or gelatin sometimes afford ease. Corrosive-sublimate baths,
one or two drachms to the bath, and alkaline baths in some cases prove
of service. After the bath an application of an ointment or mild
dusting-powder may be made to advantage. Where baths prove unsuitable
or are impracticable, mild ointments may be used, such as diachylon
ointment, vaseline, cold cream, or zinc ointment, spread upon cloth and
bound down with bandages.


CLASS IV.--HYPERTROPHIES.[5]

[Footnote 5: Purpura, constituting Class III., appears in Vol. II. p.
186, as a separate article by I. E. Atkinson.]


Lentigo.

Lentigo, or freckle, is characterized by irregularly-shaped, rounded or
angular, pinhead- or pea-sized, yellowish or brownish spots of pigment
deposit, occurring for the most part upon the face and the backs of the
hands. They may appear as blemishes scarcely perceptible to the casual
observer, or to such an extent and with such intensity of color as to
be disfiguring. They may show themselves as discrete or as confluent
lesions, and in the latter event the skin presents a spotted, rusty, or
dirty appearance. As stated, the face and the backs of the hands are
usually attacked, but other regions may also be invaded. They are
encountered at all ages, but usually in young persons, especially in
those of light complexion, and more particularly in red-haired
subjects. They pursue a chronic course, lasting, as a rule, a lifetime,
being, however, in most cases much paler in winter than in summer.
Sometimes the lesions are blackish rather than brownish, and cases are
on record where such were numerous and occupying the general surface.
Blackish freckles are also met with in connection with certain rare
forms of atrophy of the skin proper complicated with telangiectases, as
in the cases reported by Hebra and {659} Kaposi, Taylor, and one of us
(Duhring), an account of which may be found under atrophy of the skin.

The affection consists of a circumscribed deposit of pigment, which in
the majority of cases is due to the influence of the sun's rays, but
there are cases in which the lesions cannot be assigned to this cause,
as, for example, where they occur upon the trunk or other regions not
exposed to light. The treatment will be referred to in connection with
chloasma.


Chloasma.

Chloasma may be described as a pigmentary affection, consisting of
variously sized and shaped, more or less defined, smooth patches of a
yellowish, brownish, or blackish color. The affection is one merely of
coloration, the structure of the skin proper being normal. The spots or
patches vary much as to size and shape. As a rule, they are irregular
in outline, and not infrequently they are angular. They vary in size
from a small coin to a hand or larger. At times the affection may
develop as a diffuse or even as a universal discoloration. The
distribution of the pigment may be uniform, but more frequently it is
mottled, giving the skin a thick, muddy, or dirty appearance. Under
idiopathic chloasma are included the forms of pigmentation due to
various external agencies, as, for example, chemicals, sinapisms, heat,
and long-continued scratching. The symptomatic group comprises uterine
chloasma and the discolorations occurring in connection with certain
general maladies, among which cancer, tuberculosis, Addison's disease,
and malaria may be mentioned. Chloasma is also met with as a symptom in
certain diseases of the skin proper, as scleroderma, morphoea, leprosy,
and syphilis.

Chloasma uterinum, the commonest form, appears in all degrees from a
duskiness or swarthiness of the complexion to pronounced patches of
mottled yellowish or brownish discoloration, occurring on the face
usually of pregnant women. But the same condition is met with also in
single women, and at times in men. In women it usually appears as a
more or less broken patch invading the forehead, extending from temple
to temple, but the nose, cheeks, and chin are likewise very frequently
attacked. It is due both to physiological and to pathological changes
in the uterus, and also to various disorders of the menstrual function.
The nervous system in many cases is without doubt at fault, and to this
cause must be assigned those cases occurring in men. It is encountered,
as a rule, between the ages of twenty-five and fifty. Its course is
variable, depending upon the cause, but, as a rule, it is persistent,
and it may continue for a long period. It is liable to be confounded
with tinea versicolor, from which, however, it may be readily
distinguished by the observation that in the latter disease the surface
of the skin is the seat of more or less furfuraceous desquamation,
which becomes more evident by scraping. In chloasma the skin is normal
in structure. The patches of tinea versicolor are usually more numerous
than those of chloasma, and occupy the trunk, a region seldom invaded
by the latter affection. The face is the common seat of chloasma, a
region practically exempt from tinea versicolor.

The treatment consists in removing the cause where this is possible, or
{660} in modifying it by such general remedies as appear indicated.
Among the various local remedies corrosive sublimate is one of the most
valuable, used in the form of a lotion with water, alcohol, or almond
emulsion. Its strength should vary from half a grain to five grains to
the ounce, according to the region, size of the spot, sensitiveness of
the skin, and the effect produced. Two or three grains to the ounce
will generally be found of sufficient strength; and this may be
applied, dabbed on lightly for five or ten minutes, twice daily, until
irritation or desquamation appears. A lotion recommended by Hardy is
the following:

  Rx. Hydrargyri chlor. corros., gr. viiss;
      Zinci sulphatis,           drachm ss;
      Plumbi acetatis,           drachm ss;
      Aquæ,                      fluidounce iv.  M.

Ammoniated mercury, from forty to eighty grains to the ounce of
ointment, may also be referred to as of positive value.

The following formula may also be given:

  Rx. Hydrargyri ammoniati, drachm j;
      Bismuthi magist.,     drachm ss;
      Ugt. aquæ rosæ,       ounce j.

M.--Sig. Apply at night.

Sulphur ointments, as of precipitated sulphur one or two drachms to the
ounce, are also at times useful. The applications may be suspended from
time to time should irritation occur. The treatment in some cases is
followed by good results, while in others it is unsatisfactory. The
discoloration, having been removed, may remain away, or, as often
happens, may recur. The treatment recommended for chloasma is that
which will be found of most service in lentigo.

       *       *       *       *       *

There are other discolorations, of a different nature, which may be
referred to here, as the staining due to the coloring matter of the
bile, and that sometimes following the internal use of nitrate of
silver, known as argyria, where the skin assumes a bluish-gray, bronze,
or blackish shade. Neumann states that reduced silver is found in all
parts of the skin except the lining epithelia of the glands and the
cells of the mucous layer of the epidermis. The deposit also occurs in
the internal organs.


Keratosis Pilaris.

Keratosis pilaris (also called lichen pilaris and pityriasis pilaris)
is an hypertrophy of the epidermis about the apertures of the
hair-follicles, forming pinhead-sized, conical epidermic elevations.
The lesions are met with usually about the extensor surfaces of the
thighs and arms, especially the former, but they may also occur on
other parts. They are whitish, grayish, or blackish in color, are
rarely larger than a pinhead, each being pierced by a hair, around
which are accumulated, in the form of strata, the horny cells of the
epidermis. In some lesions the hair is broken off at the apex,
appearing as a black central point; in others the hair is not visible,
but is found coiled or twisted up within the papules. The skin is dry,
harsh, or rough, and together with the papules may feel like a
nutmeg-grater. The skin at the base of each papule is of a normal {661}
color or slightly reddened. The elevations consist of an accumulation
of epidermic cells and sebaceous matter about the orifices of the
hair-follicles. The affection in its milder forms is not uncommon, and
is encountered usually in cold weather, and especially in those who
bathe infrequently. It may occur at any age, but is most common in
early adult life. Slight itching is occasionally present. As ordinarily
observed, it is a slight disorder, but shows a tendency to persist. It
resembles somewhat cutis anserina, the miliary papular syphiloderm in
the desquamating stage, and also lichen scrofulosus. In goose-flesh
(cutis anserina) the elevations are of a different nature, being due to
cold, heat, or nervous excitement. The papules of the syphiloderm tend
to group, are firmer, more deeply seated, less scaly, and of a reddish
color. In lichen scrofulosus the papules are more solid in character,
incline to group, are less scaly, and usually appear about the abdomen.

The disease is readily removable by treatment. Hot baths with the free
use of strong soap, as sapo viridis, will usually suffice in ordinary
cases; alkaline baths are also serviceable. In rebellious cases oily
applications, such as the petroleum preparations, lard, and glycerin,
or sulphur ointment, may be used in conjunction with the baths.


Molluscum Epitheliale.

Molluscum epitheliale, also called molluscum contagiosum and molluscum
sebaceum, is characterized by rounded, semiglobular, flattened, or
verrucous papules or tubercles of a whitish or pinkish color, varying
in size from a pinhead to a pea. As generally met with, they are the
size and shape of a small split pea; in other cases they are more
acuminated or are in the form of a very small pearl button. They have a
broad base and are seated close to the general surface. As a rule, they
are multiple, three or six or more being present in different stages of
evolution. They are unaccompanied by subjective symptoms. The skin
covering them is stretched, and they have a glistening or waxy look,
and at times resemble a drop of wax. In consistence they are usually
firm, becoming soft with age. Their summits are sometimes flattened and
umbilicated, with a central darkish point representing the mouth of the
follicle. Their usual seat is the face, especially the eyelids, cheeks,
and chin, but the neck, breast, and genitalia may also be invaded. They
grow slowly in most cases, and are unaccompanied by inflammatory
symptoms. Later, they become soft and tend to break down, with at times
ulceration.

The disease is rare in this country, and is seldom encountered in our
experience either in dispensary or in private practice. It occurs
chiefly in children, and more especially among the poorer classes. Its
cause is obscure. By some authorities it is considered to be
contagious, this view being more generally entertained in England
(where the disease seems to be more frequently encountered than
elsewhere) than in other countries. The evidence for believing it to be
contagious, however, does not seem sufficient to warrant such a
conclusion. Inoculation has failed to develop the disease. Some
observers consider that the process has its origin in the sebaceous
glands, while others--ourselves among the number--hold that it is a
disease of the rete mucosum. It is to be regarded as a {662}
hyperplasia of the rete. If the tumor be cut into, the contents may
usually be expressed in the form of a whitish or yellowish rounded mass
of a thick or thin cheesy consistence. Under the microscope it is seen
to be composed of epithelial cells with nuclei and of peculiar rounded
or ovoidal, sharply-defined, fatty-looking bodies--the so-called
molluscum bodies, which are to be viewed as a form of epithelial
degeneration. The growth probably begins in the hair-follicles, as
originally stated by Virchow and more recently confirmed by Thin.

The disease is to be distinguished from molluscum fibrosum, from
papillary warts, and from acne. Local treatment, consisting of incision
and expression of the contents, with subsequent cauterization with
nitrate of silver, is the best procedure. They may also be ligated. As
the disease tends to spontaneous cure, the remedies employed should be
simple in character.


Callositas.

Callositas (syn., tylosis, tyloma, callus) is characterized by the
formation of a hard or horny thickened patch of epidermis, variously
sized and shaped, and of a grayish, yellowish, or brownish color. The
patches are usually coin-sized, more or less rounded in shape, grayish,
yellowish, or brownish in color, somewhat elevated, and of a dense and
firm texture. They are most common about the hands and feet, and in a
measure are protective to the more sensitive corium beneath. The
ordinary surface lines are less distinct than on the surrounding
healthy skin, into which the patch gradually merges. The thickening and
elevation may be slight or excessive, and are most marked at the
centre. The process rarely gives rise to any annoyance or pain, but
when excessive the more delicate movements of the parts are restricted.
Occasionally, from accidental injury, the underlying corium becomes
inflamed, suppurates, and as a result the thickened mass is cast off.
When occurring about the joints from motion of the parts, it may,
moreover, become fissured and painful. Pressure and friction are the
main factors in the production of a callosity--on the hands from the
use of tools and implements, and on the feet from ill-fitting shoes.
But cases are seen exceptionally in which there has been no apparent
external cause; moreover, the same amount of pressure or friction in
different individuals may give rise to different degrees of callosity;
hence there must in some cases be other causes which at times enter
into its production, as, for example, altered nerve-supply. The
epidermis is the only part involved; fissuring and suppuration, it is
true, involve the deeper structures, but these conditions are
accidental and secondary. A section of a callosity shows a thickening
of the horny layer, the corium remaining normal.

Unless the callosity is excessive or gives rise to inconvenience,
treatment is rarely demanded. When advisable, the parts are to be
softened by means of hot-water applications or poultices, solutions of
caustic potash, or sapo viridis used as an ointment; after which the
callus may be removed by scraping with a dermal curette or shaving with
a sharp knife. An excellent method of treatment consists in the
continuous application for some days of a plaster of salicylic acid of
10 or 12 per cent. strength, the same to be renewed every few days; at
the end of a week or two the {663} parts should be soaked in hot water,
and the mass will readily come away. A solution of salicylic acid in
collodion of the same strength or stronger, applied frequently for five
or six days, will often act in like manner.


Clavus.

Clavus, or corn, is a small, circumscribed hypertrophy of the horny
layer of the epidermis, painful upon pressure, situated usually about
the feet. As commonly met with, it is about the size of a pea, with a
smooth and shining surface, having a hard and horny feel. Corns are
seen most frequently upon the outer surface of the little toe, but are
often met with also upon the other toes and on the soles of the feet.
Occurring between the toes, the moisture and friction of the part have
a softening effect, and as a result the corns are soft and spongy,
constituting soft corns. One, several, or more may be present. When
slightly developed they cause very little disturbance or discomfort,
but if large or irritated they may become sensitive and render walking
painful. Continued pressure and friction, as from badly-fitting shoes,
are the active factors in their production. Anatomically, a corn is a
localized epidermal hypertrophy, consisting of a horny mass,
cone-shaped, with the base externally and the apex pressing upon the
rete and corium; the cone being made up of concentrically-arranged,
closely-packed layers of epidermic cells. The corium upon which this
cone-shaped mass presses may be atrophied or hypertrophied.

The first essential in the treatment is a removal of the cause. The
feet should be properly fitted. The corn is to be softened by means of
continuous or repeated soaking in hot water or by poulticing, after
which it may be pared down or extracted. Salicylic acid, either in
solution or in the form of a plaster, 15 or 20 per cent. strength,
applied for several nights, will often give relief. A well-known and
efficient formula is the following:

  Rx. Acidi salicylici,     gr. xxx;
      Ext. cannabis Indicæ, gr. x;
      Collodii,             fluidounce ss.  M.

Sig. Paint on every night and morning. At the end of several days or a
week the part is soaked in warm water and the epidermic mass, or
greater portion of it, is readily detached. Nitrate of silver is useful
after softening of the growth has been brought about, and is also of
advantage in the treatment of soft corns. Caustic potash, thirty to
sixty grains to the ounce of water or alcohol, is also of service, but
is to be employed cautiously. Considerable relief to the soft formation
is obtained by separating the toes with a thin layer of raw cotton. A
ring of rubber, wadding or felt should be employed to prevent pressure
and friction upon a corn, and, as this removes the exciting cause,
permanent relief may follow.


Cornu Cutaneum.

Cornu cutaneum (syn., cornu humanum, horny tumor) is characterized by
the development of a true horny formation of variable size and shape,
{664} arising from the skin. The growth bears a striking similarity to
the horns of the lower animals. It is a solid, dry, harsh, somewhat
brittle formation, usually more or less tapering, conical, or rounded,
crooked or twisted, with a laminated, irregular, and fissured surface,
and of a grayish-yellow or brownish color. Horns vary as to size and
form, being a few lines or several inches in length, with a broad base,
and tapering toward the end. They may be broad and flat or elongate.
They have a flattened or concave base resting directly upon the skin,
with the underlying and surrounding tissue normal, slightly elevated,
or inflamed and undergoing epithelial degeneration. In some cases the
papillæ are much enlarged and extend up into the growth. Ordinarily,
there is present but one growth, but in some instances several or a
dozen or more have been observed in a single case. The face and scalp
are favorite regions, and to a less degree the male genitalia. As a
rule, the horns are painless, but if injured more or less pain is
usually experienced about the base. They rarely develop before middle
age, attain a certain size, and then tend to loosen and fall off,
disclosing an ulcerating base, from which a new growth is usually
reproduced. Epitheliomatous degeneration is not an uncommon sequela.

Anatomically, the growth has its origin in the deeper layers of the
stratum mucosum, either from that lying directly over the papillæ or
from that lining the follicles and glands. It is essentially an
epidermic hypertrophy, similar or closely related to warty formation. A
variable degree of papillary hypertrophy, the papillæ running up into
the base of the horn, is invariably present, and precedes, doubtless,
the horny outgrowth. The horny cells are massed together to form
columns, and in the columns themselves are concentrically arranged.
Blood-vessels also appear in the base of the growth. There can be no
difficulty in the diagnosis. In regard to prognosis the possibility of
degeneration into epithelioma is to be kept in view. If the horn
becomes detached or is knocked off, it is almost invariably reproduced.
Properly managed, horns are easily removed and permanent freedom
assured. The possibility of epitheliomatous degeneration, as well as
their unsightliness, demands active treatment. The formation is to be
detached and the base thoroughly scraped with the dermal curette, and
pyrogallic acid or arsenious acid applied, as in epithelial cancer; or
it may be cauterized with zinc chloride or caustic potash. The
galvano-cautery is also efficient, while in some cases excision may
prove the best method of treatment. If the base is properly treated, a
return of the growth rarely occurs.


Verruca.

Verruca, or wart, is a hard or soft, rounded, flat, or acuminated,
circumscribed epidermal and papillary formation. There are several
forms of warts. The most common variety, verruca vulgaris, is seen
mostly upon the hands. It is usually split-pea-sized, elevated,
circumscribed, rounded, with a broad base. At first there may be
epidermal hypertrophy, but later this in a measure disappears, and the
hypertrophic papillæ constitute the growth and are seen as minute
elevations. It is firm, hard, or horny, and the color is ordinarily the
same as the {665} surrounding skin, but at times it is darker. The
papillæ forming a wart are sometimes so irregularly developed as to
make it appear lobulated, causing a cauliflower-like form. One,
several, or great numbers may be present. Another form is verruca
plana, or flat wart, differing from the ordinary wart described above
in being flat and broad. It is usually the size of a split pea or
finger-nail; occurs most frequently upon the back, especially in
elderly people; and is usually brownish or blackish in color,
constituting verruca senilis and keratosis pigmentosa. Verruca
filiformis, a third variety, is a thread-like formation, usually about
an eighth of an inch in length, occurring singly or in groups, and
generally about the face, eyelids, and neck. Verruca digitata, another
form, is mostly observed upon the scalp, and occurs as a slightly
elevated formation, varying in size from a pea to a finger-nail, and
marked by digitations, especially noticeable about the border.

Verruca acuminata (syn., venereal wart, pointed wart, moist wart, fig
wart, pointed condyloma, cauliflower excrescence; verruca elevata)
consists of one or more groups of acuminated or irregularly-shaped
elevations, usually so closely packed together as to form a more or
less solid mass of vegetations. At times they present an appearance of
granulation tissue. In color they are usually pinkish or reddish, and
are seen mainly about the genitalia, more particularly about the glans
penis, on the inner side of the prepuce, and about the labia, and more
rarely about the arms, axillæ, umbilicus, and toes. They are dry or
moist according to the regions about which they occur and to other
circumstances. The secretion from the moist formation is yellowish and
of a puriform character, undergoing rapid decomposition and giving rise
to a penetrating and often disgusting odor. They are seen both in men
and women, especially in young people; develop rapidly, at times
attaining the size of a fist; and variously resemble the cauliflower,
cock's-comb, fungi, or raspberries.

The etiology of warts is not known. They are common to both sexes, and
are much more frequent in the young. The various causes which, in the
popular mind, are capable of producing these growths are merely
conjectural, and in most instances have no foundation in fact. The
acuminated wart is usually caused by irritating secretions.
Anatomically, a wart consists of a connective-tissue growth as a basis,
with papillary and slight epidermic hypertrophy, the interior of the
growth containing vascular loops. In the acuminated or venereal wart
there is considerable connective-tissue growth, the papillæ being
markedly enlarged, the cells of the mucous layer highly developed, and
the vascular supply abundant.

There is rarely any difficulty in the diagnosis, as the formations are
well known and their characters pronounced. Prognosis is favorable; as
a rule, the growths respond rapidly to treatment; at times, however,
they prove obstinate. When they exist in numbers it is best to remove a
part only of the whole manifestation at a time. Occasionally removal of
several will be followed by spontaneous disappearance of the others. In
some cases, indeed, after existing a shorter or longer period, they
tend to disappear without treatment.

Excision by means of the curved scissors or a knife in some cases will
be found the best method of dealing with them, their bases immediately
after the operation being touched with nitrate of silver. {666}
Caustics, such as potassa, chromic acid, nitric acid, and acetic acid,
may be employed, but strong remedies should be applied with care.
Touching the growths frequently with a 10 to 20 per cent. solution of
salicylic acid or a salicylic-acid plaster of the same strength,
constantly applied, will be found useful. Multiple flat warts may be
treated with a paste of precipitated sulphur and equal parts of acetic
acid and glycerin, prepared at the time of using. In obstinate and
relapsing cases the internal use of arsenic has been recommended.
Stimulating powders and lotions, such as calomel, burnt alum, powdered
savine, solution of chlorinated soda, and carbolic acid, may be used in
the acuminated variety.


Nævus Pigmentosus.

Nævus pigmentosus, commonly called mole, is a circumscribed pigmentary
deposit in the skin. In addition to hypertrophy of pigment there may
also be hypertrophy of one or of all of the other cutaneous structures,
especially of the hair. When the surface of the nævus is normal and
smooth it is termed nævus spilus; if there is a growth of hair upon it,
nævus pilosus; if the connective tissue is increased, forming growths
of variable dimensions, it is designated nævus lipomatodes; if the
surface is rough and warty, nævus verrucosus. Moles may be congenital
or acquired, usually the former. As ordinarily met with, they are
rounded, of the size of a coffee-grain, the color varying from a light
yellowish-brown to a chocolate or black. The trunk, neck, back and face
are favorite localities. One or more may be present, usually upon
different parts of the body, or in exceptional cases following
nerve-tracts. When once formed there is little tendency to change. They
occur with equal frequency in both sexes. Anatomically, there is found
an increase in the natural coloring-matter of the skin, and in almost
all cases variable degrees of connective-tissue hypertrophy.
Enlargement of the papillæ gives rise to nævus verrucosus, and an
increase in size and numerically of the hair-bulbs constitutes nævus
pilosus.

Treatment of a nævus consists in its removal by means of caustics or
the knife. The small and flat lesions may be removed with potassa or
the ethylate of sodium; a 1 per cent. solution of corrosive sublimate,
applied for a few hours by means of compresses, causes blistering and
usually the removal of the pigment. Excision or thorough cauterization
may be employed for nævus verrucosus and nævus lipomatodes. The
galvano-caustic has also been advocated.


Ichthyosis.

Ichthyosis, also called xeroderma and fish-skin disease, is a chronic,
hypertrophic disease, usually occupying the whole surface,
characterized by dryness or scaliness of the skin, with a variable
amount of papillary growth. There are two varieties of the
disease,--ichthyosis simplex and ichthyosis hystrix, arbitrary
divisions, however, employed to designate the milder and more severe
forms respectively.

The milder variety is that which is usually encountered. In this form
{667} the disorder may be so trifling in character as to give rise to
simple dryness or harshness of the integument,--a condition to which
the term xeroderma has been given. In others the process may be more
developed, and the scales somewhat thick, having a polygonal or
plate-like form. When the latter is the case, the form and size of the
plates are usually determined by the natural lines or furrows of the
parts. The scaling may be merely thin and bran-like or thick and horny,
resembling fish-scales. In the milder forms of this variety the color
of the scales may be light and pearly; when more or less thickly
developed, may be dark, even olive-green or blackish. This color cannot
be attributed entirely to extraneous matter, pigment-granules having
been demonstrated in the scales. The amount of scaling depends somewhat
upon the age of the patient, the severity of the disease, and also the
frequency of ablutions. If the scales are allowed to accumulate, they
may become enormously thickened. The disease is found most developed
upon the extensor surfaces of the upper and lower extremities,
especially the latter, the flexor surfaces in mild cases being free.
The scales are firmly attached, but can usually be removed without
injury to the underlying parts.

In the other variety of the disease--ichthyosis hystrix--in addition to
excessive formation of scales there is marked papillary hypertrophy, at
times the papillary outgrowths reaching several lines, bearing
resemblance to the quills of a porcupine. This resemblance has given
rise to the qualifying term hystrix. This variety of the disease is not
apt to be so generalized as the milder variety. It is not infrequently
seen to occur as one or more rounded, irregular or linear patches,
solid, corrugated, warty or spinous in character. The patches may exist
close together or widely separated or along nerve-tracts, and the other
parts of the surface may exhibit the milder variety.

Ichthyosis is usually first noticed in the early months of childhood,
from which time it becomes progressively worse until it reaches a
certain point, and then usually remains stationary throughout life. It
is common to both sexes. The scalp and face usually escape. The
condition is affected favorably by warm weather, so much so that the
milder forms of the disease disappear entirely during the summer, to
reappear as soon as the cold season begins. Even the severer forms of
the affection disappear to some extent during the warm months. This
change is due to the activity of the glands in the summer, the
secretions macerating the epidermis, rendering the removal easy and
thus relieving the patient. Unless the affection is well marked
subjective symptoms rarely exist, but slight itching is sometimes
present. In the well-developed cases, however, the scales may become so
thick and the hypertrophy so marked as to interfere with the natural
mobility of the parts, or as a result of motion fissures may occur. The
general health of patients suffering with ichthyosis is usually noted
to be good.

The causes of the disease are not clearly understood. An hereditary
tendency is frequently traceable. The affection is to be looked upon
more in the light of a deformity than as a disease. Although it does
not manifest itself, as a rule, until the end of the first or second
year, it is nevertheless to be considered, in most instances at least,
as born with the individual. The disease is so slight in the beginning
that in view of the repeated ablutions that infants are subjected to it
might {668} exist slightly in the first months of life without being
noted. Race and climate have been stated as important factors in its
production. It will be found, however, that where it exists in any
great proportion, as in Paraguay and in the Moluccas, for various
reasons intermarrying among the natives is the practice, and it is
unquestionably a natural consequence that a distinctly hereditary
disease should become frequent under such conditions. In this country
the disease in its marked form is comparatively rare.

Anatomically, a constant feature of the disease is epidermic
hypertrophy. This may be slight or marked according to the severity of
the process. There is usually also considerable hypertrophy of the
papillæ. In some cases, in addition to these conditions the rete may
found hypertrophied, the blood-vessels dilated, the hair-follicles and
the sweat and sebaceous glands more or less involved. The features of
the disease--the harsh, dry skin, the hypertrophy of the epidermis and
papillæ, the furfuraceous or plate-like scaliness, the greater
development of the affection upon the extensor surfaces, and the
history--are so characteristic that a diagnosis is a matter of no
difficulty. From psoriasis, scaly eczema, and the other inflammatory
scaly disorders it may be distinguished by the absence of inflammation.

The prognosis of the affection, as already intimated, is unfavorable as
regards its cure. In only a few cases has a cure been noted. Hebra
reports two such cases, the disappearance of the affection having
followed an attack of one of the exanthematous fevers. Internal
treatment is very rarely, if at all, of any benefit. Some good has been
stated to follow the administration of linseed oil. In a few cases
under observation jaborandi in moderate doses has temporarily
influenced the disease favorably, probably by increasing the action of
the sweat-glands. Although the prospect of a cure is entirely
unfavorable, the affection may be, in almost all cases, kept in
abeyance by external measures. Oily applications, soaps, and frequent
bathing are the measures to be advised. In mild cases simple baths,
frequently repeated, will suffice. In others it may be necessary to
make the bath alkaline by the addition of bicarbonate of sodium, three
to six ounces to the bath: the patient should soak in the bath for
thirty minutes or longer. Where the alkaline baths seem unsuitable or
fail to benefit sufficiently, the hot bath and washing with sapo
viridis may be employed. The vapor bath is particularly serviceable in
these cases. Rubbing in some mild ointment, allowing it to remain a few
hours or longer, and then following it with a hot bath and green-soap
washing, subsequently rinsing with simple warm or hot water, and then
again anointing the surface with the ointment, will be found valuable
in the more severe cases. An ointment such as the following may be
employed for this purpose:

  Rx. Adipis benz.,  ounce j;
      Glycerinæ,     drachm j;
      Ugt. petrolei, ounce j.

M. Ft. ugt.--Apply after bathing.

Or,

  Rx. Potassii iodidi,  scruple j;
      Glycerinæ,        drachm j;
      Adipis benz.,
      Ol. bubuli,   aa. ounce ss.

M. Ft. ugt.--Apply once daily.

Or any simple oil or salve may be substituted. In the more severe cases
{669} of the hystrix variety, in addition to the measures already
described, it may be necessary to employ caustics, or even the knife,
for the removal of the horny patches which form. For localized patches
a 10 to 20 per cent. salicylic-acid plaster will be found useful. For
the general scaliness the same drug in ointment form, 5 to 10 per
cent., will prove of benefit.


Onychauxis.

Onychauxis (syn., onychogryphosis, hypertrophy of the nail) is seen as
an idiopathic affection and also as a consequence or accompaniment of
other diseases. The hypertrophy may consist in excessive length, width,
thickness, or all combined. In addition to the increase in size, the
nails may be abnormal as regards their shape, being twisted, conical or
curved, their surface roughened, uneven or furrowed, and may also be
attended with changes in color and consistence. If the hypertrophy
increases the width to any marked extent, the parts encroached upon
become irritated and inflamed, resulting in paronychia. At times the
matrix may be the seat of inflammation, giving rise to structural
changes in the nail-substance,--onychia. One, several, or all the
nails, both of the fingers and toes, more frequently the latter, may be
involved. Hypertrophy of the nail is met with in eczema, psoriasis,
ichthyosis, leprosy and syphilis, and also as a result of the invasion
of the vegetable parasites of tinea trichophytina and favus. The rare
diseases lichen ruber and pityriasis rubra may also involve the nails.
In syphilis infiltration of the matrix gives rise to the changes in the
nail-substance. The nails in eczema and psoriasis are thickened and
brittle, with an uneven surface. In some cases, especially those due to
the vegetable parasites (onychomycosis) softening occurs.

Treatment depends upon the cause. Both constitutional and local means
are in most cases employed. The nail should be softened and trimmed by
means of the scissors or knife. Inflammation of the surrounding tissues
is to be combated by the ordinary methods, and all sources of
irritation avoided. Ingrowing nails should be cut transversely and not
rounded, and the soft parts may be relieved of pressure and irritation
by placing a piece of lint or cotton between the nail and skin-fold. In
hypertrophy due to syphilis, psoriasis, and like diseases appropriate
constitutional treatment is essential. In onychomycosis the
parasiticides are to be applied.


Hypertrichosis.

Hypertrichosis (hirsuties), or hypertrophy of the hair, is a term
applied to unnatural growth of hair, either as regards region, extent,
age, or sex. It may be slight or excessive; thus, it may be universal,
as in the so-called hairy people (homines pilosi), or limited, as upon
a wart or nævus (nævus pilosus). The hairs themselves may be fine,
coarse or of the average thickness. The hair of the scalp, eyebrows,
axillæ, pubes, and beard in men may show excessive development either
in thickness or length. Increased activity of hair-growth may take
place in the fine downy hairs present {670} over the greater portion of
the surface. It may occur in the very young--in fact, may be
congenital--and the growth may also appear on the face, arms, and other
parts of females, resulting, of course, from a hypertrophy of the
natural lanugo hairs.

It is difficult to give any definite or satisfactory explanation of the
causes which give rise to unnatural growth of the hair. It is seen more
frequently in persons of dark complexion, and may be congenital or
acquired; if the latter, the tendency to excessive development
manifesting itself, as a rule, toward middle life. It is frequently
associated in women with other masculine peculiarities, appearing
especially at the climacteric period, and also noted in connection with
the diseases of the uterus and ovaries. It is sometimes seen in sterile
women, also on the faces of insane women. Local stimulation or
irritation will at times have a curative influence.

For general hirsuties there is no remedy. Hairy nævi, if small, may be
treated by excision, or, if large, the hairs may be removed by
electrolysis, as described below. The excessive growth seen about the
faces of women is an annoying disfigurement, and such patients will
submit to almost any treatment with the hope of relief. Extraction of
hairs and shaving are frequently employed, but give only temporary
relief. The method of removal by electrolysis is the only plan which
promises permanent success. A fine needle in a suitable handle is
attached to the negative pole of a galvanic battery, introduced into
the hair-follicle alongside of the hair to the depth of the papilla,
and the circuit made by the patient touching the sponge electrode
attached to the positive pole. At the point of insertion the parts
become blanched, and frothing appears at the aperture of the follicle,
a result of the decomposition of the tissues at the point of the
needle. The action should be continued for several seconds or longer,
and then the circuit broken by the patient removing the hand from the
sponge electrode, after which the needle is to be withdrawn. If the
papilla has been destroyed, the hair may be readily extracted by the
forceps with very little traction. In most cases, after the needle is
withdrawn, or at times even before this, a wheal-like elevation appears
at the point of insertion. In some cases the follicles may suppurate.
Scarring, which is liable to take place, is to be guarded against. It
occurs more markedly in some subjects than in others. Noticeable
scarring, however, may generally be prevented if the operator is
skilful. The operation is somewhat painful, the amount of pain varying
with different persons, in some being slight, while in others it is
severe. A current from four to twelve cells of a freshly-charged
battery usually suffices.

Removal of hairs by the use of depilatories is considerably practised,
but, as they are caustic in their nature, they should be employed with
care. If prescribed, one made up of two drachms of barium sulphide and
three drachms each of oxide of zinc and starch may be recommended.
Enough water is added to the powder to make a paste, which is thinly
laid on the parts for ten or fifteen minutes. Heat of skin or a burning
sensation soon occurs, upon the advent of which the paste is
immediately to be scraped off, the parts thoroughly cleansed, and a
mild ointment applied. As with extraction and shaving, this method is
only temporary in its effects.


{671} Sclerema Neonatorum.

Sclerema neonatorum, or sclerema of the new-born, is a disease of
infancy manifesting itself usually at birth, characterized by a diffuse
stiffness, rigidity or hardness of the integument, accompanied by
coldness, oedema, discoloration, lividity, and general circulatory
disturbance. Frequently it is congenital. It usually begins on the
lower extremities, extending upward and invading the trunk, arms, and
face. The skin is reddish, purplish or brownish, glossy, and tense or
stretched, causing more or less rigidity and stiffness. The surface is
usually cold, and upon pressure oedema, together with an infiltrated
state of the tissues, is noted. When the disease is general the body
bears resemblance to a half-frozen corpse. The child is unable to move,
respires feebly, and usually perishes in a few days. The disease is
very rare. It is in most cases found associated with pneumonia or with
affections of the circulatory apparatus. The causes are obscure. After
death the condition of the skin undergoes but little change, the
induration remaining; on incision a considerable quantity of serous
fluid is poured out, when the tissues become softer and resemble
ordinary oedematous tissue. The treatment should consist of warm
applications, frictions, and like measures. The prognosis is
unfavorable.


Scleroderma.

Scleroderma, known also as sclerema and scleriasis, is an acute or
chronic disease, characterized by a diffuse, more or less pigmented,
rigid, stiffened or hardened, hide-bound condition of the skin. It was
first described by Alibert with the name sclérèmie des adultes, since
which time many cases have been recorded. The first symptoms consist of
more or less rigidity or induration of the integument, which may
increase rapidly, or, as is usually the case, slowly, until the region
affected becomes hard and bound down to the tissues beneath. In some
cases febrile symptoms, oedema, and pigmentation precede the
induration, but usually the process asserts itself insidiously, the
first symptom noted by the patient being the sclerosis. In marked cases
the skin is rigid, tight, or immovable, and is firm or positively hard
to the touch, as though frozen, but without the sensation of cold. In
some cases it may seem wooden or as though undergoing petrifaction. It
is hide-bound, and cannot be made to glide over the structures beneath,
nor can it be taken up between the fingers. The skin, owing to the
immobility, becomes set or fixed, the natural lines and wrinkles
disappearing, causing persons to look younger. The induration is
diffuse, being neither circumscribed nor defined, and generally
occupies a considerable area, the face, neck, back, chest, and upper
extremities being the regions most frequently involved. It may occupy
variously sized and shaped areas, for the most part irregular in
outline, or it may appear in the form of narrow or broad bands or
elongated patches, which usually become more or less shrunken and
sunken atrophic lesions.

The surface of the integument in scleroderma is usually on a level with
the neighboring healthy skin, except in the later stages where atrophy
has occurred, and is generally smooth and shining. Pigmentation is in
{672} most cases a marked symptom, being yellowish or brownish, in the
form of patches, giving a dirty, chloasmic appearance to the part.
Subjective symptoms are usually wanting, although there may be numbness
or cramp-like pains, especially when the limbs are the seat of the
disease. The skin in all cases feels contracted, tightly stretched or
too short. The disease may be limited, as is generally the case, or it
may occupy the greater portion, or even the whole, of the body. It is
usually symmetrical. It pursues a variable course, at times acute, but
more frequently chronic, extending over a period of years or throughout
life. Sooner or later resolution and recovery set in, or atrophic
changes take place, characterized by a wasting or a condensation of the
integument and of the subjacent tissues, causing contraction and
deformity, which are especially marked when occurring about joints. As
a rule, the general health remains good. The disease in some cases is
accompanied by patches of morphoea, which affection is regarded by some
authors as being merely a circumscribed variety of scleroderma.

The causes are obscure. The disease is rare, and is encountered oftener
in women than in men, and occurs usually in early adult or middle life.
Sudden changes of temperature, exposure to wet or cold, and violent
impressions on the nervous system have been cited as causes. The
anatomy of the disease has been studied by various observers, but with
different results, in the majority of cases slight structural changes
only having been found. Both the true skin and the subcutaneous
connective tissue are the seat of the process, showing a marked
increase of the connective tissue, with thickening and condensation of
the fibres. The disease may be viewed as a tropho-neurosis. The
diagnosis, as a rule, presents no difficulty. From morphoea, to which
it is closely allied, it may be distinguished by its tendency to
involve large areas, occupying sometimes the greater portion or the
whole of the integument, whereas morphoea usually appears in smaller
lesions. Scleroderma manifests itself diffusely and without lines of
demarcation; morphoea is circumscribed, and in its early stage is
surrounded by a pinkish border. Scleroderma is always characterized by
stiffness or hardness, whereas morphoea is usually soft or firm. In
scleroderma the skin is merely rigid or hard in the beginning, whereas
in morphoea there is hyperæmia and only slight induration.

Concerning the treatment of this disease there is but little to be
said. Constitutional remedies, such as arsenic, quinine, and cod-liver
oil, together with the employment of stimulating oily or fatty
applications, frictions, and electricity are indicated, though it is
difficult to state their intrinsic value. The course and termination of
the disease varies. In some cases spontaneous involution sets in sooner
or later, while in other instances the process continues to progress,
and lasts throughout life.


Morphoea.

Morphoea, formerly known as keloid of Addison, is characterized by one
or more rounded, ovalish or elongate, coin-sized patches, which, as a
rule, are circumscribed and clearly defined. At first they are
hyperæmic and pinkish, becoming as the process advances pale yellowish
or whitish, {673} with a faint pinkish or lilac border made up of very
minute injected capillaries. The patch may be slightly elevated or
puffed in the beginning, but later is on a level with the surrounding
skin, or even somewhat depressed. When typically developed it is either
soft or firm to the touch, or, more rarely, leathery or brawny. The
surface is usually smooth, and may be shining and have an atrophic
appearance. Not infrequently it resembles in color and in look a piece
of cut bacon or ivory laid in the skin. Around the patch there is
usually, in addition to the hyperæmic border, more or less diffuse,
mottled yellowish or brownish pigmentation. The disease exhibits no
disposition to symmetry, but not infrequently it manifests itself over
nerve-tracts. The regions commonly invaded are the face, neck, chest,
mammæ, back, abdomen, arms, and thighs. The lesions pursue a variable
though usually chronic course, lasting, as a rule, years. There is
always a marked tendency to varied atrophic changes, which in most
cases appear early, the skin becoming thin, shrivelled, or
parchment-like, later being bound down to the tissues beneath, forming
cicatriform, keloidal lesions, which may cause contraction and
deformity, with, in some cases, wasting and general atrophy, more
particularly of the extremities.

In addition to the usual characteristic circumscribed patches
described, there may exist distinctly atrophic lesions consisting of
small pit-like depressions resembling scars; also, reddish or bluish,
tortuous, short or long, large and minute, dilated, superficial
cutaneous blood-vessels and telangiectases, together with smooth,
glazed, whitish, slightly-depressed spots or grooved streaks--true
maculæ et striæ atrophicæ. Accompanying these various lesions there is
usually considerable diffuse or patchy yellowish or brownish
pigmentation. The process in some cases is simple as regards the
lesions, but not infrequently it is complex, being characterized, as
indicated, by a variety of lesions in different stages of evolution.
The course is chronic, extending in the majority of cases over years.
The disease in some cases eventually tends to spontaneous recovery; and
this is all the more remarkable considering that atrophy has existed.
The disease is met with more frequently in females than in males.
Impaired nerve-power is without doubt the important factor in its
production. Concerning the relation of morphoea to scleroderma, it may
be said that these affections are closely allied, and that they may
occur together. The pathological anatomy of the characteristic patches
varies with the stage of the disease. In the early stages there is
shrinkage or atrophy of the papillary layer, with condensation of the
connective tissue of the corium. Crocker further noted marked
cell-infiltration around the sebaceous glands, hair-follicles, and
vessels, and in the later stages the transformation of these cells into
fibrillar tissue, its contraction, and the consequent obliteration of
blood-vessels, with atrophy of the sebaceous and sweat glands.

Morphoea is to be distinguished from scleroderma, from vitiligo, and
from the anæsthetic patches of leprosy. In appearance morphoea and
leprosy possess features in common, and it is probable that they are
both due to the same cause--namely, perverted innervation. As a rule,
no difficulty will arise in the diagnosis, for the reason that in
leprosy other symptoms of that disease will almost invariably be
present.

To be viewed as a variety or form of morphoea, we may mention {674}
hemi-atrophia facialis, or unilateral atrophy of the face, which
affection consists of a variable degree of atrophy of the skin and
deeper structures, the cutaneous lesions being the same as those in
morphoea. The neurotic origin of the disease in this case is plain.

A general tonic treatment, with the long-continued use of such remedies
as arsenic, quinine, cod-liver oil, iodide of potassium, and
electricity, is called for, most reliance being placed upon arsenic.
Good results sometimes follow its administration. The prognosis should
always be guarded.


Elephantiasis.

Elephantiasis, or elephantiasis arabum (also called pachydermia,
Barbadoes leg, elephant leg), is a chronic hypertrophic disease of the
skin and subcutaneous tissue, characterized by enlargement and
deformity of the part affected, accompanied by lymphangitis, swelling,
oedema, thickening, induration, pigmentation, and more or less
papillary growth. The legs and genitalia, especially the former, are
favorite localities for its development; about the latter, the penis,
scrotum, and clitoris are most frequently involved. It begins with an
inflammation of the parts, erysipelatous in character, attended with
febrile disturbance, swelling, pain, heat, redness, and lymphangitis.
The inflammation may have its starting-point in a local lesion, as a
wound or scar, or, as is usually the case, manifests itself without any
apparent cause. Similar attacks occur more or less frequently, after
each of which the part remains increased in size. After a year or
longer, during which time repeated attacks may have taken place,
considerable increase in size is noted: the part is swollen,
oedematous, and hard, and the skin hypertrophied, fissured, pigmented,
and the papillæ enlarged and prominent. Later, the hypertrophy becomes
still more marked; the part is often enormously enlarged and swollen,
the skin rough, fissured, and warty. In Eastern countries the disease
assumes huge proportions. Eczematous inflammation may coexist and
complicate the appearance. The fissures may be slight or large and
deep, the normal lines and folds of the surface exaggerated, with more
or less maceration of the epidermis taking place, especially about the
folds. Ulcers sooner or later tend to form, developing usually from
varicose veins, while scales and crusts may also be present. Pain
varies, being usually marked during the inflammatory attacks.

Elephantiasis is met with in all parts of the world, but much more
frequently in tropical climates, especially about the West Coast of
Africa, Brazil, the West Indies, and particularly India, and to less
extent in Mediterranean regions and Arabia. In our own country, and
also in Europe, it is not common. It rarely occurs before puberty.
Heredity has no influence, nor is it contagious. It is commonly
observed among the poor and neglected.

The immediate cause of the disease is to be found in inflammation and
obstruction of the lymphatics. This obstruction is, according to late
investigations, probably due to the presence in the lymphatic vessels
of the parasite filaria and its ova. The filaria--a microscopic
thread-worm--has been found in large numbers adhering to the walls of
the lymphatics and blood-vessels, but is discoverable only during
certain hours {675} of the day. The parasite has also been found in
lymph-scrotum, a disease closely related to, if not identical with,
elephantiasis.

The great mass of the growth in the disease is made up of hypertrophic
connective tissue and connective-tissue new growth. All parts of the
skin and the subcutaneous tissues share in the hypertrophy. Papillary
enlargement is usually a marked feature. The lymphatic glands are
swollen and enlarged and the lymphatic vessels prominent. There is
marked oedematous infiltration, lymphatic in character. As a result of
pressure, the glandular structures of the skin are atrophied or
destroyed, the fat atrophied, and the muscles degenerated. The walls of
the blood-vessels are thickened.

In well-developed cases of elephantiasis the symptoms are so
characteristic that the disease is readily recognized. Recurrent
attacks of erysipelatous inflammation of the leg or genitalia will
point, with probability, to a development of the disease, even before
marked hypertrophy or the clinical features are developed. As regards
the outcome of the disease, if the case comes under treatment in the
early months of its development the process may be checked or held in
abeyance; later, after the affection has become well established, but
little more than palliation can be effected.

The inflammatory attacks are to be treated with rest in bed, hot or
cold applications, lead-water, and similar measures. Quinine and iron
internally, especially the former, are of value. Potassium iodide has
also been well spoken of. Climatic change, especially in the early
stages, may prove of marked advantage. After the acute symptoms of the
erysipelatous attacks have subsided inunctions of iodine or mercurial
ointments may be employed to soften the skin and promote absorption.
The parts should also be firmly bandaged, either the roller bandage,
or, preferably, one of rubber, being used. Instrumental compression and
ligation of the main artery of the limb have been employed, at times,
with diminution in the size of the part; also excision of a portion of
the sciatic nerve was practised in a single case by Morton with
reduction in the size of the limb, but these methods of treatment are
not to be recommended. Lately, the use of the strong, constant current
has been extolled as having a beneficial effect. Elephantiasis
involving the genitalia is, if the disease is well advanced, to be
treated by the knife, amputation of the parts being practised.


Dermatolysis.

Dermatolysis consists of a more or less circumscribed hypertrophy of
the cutaneous and subcutaneous structures, characterized by softness
and looseness of the skin and a tendency to hang dependently. It may be
slight or extensive, and may be limited to a certain region or show
itself simultaneously in several different parts. The integument is
thickened, bulky, superabundant, and to a greater or less extent hangs
down in folds. The hypertrophy is general over the area affected; the
glandular structures, connective tissue, muscular fibres, pigment, and
the subcutaneous areolar tissue share in the process. The surface is
usually soft and pliable to the touch, but is uneven, in consequence of
the hypertrophy of the follicles and {676} the natural folds and rugæ.
As a result of the increase in pigment the skin is more or less
brownish in color. The tissues may develop to an enormous size, and the
redundant parts may hang down in several folds, overlapping one another
and forming a cloak to the parts below.

Dermatolysis may be congenital or may not develop until after puberty.
It is a simple hypertrophy involving the integument and all its
component parts, especially the subcutaneous connective tissue. The
causes which bring about this condition are not known. It appears to be
closely allied to molluscum fibrosum, the two diseases sometimes
occurring together. It is not malignant, but its presence impedes
locomotion and its weight is a discomfort.

The affection is classified under the head of elephantiasis by German
writers, but the clinical features and course of the two diseases are
entirely different. Elephantiasis telangiectodes is a term that has
been given to a form of simple hypertrophy of the skin in which a
marked new growth of vascular tissue takes place. In connection with
this disease mention may be made of the condition characterizing the
so-called rubber or elastic-skin man. In this condition there is no
hypertrophy. The mobility and elasticity of the skin are probably due
to a peculiar and abnormal looseness of the subcutaneous areolar
tissue. It is to be looked upon as a congenital deformity. The
treatment of dermatolysis is by excision when this operation is
practicable.


CLASS V.--ATROPHIES.


Albinismus.

Albinismus is a term employed to designate that condition in which
there is congenital absence of the normal pigment. It may be localized
(albinismus partialis) or general (albinismus universalis). Persons in
whom it is universal are called albinos. They are characterized by more
or less complete absence of pigment in the skin, hair, iris, and
choroid. The skin is milky-white, with, usually, a pinkish tint; the
hair is white or yellowish, fine, thin, soft, and silky. The eyes are
sensitive to light, the pupils appear red and contract and dilate
continuously; oscillation of the eyeballs is noted, and also rapid and
constant winking. These individuals are usually physically and mentally
deficient, with a tendency to pulmonary disease.

Partial albinismus is seen more frequently in the negro. There may be
one or more whitish or pinkish-white patches, variable as to size and
shape, occurring upon any region. The skin is normal with the exception
of loss of pigment. The hairs existing upon the spots are blanched. The
eyes show no loss of pigment. The negroes in whom the patches occur are
termed pied, or piebald. In exceptional instances a redeposit of
pigment has been observed. Albinismus is not confined to any race or
climate, and is comparatively rare. Its causes are not known. It is
frequently inherited.


{677} Vitiligo.

Vitiligo (known also as acquired leucoderma or leucopathia) is a
disease consisting of one or more usually sharply-defined, rounded or
irregularly-shaped, variously-sized and distributed, smooth, whitish
spots, whose borders usually show an increase in the normal amount of
pigmentation. The patches may appear on any region, the backs of the
hands and the trunk being favorite localities. The disease begins by
the appearance of small pale spots, which gradually increase in size,
new patches showing themselves from time to time. They are well defined
in outline, the pale milky whiteness of the patches contrasting
markedly with the surrounding pigmented skin. The increased
pigmentation of the borders is almost an invariable accompaniment of
the disease, and may be slight or excessive, gradually becoming less
intense as the healthy skin is approached. The patches are smooth, on a
level with the surrounding skin, rounded, ovalish, or irregular. They
may be small or large, depending upon their age and also upon the
rapidity of their growth. If several coalesce, as is frequently the
case, large irregular patches are formed. The secretion of the sweat
and sebaceous glands and the sensibility of the skin are not disturbed.
With the exception of the loss of color the skin is normal. Hairs
included in the patches may or may not be whitened. There are no
subjective symptoms.

As a rule, the progress of the disease is slow, years frequently
elapsing before the patches attain a large area. In some instances,
after reaching a certain size, they remain stationary, either for a
time or permanently. In most cases, however, the disease is
progressive. In rare instances the skin has been known to become normal
again. The sole annoyance the disease occasions is the disfigurement,
and this is often striking. The spots are but little, if at all,
affected by the sun, except that they are rendered more conspicuous by
the bronzing of the normal skin which its rays cause. As a rule, the
affection first shows itself in early adult life, although it may
appear earlier or later. Both sexes, whether of a light or dark
complexion, are attacked. The general health is usually good. It is
attributed to a disturbance of innervation. Alopecia areata and
morphoea have been seen in association with it.

Anatomically, it consists of both an atrophy and a hypertrophy of the
normal pigment of the skin, the pale patch resulting from the former,
and the pigmented border from the latter. There is no textural change
in the skin. It may be mistaken for chloasma, tinea versicolor, and
morphoea. In the former diseases, when several patches are close
together, the normal skin between appears, in comparison, pale, and if
cursorily examined might be mistaken for the pale patches of vitiligo,
while the surrounding yellowish patches of tinea versicolor or chloasma
may appear as the pigmented borders. In tinea versicolor the patches
are slightly scaly. In morphoea there is always structural change.

Treatment in most cases is unsatisfactory. The functions and the state
of the general health must receive attention. In some cases arsenic
long continued proves of benefit. It is the only known remedy of any
value. The disfigurement produced by the patches can in a measure be
removed. For this purpose the darkened border should receive
appropriate applications, such as are used in the removal of patches of
chloasma. The white {678} spots sometimes may be made darker by the
application of cantharides, promoting capillary congestion.


Canities.

Canities is a term applied to grayness or blanching of the hair. Loss
of pigment in the hair may be partial or general. It may occur early in
life or, as is commonly the case, as the result of old age. The change
in color may take place throughout the entire hair or in parts. The
color varies from slight blanching to white. It is usually grayish. In
rare instances the color is to a moderate degree regained in summer.
Grayness of the hair in the young--canities præmatura--is exceptional;
in the old--canities senilis--it is constant, individuals differing
considerably, however, as to the time of life at which the change
begins. After the hair has become gray it rarely recovers its coloring
matter, although occasionally in the young, after the lapse of years,
the hair may again become dark. In those of a dark complexion the loss
of pigment occurs, as a rule, much earlier than in those whose hair is
of the lighter shades. Usually considerable time is required in the
complete change to gray or white, but authentic cases are on record in
which the change has taken place in the course of a night or within a
few days. The pathology is obscure.

Canities, as may be readily inferred, depends upon a deficient
production of pigment. The causes which gives rise to this deficiency
are not understood. Hereditary influence is often noticeable.
Conditions which impair the general nutrition, such as chlorosis,
anæmia, fevers, etc., and those that hinder the local nutrition, as
seborrhoea and inflammatory diseases of the parts, may possibly have
some influence. In sudden blanching of the hair fright, intense
anxiety, and the like are the usual causes. Treatment, whether internal
or external, has no effect in preventing the loss of pigment or in
restoring it. Dyeing, however, may be practised, and the condition
masked; but it is not to be recommended, as the skin of the scalp
becomes discolored and the nutrition of the hair interfered with.


Alopecia.

Alopecia consists of partial or complete deficiency of hair,
irrespective of cause. There are several varieties, named according to
the causes which have produced the affection. Thus, congenital alopecia
consists of a partial or complete absence of hair, either over the
entire surface or confined to a portion. In some instances there is
scantiness or irregular development. In rare cases there is complete
absence of the hair, microscopical examination failing to show the
existence of hair-bulbs. In cases of congenital deficiency there
usually exists an hereditary predisposition.

Senile alopecia and senile calvities are terms applied to the baldness
of advanced years. With the loss of hair there is usually atrophy of
the other cutaneous structures. In these cases the hairs, as a rule,
first turn gray, become dry and thin, and fall out, with no tendency to
a new growth. The condition is seen upon the scalp, beginning usually
at the crown; in {679} occasional instances other parts of the body may
also sooner or later show more or less atrophy of the hairy appendage.
Upon the scalp, the skin, which is more or less free of the hair,
becomes atrophied, smooth and glossy. The alterations in the cutaneous
structures in senile baldness consist of marked atrophy of the
sebaceous glands, of the hair-follicles and of the skin itself. The
affection is common in men, but is comparatively infrequent in women.
No satisfactory reason can be assigned for this. Idiopathic premature
alopecia is the term applied to the baldness which begins to manifest
itself about the age of twenty-five or thirty. The hairs may fall out
rapidly or the loss may take place slowly. In these cases the normal
hairs are usually replaced with finer, thinner, and shorter hairs, but
finally even these eventually cease to be reproduced, and more or less
alopecia results. There is no seborrhoea, and the skin shows no other
atrophic change. As a rule, several years elapse before the condition
becomes marked. The location affected is the same as in senile
alopecia, and the same statement may be made as to its frequency in the
two sexes. According to microscopical examination, there is an increase
in the connective tissue, compressing the blood-vessels, and thus
interfering with the blood-supply of the parts.

Symptomatic premature alopecia includes all those forms of alopecia
which are the result of disease, either local or general. Falling of
the hair is frequent after fevers and other systemic diseases. Mental
anxiety, nervous exhaustion, and depraved conditions of the general
health may also cause varying degrees of alopecia. In these cases the
shedding of the hair usually takes place rapidly, constituting
defluvium capillorum. With a disappearance of the exciting cause there
is usually a regrowth, but this is not always the case, as not
infrequently the baldness is permanent. Among local diseases which give
rise to baldness, chronic seborrhoea is the most important. As a result
of the seborrhoea, atrophy of the glands occurs, and alopecia sooner or
later sets in. Many other local affections, as lupus erythematosus,
erysipelas, variola, tinea tonsurans, and tinea favosa, are at times
attended with loss of hair. Syphilitic alopecia may occur at two
different periods of that disease. It is noted as one of the early
symptoms, and later as the result of the general cachexia, or in
localized patches as the result of ulceration and destruction of the
skin. The alopecia appearing as a secondary symptom of the disease may
be slight or complete baldness may take place, but in either case the
loss is rarely permanent if the patient is under proper treatment. As a
rule, in the course of a few months the hair is reproduced. The
alopecia resulting from ulcerative lesions is permanent.

The treatment of the various varieties of alopecia named depends, as
will be readily inferred, upon the etiological causes. Senile alopecia
is rarely amenable to treatment. Idiopathic premature alopecia may
frequently be benefited by therapeutic measures. The general health is
to be looked after. In these cases arsenic in moderate doses long
continued may prove of some value. The external treatment has in view
the promotion of the nutrition of the skin, which is attained by the
use of stimulating applications for the purpose of increasing the
vascular supply. The treatment of symptomatic premature alopecia is
that of the primary disease. The external remedies and formulæ which
are employed in cases {680} of alopecia for their stimulating effects
will be found in detail under the head of alopecia areata.


Alopecia Areata.

Alopecia areata (syn. area celsi, alopecia circumscripta, porrigo
decalvans, tinea decalvans) is an atrophic disease of the hairy system,
characterized by the more or less sudden appearance of one or more
circumscribed, variously sized and shaped, whitish bald patches. The
scalp is the region most frequently the seat of the disease, but other
hairy parts, especially the face in the male, are often invaded, and
even the whole surface may be involved. Occurring upon the scalp, one
or several patches may be present, which are usually rounded and
circumscribed. The hair may fall out suddenly without any previous
signs of weakening, the individual awaking in the morning to discover
an area of partial or complete baldness on the scalp; or, as is usually
the case, the loss of hair takes place insidiously or more gradually,
several days or weeks elapsing before the bald patch is of sufficient
size to attract observation. The parietal region is perhaps most
frequently involved. In most cases but a single patch appears at first,
but this usually is followed by others. The areas incline to grow
larger and larger, and, as a rule, finally coalesce, eventually the
whole scalp, with possibly the exception of a tuft or patch here and
there, being bald. In most cases, however, the patches, after reaching
a certain size, remain stationary.

The skin of the affected areas has a smooth, whitish, polished,
atrophied appearance, and is usually entirely devoid of hair or with a
few straggling long or short hairs scattered over it. The orifices of
the follicles become less appreciable, and the skin is thin, and
resembles that seen in the baldness of advanced years. The hairs
surrounding the affected area are usually found to be firmly seated in
their follicles, but if the patch has not ceased enlarging they may be
loose and readily extracted. In some cases about the border are noted a
few short atrophied hairs, resembling the short, broken-off hairs of
tinea tonsurans. At first the skin may be slightly puffed, but usually
it is on a level with the surrounding parts; later, it may be somewhat
depressed, as though atrophied. It is neither scaly nor inflamed.
Slight anæsthesia may be present. There are, as a rule, no subjective
symptoms. Involving the regions of the moustache and eyebrows, the
clinical phenomena are essentially the same as when affecting the
scalp. In those cases in which universal loss of hair results, the
process usually begins in the same way, first appearing as well-marked
areas, which rapidly increase in size; new patches are added,
coalescence results, and eventually the entire surface is involved.
After the disease has come to a standstill it may so remain
indefinitely, or lanugo hairs may appear from time to time, reach an
inch or a fraction thereof in length, may become slightly darkened, and
then fall out. Finally, in favorable cases, instead of falling out,
their growth continues; they become dark, and recovery takes place. In
these latter cases the disease may have existed several months before
signs of a permanent regrowth show themselves; on the other hand,
several years may have elapsed.

The disease is met with in both sexes, in children and adults, and
among {681} the wealthy and the poor. It is not a rare disease, nor is
it common. Impaired nutrition as the result of functional
nerve-disturbance is probably the important etiological factor, leading
to the view that the affection is a trophoneurosis. It is often seen to
follow neuralgias, nervous shock, and debility. Morphoea and vitiligo,
both diseases of a neurotic character, are occasionally seen in
association with it. In the greater number of cases no appreciable
cause is discoverable. It is not parasitic, nor is it contagious.
Microscopic examinations have given negative results, the skin
remaining normal and the glandular structures unchanged. Atrophy of the
hair shafts and bulbs, and occasionally breaking and bulging of the
hairs, are usually noted. The atrophic condition of the bulbs is
similar to that seen in hairs which have reached the end of their
normal life.

The disease with which alopecia areata may, by the inexperienced, be
sometimes confounded is tinea tonsurans, and yet the incomplete
baldness, the short, stumpy, split, gnawed-off-looking hairs, the
scaliness, the increased prominence of the follicular openings, and the
history and course which characterize ringworm, are entirely different
from the clinical signs of alopecia areata. Where there is doubt the
microscope is to be employed. It is to be remembered, also, that
ringworm of the scalp is not seen in individuals past the age of
puberty. The peculiar clinical features of the disease will distinguish
it from other forms of baldness.

TREATMENT.--The uncertainty of the duration and ultimate termination of
the disease is to be kept in view in expressing an opinion. It may be
stated, with a degree of positiveness, however, that in young
individuals the eventual result is, as a rule, good; but occurring in
persons past adult age, the prognosis as to a regrowth is not so
favorable, and becomes less so as age increases. The length of time
elapsing in favorable cases before the hair reappears, as already
mentioned, is uncertain: it may be several months, or on the other
hand, as many years. On both points proper and persevering treatment
has sometimes a material influence.

Local and general measures are called for. Of the two, the general
treatment is the more important, and among remedies employed arsenic
stands prominent. It should be continued for months. In addition, such
tonics as iron, quinine, cod-liver oil are to be advised as the case
demands. In some instances potassium iodide in moderate doses is of
service.

External treatment is of value, and is in most cases to be advised. The
object in view is a stimulation of the vascular supply, and through
this an improvement in the nutrition of the papillæ and hairs. The same
remedies in various combinations are employed as in the treatment of
other forms of alopecia. Rubefacients and irritants, such as alcohol,
the essential oils, sulphur, tar, cantharides, corrosive sublimate and
other salts of mercury, carbolic acid, iodine, turpentine, ammonia,
chrysarobin, and spiritus saponatus kalinus, are variously used. They
are, as a rule, employed either in alcoholic or ethereal fluids or in
the form of oils or ointments. It is to be borne in mind that the scalp
tolerates strong remedies. The applications are to be made once or
twice daily, according to the demands of the case, and with
considerable friction, employing for the application a flannel rag or
mop. Such remedies as iodine, corrosive sublimate, are usually to be
painted or dabbed on.

{682} Sulphur, two to four drachms to the ounce; corrosive sublimate,
one to four grains to the ounce of alcohol; tar, ol. cadini, or ol.
rusci, one to four drachms to the ounce of alcohol or ointment,--are
all serviceable remedies. Cantharides and capsicum are stimulating, and
may be prescribed as in the following formula:

  Rx. Tinct. cantharidis,
      Tinct. capsici,    aa. fluidounce iss;
      Olei ricini,           fluidrachm ij;
      Alcoholis,             fluidrachm vj;
      Spts. rosmarini,       fluidrachm ij.  M.

The following, containing the oil of mace, is also serviceable:

  Rx. Olei myristicæ exp.,    fluidrachm ij;
      Alcoholis,
      Spiritus lavandulæ, aa. fluidounce ij.  M.

Carbolic acid may be used as follows:

  Rx. Acidi carbolici cryst., drachm ij;
      Alcoholis,              fluidounce iij;
      Olei ricini,            fluidrachm iv;
      Spts. rosmarini,        fluidrachm iv.  M.

Aqua ammoniæ may sometimes be employed with benefit, as in the formula
recommended by Wilson:

  Rx. Olei amygdalæ dulc.,
      Aquæ ammoniæ fort., aa. fluidounce ss;
      Spiritus rosmarini,     fluidounce ij;
      Olei limonis,           fluidrachm ss.  M.

Blistering the affected areas by means of a cantharidal vesicating
fluid, frequently repeated, sometimes proves of advantage. Friction
with oil of turpentine once or twice daily may in some cases be
practised with benefit; when the skin becomes sensitive it should be
discontinued for a few days. Chrysarobin in ointment, 5 to 15 per cent.
strength, is an active irritant which may be cautiously employed.
Oleate of mercury, 10 to 30 per cent. strength, rubbed in once or twice
daily, is useful in some cases, and the same may be said of the other
mercurial ointments, such as citrine and white precipitate ointments.
Electricity sometimes proves of service, and may be tried in obstinate
cases.


Atrophia Pilorum Propria.

Atrophia pilorum propria, or atrophy of the hair, may be either
symptomatic or idiopathic. As a symptomatic affection it is seen as a
result of such diseases of the scalp as seborrhoea and the parasitic
affections, and also following various constitutional diseases, such as
syphilis and fevers, in consequence of impaired nutrition. The hairs
become dry, brittle, atrophied, and exhibit a marked disposition to
split up. Idiopathic atrophy of the hair is characterized in one of its
forms (fragilitas crinium) by a brittle state of the hair-shaft, an
irregular and uneven formation of its structure, and a tendency to
separate into its filaments. It is seen about the scalp and beard, and
may be slight or markedly developed. A somewhat similar condition of
the hair of the beard has been described (Duhring), in which the bulb
is {683} atrophied and the shaft split up, fission taking place within
the follicles, causing irritation of the skin. Another form
(trichorexis nodosa) of the idiopathic affection is characterized by
shining, semi-transparent, rounded swellings of the hair-shaft, seen
usually upon the beard and moustache. At first sight they look not
unlike the ova of pediculi; one or several may be present upon a single
hair. Upon close inspection they are seen to be localized swellings of
the hair-structure. At these points the hairs readily break off,
leaving a brush-like end; if many of these are present, which is
usually the case, they give the impression that the hair has been
singed. The medullary as well as the cortical substance, as determined
by microscopical examination, is swollen, and in consequence of the
swelling of the medullary portion the cortex is burst and split into
filaments. In regard to the cause of idiopathic atrophy of the hair
nothing is known, and but little can be done in the way of treatment.
Shaving and cutting the hair have exceptionally been followed by a
normal growth.


Atrophia Unguis.

Atrophy of the nail is commonly an acquired affection. It is
characterized by deficient development or growth of the nail-substance,
as shown by a thin, brittle, soft, crumbly or worm-eaten condition. The
nail may be pale, opaque or dark in color. It may occur in consequence
of injury or disease of the nerves of the part, or as a result of some
general disease, as syphilis, or from general debility. Eczema,
psoriasis, and allied diseases, which may be productive of hypertrophy
of the nails, may also cause atrophic changes. Treatment of atrophy of
the nail depends upon the cause. In simple atrophy, and also in that
due to eczema and psoriasis, arsenic is of value.


Atrophia Cutis.

Atrophy of the skin, or atrophia cutis propria, in its various forms is
not infrequently encountered. It may occur as an idiopathic affection,
or as a symptom in connection with other well-known diseases. Thus, as
an example of the former condition the well-known striæ atrophicæ may
be cited, while lupus, syphilis, and tinea favosa are sometimes
followed by symptomatic atrophy. Injuries to nerves are also at times
followed by more or less cutaneous atrophy, usually in connection with
wasting of the subcutaneous structures, the skin becoming thin, dry,
shrivelled, and yellowish or brownish in color. Atrophy of the skin may
be general, as in the senile form, or localized, as in morphoea. Where
degenerative atrophy exists the skin is usually somewhat hardened,
yellowish or whitish in color, and has a waxy, fatty appearance. In the
condition known as glossy skin, generally seen upon the fingers, the
skin is reddish, smooth, and shining as though varnished, the affection
resembling chilblains. The hairs are usually shed, and excoriations or
fissures often exist. It is accompanied with pain of a burning
character.

Cases of general idiopathic atrophy of the skin have from time to {684}
time been reported, the disease in almost all instances being more
marked in some localities than in others, occurring in the form of more
or less extensive patches. The disease originally described by Hebra
and Kaposi with the name xeroderma, or parchment-skin disease, may here
be referred to. The lesions consist of numerous disseminated
pigment-spots, resembling freckles; telangiectases, or minute congeries
of blood-vessels; atrophic macules of variable size; with more or less
shrinking and contraction of skin, followed in most cases by
epitheliomatous tumors and ulceration. The disease almost invariably
begins in early years, is prone to show itself in several children of
the same family, and lasts during life. The advanced stages of
scleroderma and morphoea likewise show marked atrophic changes, which,
however, will be considered in speaking of those diseases.

Senile Atrophy.--This form of atrophy, taking place as the result of
old age, may be simple or degenerative, both usually occurring
together. The integument becomes thin and wasted, the surface being
dry, wrinkled and more or less discolored by pigmentation, with loss of
hair. In degenerative atrophy the connective tissue of the corium
becomes changed into a fine or coarse granular matter or into a
homogeneous vitreous mass. Fatty metamorphosis and marked pigmentary
deposits are also common.

Maculæ et Striæ Atrophicæ.--Atrophic streaks and spots may occur
idiopathically or symptomatically. The idiopathic form is that most
frequently encountered, and occurs without known cause, generally
making its appearance insidiously. It is characterized by lines or
streaks constituting the so-called linear atrophy, striæ atrophicæ; or
by spots, maculæ atrophicæ. The streaks are more frequently met with,
and consist of irregular curved or tortuous lesions, usually about a
line in width and of variable length, running parallel with one
another. The macules are rounded or ovalish, varying in size from a
pinhead to a finger-nail. Both are smooth and glistening, and the skin
is thinned and scar-like. They are slightly depressed or grooved, and
possess a pinkish, whitish, or bluish-gray color. They may appear upon
any region, but the abdomen, buttocks, and thighs are the favorite
localities. They pursue a slow course over a period of years or a
lifetime, occasioning no inconvenience. The first stage of either
variety of the disease is characterized by erythema, the lesion being
reddish, hyperæmic, and slightly raised or puffed. This sooner or later
disappears, followed by depression and atrophy.

The symptomatic form of the affection is usually noted to take place as
the result of extreme distension of the cutaneous structures. It occurs
sometimes in obese subjects, and in the latter stages of pregnancy upon
the abdomen and mammæ, and over large abdominal and other tumors where
the skin is greatly stretched, constituting the so-called lineæ
albicantes.


{685} CLASS VI.--NEW GROWTHS.[6]

[Footnote 6: Lepra (leprosy), an important disease of this class,
appears, in Vol. I. p. 785, as a separate article by J. C. White.]


Keloid.

Keloid is a connective-tissue new growth, characterized by one or more
irregularly-shaped, variously-sized, elevated, smooth, firm, somewhat
elastic, pale-reddish, cicatriform lesions. It ordinarily begins as a
nodule or tubercle, pea- or bean-sized, which slowly, usually in the
course of years, increases in dimension. When fully developed, the
growth appears as an ovalish, elongated, cylindrical, fungoid or
crab-shaped patch, occupying usually an area of one or several inches,
distinctly elevated, sharply defined, and firmly implanted in the skin.
In some cases the lesion does not exceed the size of a pea or a bean.
The color is usually pinkish-white. The surface is smooth, shining, and
commonly devoid of hair, with no tendency to scaliness or ulceration,
and generally marked by ramifying vessels. It is firm and elastic to
the touch. The disease sometimes appears in the form of streaks or
lines. It is seen most frequently upon the sternum, although other
regions, as the neck, mamma, ear, sides of the trunk, or back are often
invaded. It is more common in the colored race. The lesion is usually
single, though several may coexist. Itching to a slight degree is
sometimes present, and more or less pain, especially on pressure, may
also exist. Depending upon the origin of the growth, whether arising
spontaneously or upon the site of various injuries of the skin, keloid
is termed, respectively, spontaneous, or true, and cicatricial, or
false. Clinically and pathologically, both varieties are the same.

It is often met with as the result of burns, cuts, flogging, and all
ulcerative affections. Not infrequently it takes its origin in the
scars of acne and variola; occasionally it is seen to develop on the
lobe of the ear, taking its start at the point where the ear has been
pierced. Pathologically, the lesion is a connective-tissue new growth,
made up of a dense, fibrous mass of tissue, whitish in color, having
its seat in the corium. The clinical features of keloid are so
characteristic that no difficulty is experienced in recognizing it. The
course of the disease is chronic, usually lasting throughout life; in
exceptional instances spontaneous involution has been noted.

Treatment is usually negative. Removal by excision or caustics is, as a
rule, followed by a return of the growth, and sometimes in an
aggravated form. If its destruction or extirpation is decided upon, it
should not be done while the growth is still progressive. Improvement
has been reported by Vidal from multiple linear scarification. If the
formation is painful, various anodyne applications may be made. Iodine,
mercurial, and lead plasters may be tried with the object of promoting
absorption. Painting the growth with a solution composed of potassium
iodide one drachm, and an ounce each of soft soap and alcohol, followed
by the application of lead plaster spread on a piece of soft leather,
has been advised by Wilson. The use of lead plaster alone, applied
continuously as a plaster, is sometimes followed by softening and
diminution in size.


{686} Fibroma.

Fibroma (molluscum fibrosum, fibroma molluscum) is a connective-tissue
new growth, characterized by sessile or pedunculated, soft or firm,
rounded, painless tumors, varying in size from a pea to an egg or
larger, seated beneath and in the skin. A single growth may occur, or,
as is more commonly the case, they are present in large numbers, and
usually scattered over the greater portion of the body, having a
preference for the softer tissues,--for example, the trunk. They may be
of various shapes, rounded and sunken in the skin itself or in the
subcutaneous tissue, or club- or pear-shaped and pedunculated. They
usually begin as soft masses in the skin. If but one tumor exists, it
is apt to be pedunculated or pendulous, and to attain considerable
dimensions, in some cases weighing several pounds. In these instances
surface-ulceration is occasionally noted as the result of mere weight
or pressure. As commonly met with, however, the growths are numerous,
several hundreds existing, varying from a pea to a cherry in size, with
larger ones scattered here and there. The overlying skin is normal,
pinkish or reddish, or may be loose or stretched, hypertrophied or
atrophied. They are unattended with pain. They may make their
appearance at any age, often in childhood, and grow as a rule slowly.
After reaching a certain size they are apt to remain stationary; in
rare instance spontaneous involution of some of the growths has been
noted to take place. The affection is not common. It is often
inherited, and may show itself in several members of the same family.
Those in whom it is observed are usually noted to be stunted in their
physical and mental development. The general health is not involved.
Opinions are divided as to whether the growths take their origin in the
connective-tissue framework of the fatty tissue, in the connective
tissue of the corium, or in that of the walls of the hair-sac. The
developed tumors consist of a connective-tissue capsule enclosing a
whitish fibrous mass, with the central portion more or less soft and
pulpy, out of which may be squeezed a small quantity of yellowish
fluid. Small, recent tumors are composed of gelatinous, newly-formed
connective tissue, while old growths consist entirely of a dense,
firmly-packed fibrous tissue.

They are to be distinguished from the tumors of molluscum epitheliale
by the absence of an aperture or depression upon their summits. They
can scarcely be confounded with multiple neuromata or with lipomata, as
the accompanying pain of the former and the lobulated structure and
soft feel of the latter are sufficiently distinctive. Their removal, if
desired, may be effected by the knife, or in the case of the large and
pedunculated growth by the ligature or by the galvano-cautery.


Neuroma.

Neuroma cutis, or neuroma of the skin, is characterized by the
formation of variously-sized fibrous tubercles, containing new
nerve-elements, having their seat primarily in the corium, and
accompanied in their development by violent paroxysmal pain. It is
exceedingly rare, there being but few cases recorded. It appears on the
shoulders, arms, thighs or buttocks in the form of numerous,
disseminated, pinhead to hazelnut in {687} size, round or ovalish
tubercles or nodules, which at the outset may be either painful or
painless; in the later stages, however, pain, both spontaneous and upon
pressure, is a constant symptom. The growths are firm, immovable, and
elastic, and are seated in the corium, extending into the deeper
structures. They may be covered scantily with fine, laminated,
glistening scales, as in the case reported by one of us. Anatomically,
the tumors are composed of nerve-fibres, yellow elastic tissue,
blood-vessels, and lymphoid cells. Excision of a portion of the
nerve-trunk leading to the affected area has been practised in one case
(Kosinski's) reported, with permanent relief; in another (Duhring's)
the relief was merely temporary.


Xanthoma.

Xanthoma (also called vitiligoidea and xanthelasma) is a
connective-tissue new growth, characterized by the formation of
yellowish, circumscribed, irregularly-shaped, variously-sized,
non-indurated, flat or raised patches or tubercles. Two varieties are
met with. The macular, or flat form (xanthoma planum) is commonly seen
upon the eyelids, looking not unlike pieces of chamois-skin inserted in
the lids. This form may also be encountered occasionally on other parts
of the face, as well as upon the body. The patches are smooth, opaque,
usually sharply defined, and to the touch soft and apparently normal in
texture; they are on a level with the surrounding integument or
slightly raised, and of a creamy or yellowish color. They vary in size
and shape, and may coalesce, forming a band extending across the
eyelids, especially the upper lids. The tubercular form (xanthoma
tuberosum) is usually met with upon the neck, trunk, and extremities,
the eyelids seldom being invaded. It occurs as small, isolated nodules,
or in patches slightly raised above the level of the skin, consisting
of aggregations of tubercles of the size of a milletseed or larger.
Both forms of the disease not infrequently occur in the same
individual. After reaching a certain development it is apt to remain
stationary throughout life, and with no involvement of the general
health. As a rule, the lesions are few in numbers; on the other hand,
rarely they may be numerous (xanthoma multiplex). The affection is
usually encountered in middle and advanced life, although it is
occasionally met with in the young. It is more common in women than in
men. Jaundice has been frequently noticed as preceding or accompanying
it, especially the tubercular variety. Pathologically, it is a
connective-tissue new growth with fatty degeneration. Excision, where
practicable, constitutes the sole method of treatment.


Myoma.

Myoma cutis, or dermato-myoma (known also as liomyoma cutis), is a rare
affection, consisting of tumors of the skin composed of muscular
fibres. They occur either as single or multiple tumors, varying in size
from a lentil to an egg, localized in a special region, as the nipple,
scrotum, labia majora, thigh, hand, or foot; or, more rarely, numerous,
and scattered over the greater portion of the whole body. They are
{688} either flat or pedunculated, rounded or oval in form, pale-red in
color, with a smooth surface; although generally painless, they are
sometimes tender upon pressure, The growth consists essentially of a
new formation of unstriped muscular fibres. At times it is composed
largely of connective tissue (fibromyoma), or it may contain an
abundance of blood-vessels, giving rise to cavernous erectile tumors
(myoma telangiectodes). The disease is benign.


Angioma.

Angioma, or nævus vasculosus, is a congenital formation composed
chiefly of blood-vessels and having its seat in the skin and
subcutaneous tissue. Several forms of the affection are met with, all
of which, however, may be grouped under two heads--non-elevated and
prominent. The former (nævus flammeus, nævus simplex, angioma simplex)
is illustrated by the so-called port-wine mark, or claret-stain, known
in German as feuermal, and in French as tache de feu. The prominent
variety (angioma cavernosum, nævus tuberosus) may be turgescent,
erectile, pulsating, tumor-like, circumscribed growths, with an uneven
or rugous surface. In shape nævi are usually roundish, but may be
irregular; in color, bright or dark red, violaceous, or bluish; and in
size as large as a pea or a bean, or in some cases involving areas
several inches in diameter. As a rule, they are single formations. They
may occur on any part of the body, but are most frequently seen about
the face. Their course varies. In many instances, after attaining a
certain size, they remain stationary, or in some cases may retrograde
or undergo spontaneous involution, this remark applying more
particularly to the flat variety in early life. Ordinarily, they are
permanent deformities. They become pale under pressure, and the more
prominent growths are markedly compressible. Anatomically, the growth
consists of a dilatation and hypertrophy of the arterial and venous
blood-vessels of the corium and subcutaneous tissues, and in some
instances there is increase in connective tissue. In some cases the
connective-tissue hypertrophy is made up mainly from the adipose layer
(angioma lipomatodes). Occasionally there may be more or less
pigmentation.

In the treatment, the extent, form, and region involved are to be
considered. Various methods have been advised for their removal. For
pinhead-sized nævi puncturing with a red-hot needle, or with a needle
charged with nitric or chromic acid, may be employed. Those of pea size
may be treated by caustic applications. Sodium ethylate, as recommended
by Richardson, is an efficient caustic for the more superficial forms:
it should be pure and applied with a glass rod; a dry dressing is to be
employed and the crust permitted to loosen itself. Painting a nævus
with liquor plumbi subacetatis will, if repeated daily for several
weeks or months, sometimes succeed. Caustic potash in solution, from
one to two drachms in the ounce, and nitric acid, may both be
cautiously used. An ointment of a drachm of adhesive plaster and nine
grains of tartar emetic applied to small nævi will, according to
Neumann, cause free suppuration and healing. A solution of eight grains
of corrosive sublimate in a drachm of collodion is sometimes effective.
Injections of astringent and irritating liquids, such as the tincture
of the chloride {689} of iron and cantharidine, as formerly practised,
possess no advantage over safer methods. Linear and punctate
scarifications--in the latter the needles being charged with a 50 per
cent. solution of carbolic acid or a 25 per cent. solution of chromic
acid--have been recommended. In small formations vaccinating the nævus
is often successful. The galvano-cautery and the actual cautery are
both serviceable in treating the smaller nævi. Electrolysis constitutes
a valuable plan of treatment. A current of from six to twelve cells is
usually required. One or more platinum needles are attached to the
negative pole and a single needle or charcoal point to the positive
pole. Slight frothing at the points of insertion indicates that the
action has been sufficient. Suppuration and sloughing should not occur
if proper care is exercised. If the nævus is extensive, only a small
portion is to be treated at the one sitting. In the port-wine mark this
method promises the best results; the color is made much lighter, and
exceptionally is made to disappear entirely. In prominent, and
especially in pedunculated, tumors a ligature may be employed.


Lymphangioma.

Lymphangioma (also described as lymphangioma tuberosum multiplex) is a
rare disease, characterized by numerous, scattered, pea- or bean-sized,
ovalish or rounded, brownish-red, glistening, smooth, slightly-elevated
tubercles, having a somewhat translucent look, occurring for the most
part about the trunk. They are firm and elastic to the touch; are
situated in the cutis, but are not sharply defined; they can be readily
made to sink below the level of the surrounding integument, owing to
their marked compressibility. At times they have a lilac or bluish
tinge. The growths bear some resemblance to the large papular
syphiloderm. They are generally congenital or appear in childhood.
Anatomically, they consist of immensely dilated and hypertrophied
lymphatic vessels. The course of the disease is slow, and evinces no
disposition to malignancy. The general health is not involved.


Lupus Erythematosus.

Lupus erythematosus (also known as lupus erythematodes, seborrhoea
congestiva, and lupus sebaceus) is a small-celled new growth,
characterized by one or more circumscribed, variously sized and shaped,
reddish patches, more or less covered with adherent grayish or
yellowish scales. The affection usually begins as a rounded,
circumscribed, pinhead- to pea-sized, slightly elevated lesion, which
increases in size by peripheral extension until considerable surface is
involved; or, as is often the case, the disease starts with several
such spots, which grow and generally coalesce, sooner or later
involving considerable surface. The spots are at first erythematous and
slightly scaly, with but little elevation, later becoming thickened,
with a more or less raised border sharply defined against the healthy
skin, covered with small, firmly adherent yellowish or grayish scales,
with enlarged and plugged or patulous follicles, the centre of the
patch being somewhat depressed. The color is pinkish, reddish, or {690}
violaceous. In the beginning the disease often closely resembles
seborrhoea,--so much so that it was originally described by Hebra as
seborrhoea congestiva. The scaling is usually scanty, but in
exceptional instances may be abundant. At times the lesions show little
tendency to peripheral growth, the large areas of disease resulting
from the continuous appearance of new patches in proximity which run
together. Occasionally the patches are small, discrete, and numerous,
when the disease is apt to be disseminated over considerable surface.

Lupus erythematosus is seen most frequently about the face, one or
several patches, varying in size from a pea to a silver dollar,
ordinarily being present. The nose and the cheeks are favorite
localities, and, seated here, the disease is apt to be symmetrical,
extending from one cheek across the nose to the other cheek, in shape
representing rudely the outline of a bat or butterfly with outstretched
wings. The lips, ears, scalp, and other parts of the body are often
affected. The progress of the disease is variable; the patches, as a
rule, reach a certain size, and then remain stationary or retrogress,
or, as generally happens, the central portion becomes depressed and
more or less atrophied. The resulting scar is whitish, usually soft,
punctate, and superficial. As old patches disappear it is not uncommon
to see new patches appearing close by. It is essentially a chronic
disease: the individual lesions may be acute in their course, and when
such is noted, as a rule new areas of disease continue to appear in
rapid succession. Ordinarily, however, the individual patches
themselves are chronic in their course. The disease is not attended
with ulceration. The subjective symptoms of itching and burning are
usually mild in character, and sometimes are entirely wanting.

The condition of the general health is, as a rule, good. The disease is
seen more frequently in women than in men, and is rarely observed
before puberty, being chiefly encountered in early adult and middle
age. The causes are not known. It frequently begins as a seborrhoea,
but it may occur (although rarely) upon the palms of the hands, where
sebaceous glands are not to be found. It is a notable fact, however,
that the disease is most commonly encountered in those who are subject
to disorder of these glands. It is observed more often in persons of
light complexion. It is comparatively rare. The condition of the
general health apparently exercises no causative influence.

Pathologically, the process is essentially a chronic inflammation of
the cutis, superinducing degenerative and atrophic changes. In the
majority of cases the disease originates in the sebaceous glands, but
later all parts of the skin become affected. It is even authoritatively
stated that it may in some instances take its start in the subcutaneous
connective tissue. In some respects it has the character of a new
growth, which until late years it has been considered. In the light of
recent investigations, however, it seems possible that it may be a
chronic inflammation leading to degenerative changes. The process never
ends in the formation of pus. There is small-celled infiltration about
the follicles and glands, the blood-vessels are dilated, the
surrounding tissue is infiltrated with embryonic corpuscles, and the
sebaceous glands are enlarged and their walls infiltrated with small
cells. The whole affected area is, in fact, infiltrated with a
small-celled inflammatory new growth. If retrograde changes occur, the
{691} infiltration may disappear by absorption without leaving a trace.
On the other hand, and as is usually the case, degenerative
metamorphosis, resulting in absorption and atrophy, takes place.

There is very little difficulty in recognizing a fully-developed patch
of lupus erythematosus, as its features are usually characteristic. The
sharply circumscribed outline, the reddish or violaceous patch with
elevated border, the tendency to central depression and atrophy, the
plugged-up or patulous sebaceous ducts, the adherent grayish or
yellowish scales, together with the region attacked (generally the nose
and cheeks), are characters which, when taken together, are common to
no other disease. Lupus vulgaris may be excluded by the absence of
papules, tubercles, and ulceration. The sebaceous involvement and the
peculiar atrophy and superficial scarring are, moreover, not seen in
lupus vulgaris. Erythematous lupus begins, as a rule, during adult
life; lupus vulgaris usually in childhood. In psoriasis the course and
symptoms peculiar to that disease will distinguish it from lupus
erythematosus. It is scarcely possible to confound the disease with
eczema or syphilis. In some cases in the beginning of the affection it
may resemble seborrhoea; in fact, it often has its starting-point in
that disease. The inflammation, infiltration, sharply-defined
characters, atrophy, and scarring are absent in seborrhoea.

TREATMENT.--The prognosis of lupus erythematosus, as regards the
general health and welfare of the patient, is good, but respecting the
disappearance and cure of the disease an opinion should always be
guarded. Occasionally the patches yield readily, but, on the other
hand, cases are frequently met with that prove exceedingly rebellious,
responding only after long-continued treatment. Constitutional remedies
are in most cases of but little value. Occasionally arsenic and
cod-liver oil, used continuously for a long period, prove serviceable.
Iodized starch, in the dose of one or two teaspoonfuls three times
daily, has been recommended, and in some cases potassium iodide has a
favorable influence.

It is to the external treatment, however, we look for positive effects.
In the selection of remedial applications it is to be remembered that
the patches of disease sometimes disappear spontaneously, occasionally
with little or no scarring, and therefore treatment that would have as
an effect marked scarring or disfigurement is to be avoided. The
simplest remedy, at times useful, is soft soap, the sapo viridis of the
shops. This may be used as such or in solution in alcohol, two parts of
the soap to one of alcohol, constituting the well-known spiritus
saponatus kalinus. It is to be energetically rubbed into the diseased
parts once or twice daily. The application of the sapo viridis as a
plaster is a more energetic method. After several days the soap is to
be discontinued and a soothing ointment applied. In addition to its
therapeutic properties, sapo viridis--or, better, its alcoholic
solution--may be advantageously employed to cleanse the parts
preparatory to other remedial applications. Mercurial plaster
constantly applied to the patches will in some cases effect a cure. A
10 to 25 per cent. oleate-of-mercury ointment, rubbed on the parts once
or twice daily, is sometimes of value.

In almost every case where the inflammatory symptoms are marked the
following lotion will prove palliative, and in some cases of the mild
and superficial form of the disease it has in time effected a cure:
{692}

  Rx. Zinci sulphatis,
      Potassii sulphidi,  aa. drachm ij;
      Aquæ,                   fluidounce iij;
      Alcoholis,              fluidounce j.

The salts are to be dissolved separately in the water, and then mixed,
and after reaction the alcohol is to be added. Properly made, the
resulting lotion is without odor, contains a whitish sediment, which
when agitated gives the lotion a milky appearance. It is to be shaken,
and the parts dabbed with it for from fifteen to thirty minutes twice
daily, allowing it to dry on. Sulphur ointment and alcoholic sulphur
lotion, such as are used in the treatment of acne, are also sometimes
serviceable. Tincture of iodine, either alone or with an equal part of
glycerin, painted over the parts once or twice daily until a coating
forms, in some cases proves useful. The same may be said of the
following formula:

  Rx. Iodinii,
      Potassii iodidi,  aa. drachm iv;
      Glycerinæ,            drachm j.

M.--Sig. Paint over the part until a coating is produced. Painting pure
carbolic acid over the patches is sometimes followed by good results. A
mixture that is serviceable as a stimulant is the following:

  Rx. Olei cadini,
      Alcoholis,
      Saponis viridis,  aa. drachm iij.

M.--Sig. Rub into the patches night and morning.

Stronger applications are often necessary if the disease fails to yield
to the simpler remedies. Pyrogallic acid in ointment, from forty to
ninety grains to the ounce, and chrysarobin in the same strength, are
serviceable. The latter is a dangerous remedy to use about the face,
occasioning at times a violent conjunctivitis with oedema. Pyrogallic
acid is safer, and sometimes proves more satisfactory when applied in
flexible collodion or liquor gutta-perchæ than in ointment form, as in
the following formula:

  Rx. Acidi pyrogallici,    drachm j;
      Liquor. gutta-perchæ, fluidrachm iv.

M.--S. Apply with a brush. This is to be painted over the patches
several times daily until considerable reaction takes place or a crust
forms, then discontinued, and as soon as the crust is removed or falls
off the application is to be repeated. If there is much scaling, thirty
grains of salicylic acid may be added to the above formula. In most
cases it is advisable as soon as the crust forms to remove it, and
immediately to resume the pyrogallic-acid painting. Cantharidal
blistering fluid, repeatedly applied, has been recommended. Nitrate of
silver, either in stick or strong solution, is a comparatively safe
caustic, and is at times useful. Treatment by linear scarifications,
especially in obstinate, sluggish, and infiltrated patches, is often
valuable. The scar left is, as a rule, insignificant. Erasion with the
curette is a method that sometimes proves of advantage in the severer
and deeper-seated forms of the disease. Although in almost all
instances stimulating or active treatment is demanded and well borne,
there are cases occasionally met with in which, on account of the
inflammation and pain, soothing applications must, for a time at least,
be employed. These cases, it will be found, are aggravated by
stimulating remedies.


{693} Lupus Vulgaris.

Lupus vulgaris (known also as lupus exedens, lupus vorax) is a cellular
new growth, characterized by variously-sized, soft, reddish-brown
patches, consisting of papules, tubercles, and flat infiltrations,
eventually terminating in ulceration and cicatrization. The disease
appears differently as seen in the several forms and stages of its
development. All the varieties usually begin in one and the same way.

The primary lesions are pinhead- to small pea-sized, deep-seated,
brownish-red or yellowish papules, having their seat in the deeper part
of the corium. They are softer and looser in texture than normal
tissue, and as the disease progresses form variously sized and shaped
patches. They may be so closely aggregated as to form flat
infiltrations. The patches tend to be round, serpiginous, or ill
defined. As the papules increase in size they may be distinctly
recognized both by the eye and by passing the finger over the surface;
later even reaching the size of small peas. The lesions having attained
a certain size or development and being covered with imperfectly-formed
epidermis, may so remain for a time, or retrogressive changes may
immediately occur. They may disappear by absorption, fatty degeneration
taking place, leaving a desquamating, atrophic or cicatricial
tissue--lupus exfoliativus--or disintegration and destruction of the
diseased skin may occur, resulting in ulceration--lupus exedens, or
exulcerans. This latter is the usual course of the disease. The
ulcerations are rounded, shallow excavations with soft and reddish
borders. If the ulcerations are the seat of exuberant granulations, the
condition is known as lupus hypertrophicus. Papillary outgrowths may
occur in the healing ulcers, and a rough, verrucous condition
results--lupus verrucosus.

The lesions of lupus are seldom painful. The ulcers secrete a slight or
moderate amount of pus which forms crusts. Soft or firm cicatricial
tissue finally results. In almost all cases of long standing the
several stages of the disease may be recognized, each lesion, whether
the first or the last, going through a similar course, either of
absorption and exfoliation or ulceration and cicatrization. The deeper
parts may be involved in the process, subcutaneous connective tissue,
cartilage, and mucous membrane being liable to invasion. The mucous
membrane of the mouth, gums, velum and larynx may even be primarily the
seat of the lupus infiltration, considerable destruction eventually
resulting. The face, especially the nose, is the most common site of
the disease. Occurring about the eye, the process may eventually
destroy that organ. The ears are likewise frequently attacked. Not
infrequently the extremities, and occasionally the trunk, are invaded.
The disease begins, as a rule, in childhood. It is always a destructive
process, usually resulting in disfiguring cicatrices.

The causes of the disease are obscure. Although it usually appears in
early life, it is never congenital. Heredity has little if any
influence. It is comparatively rare in this country, less so in England
and Ireland, but is more common in Austria, Germany and France. It is
most generally observed among the strumous and debilitated, but is also
frequently seen in those who enjoy all the advantages of life and who
are otherwise in average health. It is entirely distinct and
independent of syphilis. The French consider it a scrofuloderm
(scrofulide), and yet in many cases there {694} is clinically a
considerable difference. On the other hand, cases are met with in which
its close relationship, if not identity, with the scrofulodermata is
not to be questioned. The view that it is a tuberculosis of the skin
due to the same cause as at present advanced for tuberculosis of the
lungs--the bacillus--has lately been suggested. The disease attacks
both sexes, but is somewhat more common in women than in men.

Anatomically, the process is a chronic inflammation, consisting
essentially of small-cell infiltration, affecting primarily the corium,
eventually spreading to other parts. The epithelial structures are
usually involved in the first stages of the disease. Recent lesions are
rich in vessels, the vascularity when retrogressive changes take place
rapidly decreasing, beginning at the centre of the nodule. The
cutaneous tissues undergo cicatricial contraction, a part, however,
being organized into coarse connective tissue. In addition to the
formation of the nodular mass, the cell-infiltration is found to spread
along the vessels of the corium and papillæ, and also into the deeper
portions of the skin. The papules may be so close and the
cell-infiltration so extensive that a large area of disease results and
undergoes the same changes as an individual lesion. The sweat and
sebaceous glands are involved. Sometimes epithelial hyperplasia takes
place, the epithelial outgrowth from the rete dipping down and joining
similar outgrowths from the cells of the sweat-glands and hair
root-sheaths, forming an epithelial network which may become a
histological basis for the development of epithelioma. The occurrence
of this latter disease in lupus tissue, in association or as a sequela,
has been noted by several observers. According to the latest
investigations the infiltration of lupus is due chiefly to
cell-proliferation and outgrowth from the protoplasmic walls and
adventitia of the blood-vessels and lymphatics. The fibrous-tissue
network, vessels, and a portion of the cell-infiltration are thus
produced, the fixed and wandering connective-tissue cells of the
inflamed stroma of the cutis being responsible for the other portion of
the new growth.

DIAGNOSIS.--Ordinarily, the features of lupus vulgaris are so
distinctive as to render a diagnosis a matter of no difficulty. The
characteristic soft, small, reddish-brown subcutaneous papule--the
primary efflorescence of the disease--is generally to be found,
especially about the periphery of the patch, and when present is
diagnostic. At times, however, it bears resemblance to syphilis,
epithelioma, lupus erythematosus, and acne rosacea.

It is chiefly in the serpiginous forms of the late tubercular and
ulcerative syphilodermata that the resemblance to lupus vulgaris is
sometimes very close. There are several points of difference. Syphilis
is much more rapid in its course, marked ulceration following
frequently within a few weeks or months of its appearance. With lupus,
on the other hand, years may elapse before the same amount of
destruction results. In lupus there are usually several points of
ulceration; in syphilis, one or several, which incline to coalesce. The
ulcers of lupus are apt to be superficial, whereas those of syphilis
are usually deep, with a punched-out appearance. Lupus papules are
small, soft and but slightly elevated, and frequently reappear in the
scars left by the disease; the papules or tubercles of syphilis are
larger, more elevated, firm and harder, and are seldom seen in the scar
or track of the disease. The secretion of the {695} syphilitic ulcer is
abundant, purulent and offensive, and the crusts thick, often
oystershell-like, and of a greenish or blackish color; the secretion of
lupus ulceration is slight, odorless, the crusts thin and scanty and of
a reddish or reddish-brown color. The scar of lupus is generally hard,
shrunken, yellowish, and more or less distorted, while that of syphilis
is soft and, compared to the amount of ulceration, but slightly
disfiguring. The bone-structures are not involved in lupus; they may be
in syphilis. The two diseases have different histories: lupus generally
begins in childhood and runs a slow and chronic course; syphilis is
usually seen after adolescence or adult age, and progresses more
rapidly. In syphilis, moreover, other evidences of the disease may
usually be found.

Lupus vulgaris differs from epithelioma in several important points.
The edges of the epitheliomatous ulcer are hard, elevated, and waxy;
the base is uneven, and the secretion is thin, scanty, and apt to be
streaked with blood; the ulceration usually starts from a single point;
it is often painful; the tissue-destruction may be considerable; and,
finally, epithelioma is, as a rule, a disease of advanced age. Lupus
vulgaris differs essentially in all these particulars.

As a rule, there is no difficulty in differentiating lupus vulgaris
from lupus erythematosus. The absence of papules, tubercles and
ulceration is sufficiently distinctive. Lupus erythematosus is,
moreover, a superficial disease, pinkish or violaceous in color,
showing itself in circumscribed patches covered with thin adherent
scales, and with usually evident involvement of the sebaceous glands.
It rarely begins before adult age, whereas lupus vulgaris, as a rule,
first appears in childhood. Attention to the ordinary characters of
acne rosacea--the hyperæmia, the dilated vessels, comedones, acne
papules and pustules, its advent at or after maturity, and the
history--will prevent an error in diagnosis.

TREATMENT.--Lupus vulgaris is always a chronic disease, and one that
calls for a guarded opinion as to treatment. Although it be removed,
relapses are prone to occur, and new papules may show themselves even
about the scar resulting from treatment. If it is localized the chances
of permanent cure are more favorable. The deformity attending and
following the disease is often great,--contraction of joints,
destruction of cartilages, and sometimes partial closure of the
orifices resulting. The general health is usually good. Death by
tuberculosis of the lungs has been noticed in some cases.

Treatment has in the main two objects,--to limit the development or
spread of the disease and to remove the morbid tissue that is already
present. In accomplishing the former constitutional treatment is
occasionally useful; although much cannot usually be attained in this
way, yet from our own observations we are convinced that in some cases
the disease may be favorably influenced and its spread limited.
Cod-liver oil, administered in full doses and for a long period, is
sometimes of decided value. Potassium iodide is another remedy which at
times proves serviceable. Iodoform in half-grain doses three times
daily has been recommended, as have also muriate of lime, in the dose
of twenty grains three times a day, and calx sulphurata, in small
doses. Hygienic measures are to be enforced, and a generous, nutritious
diet advised.

External remedies are essential in every case, and constitute the only
plan of treatment to be relied upon. Removal of the diseased tissues by
{696} caustics or operation is the method practised. In the earlier
stages of the disease or before adopting radical measures it is
advisable to make an attempt to bring about absorption by the
employment of stimulating applications. Equal parts of tincture of
iodine and glycerin, or one part each of iodine and potassium iodide
and two parts of glycerin, may be painted over the parts daily or every
other day. Mercurial plaster, renewed once or twice a day and kept
constantly applied, is valuable in some cases. Corrosive sublimate in
the form of a lotion or ointment, one-half to two grains to the ounce,
has lately been advised. Cashew-nut oil applied with friction has been
recommended for the non-ulcerative form. Tar and sulphur ointments may
also be employed. Chrysarobin, either in the form of an ointment or as
a solution in liquor gutta-perchæ, has also been advised.

For the radical treatment of the disease there are numerous caustics in
use, but there are some which are more positive in their effect and
whose action may be controlled. Nitrate of silver, pyrogallic acid,
arsenic, caustic potash, the curette, scarifier, and the actual and
galvano-cautery are all valuable. Nitrate of silver is best used in
stick form. The lesions are forcibly pierced and bored with the stick,
and thoroughly cauterized. The operation is to be repeated every three
or four days. It is a safe remedy, and is especially useful about the
face, as the scars left are soft and smooth. Pyrogallic acid in the
form of an ointment or plaster, from 15 to 25 per cent. strength, is
often of great value. It is a mild and safe caustic; it is usually
painless and leaves a smooth, soft scar. The ointment should be stiff
and adhesive, and kept applied constantly for several days or more,
renewing twice daily. The following formula serves well:

  Rx. Acidi pyrogallici,   drachm ij;
      Emplastri plumbi,    drachm j;
      Cerati resinæ comp., drachm v.

M.--Sig. Apply as a plaster. In winter the lead plaster may be omitted.
The remedy may also be applied in liquor gutta-perchæ, but is not so
satisfactory. The tissues become soft and blackish, and then the parts
are to be poulticed and the slough removed; and if the diseased tissue
is not sufficiently destroyed the dressing is to be renewed.
Subsequently the ulcer is dressed with mercurial ointment or a simple
salve. Healing should take place in the course of a few weeks. Iodoform
is well spoken of. In deep-seated infiltration the upper epidermic
layers should first be removed by a solution of caustic potassa. The
iodoform is then put on and a layer of cotton is applied over it, and
the dressing remains undisturbed for a week. The lupus nodules are soon
destroyed. Several repetitions of the remedy may be necessary.
Excepting the preliminary application of the potassa the method is
painless.

A solution of caustic potash is sometimes employed for the destruction
of the lupus deposit. It is thorough in its action, but is painful and
must be used with great caution. The cicatrices left after the use of
this caustic are apt to be large and hard. In the application, as soon
as the diseased tissue has been thoroughly destroyed by the caustic,
the further action may be stopped by neutralizing the alkali with
diluted acetic acid. Arsenic in the form of paste is another valuable
caustic. It has the advantage of sparing the healthy, and even the
cicatricial, tissues. Hebra's modification of Cosme's paste is an
eligible formula: {697}

  Rx. Acidi arseniosi,            scruple j;
      Hydrargyri sulphuret. rub., drachm j;
      Ugt. simplicis,             ounce j.

M. Ft. ugt.--Sig. Spread upon a piece of kid or cloth and apply as a
plaster. The paste is to be applied for two or three days
consecutively, at the end of which time the parts are somewhat swollen
and painful. The lupus nodules are seen as black, necrosed spots.
Poultices are then applied until the slough comes away, usually in a
day or two; subsequently a mild, stimulating ointment is employed.
Rapid cicatrization usually takes place, and the cicatrices are, as a
rule, satisfactory. The chief objection to arsenical applications is
the intense pain that usually develops soon after the remedy is
applied. In other respects the method has its advantages.

Acetate of zinc in crystal form, repeatedly applied to the lesions, has
been advised. It is painful at the time of application, but the pain
may be somewhat relieved by washing the parts with water. Red iodide of
mercury in the form of a strong ointment (equal parts of the salt and a
fatty base), applied upon a piece of kid or cloth, will have a speedy
caustic effect. There are other caustic remedies which may be
mentioned. Chloride of zinc, with an equal part of chloride of antimony
and sufficient hydrochloric acid to dissolve the zinc chloride, and
enough powdered licorice added to make a paste, and applied as a
plaster, is an efficient caustic. It produces an eschar in twelve to
twenty-four hours. The parts are then dressed with a simple ointment,
and healing allowed to take place. It is a strong caustic, and is
destructive to healthy as well as diseased tissue. The same may be said
of Vienna paste, consisting of equal parts of lime and potassa. The
latter mixture is made into a paste at the time of application by
adding alcohol. It is not to be applied more than five to ten minutes,
and its further effects are to be counteracted by the application of
acetic acid. In the application of such powerful and destructive
caustics it is advisable to protect the adjacent skin with strips of
adhesive plaster. Salicylic acid has lately been recommended in the
form of an ointment of the strength of one to two drachms to the ounce.
It is thickly spread on linen and applied continuously. The remedy is a
mild one and acts slowly. Mention may also be made of lactic acid,
applications of which, it is stated, have been productive of beneficial
results.

Of late years the mechanical removal of the lupus deposits has been
largely practised. In small patches excision of the entire diseased
area has been recommended, but as considerable healthy tissue is
necessarily removed with it, and the resulting scar is deep and
disfiguring, it is not to be advised. Excision followed by
transplantation of healthy skin has also been advocated. An excellent
method of removal is by means of the dermal curette, or scraping-spoon.
It is one that answers well in many cases. The diseased tissue should
be thoroughly scraped out. It is painful, and it is often necessary to
operate under ether. The healthy tissues are unyielding and cannot be
readily scraped away, so that only the morbid deposit is removed. As it
is difficult to remove the new growth from the interstitial spaces, we
are in the habit of supplementing the operation with a caustic, either
cauterizing lightly with caustic potash, or, what is advisable in the
greater number of cases, {698} applying the pyrogallic-acid ointment
for several days following the curetting. This method--the curetting
and subsequent cauterization--has, on the whole, proved satisfactory.

Linear or punctate scarification is another method of treatment that is
often valuable. It is of most service in the non-ulcerating forms.
Linear scarification is the more satisfactory. The parts are thoroughly
cross-tracked and a simple ointment applied. If the bleeding is marked,
cold compresses may be applied. Anæmia of the parts results, the
papules are disturbed, and the new growth rapidly undergoes
retrogressive changes. If the area to be operated upon is large, the
patient should be anæsthetized. Charging the knife, or if punctiform
scarifications are practised the pointed instrument, with iodized
glycerin (one part iodine to twenty of glycerin) has been advised, as
rendering a successful result the more certain. The scar following the
curette and linear and punctate scarification is usually soft and
white, much less disfiguring, as a rule, than that following the action
of the stronger caustics. Destruction of the new growth by means of the
galvano-cautery or by the actual cautery has from time to time had its
advocates. Piercing the individual lesions with a platinum needle-point
heated to dull red by means of the battery has been strongly advised;
comparative absence of pain, rapidity, and good results are claimed for
it.


Scrofuloderma.

Scrofuloderma is a term employed to designate certain morbid conditions
of the skin which are dependent upon that state of the system known as
scrofula, or struma. The most common form of the cutaneous
manifestation is that which has its beginning in one or more of the
lymphatic glands. The gland slowly increases in size, without any of
the ordinary signs of inflammation, and after reaching the dimensions
of an almond may so remain or undergo fatty or cheesy degeneration. As
a rule, however, sooner or later the gland grows much larger, the
new-cell growth breaks down, the superjacent skin becomes hyperæmic,
thin, sensitive, and of a violaceous or purplish color. Finally, the
tumor breaks, and a thick, cheesy pus mixed with blood is discharged;
sinuses are apt to form, the skin ulcerates, and the process may so
continue for months, partial cicatrization taking place, and then again
breaking down. The resulting ulcers are irregular or ovalish in shape,
with undermined edges, and the surrounding thin and chronically
inflamed skin of a violaceous color. Their bases are uneven and covered
with pale, unhealthy-looking granulations. If there is crust-formation,
it is seen to be thin, grayish or brownish. The process is slow and
chronic. The scars are irregular, knotty, contracted, and often
hypertrophic. The affection is seen most frequently about the neck,
especially under the lower jaw. Other evidences of scrofula are usually
present.

A less frequent cutaneous manifestation consists of one or several
large, rounded, ovalish or irregularly-shaped, flat pustules upon an
inflamed or violaceous base. The crust forms slowly, is thin and flat,
and of a brownish color. The ulceration beneath has the peculiar
scrofulous characters. The scars which follow are soft, flat, and
superficial.

{699} A scrofuloderm occasionally met with consists of one or several
papillary or fungoid growths of a bright or dull violaceous red color,
with an ulcerated and discharging surface. They occur perhaps most
frequently about the hands, are chronic, and often lead to deep-seated
ulceration, which may involve the bones and give rise to deformity. The
disease resembles the verrucous and hypertrophic varieties of lupus
vulgaris.

Another variety of disease, seen usually in scrofulous subjects,
described by one of us (Duhring), manifests itself as small pinhead- to
pea-sized, disseminated, yellowish, flat papulo-pustules upon a red or
violaceous base, which slowly dry to crusts, and leave
punched-out-looking scars resembling those of variola. The lesions are
irregularly distributed, occurring for the most part about the face and
extremities. The process may continue for years. The lesions resemble
those of the small pustular syphiloderm.

The manifestations of scrofula are at the present time supposed to be
due to the specific infecting agent, the bacillus. Other conditions
which have been considered influential, and which are unquestionably
important predisposing causes, are heredity, blood-marriages,
insufficient and unwholesome food, continued exposure to wet and cold
and impure air. It generally develops in childhood, often after
measles, scarlatina, and similar diseases. Negroes are especially
predisposed to it. The scrofulodermata are, as a rule, readily
distinguished by their peculiar clinical characters. Other symptoms of
scrofula are, moreover, usually present and aid in the diagnosis. It is
to be differentiated from the gummatous ulcerations of syphilis by its
history, course, locality, the absence of the specific infiltration at
the borders of the ulceration, and the violaceous tint.

The constitutional treatment is the same as employed in other
scrofulous affections--cod-liver oil, syrup of the iodide of iron,
sulphide or muriate of lime, phosphorus, and iodine preparations being
the most reliable remedies. The diet should be liberal, consisting of a
large proportion of animal food. Hygienic measures are active
adjuvants. The external treatment of scrofulous ulcerations consists in
the use of stimulating applications. Mercurial ointments, corrosive
sublimate in alcohol, one-fourth to one grain to the ounce, and yellow
wash, are serviceable applications. Iodoform, in powder or ointment, is
often of benefit. A 1 or 2 per cent. nitrate-of-silver-ointment may
also be mentioned. Curetting, as in lupus vulgaris, is one of the most
valuable methods of treatment, especially useful in the fungoid
variety. Milton has had good results with calomel or gray powder, taken
at night two or three times weekly for a few weeks, and a saline every
morning in sufficient dose to produce a daily evacuation. The mercurial
is then intermitted for two or three weeks. Bitters and mineral acids
are given if the appetite fails. A simple ointment is used locally.


Syphilis Cutanea.

Syphilis (syphiloderma, dermatosyphilis, syphilis of the skin)
manifests itself in various forms upon the integument. Preceding or
ushering in the early eruptions there is sometimes considerable
systemic {700} disturbance, such as slight fever, loss of appetite,
muscular pains, and headache. In the greater number of cases, however,
general symptoms are wanting. Along with the cutaneous manifestations
there are usually other signs of the disease. In the early eruptions
the lymphatic glands are enlarged, and sore throat and mucous patches
may exist. Sometimes there is loss of hair. In the later syphilodermata
pains in the bones, bone lesions, and other symptoms may be observed.
The early eruptions are generalized; the later manifestations are
usually limited in extent, and have a tendency to appear in circular,
semicircular or crescentic forms. There are rarely any subjective
symptoms. The color of established syphilitic lesions is usually a dull
brownish-red or yellowish-red.

Syphilis may show itself as a macular, papular, vesicular, pustular,
bullous, tubercular or gummatous form of disease. In many instances,
although a particular efflorescence may predominate, lesions of other
varieties may be found intermingled.

SYPHILODERMA ERYTHEMATOSUM (syn., exanthematous syphilide, syphilis
cutanea maculosa, roseola syphilitica, macular syphiloderm) is a
general eruption, showing itself usually six to eight weeks after the
appearance of the chancre. The appearance of the eruption is retarded
by treatment. It consists of macules of various sizes and shapes, for
the most part the size of a pea or small bean and rounded, on a level
with the surrounding skin or slightly raised, giving the skin a mottled
or marbled look. At first the spots disappear under pressure, but
later, owing to the presence of more or less pigmentation, they
persist. Their outline, which is ill defined, is usually brought out
more distinctly on exposure. They vary in color from a pale pink to a
dull violaceous red, depending upon their duration and also upon the
natural complexion of the individual, and as they fade away become
yellowish or coppery. As a rule, they exist in profusion, so much so as
to cover not infrequently almost the entire surface, appearing without
order of distribution; exceptionally they exist sparsely and faintly,
in which case the eruption may be overlooked. The face, backs of the
hands, and feet frequently escape. Subjective symptoms are wanting. The
efflorescence may appear with or without systemic disturbance, but
malaise and slight fever frequently precede it. The chancre or its
scar, enlarged inguinal and cervical glands, erythema of the fauces,
rheumatic pains, and more or less falling of the hair usually accompany
its development. It may manifest itself slowly and insidiously, a week
or two elapsing before its height is reached, or the invasion may be
sudden, taking place in the course of twenty-four or forty-eight hours.
This syphiloderm probably occurs in the majority of cases of syphilis,
but in many instances is so faint as to escape observation. As a rule,
it responds rapidly to treatment.

It is to be distinguished from measles, rötheln, urticaria, simple
erythema, tinea versicolor, and certain medicinal eruptions. The
catarrhal symptoms, the fever, form, and situation of the eruption of
measles; the rapid formation and disappearance of the patches of simple
erythema; the wheals and intense itchiness of urticaria; the slight
scaliness, peripheral growth, and distribution of tinea versicolor; the
small roundish, confluent pinkish or reddish patches, precursory
pyrexic symptoms, the epidemic nature, short duration of rötheln; and
the history, fever, form, {701} and duration of the medicinal
rashes,--are points of difference which serve to distinguish these
diseases from the syphiloderm.

So-called Syphiloderma Pigmentosum, or pigmentary syphilide, may here
be referred to. It is a rare manifestation, and is characterized by
rounded, ovalish or irregularly-shaped, variously-sized, discrete or
confluent, pale grayish, yellowish, or brownish, usually ill-defined
faint macules. It occurs most frequently about the neck, is seen almost
exclusively in women, and is encountered during the latter half of the
first and in the second year of the disease. It develops slowly, and
may continue one or two months or as many years, and is uninfluenced by
antisyphilitic treatment. It is a simple pigmentary affection, similar,
apparently, to chloasma, from which and tinea versicolor it is to be
differentiated.

SYPHILODERMA PAPULOSUM (syn., syphilis cutanea papulosa, papular
syphilide, papular syphiloderm) is characterized by the formation of
variously-sized papules. The lesions are small or large, and in some
cases undergo various modifications.

The Small Papular Syphiloderm (syn., miliary papular syphiloderm,
lichen syphiliticus) consists in an eruption of disseminated or
grouped, more or less confluent, firm, small or minute, rounded or
acuminated papules, the size of a pinhead or milletseed. Their summits
may be smooth or covered with fine scales, or may show pointed
pustulation; this last symptom occurring especially in those through
which a hair protrudes. Miliary pustules, scattered here and there over
the surface, may also be present. At first the eruption is bright- or
dull-red, but later it generally assumes a violaceous or brownish tint.
In some cases the lesions are numerous and grouped, forming patches.
The eruption is seen most frequently about the trunk and upon the
limbs. It may appear during the third or fourth month or later. Large
flat papules or moist papules may exist simultaneously. It has a
chronic course, with a tendency to relapse, and is usually rebellious
to treatment. It is to be distinguished from keratosis pilaris, lichen
scrofulosus, psoriasis punctata, papular eczema, and lichen ruber. The
extent of the eruption, the color, grouping, with usually the presence
of pustules and large papules and other concomitant symptoms of
syphilis, are points of differentiation.

The Large Papular Syphiloderm (syn., lenticular syphiloderm) is
characterized by the formation of large, flat, circular or ovalish,
firmly-seated, more or less raised pale- or dull-red papules, varying
in size from a small split pea to a dime. In their early stage they are
usually smooth, but they subsequently become covered with exfoliating
epidermis. The forehead, region of the mouth, neck, back, flexor
surfaces of the extremities, scrotum, labia, perineum, and margin of
the anus are all favorite localities. The lesions, as a rule, develop
slowly, and, having attained various sizes, remain for weeks or months.
It is one of the commonest forms of cutaneous syphilis; it may be an
early or late eruption, and shows a disposition to relapse. As a rule,
it yields readily to treatment. The lesions may undergo more or less
modification, due either to the locality in which they exist or to
other influences. Ordinarily, they persist as typical papules, and
gradually pass away by absorption. At times they become soft and
spongy, while occasionally they become excoriated, with slight moisture
and crusting. This latter condition is {702} usually observed about the
junctures of the mucous membrane and the skin.

A common change is into the Moist Papule (syn., mucous papule, mucous
patch, broad, or flat, condyloma; _Fr._ plaques muquese). This takes
place upon those regions where opposing surfaces and natural folds of
skin are subjected to more or less contact, as about the nates,
umbilicus, axillæ, beneath the mammæ, etc. The lesions are more or less
moist, covered with a grayish, sticky, mucoid secretion consisting of
macerated epidermis. They are usually flat, and may coalesce, and so
form large patches. They may become hypertrophic, warty, and papillary,
constituting the vegetating syphiloderm (syphilis cutanea vegetans). In
this form the lesions become elevated, more or less circumscribed, and
may assume a warty character, resembling the cauliflower formation,
with a contagious secretion which dries to yellowish-brown crusts.
Heat, moisture, friction, and uncleanliness favor their development.
They usually disappear rapidly under local treatment.

Another modification which the papule frequently undergoes is into the
squamous papule, forming the Papulo-squamous Syphiloderm (syn. squamous
syphiloderm, syphilis cutanea squamosa, psoriasis syphilitica). The
papules become somewhat flattened, and are covered with dry, grayish,
adherent scales. The scaling may be slight or relatively abundant, but
is rarely as luxuriant as in psoriasis. On removing the scales the
papular character of the lesion may readily be detected. As a rule, the
eruption is not extensive; it may show itself on any part, and is
exceedingly persistent. It is most frequently encountered on the palms
and soles, where, on account of the peculiarities in the structure of
the skin, the lesions are somewhat modified. Occurring on these parts,
it is known as the palmar or plantar syphiloderm. The lesions partake
more of the nature of macules than papules; they are slightly raised
and are irregular in outline, and, as a rule, ill defined, varying in
size from a pea to a finger-nail. They may coalesce and form roundish
serpiginous or crescentic patches covered with dry, scanty,
semi-detached, grayish flakes of epidermis, which are most abundant
about the edges; at times the exfoliation is marked, and then the
patches are distinctly squamous, as in psoriasis. It is, as a rule,
symmetrical, and is frequently observed in the centre of the palms or
soles and upon the ball of the thumb and about the volar surfaces of
the fingers. It is rebellious to treatment. It may be an early or late
manifestation, but is usually the latter.

The papulo-squamous form of the syphiloderm may resemble eczema and
psoriasis. In eczema heat, itching, and sometimes discharge, together
with the history and course, will be sufficient points of distinction.
Psoriasis upon the palms rarely occurs except as a part of a general
eruption; the character and abundance of the scales, their lamellar
arrangement, the red rete beneath, and the absence of infiltration are
diagnostic. The differential diagnosis of the papulo-squamous
syphiloderm and psoriasis when occurring on the other parts of the body
are fully given in treating of the latter disease.

SYPHILODERMA VESICULOSUM (syn., vesicular syphilide, syphilis cutanea
vesiculosa) is an exceedingly rare form of cutaneous syphilis, and in
the majority of cases may be more properly classed under {703} the head
of the pustular variety. The lesions vary in size from a pinhead to a
split pea. If small, they are more or less acuminated, disseminated, or
grouped, usually involving the hair-follicles; if large, semiglobular
or flat, with or without a tendency to umbilication. The vesicles, as a
rule, pass into pustules. It is an early eruption, occurring usually
within the first six or eight months; is rarely extensive, pursues a
rapid course, and is generally associated with other symptoms of the
disease.

SYPHILODERMA PUSTULOSUM (syn., pustular syphilide, syphilis cutanea
pustulosa) is an important manifestation, although not so common as the
macular and papular varieties. The lesions assume one of several forms,
although not infrequently they are found intermingled.

The Small Acuminated Pustular Syphiloderm (syn., miliary pustular
syphiloderm) is characterized by the formation of milletseed-sized
acuminated pustules, usually seated upon minute reddish papular
elevations. The puriform contents dry to crusts, which fall off and are
followed by a slight fringe-like exfoliation around the base,
constituting a grayish ring or collar. The lesions commonly involve the
hair-follicles, are present in great numbers and scattered over the
whole surface, and may be either disseminated or in groups; in relapses
the eruption is usually localized. Variously-sized larger papules are
sometimes seen scattered sparsely over the surface. It may be an early
or a late secondary eruption. Minute pinpoint atrophic depressions and
stains are left, which gradually become less distinct. Other symptoms
of syphilis are usually present. The diagnosis is rarely difficult.

The Large Acuminated Pustular Syphiloderm (syn., acne-form syphiloderm,
acne syphilitica, variola-form syphiloderm) consists of small or large
split-pea-sized pustules, more or less acuminated, resembling the
lesions of simple acne or variola. The resulting crusts are yellowish
or brownish, usually thick and bulky, and are seated upon ulcerated
bases. The lesions may develop slowly or rapidly, with or without
malaise or febrile symptoms, are disseminated or grouped, at first
looking more or less papular. In the subacute or relapsing cases the
eruption is apt to be localized. It pursues a rapid and usually a
benign course, and is to be distinguished from acne, from the
potassium-iodide eruption, and from variola. The usual limitation of
acne lesions to the face and shoulders, their rapid formation, and the
chronic character of the disease, together with the absence of the
concomitant symptoms of syphilis, are points which may be utilized in
the diagnosis. Variola differs in the intensity of the general
symptoms, the umbilicated pustules, and the definite duration of the
disease. The acute character, bright color, course, and history of the
potassium-iodide eruption are generally sufficiently characteristic.

The Small Flat Pustular Syphiloderm (syn., impetigo-form syphiloderm,
impetigo syphilitica) shows itself in the form of pea-sized, flat or
raised, discrete, irregularly-grouped, or confluent pustules. The
crusts, which form rapidly, are a yellow, greenish-yellow, or
brownish-yellow color, more or less adherent, thick, bulky, uneven,
with a tendency to become granular and to crumble. Where the lesions
are confluent there results a continuous sheet of crust. Beneath the
crusts there may be superficial or deep ulceration. The eruption is
most frequently {704} observed about the nose, mouth, and hairy parts
of the face, on the scalp, and also about the genitalia. When upon the
scalp it is apt to resemble pustular eczema; the erosion or ulceration
beneath, however, will serve to differentiate it.

The Large Flat Pustular Syphiloderm (syn., ecthyma-form syphiloderm,
ecthyma syphiliticum) appears in the form of large pea- or dime-sized,
flat pustules, with a deep red base. Crusting usually follows
immediately. There are two forms of the lesion--a superficial and a
deep. In the superficial variety the crust is flat, rounded, or
ovalish, yellowish-brown or dark brown, and seated upon a superficial
erosion or ulcer, having a grayish or yellowish secretion. It may occur
upon any region, but is most common on the back, shoulders, and
extremities; the lesions are sometimes numerous. It appears, as a rule,
within the first year and runs a benign course. In the deep variety the
crust is raised and more bulky, dark-greenish or blackish, inclining to
become conical and stratified, like an oyster-shell, constituting what
is designated rupia. A crust of the same character occurs in the
bullous syphiloderm. If the crust is removed, an excavated ulcer is
seen, having a defined or irregular outline and a greenish-yellow,
puriform secretion. It is a late and a malignant manifestation, and is
not infrequently met with in hospital and dispensary practice.

SYPHILODERMA TUBERCULOSUM (syn., tubercular syphilide, syphilis cutanea
tuberculosa) is characterized by one or more firm, circumscribed,
rounded, acuminated, or semiglobular, deeply-seated, smooth, glistening
or slightly scaly elevations, yellowish-red, brownish-red, or coppery
in color, varying in size from a split pea to a hazelnut. They rarely
occur in great numbers, and are, as a rule, confined to certain
regions, and show a decided tendency to occur in groups, often forming
segments of circles. When several such groups coalesce, the result is a
serpiginous tract, the so-called serpiginous tubercular syphiloderm.
The face, back, and extremities are favorite localities. The lesions
develop slowly, are unaccompanied by subjective symptoms, and usually
occur as a late manifestation, at times appearing many years after the
initial lesion. A history of earlier symptoms of the disease is usually
obtainable.

The eruption terminates or disappears either by absorption or by
ulceration. If the former, a pigment-stain, which is usually
persistent, and in some cases slight atrophy, mark the site of the
lesions, and there may be also a slight amount of exfoliation. If
ulceration results, it may be superficial or deep, more frequently the
latter. It begins on the summit or in the interior, and the result is a
deep, punched-out, more or less crescentic ulcer with a gummy,
grayish-yellow deposit or covered with a crust. If the ulcerative
process takes place in a patch of grouped tubercles, an extensive
excavated ulcer may result. Sometimes the ulceration occurs in a
crescentic or serpiginous course. In some instances from the ulcerating
surface spring up papillary, wart-like, or cauliflower excrescences,
with a yellowish, offensive, puriform secretion, the so-called syphilis
cutanea papillomatosa. This condition is most frequently encountered
upon the scalp.

Tubercular syphiloderm is to be differentiated from lupus vulgaris,
leprosy, and cancer--especially the first, to which it at times bears a
close resemblance. In syphilis the lesions are firmer and deeper, and
form more rapidly, than in lupus; moreover, the disease is usually one
of {705} adult life and middle age, whereas lupus appears, as a rule,
first in childhood.

SYPHILODERMA GUMMATOSUM (syn., gummatous syphilide, syphilis cutanea
gummatosa) consists in the formation of a rounded or flat, slightly
raised, moderately firm, more or less circumscribed tumor, having its
seat in the subcutaneous tissue, which later shows a tendency to break
down. As a rule, only one or two tumors are present. The growth is
variously known as a gumma, gummy tumor, and syphiloma. The lesion,
which is usually a late manifestation, begins as a small, pea-sized
deposit beneath the skin, which gradually increases in size; the
overlying skin, which is at first of a natural color, becoming pinkish
or reddish. It may eventually attain the size of a walnut or may be
even larger. It is firm or soft and doughy to the touch, is usually
painless, and tends to break down, disappearing by absorption or
ulceration, the ulcer being usually deep with perpendicular edges. It
is to be distinguished from furuncle, abscess, and fatty and fibrous
tumors. In most cases other symptoms of syphilis are present.

SYPHILODERMA BULLOSUM (syn., bullous syphilide, syphilis cutanea
bullosa, pemphigus syphiliticus) appears in the form of discrete,
disseminated, rounded or ovalish blebs, varying in size from a pea to a
walnut, and containing a serous fluid which rapidly becomes cloudy or
thick. In some cases the process is distinctly pustular from the
beginning. The blebs, which are, as a rule, partially or fully
distended, after a variable time dry to crusts of a yellowish-brown or
dark-greenish color, which may be thick and raised or conical and
stratified, the latter constituting rupia, as in the case of the large,
flat pustular syphiloderm. They are easily removed, and cover erosions
or ulcers which secrete a greenish-yellow fluid. It is a rare
manifestation, occurring late, is variable in its course, and is seen
usually in broken-down individuals. It is not infrequent in hereditary
syphilis in the new-born.[7]

[Footnote 7: For the cutaneous manifestations of hereditary syphilis
see article by J. William White on that subject in Vol. II. p. 254.]

ANATOMY.--Anatomically, the syphilitic deposit consists of a round-cell
infiltration. It is most typically shown in the papule and tubercle; in
the macule there is hyperæmia, with beginning tissue-cell
proliferation, but the specific cell-infiltration is not
distinguishable. The process usually involves the mucous layer of the
epidermis, the corium, and, in the deep lesions, the subcutaneous
connective tissue. The extent and depth of the infiltration depend upon
the size and form of the growth.

TREATMENT.--Cutaneous syphilis, as in the case of all other
manifestations of this disease, requires constitutional treatment, and
generally local medication also. In order that relapses may in a great
measure be obviated, prolonged treatment by appropriate remedies is
essential. Even with such management and under the best circumstances
relapses will frequently occur. The advantage of temperate and regular
living and hygienic influences in promoting a disappearance of the
manifestations and keeping the disease in abeyance cannot be too
strongly urged. In syphilitic subjects anæmia, dyspepsia, malaria, or
any similar condition is apt to render the syphilis more violent, and,
if present, should receive appropriate treatment. Ill health from any
cause predisposes to a relapse.

{706} The remedies which, in a sense, may be considered to exert a
specific action in syphilis are mercury and potassium iodide. They are
indispensable in the treatment of the disease. Both are important,
although the former is the more valuable. As a rule, mercury is the
remedy to be given in the first stages of the disease, and the cases
are exceptional in which its use is not permissible. In such instances
potassium iodide is to be prescribed. As the later stages of the
disease approach the iodide of potassium becomes relatively more
important. Even in the late syphilodermata, however, mercury in small
doses holds a prominent place in the treatment, as it seems to possess
a greater influence in preventing relapses. In the administration of
mercury salivation is to be carefully guarded against, as its
occurrence is detrimental to the health of the patient, and indirectly
as well as directly it exerts an unfavorable influence on the course of
the disease. Beyond slight tenderness of the gums its action should
never be pushed.

There are several methods of administering mercury, but that by the
mouth is for many reasons the best. For this purpose various
preparations, such as blue mass, calomel, corrosive sublimate, the
protiodide and biniodide, as well as other mercurials, are used. In the
average case the protiodide is one of the best, and is probably in most
general use. It is given in pill form in the dose of one-fourth or
one-half a grain three times daily. If gastric or intestinal
disturbance, such as pain and diarrhoea, is produced by its use, as is
occasionally the case with this and all other preparations of mercury,
a small proportion of opium may be added to each pill. Blue mass is an
important mercurial in the early syphilodermata, and is given in doses
of two or three grains three times daily. For bringing the system
rapidly under the influence of the mineral, an important consideration
in some cases, calomel in doses of one or two grains combined with
opium, three or four times a day, is the most active. Corrosive
sublimate is slow in its action, but is usually well borne and shows
but slight disposition to salivate. The dose is one-twenty-fourth to
one-eighth of a grain in pill or solution three times daily. It is
rarely employed in early syphilis, but is a useful mercurial for
long-continued administration, and also in the later stages of the
disease.

Inunction is another method of introducing mercury into the system, and
is especially useful in treating the disease in the infant. For this
purpose two preparations are used--blue ointment and oleate of mercury.
The latter, 5 to 20 per cent. strength, has lately been somewhat
extensively employed, but it is not comparable in value for this
purpose to the blue ointment. The sole advantage of the oleate is its
light color. The blue ointment may always be prescribed with confidence
as to its effect; the same cannot be said of the oleate. Various
regions are selected for the inunctions--the arms, axillæ, thighs,
abdomen, chest, and back being taken in turn, so as to obviate as far
as possible local irritation. About a drachm of the blue ointment
suffices for an inunction. For infants the preparation should be
weakened. By means of inunctions the system may rapidly be brought
under the influence of the remedy.

Another method of introducing mercury is by hypodermic injections.
Corrosive sublimate is the preparation commonly employed; about
one-tenth of a grain, with about the same quantity of morphia,
dissolved in fifteen minims of water, constitutes the average amount
for an {707} injection, one being made daily. The back, especially the
lateral regions, is the part usually selected. The method has the
advantage of rapidity of action, twenty to thirty injections sufficing,
as a rule, to remove the lesions. At the same time potassium iodide, if
indicated, may be given by the mouth. The method, however, is
objectionable, the injections producing pain, inflammatory swelling,
and induration, and not infrequently abscesses. Ptyalism, a possible
accident also, is to be guarded against.

The mercurial vapor bath is in many cases of value. Calomel or the
black oxide of mercury is commonly used, about thirty grains of either
to the bath. A vaporizing apparatus, containing the mineral and water
required, is placed beneath the stool or chair, and the patient
enveloped in a sleeveless flannel gown and covered over with a rubber
blanket, the bath lasting about thirty minutes. The patient remains
covered until cooled off, and then goes to bed in the flannel gown. The
plan has cleanliness and simplicity as well as effectiveness to commend
it. The corrosive-sublimate water bath is another method that is
useful, especially for infants--ten to thirty grains to the bath for an
infant, and two to four drachms for an adult. From fifteen minutes to
half an hour should be passed in the bath.

Potassium iodide is, as already stated, indispensable in the treatment
of late manifestations. The average dose is ten to twenty grains three
times daily, but in many obstinate cases much larger doses may be
necessary. It is usually given after meals, but it may be taken largely
diluted half an hour before eating to greater advantage. Mercury should
be, for reasons already stated, prescribed with it, the two remedies
constituting the so-called mixed treatment. Another remedy frequently
of use in the treatment of syphilis, especially in obstinate cases of
ulceration, is opium in the dose of one or two grains three times
daily, which in some cases possesses the power of arresting the
activity of the process.

Local treatment remains to be considered. In the macular and small
papular eruptions it is rarely called for, but in the more severe
syphilodermata their disappearance may be hastened by external
applications. The mercurial vapor and water baths already mentioned are
serviceable; also an ointment of ammoniated mercury, a drachm to the
ounce, a 5 to 20 per cent. oleate-of-mercury ointment, and citrine
ointment with two to four parts of lard, constitute excellent local
remedies. Mercurial plaster is frequently of value, especially in
reducing infiltrations. In the palmar and plantar syphilides strong
ointments are necessary, and should be well worked into the skin. Moist
papules always require treatment; cleanliness is of great importance.
Applications of solutions of chlorinated soda, corrosive-sublimate
lotion, and a lotion of carbolic acid, followed by a dusting-powder of
calomel, oxide of zinc, or starch, may be advised. The ulcerative
lesions, after the removal of crusts by means of hot water or oily
applications, are to be treated with the ointments or lotions named
above.


Epithelioma.

There are three varieties of epithelioma or skin cancer--superficial,
deep-seated, and papillomatous. The superficial, or flat, form begins
as a minute, firm, reddish or yellowish prominence, or it may begin as
an {708} aggregation of such lesions. The process may remain in this
stage for months or years; sooner or later, however, the summit of the
growth becomes slightly scaly and shows a softened or excoriated
centre. From this central point a small quantity of fluid oozes, which
forms a yellowish or brownish crust. This scale or crust becomes
detached from time to time, either intentionally or by accident, and is
followed by another similar in character, but possibly larger than that
which had preceded. At the same time the underlying nodule or nodules
slowly increase in size.

In this condition it may remain for months or years, but sooner or
later the process becomes more active. New nodules form about the edges
of the patch, and in a variable period go through the same steps as
those forming the original lesions. The excoriation or ulcer becomes
more marked, being as large as a pea or a dime, irregular in outline,
more or less crusted. It is defined against the surrounding healthy
skin by a flat or slightly elevated, more or less hardened, infiltrated
border. The ulcer, which has usually an uneven surface, secretes a
scanty, thin, viscid fluid, which dries to a firm, adherent crust. At
points there may be a disposition to spontaneous involution, the
epithelial growth being cast off by suppuration, depressed scar-tissue
taking its place. The ulcerative process, however, generally progresses
until often a sore of considerable size may form. The general health
remains unaffected. The superficial variety may form as described, and
may so continue its course, or it may at any stage pass into the more
malignant, deep-seated variety.

This latter variety may begin as a tubercle or nodule in the normal
skin, or it may, as already stated, start from the superficial or other
variety. Where it develops typically a pea-sized, reddish, shining
tubercle or nodule, or an area of infiltration, forms in the skin, or
even in the subcutaneous connective tissue, which grows slowly or
rapidly, usually from six months to a year or more elapsing before
exciting solicitude. Sooner or later, depending on the virulence of the
process, ulceration takes place, superficial or deep-seated in
character, depending upon the amount of infiltration. The surface of
the ulcer is granular and reddish and secretes an ichorous discharge,
and the edges are indurated and, as a rule, everted. As the
infiltration spreads the ulcer enlarges peripherally, and at the same
time involves the deeper parts, muscle, cartilage, and bone often
becoming implicated. The glands also become involved, burning or
neuralgic pains are felt, and the strength gradually declines, until
from septicæmia, marasmus, or implication of vital parts death results.

The third variety, the papillomatous, may arise in the form of a
papillary or warty growth, or it may develop, as is more commonly the
case, from either the superficial or the deep-seated variety. At an
advanced period its surface is papillomatous or warty, is ulcerated and
fissured, bleeds easily, and discharges an ichorous fluid, which dries
and forms a brownish crust.

Epithelioma is most frequently encountered about the face; the nose,
eyelids, and cheek all being favorite localities. The neck, the hands,
and the genitalia also suffer frequently. If seated about the genitals,
its course is apt to be more rapid and destructive. The predisposing
causes are not well understood. The disease rarely shows itself before
middle life, and is {709} much more common in men than in women. It is
not, as a rule, inherited. The exciting causes are frequently to be
found in long-continued alterations in the epithelial structures, such
as, for example, occur in warts. Any locally irritated tissue may be
the starting-point of the disease. The process consists in the
proliferation of epithelial cells from the mucous layer. The
cell-growth takes place downward in the form of finger-like
prolongations or columns, or it may spread out laterally, so as to form
rounded masses, the centres of which usually undergo horny
transformation, resulting in onion-like bodies, the so-called
cell-nests or globes. The rapid cell-growth requires increased
nutriment, and hence the blood-vessels become enlarged; moreover, the
pressure of the cell-masses gives rise to irritation and inflammation,
with corresponding serous and round-cell infiltration.

Epithelioma is to be differentiated from syphilis, wart, and lupus.
Occurring about the genitals, it may be confounded with chancre, but
the history, duration, character of the base and edges will serve to
differentiate the diseases. The syphilitic lesion, wherever occurring,
runs a much more rapid course than epithelioma. In tubercular syphilis
several points of ulceration are usually seen; in epithelioma usually
only one. The secretion from syphilitic ulcerations is generally
abundant and of a yellowish, creamy character; in cancer it is scanty,
viscid, stringy, and streaked with blood. The ulcer of syphilis rarely
has the elevated, infiltrated border usually seen in epithelioma. Warts
or warty growths must be distinguished by attention to their history
and course; observation extending over months may at times be necessary
before a positive opinion as to the existence of epithelial
degeneration is warrantable. In lupus vulgaris the deposits are
peculiar and are multiple, while in epithelioma the lesion is usually a
single formation. The former generally begins in early life; the latter
is a disease of the middle-aged and old. It remains to be stated that
occasionally cancer and lupus occur combined, the former usually
following the latter.

TREATMENT.--The variety, extent, and rapidity of the process are always
to be duly considered in the prognosis. The superficial form may exist
for many years without causing alarm. The deep-seated variety is always
to be viewed as a serious disease, and is often fatal. Relapses after
operation, even where this has been well performed, are frequent. The
treatment is in most cases--for the time, at all events--successful. If
the diseased tissue is thoroughly removed, the relief may be permanent
or may at the least extend over several years. If, however,
cauterization or operation is not thorough, the parts are scarcely
healed before symptoms of a recurrence manifest themselves. Internal
treatment does not seem to exert any beneficial effect upon the
disease. In regard to local treatment, whatever operation or remedy is
capable of removing or destroying the growth may be employed, caustics,
the curette, and the knife all being available for this purpose.

Among the caustic agents, potassa in stick or in solution is one of the
most valuable. Chloride of zinc in paste or stick form may also be
mentioned as being of service, but it is a painful caustic. Arsenical
pastes are efficient, and have the advantage of sparing the healthy
tissues; one consisting of equal parts of powdered acacia and arsenic,
to which a small proportion of morphia may be added, will be found
serviceable; {710} it should kept applied in the form of a plaster for
from six to twenty-four hours, or until the pain, which is apt to be
severe, becomes unbearable, and then poultices applied. Pyrogallic
acid, from one to four drachms to the ounce of resin cerate, is a very
valuable remedy. Its action is slow; it should be renewed twice daily,
and its application continued for a week or longer. As a rule, it is
painless.

One of the best plans of treatment is that with the dermal curette. The
diseased tissue is thoroughly scraped away, the wound dressed with some
simple ointment, and healing allowed to take place. Sometimes after the
use of the curette it is advisable to cauterize lightly with caustic
potash or to apply an ointment of pyrogallic acid for a few days to
ensure complete destruction of the disease. There are other cases in
which excision constitutes the most useful method of treatment. In
cases in which there is much loss of tissue a plastic operation may be
performed, being preceded by a thorough removal of the diseased
tissues. The galvano-cautery is another method which may be resorted
to.


Sarcoma.

Sarcoma cutis, or sarcoma of the skin, is a rare affection, consisting
of shot-, pea-, hazelnut-, or larger-sized, variously-shaped, discrete,
non-pigmented or pigmented tubercles or tumors. They are smooth, firm,
and elastic, are not markedly painful upon pressure, and show a
tendency to reach the surface and ulcerate. The overlying skin is at
first normal and somewhat movable, but as the lesions approach the
surface it becomes reddened and adherent, or if of the pigmented
variety the skin acquires a bluish-black color. The multiple pigmented
sarcoma (melano-sarcoma) appears, as a rule, first on the soles and
dorsal surfaces of the feet, and later on the hands, the lesions
manifesting a disposition to bleed.

The disease described by Geber and one of us (Duhring) under the name
of inflammatory fungoid neoplasm is doubtless a form of, or closely
allied to, sarcoma. It manifests itself by the formation of several
distinct kinds of lesions, the more important consisting of flat or
slightly-raised coin- to palm-sized, rounded or ovalish, superficial or
deep-seated, smooth, scaly, or crusted patches of a pale-pinkish or
deep-reddish color; and prominent, rounded, or ovalish, soft, firm, or
solid, furrowed or lobulated, tubercular or fungoid tumors, varying in
size from a pea to an egg, somewhat depressed in the centre, and
pale-red, deep raspberry-red, or violaceous in color. The flat patches
with involution assume a mottled or streaked purplish, yellowish, or
salmon color. The tumors may appear suddenly within a few hours or a
day, or gradually in the course of weeks or months. After reaching a
certain size they tend to soften, diminish in size, and undergo
spontaneous involution or ulcerate. Itching and burning are usually
complained of, but are variable. All regions may be attacked. It is
rare. The so-called lymphadenoma, lymphadénie cutanée, and mycosis
fungoide of the French may also, doubtless, be properly classified as a
variety of sarcoma.

The disease is to be distinguished from the papular, tubercular, and
gummative syphilodermata, lupus, leprosy, and carcinoma. As a rule,
sooner or later, a fatal termination takes place. Treatment is
palliative. Surgical interference may be of service in particular
situations. {711} Hypodermic injections of Fowler's solution in
increasing doses have, it is stated, influenced the disease favorably.


CLASS VII.--NEUROSES.


Dermatalgia.

Dermatalgia, or neuralgia of the skin, is characterized by pain having
its seat solely in the skin, unattended by structural change, and
associated usually with a morbidly sensitive condition of the part. The
symptoms are purely subjective, as in pruritus. The skin shows no
alteration. It is usually a local disorder, confined to a small area,
and is met with, as a rule, in adult age. It consists in a
highly-sensitive state of the integument, with a feeling of positive
pain having its seat in the superficial layers of the skin, which is
remarkably sensitive to external impressions; the touch, contact of the
clothing, and even the air, exciting more or less pain. In character
the sensation is burning, pricking or darting, or like electric shocks.
It is generally worse at night. The affection may exist idiopathically
or symptomatically, the latter being the more common and accompanying
lesions of the nervous centres. Its frequent connection with rheumatism
has been pointed out by Beau and other writers, from which fact it is
sometimes called rheumatism of the skin; but in other cases it occurs
in persons apparently in good health. Hysteria has also been noted as a
cause. The general treatment depends upon the exciting cause, but local
measures may be demanded to relieve the disagreeable or painful
sensations, among which the galvanic current, applications containing
belladonna, aconite, or iodine and blistering may be tried.


Pruritus.

Pruritus is a functional disease of the skin, characterized solely by
the sensation of itching, without the existence of structural change.
The affection must be clearly separated from the many other cutaneous
diseases accompanied by itching. In pruritus the single symptom is
itching, varying in kind and degree. There are no primary structural
lesions, but secondary lesions, resulting from scratching and local
irritation, are not infrequently present. The sensation is variously
described by the sufferers, being often likened to the crawling of
small insects over the surface. The desire to rub or scratch is
irresistible. In other cases the sensation is a tingling, or as though
some irritating substance, as flannel, was in contact with the surface.
It exists in all degrees of severity, and frequently proves a source of
great distress. It may occur at any age, but is most often met with in
middle life and in old age, constituting so-called pruritus senilis.
The itching may be constant or intermittent, but is usually the latter,
occurring in most cases paroxysmally, and being almost invariably worse
at night.

{712} The disease may be local or general, but it seldom invades large
portions of the surface at one time. In most cases it is a local
disorder, the common regions being the genitalia and anus. The trunk,
especially in elderly persons, is also not infrequently invaded.
Occurring about the female genital organs, it constitutes the pruritus
vulvæ of writers, having its seat in the labia or in the vagina. It is
a very distressing form of disease, and is met with, as a rule, in
middle life and old age. In the male the anus and the scrotum are the
regions generally attacked, the perineum sometimes also being involved
simultaneously. The anus in either sex is liable to invasion, the
disease occurring here in children as well as in adults. All of these
local varieties, as stated, are worse at night, and sometimes prove so
harassing as to interfere greatly with sleep.

The causes which give rise to the affection are varied. Thus it is
sometimes called forth by gestation and by the various disorders of
menstruation, and in other instances, in either sex, by organic
diseases of the genito-urinary tract. Diseases of the kidney and of the
liver, especially jaundice, are frequently accompanied by pruritus. The
nervous system is not infrequently at fault. Gastro-intestinal
derangement, the ingestion of certain medicines (as opium), intestinal
parasites, and hemorrhoids, are all well-known causes. The disease is
strictly functional in nature, and is due to reflex nervous action.

The diagnosis rests with the subjective symptoms as given by the
sufferer. There are no primary lesions; the secondary lesions, however,
are sometimes so extensive as to suggest other diseases, especially
prurigo and eczema, but there should be no difficulty in
differentiating these diseases if their clinical features are kept in
mind. Prurigo--a disease, practically speaking, unknown in this
country--it will be remembered, is characterized by well-defined
papules, and moreover shows predilection for the lower extremities. The
subjective symptoms of pruritus often simulate those due to the
presence of lice. In all cases these parasites, whether of the head,
body, or pubes, should be carefully excluded in the diagnosis, for it
sometimes happens that pediculosis is looked upon and treated as
pruritus, the true nature of the affection being unsuspected.
Pediculosis, it must not be forgotten, is occasionally met with in the
upper walks of life, where it is at times extremely difficult to
account for the source of contagion. Inspection of the skin and of the
underclothing should be made in all suspected cases.

The treatment naturally varies with the determined or probable cause.
The local origin of the affection should, in the first place, be
inquired into. The internal remedies are to be selected with the view
of meeting the requirements of the case. The various functions of the
body should receive due attention, the bowels, in all cases tending to
constipation, being kept open by laxatives, preferably saline
preparations. The diet should be directed, all stimulating or injurious
food and drink being interdicted. Quinine, arsenic, belladonna,
strychnine, carbolic acid, tincture of gelsemium, and pilocarpine are
remedies which may be tried in obstinate cases. In all cases the cause
should be diligently sought for, for until this is discovered and
removed there can be but little hope of complete recovery. External
remedies, though extremely grateful to the patient, and of course very
useful, as a rule are only palliative. There are cases, however, in
which they prove curative. Water in the form of very hot or {713} cold
douches, and alkaline and sulphur lotions and baths, are sometimes
serviceable, employed either alone or in connection with other
remedies. In the local varieties of the disease antipruritic and
stimulating lotions are especially serviceable. One of the most
valuable remedies is carbolic acid, in the strength of from fifteen to
forty grains to the ounce, to which may be added small quantities of
glycerin and alcohol. A strong lotion consists of carbolic acid, one
drachm and a half; potassa, twenty grains; water, eight ounces. The
tarry preparations considered in eczema, especially liquor carbonis
detergens and liquor picis alkalinus, are useful, as are likewise
thymol, a few grains to the ounce of glycerin and alcohol, and oil of
peppermint. The latter remedy, pure or mixed with glycerin, may be
applied with a brush. Sometimes a simple chloral lotion is efficacious.
In like manner lotions of acetate of lead, ten to thirty grains to the
ounce; dilute hydrocyanic acid, a few drachms to the pint; hyposulphite
of sodium; chloroform; chloroform and alcohol; diluted acetic acid;
diluted ammonia-water; diluted nitric-acid; and corrosive
sublimate,--may be tried. R. W. Taylor recommends the following:

  Rx. Fol. belladonnæ,
      Fol. hyoscyami,  aa. drachm ij;
      Fol. aconiti,        drachm ss;
      Acidi acetici,       fluidounce j.  M.

This may be diluted with water a drachm to the ounce, or may be used
with equal parts of glycerin, painted on the skin or in the form of an
ointment, a drachm or two to the ounce. Tobacco, used as an infusion,
two or three drachms to the pint, is often efficacious, especially in
pruritus vulvæ. The fluid extract of conium, applied with a brush, and
iodoform in ethereal solution, applied as a spray, may likewise be
resorted to where the disease involves this region. Camphor and borax
may be mentioned as being sometimes of service, as in the following
formula:

  Rx. Sodii boratis,  drachm ij;
      Glycerinæ,      fluidrachm iv;
      Spts. camphoræ, fluidounce ss;
      Aquæ rosæ,      ounce v.  M.

Another lotion, containing borax and morphia, may be given:

  Rx. Sodii boratis,  drachm iv;
      Morphiæ sulph., gr. xv;
      Glycerinæ,      fluidounce ss;
      Aquæ,  q. s. ad fluidounce viij.  M.

In some cases ointments prove more acceptable than lotions. Tar,
carbolic acid, thymol, and the mercurials are all valuable used in this
form, varying in strength with the locality and amount of surface to be
treated. The smaller the area, as a rule, the stronger the remedy.
Chloroform, chloral, and camphor also may be used in the form of
ointments. About one drachm each of chloral and camphor to the ounce
constitutes a good antipruritic remedy; the active ingredients are to
be rubbed together and then added to the ointment.

In pruritus of the anus one of the most valuable and neatest remedies
is carbolic acid with glycerin or olive oil, in the strength of from
fifteen to forty grains to the ounce. Very hot water applied with a
soft linen compress or sponge will usually afford temporary ease, and
may be employed from time to time in connection with other more active
{714} remedies. In some cases we have had rapid and good results from
an ointment of balsam of Peru, a drachm and a half to the ounce. Equal
parts of belladonna ointment and mercurial ointment, and a solution of
corrosive sublimate, about a quarter of a grain to the ounce, may also
be mentioned; and where there are fissures occasional pencilling with a
solution of nitrate of silver will afford relief, the latter
application, made with a piece of sponge fastened on a stick, being
also useful in pruritus vulvæ.

A long list of formulæ have been vaunted for the relief of pruritus of
the female genitalia, a few of which may be given. In addition to the
remedies already mentioned the following formulæ will sometimes prove
valuable. The fluid preparations may be used as vaginal injections or
may be applied by means of a brush, tampon or cloth, according to their
nature. Hyposulphite of sodium, a drachm to the ounce; sulphurous acid,
sufficiently diluted; alum, sulphate of zinc, tannic acid, acetic acid,
borax, and boric acid, may all be made use of in the form of
injections. In this variety of the disease, as well as in pruritus of
the anus, a 6 per cent. solution of cocaine, applied with a brush, or
the oleate used as an ointment in the same strength, may be prescribed.

The prognosis should in all cases be guarded, the ability to relieve
the disorder depending mainly upon the nature of the cause. The
majority of cases, due to no evident cause, prove obstinate. But in all
instances the patient should be encouraged to persevere in the
treatment, and the hope of an ultimate cure extended to him.

       *       *       *       *       *

PRURITUS HIEMALIS.--This is a peculiar form of pruritus, characterized
by a somewhat harsh and dry state of the skin, accompanied with
smarting and burning, unattended primarily by structural change,
dependent upon atmospheric influences, and occurring chiefly in winter.
It makes its appearance usually in the late autumn, becoming worse with
the colder weather, and disappearing in the spring. The disease
manifests predilection for certain regions, notably the extremities,
especially the inner surfaces of the thighs, the popliteal spaces, and
the calves; but in a less degree it may also invade other localities.
In its milder form it is a common affection in cold climates. At times
the itching is severe, leading to scratching and excoriations, while in
other cases it merely amounts to an annoyance. It possesses the
peculiarity of manifesting itself chiefly at night, coming on during
the evening or shortly after bed is entered. The symptoms usually vary
with the weather, being better and worse as the temperature is mild or
cold. The affection in most instances repeats itself each year, and may
thus continue indefinitely or it may partly or wholly disappear. As
stated, the disorder is due to atmospheric influences, but is
aggravated by irritating underwear and scratching. It occurs in both
sexes, at all ages after puberty, and in those who bathe freely as well
as in those who make sparing use of water. It does not seem to be
influenced by the state of the general health, nor does internal
treatment affect it favorably. Among the various external remedies,
preparations containing glycerin, the petroleum ointment, carbolic acid
and tar in the form of ointments and lotions, as in eczema, and
alkaline lotions and baths,--may be mentioned as being most useful. The
simple vapor bath is also in some cases beneficial.


{715} CLASS VIII.--PARASITES.


Tinea Favosa.

Tinea Favosa, or favus, is a contagious, vegetable parasitic disease,
due to the achorion Schönleinii, characterized by discrete or confluent
pea-sized, circular, pale-yellow, friable, cup-shaped crusts, usually
perforated by hairs. It is seen commonly upon the scalp, and at times
on other hairy regions, involving the hairs and hair-follicles (tinea
favosa pilaris), or the non-hairy portions of the integument may be
attacked (tinea favosa epidermidis), and cases are occasionally met
with in which the nails are the seat of the disease (tinea favosa
unguium). The scalp is the usual seat. It begins as a more or less
circumscribed, superficial inflammation, with slight scaling, followed
by the appearance of one or more yellowish points underneath the
superficial epidermis and surrounding hair-shafts. They increase in
size, and reach the dimensions of small peas, constituting the
so-called favus cups, favi, or favus scutula. They are sulphur-colored,
friable, circumscribed, round or oval, with depressed centres, and each
pierced with a hair. In their early stage they are bound down to the
skin by a layer of epidermis, which surrounds and envelops their
periphery. The crusts are elevated from a half to several lines above
the surrounding skin, distinctly umbilicated, and if detached an
excavated, reddened, atrophied or suppurating surface is disclosed.

The crusts are composed of closely-packed, concentrically-arranged
layers, and although they are at first discrete, sooner or later, from
increase in number and size, they coalesce, and then their peculiar
features are scarcely, if at all, distinguishable, irregular masses of
thick, yellowish-white, mortar-like crusts taking their place. If
removed, the surface is usually found atrophied, dry or inflamed and
moist, and hairless. The hair-shafts are soon involved, the nutrition
of these structures impaired, and in consequence the hairs become dry,
lustreless, brittle, break off or fall out, and eventually the papillæ
are entirely destroyed. Pustules and suppuration are in some instances
noted about the borders and beneath the crusts. The pressure of the
growing fungus gives rise to atrophy of the skin, which may be seen as
depressed, firm, shining, cicatricial-looking areas. The general
surface may also be attacked, either together with the scalp or alone.
On non-hairy regions, however, the disease is rarely persistent. If the
nails are invaded, they become thickened, yellowish, opaque, and
brittle. Favus is usually attended with itching, especially when
occurring upon the scalp. The odor of the crusts is peculiar, and may
be likened to that of mice or stale straw. Upon the scalp the disease
is always chronic, if untreated lasting indefinitely.

It is more common in children than in adults, and is seen almost
exclusively among the poor. It is comparatively rare in this country.
It is contagious. The disease is also encountered in the lower animals,
from which doubtless it is not infrequently contracted. The affection
is due solely to the growth in the upper layers of the skin of the
achorion Schönleinii. This vegetable parasite grows luxuriantly, and
constitutes almost entirely the whole mass of the crusts. It can be
readily seen by subjecting a small portion of the crust, moistened with
diluted liquor potassæ, {716} to microscopical examination, a power of
three to five hundred diameters sufficing. It consists of both spores
and mycelium. The mycelium is composed of pale-grayish or pale-greenish
narrow, flat threads or tubes branching and anastomosing in all
directions. The spores are small, variable as to size, round, oval,
flask- or dumb-bell-shaped, and are to be seen in abundance in the
meshes of the mycelium. Intermediate forms between the spores and
mycelium are always present. The hair-follicles and hair-shafts are
found to be more or less invaded. If the nails are attacked, the fungus
can be easily detected in a section or in scrapings, the mycelium
predominating.

As a rule, favus is easily recognized. The small, pale, yellow, friable
cup- or saucer-shaped crusts and the peculiar odor are sufficiently
characteristic. In some chronic cases, where the crusts are merged into
a mass, perhaps mixed with dirt and pus, it resembles pustular eczema;
but the condition of the hair, the atrophic patches, and the odor will
serve as distinguishing points. Tinea tonsurans can scarcely be
confounded with this disease, as it is wanting in the peculiar
crust-formation and the tendency to scarring. In doubtful cases the
microscope is to be employed.

Favus of the scalp is not only a chronic disease, but is also
rebellious to treatment. In neglected cases permanent baldness,
atrophy, and scarring sooner or later occur. On the non-hairy portions
of the body it is rarely obstinate; involving the nails, it is slow to
yield. The first step in the treatment of a case of favus of the scalp,
the common seat of the disease, is a removal of the crusts. This is
readily accomplished by saturating the parts with simple or carbolized
oil, and subsequently washing with soap and hot water. The hair on and
around the patches is to be clipped as a preliminary measure; keeping
the hair of the entire scalp cut short facilitates treatment, but is
not essential. The hairs in the diseased areas are then to be carefully
extracted by means of the broad-bladed forceps. This part of the
treatment, epilation or extraction of the hairs, is indispensable if
the eventual result is to be successful and permanent. Before
epilating, the surface to be operated upon is to be anointed with a
simple oil. After the operation a parasiticide is to be thoroughly
applied, so that it may penetrate the hair-follicles. The whole surface
involved is thus treated. Another plan of epilation is that in which
the hair is drawn with some force between the thumb and an ordinary
tongue-spatula, those that are diseased and loose coming out, while
those that are sound remain. In this method the hair is not clipped.
The plan is more simple and less tedious than forceps epilation, but is
not so satisfactory, as the hairs are more likely to break off, and,
moreover, many that are diseased are left unextracted.

Whatever parasiticide is used should be well and thoroughly applied to
the affected areas. Those that have the greatest penetrating power are
to be selected. Corrosive sublimate, three or four grains to the ounce
of alcohol or ether; a 25 per cent. oleate-of-mercury ointment;
carbolic acid and glycerin, one part of the former to three or more of
the latter,--may be mentioned as among the most useful. Tar, sulphur,
and ammoniated mercury and citrine ointments, of officinal strength or
weakened; sulphurous acid; a solution of hyposulphite of sodium, a
drachm to the ounce,--are also efficient parasiticides. Chrysarobin, in
ointment or in chloroform, a drachm to the ounce, has been well spoken
of, but must be used {717} cautiously. After several weeks' treatment
applications may be suspended for a week or more, so that the condition
may again be determined. In ordinary well-developed cases from three to
six months' active treatment is required for a removal of the disease.

Favus of the non-hairy portions of the surface requires, after a
removal of the crusts, the application of a mild parasiticide, the
disease, as a rule, readily yielding. In favus of the nail as much as
possible of the affected portion is to be pared or cut away, and a
simple parasiticide applied once or twice daily. In those who are
debilitated and ill-nourished favus may possibly be rendered less
obstinate by suitable internal treatment, with proper nourishment and
pure air.


Tinea Trichophytina.

Tinea trichophytina, or ringworm, is a contagious vegetable parasitic
disease, due to the trichophyton, its clinical characters varying
according to the part invaded. It is a common disease, more frequent in
children than in adults, and is met with to a varying extent in all
countries. It is contagious, but individuals vary as regards
susceptibility. The fungus (the trichophyton) consists of spores and
mycelium. The latter consists of long, slender, delicate,
sharply-contoured, pale-grayish, straight or crooked, branching,
ribbon-like threads, containing spores and granules. They are
remarkable for their length. The spores are round, small, highly
refractive, grayish or pale-greenish bodies, and are either single or
arranged in rows, which may be isolated or joined to mycelium. The
appearances of the disease, and to a certain extent its treatment, are
so different when affecting the general surface, the scalp or the
bearded region that separate descriptions are called for. When seated
upon the general surface the disease is commonly known as tinea
circinata (tinea trichophytina corporis); on the scalp, tinea tonsurans
(tinea trichophytina capitis); on the bearded region, tinea sycosis
(tinea trichophytina barbæ).

       *       *       *       *       *

TINEA CIRCINATA, or ringworm of the body, is characterized by one or
more circular or irregularly-shaped, variously-sized, inflammatory,
slightly vesicular or squamous patches. It usually begins by the
formation of one or more roundish, slightly-elevated, sharply-limited,
somewhat scaly, hyperæmic spots, which in some cases show minute
papules or vesicles, especially about the periphery. As the process
advances, usually in the course of a few days, the inflammation is more
marked and the scaliness increased. The patches assume, as a rule, a
distinctly annular character, and as they grow by extending
peripherally, their centres clear up, so that when fully developed they
are usually about an inch in diameter, and consist of a more or less
normal central area, then an intermediate pale-reddish scaly portion,
and the red, elevated, and scaly or papulo-vesicular or vesicular
border defined against the healthy skin. In rare instances
vesico-pustules may form. There may be one, several, or many patches
present, but as a rule they are not numerous. After attaining a certain
size they may remain stationary for a short time or may begin to
disappear spontaneously. Where two or more are in close proximity, they
may increase in size, gradually coalesce, and form gyrate or {718}
irregularly-shaped lesions. At times, instead of the typical annular
patches, the disease may appear in the form of disseminated, small,
reddish, slightly scaly, ill-defined spots, which may appear and
disappear rapidly, the patient rarely being free of lesions. Although
any portion of the general surface may be invaded, there are certain
regions of predilection, as the face, neck, and backs of the hands. It
is commoner in children than in adults.

Involving surfaces that are in close contact, as the axillæ, between
the buttocks, and the inner surfaces of the thighs, it tends to spread
extensively, is more inflammatory, and often proves rebellious to
treatment. Invading these parts, the condition, under the impression
that it was an eczema, was described by Hebra as eczema marginatum. It
is most common, however, about the thighs, and seated here is termed
tinea circinata cruris. It begins usually in the same manner as
ringworm on other regions, but on account of the heat, moisture, and
friction of the parts its characters become changed. The patch becomes
inflamed, slightly elevated, coalescing with similar patches, until the
greater part of the inner surface of the thighs and buttocks may be
involved. The groins and mons veneris may also be invaded. When fully
developed it is characterized by extensive, irregularly-shaped,
inflammatory patches, with at times a slightly moist surface, and is
usually well defined against the surrounding healthy skin by a more or
less raised border, which may show papules or vesicles. Sometimes
beyond the general area involved may be seen more or less typical
ringworm patches. As met with in this country, it is usually mild in
character. In Southern Europe it is encountered more frequently, is of
a severer type, and is often intractable. It is met with usually in
adults. Relapses are not uncommon.

The course of ringworm of the general surface may be acute or chronic.
It may disappear in a few weeks, or, on the other hand, may continue
indefinitely. As commonly met with in this country, it is, as a rule,
readily responsive to treatment. It is frequently seen in association
with ringworm of the scalp. Itching in variable degree is usually
present. Invading the nails, the affection is designated tinea
trichophytina unguium. These structures become dry, opaque, dirty white
or yellowish, thickened, of irregular shape, bent, soft, or brittle and
laminated, the changes taking place especially about the free border.
The nails of the toes are seldom affected. As a rule, not more than two
or three of the finger-nails are attacked. It is commonly associated
with chronic ringworm on other parts of the body.

The fungus (trichophyton) in tinea circinata has its seat in the
epidermis, especially in the corneous layer. The first effect of its
invasion is hyperæmia, subsequently inflammation, usually mild in
character, with more or less scaling. A microscopical examination, with
a power of two to five hundred diameters, of scales from the periphery
of a patch, moistened with liquor potassæ, will show both mycelium and
spores, the latter comparatively few in number. In fact, the fungus in
ringworm of the body is rarely to be found in abundance. In tinea
trichophytina unguium the substance of the nail is invaded, scrapings
of which will show the fungus, usually the mycelium, generally but few
spores being present.

The affection is to be recognized by its peculiar clinical features,
and, if necessary, by means of the microscope. This instrument should
{719} always be employed in cases of doubt. At times it bears
resemblance to eczema and seborrhoea, and to psoriasis. From eczema it
may be distinguished by its circular or annular form, its
sharply-defined margins, its tendency to clear up in the centre, its
slight desquamation, and its history and course; the itching is usually
less marked than in eczema. Seborrhoea, when occurring on the chest and
back, often consists of circular patches similar in general features to
ringworm, but the scales are greasy, and are seated upon non-inflamed
skin; the scaliness of ringworm is the result of inflammation, while
that of seborrhoea consists of dried sebaceous matter. Moreover, in the
latter affection the sebaceous follicular openings are perceptibly
enlarged, and are indicative of the nature of the disease. In psoriasis
at times the patches clear up in the centre, and in such instances a
mistake in diagnosis might occur. The scaliness of psoriasis, however,
is always a marked feature; it is usually insignificant in ringworm.
Moreover, the characters of the scales are different. Occasionally the
circinate tubercular syphiloderm has been confounded with ringworm, but
the nature of the patch in the former disease, consisting of an
irregular and incomplete ring of elevated tubercles or infiltrations,
with, at times, ulceration, is so entirely different from the latter
affection that an error should not occur. It can scarcely be confounded
with favus if the peculiar yellowish, cup-shaped crusts of that disease
are kept in mind; the clinical features of the two affections are also
in other respects dissimilar.

The treatment consists in the application of the milder parasiticides,
the disease rarely proving obstinate. In exceptional cases, where the
affection is persistent, it will sometimes be found that the general
nutrition is below the standard; and in such instances constitutional
remedies of a tonic nature, as cod-liver oil, iron, quinine, and
arsenic, are serviceable. In children the skin is delicate and strong
remedies are not well borne; nor are they, as a rule, necessary. The
parts should be first washed with soap and water, and then the remedial
applications made; the lotion or ointment should be applied two or
three times daily. If a lotion, it should be dabbed on thoroughly; if
an ointment, it should be thoroughly rubbed into the patches. The
sulphite or hyposulphite of sodium, in lotion or ointment form, a
drachm to the ounce; sulphurous acid, full strength or diluted;
ammoniated mercury, thirty to sixty grains to the ounce of lard or
vaseline; corrosive sublimate, two to four grains to an ounce of
alcohol or water; an ointment of sulphur, a drachm or two to the ounce;
tar ointment, a drachm or two to the ounce; carbolic acid, ten to
thirty grains to the ounce of water or lard,--are all parasiticides of
value which may be employed in this disease. In obstinate cases
chrysarobin, five to thirty grains to the ounce of lard, may be
cautiously used, or it may be applied in collodion or gutta-percha
solution, 5 to 10 per cent. strength. In tinea circinata cruris
applications such as the above, but stronger, are serviceable. R. W.
Taylor speaks well of a solution of corrosive sublimate in tincture of
benzoin, two to four grains to the ounce, painted over the parts. The
chrysarobin ointment or solution already mentioned may also be
especially referred to. Hebra's modification of Wilkinson's ointment
(see Scabies for formula) is useful in these cases. In tinea
trichophytina unguium the nail should be pared or scraped, and one of
the parasiticides applied.

       *       *       *       *       *

{720} TINEA TONSURANS.--Tinea tonsurans, or ringworm of the scalp, is
characterized by circular or irregularly-shaped, variously-sized,
scaly, more or less bald patches, showing the hair to be diseased and
usually broken off close to the scalp. It is met with in children,
especially in those under the age of twelve years; it is rarely seen
after puberty. It begins as one or more small, round, erythematous,
scaly spots, which may be minutely papulo-vesicular or vesicular about
the periphery. Soon by peripheral growth typical circular patches of
various sizes are formed, averaging about an inch in diameter. More or
less itching is usually complained of. A typical patch is
circumscribed, slightly elevated, reddish, grayish or slate-colored,
with more or less scaling, usually thin or bran-like in character, with
the hairs broken off close to the scalp. The color varies with the
complexion of the individual; in marked blondes it has usually an
inflammatory tint, while in those of dark hair and skin it is
bluish-gray or the color of slate. The hairs on the affected areas are
involved early in the disease, becoming lustreless, dry, brittle,
twisted, breaking off close to the skin, with their free extremities
ragged and uneven, having a gnawed or nibbled look. They are easily
extracted, or often break off within the follicles, appearing then as
blackish dots. A variable degree of baldness occurs, which, however, is
rarely permanent. In some instances the patch is non-inflammatory and
free of scales, the loss of hair, which is more or less complete,
taking place rapidly, such cases bearing resemblance to alopecia
areata. As a rule, several patches varying in duration and size are
present. They may remain discrete, or coalesce and form irregular
areas. The vertex and parietal regions are favorite localities,
although any region of the scalp may be invaded. It is not uncommon to
see patches of the disease on the non-hairy portions of the body at the
same time.

In some cases, especially in those ill nourished and scrofulous, the
inflammation may be of a higher grade, resulting in the production of
discrete or grouped pustules, terminating in crusting; or the disease
may assume the condition known as tinea kerion. This latter is seen
most commonly in scrofulous subjects. Beginning ordinarily as a simple
patch of ringworm, the affected area soon becomes inflamed, swollen,
oedematous, elevated, red, shining and boggy, covered with a mucoid
secretion which is poured out from the openings of the hair-follicles.
The stubby hairs soon fall out, leaving the patch more or less bald.
The surface is uneven and studded with the foramina, or small cavities,
containing the mucoid or sero-purulent secretion, corresponding to the
dilated hair-follicles. It bears resemblance to abscess and carbuncle.
An analogous condition is not uncommon in tinea sycosis. It may occur
with the usual form of tinea tonsurans or alone. Occasionally the
disease cures itself in this way. It may, however, be chronic. Its
causes are not understood: it may be due to the presence of the fungus
in the deeper portions of the hair-follicles, or at times to
over-treatment. It is a rare manifestation.

Other unusual forms of the disease are occasionally noted. The spots
may in the early stages be merely scaly, with or without inflammatory
symptoms, and the hairs long and firmly seated, resembling eczema or
seborrhoea. Later, however, the hairs break and the characteristic
stumps are the result. As ringworm becomes chronic (its usual course)
the clinical features become different. The disease exists in irregular
areas--as {721} a rule, non-inflammatory and more or less scaly,
especially about the follicles. The hairs are short, stubby, and broken
off near the skin or in the apertures of the follicles; in the latter
case the skin has a punctate or dotted appearance. This condition is
noted especially in brunettes; in blondes the hairs are somewhat longer
and apt to drop out insidiously. Or, the disease may be disseminated,
involving here and there over the scalp small groups of follicles, the
hairs being short, the follicles slightly enlarged, with a tendency to
scaliness; in these cases the disease may be easily overlooked.

Ringworm of the scalp is a common affection, and is observed among the
rich as well as the poor, but is most frequent in those suffering from
malnutrition. It may be communicated by means of caps, combs, brushes,
and the like. It is frequently seen in schools and children's asylums,
sometimes affecting a large proportion of the inmates. The fungus
(trichophyton) invades the epidermis, hair-follicle, bulb, and shaft.
The follicle becomes distended and raised; the hairs are permeated with
the fungus (spores markedly predominating), are disintegrated, and
destroyed. The perifollicular tissue may, in severe cases, be invaded.
The spores are present in great abundance, the mycelium existing
scantily.

As a rule, there is no difficulty in recognizing the disease. The
presence of stumps of hair having a gnawed or nibbled look, the
prominent follicles, more or less baldness, and slight or decided
scaliness, together with the history and course, constitute a clinical
picture that is scarcely mistakable. If necessary, microscopical
examination of the hair will give positive information. For this
purpose one or two of the short, stubby hairs should be selected,
placed upon a slide, a drop of liquor potassæ added, allowed to stand a
few minutes, and then examined with a power of two to five hundred
diameters; the hairs will be found full of spores, the shafts being
completely disintegrated. If a few drops of chloroform are poured upon
a patch of ringworm of the scalp and allowed to evaporate, the hairs
and follicular openings affected become whitish or light-yellow, which,
according to Duckworth, is pathognomonic. It is to be differentiated
from squamous eczema, seborrhoea, psoriasis, and alopecia areata. The
history of eczema is different: it rarely begins as circular spots,
spreading peripherally; the margins are always more or less irregular;
the hairs are not involved, but remain seated firmly in the follicles;
the itching is marked, whereas in ringworm it is usually slight.
Seborrhoea is non-inflammatory; the scales are greasy; the hairs are
not broken off; and the margins of the patch are ill defined. In
psoriasis the scaling is a marked feature; the hairs are not involved;
and the disease is usually to be found typically expressed on other
parts of the body. From alopecia areata ringworm may be differentiated
by its clinical features; in the former disease the baldness is usually
complete, the skin devoid of scales, non-inflamed, smooth, shining, and
the follicles, as a rule, less prominent than normal; the absence of
the characteristic stumps of ringworm may also be noted. In obscure
cases the microscope is to be employed.

An opinion regarding the length of time required to cure ringworm of
the scalp should always be guarded; while some cases respond in several
weeks, in others several months or more may be required. Relapses are
liable to occur. External remedies are, as a rule, alone required. In
{722} chronic cases, however, where a condition of malnutrition exists,
proper food, fresh air, and suitable internal remedies, as cod-liver
oil, iron, and arsenic, are to be advised; cleanliness is of
importance. The patches should be washed frequently with warm water and
castile soap or sapo viridis, the frequency depending upon the scaling
and the amount of disease, and also somewhat upon the remedies
employed. Occasional washing of the entire scalp is also to be advised.
Remedial applications should be, as a rule, made twice daily. In acute
or recent cases, in which the fungus has not penetrated deeply into the
hair-follicles, it often yields to the ordinary parasiticides, without
the necessity of epilation. In cases commonly encountered, however, the
disease has already lasted some length of time, and epilation becomes
essential. The main difficulty in the treatment of tinea tonsurans is
to bring the remedy in contact with the fungus; otherwise the affection
would be as easily curable as that occurring on the general surface. To
a great extent epilation aids in overcoming this difficulty, as the
parasiticide is then able to permeate the emptied follicle; and in
addition to this advantage the extracted hairs take with them the
fungus contained within their structures. The hair within and around
the affected areas should be clipped short, or, if the patches are
numerous, the hair of the entire scalp should be cut, or, what is
preferable in many cases, shaved. If the scalp is shaved, a few days
elapse before epilation is possible. On a shaved head there is no
chance for any diseased area, however small, to escape observation; in
the treatment of the disease as met with in institutions this procedure
is almost essential. In epilation the loose hairs on the patches and
about the borders should first receive attention. For this purpose a
small, broad-bladed, short forceps may be employed, a few hairs at a
time being seized. A portion of the diseased area should be carefully
gone over each day until all are removed. After each epilation the
parasiticide is to be applied.

Corrosive sublimate, two to four grains to the ounce of alcohol or
water, is a reliable remedy; also oleate of mercury, in the form
preferably of a 25 per cent. ointment. An ointment such as the
following is serviceable in many cases:

  Rx. Ugt. picis liquidæ,
      Ugt. hydrarg. nitrat., aa. drachm ij;
      Ugt. sulphuris,            drachm iv.
    M. Ft. ugt.

Or, in place of the tar ointment in the formula, carbolic acid in the
same or less quantity may be substituted. The officinal tar, sulphur,
and ammoniated mercury ointments may also be referred to as useful. In
small disseminated patches carbolic acid in glycerin, one to three
drachms of the former with enough of the latter to make an ounce, will
often prove serviceable. Thymol sometimes proves of value, and may be
prescribed as advised by Malcolm Morris:

  Rx. Thymolis,     drachm ss;
      Chloroformis, drachm ij;
      Olei olivæ,   drachm vj.  M.

Coster's paste is also serviceable:

  Rx. Iodinii,    drachm ij;
      Olei picis, ounce j.  M.

{723} This is painted on the patch, and permitted to remain on until
the crust comes off, then is reapplied: a few applications are
sometimes sufficient. In tinea kerion the hairs are extracted and a
mild parasiticide applied: sulphurous acid, a weak solution of
corrosive sublimate, carbolic acid, ten to twenty grains to the ounce
of water, or a weak ointment of the oleate of mercury or of white
precipitate, may be employed.

If the disease proves obstinate, resisting the above treatment, it may
be necessary to adopt stronger applications with a view of producing an
acute inflammation in the part. To be efficacious the inflammatory
action should be marked. For this purpose croton oil is used. It should
never be employed when the disease is extensive; or if used in such
cases a small area only, not exceeding that of a quarter dollar, should
be treated at one time. Although valuable, the remedy is severe, and
must be used cautiously. It may be applied pure or weakened with two or
three parts of olive oil. An application requires but a small quantity,
as it is apt to involve the skin beyond the area of application. In
some cases a single application is sufficient; in others several or
more are necessary before the requisite amount of follicular
inflammation and suppuration results. The applications should be made
by the physician, as it is not a safe remedy to entrust to attendants.
After the application the part should be poulticed, and subsequently
epilation practised and mild parasiticides employed. Instead of using
croton oil, the patches may be painted with glacial acetic acid or
cantharidal collodion once a week, and mild parasiticides, as
sulphurous acid, carbolic-acid lotion, or sulphur ointment, applied in
the interval. From time to time in the treatment of the disease,
usually at intervals of from three to four weeks, applications should
be discontinued a few days, and a microscopic examination of the scales
and hairs made: if fungus is found, treatment is to be resumed.

       *       *       *       *       *

TINEA SYCOSIS.--Tinea sycosis, or parasitic sycosis, is a disease
confined to the hairy portions of the face and neck in the adult male,
involving the hair and hair-follicles, with inflammation of the skin
and subcutaneous connective tissue, and the formation of tubercles and
pustules. It is popularly known under the name of barber's itch. It
usually begins as one or more small, red, scaly spots, similar, in
fact, to ringworm on the non-hairy portions of the surface. The redness
and scaliness increase, and swelling and induration are noticed. In a
short time the hairs are involved, become dry, brittle, inclined to
break, and begin to fall out, the same changes occurring as noted in
ringworm of the scalp. The fungus passes to the hair-follicles;
perifollicular inflammation is set up, and results in the formation of
deep-seated tubercles, varying in size from a pea to that of a cherry,
giving the part a distinct nodular appearance. These coalesce and give
rise to lumpy patches. The surface is of a deep reddish or purplish
color; pustulation is noted about the openings of the hair-follicles.
More or less crusting may take place; if removed, the hairs may come
away with it. The amount of suppuration depends upon the grade of
inflammation. Sometimes the hair-follicles are destroyed and permanent
alopecia results.

The disease may involve a small area, appearing as a
sharply-circumscribed, prominently-raised, deep-seated, nodular,
coin-sized patch, with or without a purulent discharge from the emptied
hair-follicles or with {724} crusting; or the whole bearded region of
the neck and chin may be invaded. It is not common on the upper lip or
the upper bearded portion of the cheeks. Burning and itching are
usually present, but are variable as to degree. The disease tends to
chronicity. It is not uncommon at the same time to see patches of
ringworm on other portions of the body. It is markedly contagious,
although individuals differ as to susceptibility. It is often
contracted at the hands of a barber. The fungus (trichophyton) which
gives rise to the disease invades the same parts as when seated upon
the scalp--the epidermis and the hair and hair-follicles; the latter
are usually found permeated with spores, the mycelium being scanty.

The affection is not common, its frequency varying in different
countries. It is to be distinguished from simple (non-parasitic)
sycosis, pustular eczema, and the vegetating syphiloderm. In simple
sycosis the process is comparatively superficial and confined to the
hair-follicles; the hairs are not involved, and in the beginning, at
least, are seated firmly in the follicles. In tinea sycosis the skin
and subcutaneous connective tissue are extensively involved, resulting
in the formation of nodular masses--a condition that is characteristic;
the hairs are affected, are loose, and often fall out. In doubtful
cases the microscope will determine. From pustular eczema it may be
differentiated by its history and course: its clinical features are
entirely dissimilar. Eczema is never attended with the nodular and
tubercular formation peculiar to this disease, nor are the hairs
affected. The absence of ulceration will distinguish the disease from
the vegetating syphiloderm. Tinea sycosis when occurring as a
circumscribed patch may sometimes resemble carbuncle.

In the treatment epilation with the use of parasiticides is employed;
as a rule, the disease yields readily to treatment. Crusts, if present,
are to be removed by means of oily applications and washings with
castile soap (or if necessary sapo viridis) and warm water. The parts
should be clipped or shaved, preferably the latter. Although this
operation is painful at first, later it may be accomplished without
much discomfort; shaving every second or third day is frequent enough.
In the interval epilation is to be practised. The milder parasiticides,
as sulphite or hyposulphite of sodium, a drachm to the ounce of water
or ointment; sulphurous acid, full strength or diluted; citrine
ointment, two or three drachms to the ounce of vaseline or lard; and a
weak sulphur ointment,--are all useful. A 10 to 30 per cent. ointment
of oleate of mercury is a valuable remedy; the same may be said of a
solution of corrosive sublimate, two to four grains to the ounce of
water or alcohol. In addition, the other parasiticides mentioned in the
treatment of ringworm of the body or scalp may be referred to. The
applications should be made twice daily; together with epilation they
should be continued until microscopical examinations of the hairs give
negative results.


Tinea Versicolor.

Tinea versicolor is a vegetable parasitic disease due to the
microsporon furfur, characterized by variously-sized,
irregularly-shaped, dry, slightly furfuraceous, yellowish, macular
patches, occurring for the most part upon {725} the trunk and in
adults. The affection may be slight, consisting of several small
patches on the upper part of the chest, or so extensive as to involve
the greater part of the trunk, neck, axillæ, flexures of the elbows,
groins, and in very rare instances the face. It never occurs on the
scalp, hands, or feet. As commonly met with, it is a disease of the
trunk, especially the anterior portion of the thorax. It begins as
small yellowish or brownish, fawn-colored, furfuraceous spots scattered
over the region affected. These gradually increase in size, new spots
may appear, and considerable surface may be invaded. In size they vary
from a pea to large irregular patches, and are scarcely, if at all,
elevated. The larger patches are irregular, and usually formed by
coalescence of several smaller spots. Rarely patches may clear up in
the centre and assume an annular form.

The number of patches varies; as a rule, a half dozen or more are
present; in other cases they may be numerous. They show more or less
furfuraceous scaling, varying with the amount of perspiration and the
frequency with which the parts are washed. The scaling, even when it is
insignificant or when the patches are apparently smooth, may be easily
detected by scratching or scraping the surface. Slight itching is
ordinarily present, especially when the parts are unusually warm; it is
rarely marked. The color is usually a pale or brownish yellow. In
sensitive skins at times the affection causes more or less hyperæmia,
and the spots have a reddish hue. The course of the disease is
variable, sometimes spreading rapidly, while in most cases its progress
is slow. It is, as a rule, persistent, existing years. Relapses are not
uncommon.

The cause of the disease is the vegetable fungus, the microsporon
furfur. It invades the superficial portion of the epidermis. The
affection is but slightly contagious. Those between the ages of twenty
and forty, of either sex indifferently, are most frequently the
subjects of the disease; it rarely if ever occurs in children or in
elderly people. It is commonly observed in those whose nutrition is
below the standard, especially in persons having pulmonary phthisis. It
is a common affection, and occurs, in varying proportions, in all parts
of the world. Scrapings or scales moistened with liquor potassæ may be
examined with a power of three to five hundred diameters, and the
peculiar features of the fungus well brought out, as the fungus exists
in abundance. It consists of mycelium and spores, the former appearing
as short, slender, variously-sized, straight or curved, twisted, wavy,
or angular threads, crossing one another in all directions. In
appearance they are homogeneous or granular, and often contain spores,
especially about the joints. The spores are ovalish or round, sharply
contoured, small in size, with a nucleus and slightly granular plasma.
They show a marked tendency to aggregate and form groups--an
arrangement which is characteristic of this fungus. The growth is found
in every stage of development from mycelium to spores.

There should be no difficulty in recognizing the disease if its
characters and distribution are kept in mind. In doubtful cases the
microscope will prevent error. It is at times confounded with chloasma,
vitiligo, and the macular syphilide. In chloasma, in which there is
merely an increase of pigment in the rete, there is no scaling, the
outlines are ill defined, and it is usually seen about the face--a
region that is practically exempt in tinea versicolor. Moreover, the
coloration in the parasitic disease is due to the {726} fungus, which
has its seat in the superficial epidermis and can be readily scraped
off. With ordinary care it is impossible to mistake vitiligo for the
disease in question. The macular syphiloderm is to be distinguished by
attention to the distribution, character, and size of the lesions.
Tinea versicolor is practically a disease of the trunk; the macular
syphiloderm is usually distributed over the whole surface; and if it is
the latter disease concomitant symptoms of syphilis are almost
invariably present.

The disease is readily curable; any simple parasiticide properly and
thoroughly applied will soon effect its removal. Lotions, as a rule,
are to be preferred, inasmuch as they are more cleanly and more
satisfactory. Washing the parts involved frequently with green soap
(sapo viridis) and warm water is to be advised as an adjuvant, and will
in some cases suffice to remove the disease. Alkaline baths, three or
four ounces of carbonate of sodium or potassium to thirty gallons of
water, are also useful. Various parasiticides are employed. Sulphite or
hyposulphite of sodium, a drachm to the ounce; corrosive sublimate, two
or four grains to the ounce of alcohol and water; sulphurous acid, pure
or diluted; a saturated solution of boric acid; Vleminckx's solution,
diluted with three to six parts of water,--are among the most useful.
Sulphur and ammoniated mercury ointments, carbolic acid, ten to twenty
grains to the ounce of lard, may be mentioned as serviceable. The
frequency of application depends upon the extent and obstinacy of the
disease, once or twice daily usually sufficing. After the disease is
apparently cured treatment should be continued, although less actively,
for a few weeks or a month, in order that a relapse may be avoided.


Scabies.

Scabies, or itch, is a contagious animal parasitic disease, due to the
Sarcoptes scabiei, characterized by the formation of cuniculi, papules,
vesicles, and pustules, followed by excoriations, crusts, and general
cutaneous inflammation, and accompanied with itching. The amount of
disturbance depends upon the duration of the disease and the
sensitiveness of the skin. The itch mite (Acarus scabiei, Sarcoptes
scabiei, or Sarcoptes hominis) through contagion finds its way upon the
skin, and begins to burrow its way through the upper layers of the
epidermis. The female only is found within the epidermis, the male, as
generally supposed, never penetrating the skin. As the female burrows
she lays a varying number of eggs, a dozen or more; by this time the
burrow, or cuniculus, has usually attained its full length of several
lines. It is to be seen as a narrow whitish or yellowish linear
epidermic elevation, as a rule irregular and tortuous, and with a
dotted or speckled look. It contains the female, its excrement, and a
variable number of eggs. In a short time the ova are hatched, and the
mites are rapidly multiplied. New burrows appear and are to be seen in
all stages of development, and thus the disease progresses.

According to the sensitiveness of the skin will the lesions produced in
consequence of the irritation of the mite vary. Usually, inflammatory
points, papules, vesicles, pustules, and excoriations are to be seen
scattered over the regions involved. The hands, especially the sides of
the fingers, {727} are almost invariably the parts first attacked, the
mite gradually invading other parts of the body, as the anterior
surfaces of the wrists, forearms, elbows, and arms, the axillary folds,
about the mammæ in females, between the buttocks, about the penis, the
inner sides of the thighs. The face and scalp are never invaded, except
in infants. Itching is a marked symptom, usually worse at night. In
well-advanced cases the secondary symptoms, such as papular elevations,
vesicles, impetiginous and ecthymatous pustules, which are often torn
by the scratching invoked, the crusts and excoriations of various
characters, and a variable amount of cutaneous inflammation, with
infiltration and pigmentation, taken together with the presence of
burrows, constitute a clinical picture of the disease. In many cases
the cuniculi are in a great measure obliterated by the scratching;
their remains, however, may usually be detected. In persons with
eczematous skin true eczema may be developed.

The disease is due solely to the presence of the itch mite. It is met
with in persons of all ages and in every station of life, but for
obvious reasons is more common and its ravages more marked among the
poor. It is encountered in all parts of the world, but is especially
frequent in the various European countries. In the United States it is
comparatively infrequent, and is seen chiefly in the seaboard cities,
and many of the cases can be traced to direct importation from abroad.
It is markedly contagious. The Sarcoptes scabiei is almost microscopic
in size, appearing as a yellowish-white rounded body. The male is but
half the size of the female, and is rarely met with, apparently having
no direct part in producing the cutaneous disturbance seen in the
disease. The full-grown female, as may be determined by microscopical
examination, is ovoid or crab-shaped, the dorsal surface convex and the
ventral surface flattened, the back being studded with a varying number
of short, thick spines and several long spike-shaped processes, all
with their points directed backward. The head is small, rounded, or
oval, without eyes, and closely set in the body, and is provided with
palpi and mandibles. There are eight legs, four situated close to the
head and four posteriorly. The entire parasite scarcely exceeds a fifth
of a line in length. The female mite is to be looked for at the blind
end of a burrow or at the roof of a vesicle.

Scabies when fully developed may usually be recognized without
difficulty. The pathognomonic symptom is the presence of the parasites
or the burrows. In the early stage cuniculi are not yet fully formed,
but often the mite may be extracted from a recent vesicle. Burrows are
usually most typically seen upon the sides of the fingers. The
distribution of the eruption, however, is, in most cases, a sufficient
basis for a diagnosis, the fingers, hands, flexor surface of the
wrists, elbows, axillæ, buttocks, penis, mammæ in females, being
especially invaded. It may be remembered also that the face and scalp,
except in infants, are not involved. The multiform nature of the
eruption is one of its prominent characteristics. It is a progressive
disease. A history of contagion is often obtainable. It is to be
distinguished from vesicular and pustular eczema and pediculosis. The
more or less discrete vesicles and pustules of scabies, the localities
affected, its progressive course, and the presence of burrows and a
history of contagion will serve to differentiate from eczema.
Pediculosis corporis involves the covered portions of the surface only,
and the {728} regions usually involved are different from those invaded
in scabies. In scabies the hands are almost invariably the parts first
and most markedly involved. The characters of the lesions are also
different.

The disease yields rapidly to proper treatment. Various remedies are
employed for the destruction of the parasite and its ova. The most
common, and one that is thoroughly efficient, is sulphur. It is usually
prescribed in ointment, one to four drachms to the ounce. In irritable
skins, or where the secondary dermatitis is marked, the weaker
proportions are advisable. A proportion of two drachms to the ounce is
the average strength, and will be found suitable for the majority of
cases. For children a drachm to the ounce is sufficiently strong; in
these cases a half drachm of balsam of Peru may be added. This latter
remedy is of itself a parasiticide. A compound sulphur ointment, known
as Hebra's modification of Wilkinson's ointment, frequently employed
abroad, is made up as follows:

  Rx. Sulphuris sublimatis,
      Olei cadini,          aa. drachm ij;
      Cretæ præparatæ,          drachm iiss;
      Saponis viridis,
      Adipis,               aa. ounce j.

Styrax is another balsam that is destructive to the itch mite, used in
the proportion of one part to two of lard. Naphthol, a drachm to the
ounce of ointment, is, according to Kaposi and others, an especially
reliable remedy, possessing the advantages of being without color or
odor, and also favorably influencing the dermatitis. Usually,
especially in sensitive skins, it may be prescribed in rose-water
ointment; in others the following formula, which has been well spoken
of by Kaposi, may be employed: Rx. Naphthol, 15 parts; pulv. cretæ
alb., 10 parts; saponis viridis, 50 parts; adipis, 100 parts.

Before beginning the remedial applications the patient is to take a
soap-and-warm-water bath. The ointment is then rubbed into every
portion of the body with the exception, in adults, of the head. The
localities favored by the parasite should receive special attention.
About an ounce of ointment is required for an application. It is to be
so applied twice daily for three days, and then a soap-and-water-bath
is to be taken. The itching becomes less marked after the first
application, but may persist in a mild degree for several days after
the ointment has been discontinued. The secondary dermatitis produced
by the parasite and the scratching usually subsides soon after the
removal of the cause; if slow, it is to be treated with mild and
soothing applications, such as are employed in the treatment of eczema.


Pediculosis.

Pediculosis, phtheiriasis, or lousiness, is a contagious animal
affection, characterized by the presence of pediculi and the lesions
which they produce, together with scratch-marks and excoriations. Three
varieties of pediculi, or lice, infest the human body, differing both
in their male and female forms, and each variety inhabiting a different
portion of the body. The three varieties are--pediculus capitis,
pediculus corporis, and pediculus {729} pubis. They obtain nourishment
by a process of suction, in so doing giving rise to a minute wound, in
consequence of which a small amount of blood and serum exudes; more or
less hyperæmia and infiltration may occur, giving rise to marked
itching, and the scratching induced results in excoriations. The
varieties of pediculosis are designated according to the names of the
species of pediculi.

PEDICULOSIS CAPITIS.--This is a condition due to the presence of the
pediculus capitis, or head louse. This pediculus is seen, as a rule,
upon the scalp only; in feeble and bedridden individuals it is, at
times, seen upon other parts of the body. It is an insect of a grayish
color, and varies in length from one and a half to three millimeters,
the female being larger than the male. It is oval in shape, consisting
of head, thorax, and abdomen, the last named occupying more than half
its length and made up of seven clearly-defined segments, marked off
from one another by deep notches. The thorax is broad, and from its
sides project six legs, each one hairy and provided with a crab-like
hook at its extremity. The head is somewhat triangular, with a pair of
short, five-jointed antennæ and two black, prominent eyes, and
furnished with a sucking apparatus. They are extremely prolific, the
progeny of a single louse numbering several thousands in about eight
weeks. The eggs, or nits, are deposited upon the hairs near the roots;
several may often be found on a single shaft. If seen on the hair some
distance from the scalp, it is due to the fact of the hairs having
grown since the nits were deposited. They are pyriform, whitish bodies,
about one-fourth of a line in length, securely glued to the hairs,
hatching out in five or six days. The young become capable of
reproduction in three weeks. According to the duration of the affection
and the habits of the individual, they are to be seen in small or large
numbers. They may be found upon the scalp or crawling over the hair,
the occipital region being especially favored. Pediculosis capitis is
commonly seen in children, and it is also not infrequent in women; it
is met with usually among the poorer classes. The irritation from the
attacks of the pediculi upon the scalp gives rise to scratching,
resulting in serous and purulent oozing, which, mixed with blood and
dirt, mats the hair and forms crusts. In marked cases the hair soon
acquires a disgusting odor. An eczematous condition is soon brought
about. Excoriations, vesicles, and pustules may often be seen beyond
the limits of the scalp, upon the back of the neck and shoulders, and
upon the forehead. From the constant irritation, intolerable itching,
loss of sleep, etc. the general health may finally suffer. Pediculosis
capitis may be recognized without difficulty. The ova, or nits, may be
seen even at a distance, and the parasites themselves may always be
detected if a search is made. An eczematous eruption of the occipital
region in children and women, especially of the poorer classes, should
always give rise to suspicion and an examination. This condition is
often a result of pediculosis, but it is to be remembered also that an
eczema of the scalp may have at first existed, furnishing a favorable
habitat for the parasites.

Treatment is satisfactory; with ordinary care the condition may soon be
removed. Cutting the hair, though facilitating treatment, is not
necessary. The main object is the removal or destruction of the
parasites and their ova; this accomplished, the irritation and
excoriations will soon {730} disappear or yield to simple treatment.
The best plan is with ordinary petroleum. The parts should be saturated
with it and then bandaged, care being taken to prevent the oil from
running down the neck or on to the face. The dressing is to be allowed
to remain on about twelve hours, usually over night, and the scalp
washed with soap and water in the morning. One or two applications, if
thoroughly made, are sufficient. An oily solution of naphthol, 5 per
cent. strength, has been well spoken of. Tincture of cocculus Indicus
is also a reliable application. Ointments may be employed in place of
lotions, but are not so cleanly or, as a rule, so satisfactory. In some
cases, however, where an eczematous condition exists, especially if the
hair is short, they may be employed with good results. An ointment of
staphisagria, or one of white precipitate, twenty to sixty grains to
the ounce, may be referred to. Oleate of mercury, in solution or
ointment, 20 to 30 per cent. strength, is also serviceable. The
parasites and nits are usually destroyed by any of these applications;
the latter, however, remain clinging to the hair. Their removal may
soon be brought about by applications of alcoholic lotions, diluted
acetic acid or vinegar, alkaline lotions, and the use of a fine comb.

PEDICULOSIS CORPORIS.--Pediculosis corporis is due to the presence of
the pediculus corporis, or body louse (more properly pediculus
vestimenti, or clothes louse), resembling in its shape and anatomical
structure the head louse, but is larger, measuring from one to four
millimeters: the female is also larger than the male. Its period of
growth and reproductive powers are also as great. In color, when devoid
of blood, it is dirty white or grayish. The eggs are similar to, but
larger than, those of the pediculus capitis. It dwells in the clothing,
trespassing upon the integument only to obtain nourishment, where it
may, when existing in numbers, often be surprised in the act of drawing
blood or crawling over the surface. The ova are deposited in the folds
and seams of the clothing, in which localities also the parasites are
usually found. The excoriations, therefore, are to be seen especially
about those portions of the body which are closest to these parts of
the clothing, as, for example, about the neck and shoulders, the waist,
hips, thighs, etc. The primary lesions consist of minute reddish puncta
with slight areolæ, the points at which the pediculi have drawn blood.
Not infrequently, instead of simple hemorrhagic points, a wheal marks
the site of attack; at times also papules, pustules, and even
furuncles, result. Intense itching is set up, and as a consequence
excoriations, scratch-marks of various kinds, and blood-crusts are to
be seen. Eventually, from the long-continued irritation and hyperæmia,
a brownish or blackish pigmentation results. The affection is met with
chiefly among the poorer classes, in the middle-aged and elderly;
children are seldom attacked. It is not common in this country. The
presence of the ova or the pediculi in the seams and folds, the
characteristic reddish puncta, and the multiform lesions and
excoriations upon the regions above named are sufficiently diagnostic.
It is not to be confounded with pruritus and scabies, in which diseases
the distribution and causes of the lesions are altogether different.

As the pediculi live in the clothing, treatment consists in their
destruction, by baking or boiling of the wearing apparel, and in
ordinary attention to cleanliness. Repeated examinations should be
made, so that no pediculi or ova are permitted to remain. Alkaline
baths, three to four ounces of {731} sodium bicarbonate to the bath,
and lotions similar to those employed in the treatment of pruritus,
will allay the itching and aid in the removal of the secondary lesions.
In those cases where the patient cannot immediately subject the clothes
to the above treatment an ointment of staphisagria, made by digesting
two drachms of the powder in an ounce of hot lard and straining, may be
applied to the skin.

PEDICULOSIS PUBIS.--Pediculosis pubis is a condition due to the
presence of the pediculus pubis, or crab louse. It is the smallest of
the three varieties, measuring from one to two millimeters. It has a
short, rounded, flat body, and an oval head, which is furnished with
two long, five-jointed antennæ and a pair of inconspicuous eyes. The
thorax, which is small and imperceptibly merged into the abdomen, is
provided with six jointed, hairy legs with hooked claws. The margins of
the abdomen are slightly indented, and from it projects eight stubby,
prehensile feet armed with bristles. It is more or less translucent,
and of a yellowish-gray color. As in the other varieties, the female is
larger than the male. It is liable to escape detection on account of
its translucency, and the fact that it is apt to remain seated near the
roots of the hairs, clutching the hair with its head downward and
buried deep in the follicles. The ova are similar in construction, but
smaller than those of the other varieties; they may be readily seen
attached to the hairs in the same manner. The excrement, minute reddish
particles, may be detected lying around the bases of the hairs. It
infests adults chiefly, being usually contracted through sexual
intercourse. Although its favorite habitat is the region of the pubes,
it may also infest the axillæ, the sternal region of the male, the
beard, eyebrows, and even eyelashes. The amount of irritation
varies--at times insignificant, while in other cases it is severe.
Pediculosis pubis may be mistaken for pruritus or eczema, but an
examination will disclose the ova, and if carefully sought for the
pediculi may always be found, usually near the roots of the hair,
looking not unlike dirt-specks or freckles; the excrement may also be
detected. For their removal any of the lotions or ointments mentioned
in the treatment of the other varieties may be employed. A lotion of
corrosive sublimate, two to four grains to the ounce of alcohol or
water; infusion of tobacco; 10 to 20 per cent. ointment of oleate of
mercury; ammoniated mercury ointment; a 5 to 10 per cent. oily solution
or ointment of naphthol,--are all efficient. The parts should be washed
with soap and water twice daily, and the remedy applied after each
washing. In order to ensure complete destruction of the ova the
applications should be continued for some days after the pediculi have
been destroyed.

       *       *       *       *       *

LEPTUS.--Two species of leptus are met with as attacking man: Leptus
Americanus (American harvest mite) and Leptus irritans (irritating
harvest mite, harvest bug, mower's mite). The former is a minute,
brick-red colored, elongate, pyriform creature with six legs, barely
visible to the naked eye. Its favorite sites of attack are the scalp
and axillæ, partly burying itself in the skin, giving rise to a small
inflammatory papule. The latter species is more common, differing from
the former merely in having a roundish oval form. It buries itself in
the skin, giving rise to inflammatory papules, vesicles, and pustules.
Its sites of predilection are the ankles and legs. The minute red mite
met with especially about {732} blackberry-bushes in the low grounds of
Pennsylvania, New Jersey, and Delaware is probably the same species.
Both varieties are common, during the summer, in our South-western
States. For treatment a weak sulphur ointment or ointments of the other
mild parasiticides may be employed.

       *       *       *       *       *

PULEX PENETRANS, OR RHINOCHOPRION PENETRANS.--This creature--the
sand-flea, known also as chigoe, chigger, and jigger--is almost
microscopic in size, closely similar to the common flea, but has a
proboscis as long as its body. It is common in tropical countries, and
also met with in our Southern States. It (the impregnated female)
burrows into the skin, depositing the ova, resulting in inflammatory
swelling, large vesicles or pustules, and even ulceration. The toes,
especially beneath and alongside of the nail, and other parts of the
feet are the regions attacked. The treatment consists in extraction; it
usually comes away in the form of a sac about the size of a small pea,
its size due to the distension of the abdomen with ova. As a preventive
the essential oils are used about the feet.

       *       *       *       *       *

FILARIA MEDINENSIS.--This parasite, the guinea-worm, known also as
dracunculus, is only encountered in tropical countries. The young bore
into the skin and subcutaneous tissue, in which their growth takes
place; sooner or later marked inflammation is produced, resulting in
painful furuncular tumors, which finally break, showing the presence of
the worms. The lower extremities, especially the feet, are the favorite
regions of attack. The worm varies from several inches to three feet in
length, according to its age, and is one-half or three-fourths of a
line in thickness. The treatment consists in extracting the worm inch
by inch, from day to day, as soon as discovered, care being exercised
not to break it. Poultices may be applied.

       *       *       *       *       *

CYSTICERCUS CELLULOSÆ.--This affection is characterized by rounded or
ovalish, smooth, elastic, firm or hard, movable, pea- to hazelnut-sized
tumors, more or less numerous, usually seated just beneath the skin,
new tumors showing themselves from time to time. After reaching a
certain size they may remain stationary. Although not painful upon
pressure, spontaneous pains may be complained of. Microscopical
examination reveals the cysticerci.

       *       *       *       *       *

OESTRUS.--This parasite (known also as breeze, gad-fly, and bot-fly) is
met with in Central and South America, and also in other countries. The
neck, back, and extremities especially are liable to be attacked. The
ova are deposited in the skin, and there result inflammatory, boil-like
tumors or swellings with a central opening, from which issues a sanious
fluid; or the lesion may assume a linear, tortuous, or serpiginous
form. Sooner or later the grub is detected, and may be easily squeezed
out or extracted.

       *       *       *       *       *

DEMODEX FOLLICULORUM.--This microscopic parasite (also known as
steatozoon, entozoon, acarus, and Simonea, folliculorum) is to be found
in the sebaceous follicles. It is harmless, giving rise to no
disturbance. It is worm-like in form, made up of a head, thorax, and a
long abdomen. {733} It is more apt to be found in those with thick,
greasy skins. Several of them often exist in a single follicle.

       *       *       *       *       *

CIMEX LECTULARIUS, OR ACANTHIA LECTULARIA.--This insect (the common
bed-bug) and its various residing-places are well known. It gives rise
to a cutaneous lesion of the nature of an urticarial wheal, with a
central hemorrhagic point which remains after the swelling has
subsided. As a result of the scratching to which the irritation and
itching give rise excoriations are often observed. A larger species
(Conorhinus sauguisuga), known as the blood-sucking cone-nose and big
bed-bug, has been met with in Southern Illinois and Ohio; its bite is
said to produce severe inflammation of the skin. For the relief of
bed-bug bites lotions containing alcohol, vinegar, lead-water,
ammonia-water, and similar remedies may be sponged upon the parts.
Pyrethrum powder and corrosive sublimate are the best preventives
against bugs in beds.

       *       *       *       *       *

PULEX IRRITANS.--This, the common flea, is found universally,
especially in hot and warm climates. As a result of its bite
erythematous spots with minute central hemorrhagic points are seen. The
presence of the areola distinguishes the lesions from those of simple
purpura, which at times they may resemble. The cutaneous disturbance is
usually slight, but in some individuals, and especially in tropical
countries, the discomfort to which these creatures give rise is often
considerable.

       *       *       *       *       *

CULEX.--Gnats, or mosquitoes, are often productive of considerable
cutaneous irritation, the typical lesion being a wheal-like elevation.
The itching is best relieved with ammonia-water.

       *       *       *       *       *

IXODES.--There are several species of wood-ticks met with in our woods
which are liable to attach themselves to the human skin. Inserting
their proboscis and head deeply into the tissues, they suck blood until
often they swell up several times their natural size. They should be
induced to relinquish their firm hold by dropping olive oil or one of
the essential oils upon the skin; they should never be extracted with
violence.

{734}


{735}


MEDICAL OPHTHALMOLOGY.


{736}


{737}

MEDICAL OPHTHALMOLOGY.
BY WM. F. NORRIS, M.D.


INTRODUCTION.--The object of the following essay is to give, as far as
practicable in the limits of an encyclopædic article, an account of the
eye symptoms which may be seen in the course of diseases of the general
system and in connection with the pathological conditions of the
various organs of the body. The eye has always been looked on as a
valuable indicator of general systemic disturbance. Its expression has
been noted as showing the general vigor or feebleness of the patient,
as well as his varying mental moods, while paralysis of its external
and internal muscles has in all times been regarded as a sign of
disturbed intracranial action or disease. In order to judge of the
state of the circulation the physician habitually looks at the lips,
the tongue, and the nails, where the capillaries are covered by
translucent material, to appreciate the state of the circulation. How
much better are we enabled to do this when, by the use of the
ophthalmoscope, we look at the interior of the eye and see the
blood-columns in the veins and arteries of the head of the optic nerve
and the retina laid bare to our view without any opaque covering
whatever! Such an examination, besides showing the state of the
circulation, will frequently reveal a neuritis which may be due to some
intracranial disease, or show a degeneration of the optic nerve which
may point to impaired power and tissue-change in the spinal cord or the
brain; or there may be characteristic retinal changes associated, as,
for instance, with disease of the kidneys, or extravasation of blood
which may be dependent on general or local causes; these frequently
serving as important indices of the state of the nerves and vascular
tissues in other organs in the body.

In so vast a field, and in one so new as regards ophthalmoscopic
appearances, there remains still much to be accomplished. Useful
knowledge has accumulated slowly, but numerous enigmatical appearances
have been referred to their true causes, while many which at first
sight seemed important have been proved to be either anomalies of
formation or to have no pathological import. A complete and accurate
description of all the eye symptoms in all diseases is an herculean
task, because it presupposes the careful study of vast numbers of cases
in every department of medicine: it is therefore out of the question
for any one man to complete such a description from his individual
efforts, and he must either remain content with a mere sketch or
collate the combined experiences of many observers in different fields
in order that it may be in any way reasonably {738} perfect. To keep
such an article within any moderate limits it has been necessary to
condense much, and to consider only those points which the combined
testimony of many observers shows to be important and of frequent
occurrence. For similar reasons the writer has abstained from giving a
complete list of all authorities treating of the subjects herein
discussed, and has referred only to those which appeared to him to be
some of the most important. Those readers who wish a more complete
bibliography can readily obtain it by referring to the various
monographs hereinafter quoted, and also by consulting the well-known
essays of Foerster,[1] Robin,[2] and of Mauthner,[3] or the treatises
of Albutt[4] and of Gowers.[5]

[Footnote 1: "Beziehungen der Allgemein-Leiden und Organ-Erkrankungen
zu Veränderungen und Krankheiten des Sehorgans," in _Graefe und
Saemisch's Handbuch der Augenheilkunde_, Bd. vii., 1877.]

[Footnote 2: _Des Troubles oculaires dans les Maladies de l'Encephale_,
Paris, 1880.]

[Footnote 3: _Lehrbuch der Ophthalmoscopie_, Vienna, 1868, and _Gehirn
und Auge_, Wiesbaden, 1881.]

[Footnote 4: _On the Use of the Ophthalmoscope_, London, 1871.]

[Footnote 5: _Medical Ophthalmoscopy_, London, 1879.]

Such an article is necessarily a chapter on symptomatology, giving the
eye symptoms in various diseases and pathological conditions, and the
reader will therefore look in vain in it for any directions as to the
treatment of such maladies, or for formulæ showing advantageous modes
of administering medicines. The writer has intended, by describing and
grouping eye symptoms, to enable the practitioner more readily to
diagnosticate the various pathological conditions of other parts of the
economy. The reader should look for a description of treatment in the
various articles of this work which are devoted to the discussion of
such diseases and morbid states. Local diseases of the eye, except so
far as they are manifestly related to or caused by general disease,
have been avoided in this paper, these topics being appropriate to a
treatise on the diseases of the eye.


Changes in the Eye-ground and its Appendages due to Diseases of the
Circulatory Apparatus--Heart, Blood-vessels, and Blood.

The ophthalmoscope has laid bare to our view a living nerve of special
sense, the highly-developed end-organ in which it terminates, and the
blood-columns circulating in them. In no other part of the body has
Nature vouchsafed to us so clear an insight into her mysteries. In a
state of health the index of refraction of the walls of the retinal
blood-vessels is so nearly coincident with that of the surrounding
media that they either entirely escape our observation or are only
slightly indicated, thus allowing us to see only the blood-columns
which circulate within them. Owing to the distance from the heart and
to the restraining influence of the intraocular pressure, as well as to
the minute size of the vessels in question, the pulse-wave has so far
died out as to be ordinarily invisible, even by the aid of the
eye-lenses which Nature has so kindly placed as magnifying-glasses to
assist us in the study of intraocular phenomena. Even where we avail
ourselves of the upright image in examining the normal eye-ground, by
which an amplifying power of seven to fifteen  {739} diameters is
obtained, we cannot usually detect any pulsation in the vessels,
although exceptionally we may observe pulsation which is always venous
and confined to the larger twigs of the venæ centrales as they pass
over the disc and dip into the nerve-substance. By slight pressure on
the eyeball with the finger venous pulse can always be produced. This
phenomenon consists of an emptying of the vein from the optic pylorus
toward the periphery, followed by a rush of return blood in an opposite
direction, which takes place in eyes where the intravenous and
intraocular pressures are nearly balanced. Under these circumstances
the injection of a fresh quantity of arterial blood into the eye causes
a temporary increase of intraocular pressure, which is transmitted
through the vitreous to the main trunks of the veins, compressing them
at the point nearest the heart (where the intravenous pressure is
least) before the column of entering blood which has been hindered by
the capillary resistance has had time to flow around to re-establish
the current. Stronger pressure on the eye will produce an arterial
pulsation by causing the intraocular pressure to become so high that
the blood enters only during the systole of the heart and diastole of
the arteries. This is not infrequently seen in glaucoma, where there is
an augmentation of the intraocular pressure, but is never visible in
the normal eye of a healthy individual. It should be kept in mind that
the venous pulse often produces a slight change in the adjacent
arteries which ought not be mistaken for arterial pulsation.[6]
Wadsworth and Putnam[7] describe an intermittent variation in the size
of the retinal veins independent of the pulsation produced by the
heart's action, and having a period of about five respirations,
analogous to the variation of arterial tension found in animals.
Besides the arterial pulse already alluded to, produced by augmented
intraocular tension, where the normal force of the circulation is not
sufficient to drive the blood in a continuous stream into the tense
eyeball, we have an analogous condition where the intraocular tension
may be normal, but the arterial tension is diminished, and a full
stream of blood can enter only during the diastole of the arteries or
maximum of intravascular pressure. We may notice examples of this in
_insufficiency of the aortic valves_, and in some very rare cases
described by Quincke[8] and Becker,[9] who found it accompanied by an
alternate flushing and pallor of the optic disc analogous to the
capillary pulse which may at times be observed in the finger-nail under
similar conditions of the general circulation. The arterial pulse may
also accompany any cause which permanently or temporarily reduces the
blood-pressure in the arterial system, such as pressure of a tumor on
the ophthalmic artery or of a swollen nerve on the central retinal
artery (as in neuritis): or, again, by feeble impulse of the heart, as
in cases of fainting or in degeneration and dilatation of the walls of
the blood-vessels.[10] Becker relates[11] a case of arterial pulsation
in a left eye, supposed to be due to aneurism of the aorta at a point
where the left carotid is given off, whilst {740} the other eye
presented the usual appearance of healthy retinal circulation: an
aneurism at the origin of the innominate might reverse this and give
arterial pulsation in the right eye. Usually, the pulse-phenomena in
the retina are confined to the vessels on the optic disc and its
immediate vicinity, but both Jaeger[12] and Becker[13] give cases where
it was visible over the entire eye-ground. In cases of _congenital
malformation of the heart_ with cyanosis, such as defective closure of
the foramen ovale or stenosis of the pulmonary artery, the retinal
vessels show markedly the general distension of the veins and the
change of color of the blood. Liebreich[14] gives a striking picture of
such a case, and Leber[15] remarks that in two cases observed by him
the dilatation affected the arteries as well as the veins. Knapp[16]
describes a case of swelling of the discs, with a vast number of
thickened arteries and veins which radiated from them, many twigs
reaching the fovea centralis. The autopsy showed general enlargement
and hypertrophy of the whole vascular system without disease of the
heart. Arcus senilis is often an accompaniment of fatty heart and an
indication of extensive fatty degeneration of other tissues of the
body, such as the small arteries of the brain and the recti muscles of
the eye.[17]

[Footnote 6: For a minute study of the phenomenon, vide Jaeger, _Med.
Zeitschrift_, 1854. See also his _Ergebnisse des Untersuchung mit dem
Augenspiegel, etc._, 1876, pp. 60, 61. See also Becker, _Arch. f.
Oph._, vol. xviii., part 1, p. 270.]

[Footnote 7: Vide _Trans. of the Amer. Oph. Society_, 1878, pp.
435-439.]

[Footnote 8: H. Quincke, _Berl. klin. Wochenschrift_, No. 34, 1868.]

[Footnote 9: O. Becker, _Arch. f. Ophth._, vol. xviii., 1, pp.
207-296.]

[Footnote 10: Wordsworth, _R. L. O. II. Rep._, vol. iv. p. 111.]

[Footnote 11: _Loc. cit._, pp. 253-256.]

[Footnote 12: _Ophth. Hand Atlas_, p. 75, Fig. 52.]

[Footnote 13: _Loc. cit._, pp. 220, 221.]

[Footnote 14: _Liebreich's Atlas_, Tab. ix. Fig. 3.]

[Footnote 15: _Graefe und Saemisch_, vol. v. pp. 524-526.]

[Footnote 16: _Trans. Amer. Ophth. Soc._, 1870, p. 120.]

[Footnote 17: Canton, _The Arcus Senilis_, London, 1863.]

Since 1859, when Graefe[18] by means of the ophthalmoscope first
diagnosticated this condition of the retina (which Schweigger[19] a
year and a half later substantiated by anatomical proof, demonstrating
a closure of the central artery by an embolus in it just behind the
lamina cribrosa), embolism of the central artery of the retina has been
a favorite explanation of all cases of sudden one-sided blindness.
Since that date Sichel,[20] Nettleship,[21] Priestly Smith,[22] and
Schmidt[23] have all published careful clinical studies of similar
cases with autopsies. Embolism is less frequent in this situation than
in many other parts of the body, and this, as has been pointed out by
Foerster, is probably due to the fact that the ophthalmic artery is
given off from the external carotid nearly at a right angle, and while
it in turn again sends off its smallest branch--the central retinal
artery--at nearly the same angle; consequently, emboli are more readily
carried past their orifices into some other vascular area supplied by
the main stem. Mauthner has suggested that the transitory but complete
blindness which sometimes precedes embolism of the central artery may
be due to the stoppage of the orifice of the artery (where it comes off
from the ophthalmic artery) by a previous embolus which has been too
large to enter the artery, and which, owing to the favorable position
of the orifice, has been washed beyond into some of the other branches.
In the majority of such cases the ophthalmoscope shows that the retinal
arteries are diminished in size and partially filled with blood, while
a white opacity of the fibre-layer of the retina extends centrifugally
from the disc and between it and the macula lutea. When the opacity
surrounds the latter, the fovea centralis (where the fibre-layer dies
out) shows {741} by contrast as a reddish or at times a cherry-red
spot. The state of the disc itself appears to differ in different
cases: some authors have described it as unusually pallid, whilst
others claim that it still retains more or less of its natural pinkish
hue. In cases reported,[24] where the disc is said to be of normal
color, this circumstance is probably due to collateral circulation
which has been established with the ciliary vessels at the optic
entrance. Where the obstruction of the artery is complete the blindness
is permanent, and the disc and retina become atrophic. Embolism also
occurs in the branches of the central retinal artery, and in such
instances there is loss of a corresponding part of the field of vision.
In some cases there is hemorrhagic infarction.[25] It is never present
in embolism of the main stem of the central retinal artery. Inasmuch as
this latter vessel is an end-artery, the absence of infarction and
subsequent sphacelus is interesting. The intraocular pressure probably
prevents the back current of venous blood into the obstructed area,
while the nearness of the vessels of the chorio-capillaris allows the
retina to obtain sufficient nutriment to prevent death without allowing
it to carry on its functions. In the case of embolism of a branch, all
the retinal blood being under the intraocular pressure, there would be
no hindrance to the entrance of venous blood from the areas of the
retina supplied by other arterial branches, although, as above
mentioned, the infarction is not present in all such cases. _Thrombosis
of the central retinal vein_ is also a rare affection, only recognized
and diagnosticated of late years. Michel[26] reports 7 cases, with
plates of the ophthalmoscopic appearances in 4 of them. The patients
were all between fifty-one and eighty-one years of age, and all had
rigidity of the peripheral arteries. The suddenness of the attack
recalls the symptoms of embolism, but in thrombosis the blindness is
said never to be absolute. The ophthalmoscopic appearances are
described as consisting of a diffuse and intense reddish haze of the
fibre-layer of the retina, hiding the outlines of the disc and usually
extending one and a half disc-diameters from it. This area of haze
shows numerous small hemorrhages, mostly linear, in the direction of
the retinal fibres, and beyond it the arteries and veins of the retina
again become visible. The veins are dilated, excessively tortuous, and
carry dark blackish blood. In the periphery of the retina the
hemorrhages are rounded and splotchy, whilst a dark rounded hemorrhage
occupies the fovea centralis. There is no swelling or prominence of the
disc. When the thrombosis has been complete, atrophy of the intraocular
end of the optic nerve follows. Zehender[27] makes two classes of
cases--the marasmic in old people, and the phlebitic in
young--reporting an interesting case in a patient twenty-six years old.
Leber[28] details a case of hemorrhagic retinitis with thrombosis of
some of the venous trunks in the retina, which were swollen to two or
three times their usual calibre, and filled with very dark, almost
blackish, blood: as they approached the disc they rapidly diminished in
size, and were almost thread-like as they dipped into it.
Galezowski[29] {742} cites two instances--one in a case of injury to
the ciliary region, and one after injury to the eye by steam. In the
latter, the thrombosis affected the artery, and the subject was
forty-nine years of age.

[Footnote 18: _A. f. O._, v. 1, S. 136.]

[Footnote 19: _Vorlesunqen über den Gebrauch des Augenspiegels_, S.
140.]

[Footnote 20: A. Sichel, _Archiv der Phys. Norm. et Path._, No. 1, pp.
83-89 and pp. 207-218 (quoted by Leber).]

[Footnote 21: _R. L. O. H. Rep._, vol. viii., pp. 9-20.]

[Footnote 22: _Brit. Med. Journ._, 1874, April, p. 452.]

[Footnote 23: H. Schmidt, _A. f. O._, xx., 2, pp. 287-307.]

[Footnote 24: Vide case by Schmidt, _Archiv f. Ophthalm._, xx., 2, p.
288.]

[Footnote 25: Knapp, _Archives of Ophthalmology and Otology_, vol. i.
p. 84 (with plates), and Landesberg, in same journal, vol. iv. pp. 39,
40, have each given cases of embolism of a branch of the retinal
artery, with infarction.]

[Footnote 26: _A. f. O._, xxiv., 2, pp. 37-70.]

[Footnote 27: In clinical lecture reported by Angelucci, _Klin.
Monatsblätter f. Augenheilkunde_, 1880, p. 23.]

[Footnote 28: _Graefe und Saemisch_, vol. v. p. 531.]

[Footnote 29: _Gaz. méd. de Paris_, 1879, p. 217.]

Retinal hemorrhage is of frequent occurrence. It is often associated
with inflammation in cachectic conditions of the system, as in the
various forms of symptomatic retinitis, but is also found where there
is not any demonstrable constitutional disease. Here, as in the other
tissues of the body, apoplexies are favored by disease of the coats of
the vessels, by alteration in the state of the blood, and by increased
intravascular pressure. Anatomical examination has shown in the most
common form of disease in the retinal vessels fatty degeneration of
their walls, with calcareous deposits in them, and a condition
(denominated sclerosis) in which the coats become thickened,
homogeneous, and of a higher index of refraction. In this hardened
tissue there is a condition similar to amyloid degeneration, but no
reaction is to be obtained from iodine (Leber). No ruptures can be seen
with the ophthalmoscope, but the vessels appear to pass on in contact
with the hemorrhage without change of course or calibre. These
circumstances have led Leber[30] to suppose that most retinal
hemorrhages are due to diapedesis, and not to rhexis. When the blood
escapes into the fibre-layer of the retina, it frequently diffuses
itself along the course of the fibres and between them, and gives rise
to linear and striated hemorrhages, while in the deeper layers its
progress is barred by the connective-tissue elements--notably by the
radiating fibres of Müller--and forms irregular masses which appear as
more or less rounded clumps when looked at by the ophthalmoscope. Such
extravasations of blood are frequently absorbed, or, again, they may
leave black spots of pigment as the only marks of their presence. At
other times they produce yellowish-white masses which disappear slowly,
and often leave connective-tissue cicatrices behind them, dragging upon
and displacing the retinal elements. When the hemorrhage is
considerable, it may cause primary distortion of the images and
impairment of vision by pressure on the rods and cones. At times it
breaks through the limitans interna into the vitreous, giving rise to
floating opacities, more rarely spreading itself out in a layer between
the vitreous and the retina. The writer well remembers such an instance
in the case of an apparently healthy woman about forty years of age,
who, while sitting quietly in church, noticed that objects looked red
and that a dense cloud came before the eye. Examination with the
ophthalmoscope showed a large hemorrhage which covered the entire
region of the macula and extended far beyond it, overlapping the
temporal edge of the disc. This hemorrhage was slowly absorbed, and
four years later the patient had a vision of 20/xx, and no trace of
hemorrhage was visible in the entire eyeground. Liebreich[31] gives a
good illustration of a similar case in a woman of forty-five years of
age who, after suppression of the menses, had a similar state of
affairs. Leber[32] has seen several such cases, in one of which the
hemorrhage was changed into a brilliant white mass. This was entirely
absorbed, leaving only a small pigmented stripe at its lower border as
the sole trace of the previous large extravasation of blood.
Occasionally retinal hemorrhage {743} ushers in glaucoma. Retinal
apoplexies, like extravasations of blood in the conjunctiva of the
eyeball, often come without apparent cause. In many cases they are
finger-posts pointing to grave disease of the vessels in other parts of
the body. The writer recalls a patient of seventy years of age who
believed himself in perfect health until alarmed by a retinal
hemorrhage, which a few months later was followed by a cerebral
apoplexy which caused his death.

[Footnote 30: _Graefe und Saemisch_, vol. v. p. 554.]

[Footnote 31: _Atlas_, Table viii. Fig. 2 (1863 ed.).]

[Footnote 32: _Graefe und Saemisch_, v. p. 553.]

Aneurism of the central retinal artery is of excessively rare
occurrence. Sous of Bordeaux quotes[33] the elder Graefe and Scultetus
as having anatomically demonstrated the existence of the lesion, and
Mackenzie refers[34] to a pathological specimen in the collection of
Schmidler of Friburg where there was an aneurism of the central artery
of each retina. Sous was the first who recognized it with the
ophthalmoscope, and describes it as a red egg-shaped, pulsating
dilatation of one of the main branches near the disc. Vision was so far
destroyed that the patient was unable to recognize the largest letters.
Martin describes[35] a similar case, while Magnus records what he
supposed to be an arterio-venous aneurism following severe contusion of
the eyeball, and Mannhardt a case of rupture of the choroid with a gray
pulsating mass in the disc, which was also supposed to be aneurismal in
nature. Schirmer has recorded[36] a case of widely-spread congenital
telangiectasis of the face with a similar condition of the retinal
veins of one eye. Liebreich[37] has pictured curious bead-like
dilatations of the veins in a glaucomatous eye. Jacobi[38] gives three
woodcuts of varix-like tortuosities of the retinal veins. Offsets
extending from the retinal vessels forward into the vitreous have been
observed during life and described by Coccius,[39] Becker,[40]
Jaeger,[41] Samelsohn,[42] Jacobi,[43] and Norris.[44] They probably
occur to some extent in many severe inflammations of the eye, and have
been not unfrequently found and described in anatomical examinations of
that organ; but their development is usually attended with so much
cloudiness of the media as to prevent accurate ophthalmoscopic
examination.

[Footnote 33: _Annales d'Oculistique_, 1865, pp. 241-243.]

[Footnote 34: _Practical Treatise on the Diseases of the Eye_, London,
1854, 4th ed., p. 1042.]

[Footnote 35: _Atlas d'Ophthalmoscopie_.]

[Footnote 36: _A. f. O._, vii., 1, pp. 119-121.]

[Footnote 37: _Atlas_ Plate xi. Fig. 1.]

[Footnote 38: _Klin. Monatsblätter_, 1874, pp. 253-260.]

[Footnote 39: _Glaucom._, 1859, p. 47.]

[Footnote 40: _Bericht der Wiener Auqenklinik_, 1866, pp. 65-74.]

[Footnote 41: _Ophth. Hand-Atlas_, Table xv. p. 72.]

[Footnote 42: _Klin. Monatsblätter_, 1873, pp. 216-218.]

[Footnote 43: _Klin. Monatsblätter_, 1874, pp. 252-260.]

[Footnote 44: _Trans. Amer. Oph. Soc._, 1879, p. 548.]

When carefully examining eyes with the ophthalmoscope, it is not a very
unusual circumstance to see a small grayish tag arising from the
lymph-sheath of the central retinal vessels and extending a short
distance forward into the vitreous. These tags usually present slow,
sinuous movements, following motions of the eyeball. It is, however,
rare to have such obliterated vessels extend through the vitreous and
show their previous distribution in the posterior capsule of the lens,
as in the instances reported by Zehender,[45] Liebreich,[46] and
Becker;[47] in Zehender's case the artery was patulous and
blood-bearing. Little[48] has also depicted a case where the hyaloid
artery was filled with blood. The central canal of the vitreous, which
is occupied in the foetal eye by the artery in question, is readily
demonstrated in pigs' eyes by allowing colored fluid to {744} flow into
it from its central end. According to H. Müller,[49] atrophied remnants
of the artery are always present in the eyes of oxen. Manz[50] gives an
anatomical description and plate of a continuance of the lymph-sheath
of the central artery through the vitreous forward to the capsule of
the lens, the remnants of the artery being found only in its proximal
portion: observation had been impossible during life on account of
corneal opacities. The same writer describes a convolution of vessels
as penetrating the posterior part of the vitreous from the retina in
the eyes of some Australian reptiles (Trachyeaurus and Lygosoma), and
regards it as a similar formation to the pecten of the bird's eye.
According to Ammon, some forms of congenital cataract are connected
with the too early obliteration of the hyaloid artery, which is so
important in furnishing nutriment to the growing lens.

[Footnote 45: _Klin. Monatsblät. f. Augenheilkunde_, 1863, pp.
260-349.]

[Footnote 46: _Ibid._, p. 350.]

[Footnote 47: _Annales d'Oculistique_, 1865, p. 350.]

[Footnote 48: _Trans. Amer. Ophth. Soc._, 1881, pp. 211-213.]

[Footnote 49: _Gessamm. Schriften_, p. 365.]

[Footnote 50: _Graefe und Saemisch_, vol. ii. pp. 97-99.]

Von Graefe remarks, however, that this very unusual yet incomplete
development of the retinal vessels is common in congenital amaurosis.
He reports[51] an instance in a blind eye of a boy ten years of age,
who also exhibited a convergent squint and nystagmus. Mooren[52] also
gives a case of entire absence of the retinal blood-vessels in a child
seven months old. Pathological conditions of the blood often give rise
to visible changes in the eye-ground.

[Footnote 51: _Arch. f. Ophth._, vol. i., part 1, pp. 403, 404.]

[Footnote 52: _Ophthalmiatrische Beobachtungen_, 1867, p. 260.]

LEUCÆMIC RETINITIS.--Liebreich[53] was first to call attention to a
retinitis which is due to leucæmia. In his _Atlas_ he gives an
interesting picture of it, and states that he had then already had an
opportunity of seeing six cases in the splenic variety of the disease.
His plate shows a diffuse retinitis with scanty hemorrhages, with
marked change in the color of the eye-ground and of the blood in the
retinal veins and arteries. The blood-columns, especially in the veins,
have acquired a slight rose tint, and have become less intense in
color, whilst the hemorrhages appear slightly redder. He also describes
white splotches like those of the retinitis of Bright's disease,
differing from the latter only in the more peripheral situation. In one
case these splotches were examined by Recklinghausen, and found to
consist of patches of sclerotic degeneration of the nerve-fibres.
Becker has pictured[54] two interesting cases, where, besides the
diffuse retinitis with scanty hemorrhages, the main characteristics
were the yellow color of the eye-ground and large white plaques with a
red hemorrhagic border in the periphery. In the few cases, which the
writer has had an opportunity of studying in the wards of his
colleagues, the most striking change has been that of the color of the
eye-ground and of the blood. In none of these were there either the
white patches with red border or any extensive hemorrhage. We probably
must not expect them in all cases and at all stages. In one of the
patients, a negress, who was examined at the time of her admittance to
the hospital, before any diagnosis had been made, the change in the
color of the blood and fundus was so marked that he was able to call
attention to it, as a probable case of leucæmia, and had the
satisfaction of having the diagnosis confirmed by subsequent careful
examination. Leber[55] states that the disease sometimes assumes the
form of hemorrhagic {745} retinitis, such as is often seen in cases of
disease of the heart and blood-vessels. Gowers[56] thinks that there is
a much greater tendency to hemorrhage in leucocythæmia than in simple
anæmia, and that the effused blood is of a pale chocolate color, while
white or yellowish splotches, often edged by a halo of
blood-extravasations, are commonly present. Immermann has seen the
retinal affection occurring in mylogenic leucæmia, but in most of the
instances above cited they accompanied the splenic form of the disease.
In one of Becker's cases, in which Stricker examined the blood, the
bulk of the white corpuscles exceeded that of the red ones, whilst some
individual white corpuscles were so much increased in size that one
white one might readily contain fifty red ones. Leber[57] describes a
leucæmic tumor of the lids with exophthalmos, and marked leucæmic
retinitis with hemorrhages, which affected both eyes of a patient who
had enlargement of the liver and spleen. He quotes Chauvel as having
recorded a somewhat similar case. In both of Leber's and Chauvel's
patients there was also disease of the kidneys, as evidenced by the
presence of albumen and casts in the urine. Another leucocythæmic tumor
of the orbit has been described by Osterwald.[58]

[Footnote 53:  _Atlas_, Plate x., 1863.]

[Footnote 54: _Archives of Ophthalmology_ (Knapp and Moos), vol. i.,
1869, pp. 341-358, Tab. B. and C.]

[Footnote 55: _Graefe und Saemisch_, vol. v. p. 599.]

[Footnote 56: _Medical Ophthalmoscopy_, 1879, p. 192.]

[Footnote 57: _Arch. f. Ophth._, xxiv., 1, pp. 295-312.]

[Footnote 58: _Ibid._, xxvii., 3, pp. 202-224.]

PERNICIOUS ANÆMIA.--Biermer (1871) was the first to call attention to
the retinal changes in this grave and rare disease. Since that date
Horner[59] and Quincke[60] have given us the results of the careful
study of a considerable number of cases. The former had seen 30 cases,
and remarks that the color of the blood, the distension and tortuosity
of the veins, and the numerous hemorrhages recall the cases of leucæmic
retinitis: in all of his cases the discs were entirely white. The
latter, in his latest paper on the subject, records 17 cases, and gives
a careful chromo-lithographic picture of one of them. He describes the
affection as an oedema of the retina with numerous hemorrhages, many of
which have white or grayish centres, whilst others envelop the
blood-vessels, and by irregularly distending their lymph-sheaths cause
them to appear varicose. The oedematous condition of the retina
produces an appearance as if a thin bluish-white film had been spread
over the fundus oculi. The writer has had an opportunity of observing
three cases of this rare affection: in each there was a diffuse
retinitis, the veins were distended, the blood pallid, and the disc was
dirty white with a faint greenish tint, whilst the eye-ground was
decidedly yellow in hue. In one of them there were no other
pathological appearances; in the second, only a few small hemorrhages
into the lymph-sheath of some of the vessels near the macula; in the
third, numerous irregularly round or ovoid hemorrhages with
yellowish-white centres. It is evident, however, from the reports of
Quincke, that any one case might in its various stages present all
these phases. Horner considers[61] the colorless centre of the
hemorrhages to be due to a commencing absorption of the blood, while
Manz[62] holds that these yellowish-white spots are the dilated
extremities of retinal capillaries.

[Footnote 59: _Klinische Monatsblätter für Augenheilkunde_, 1874, pp.
458, 459.]

[Footnote 60: _Deutsches Archiv f. klinische Medizin_, 1877, pp. 1-31
(with plate).]

[Footnote 61: Quoted by Quincke, _loc. cit._, p. 23.]

[Footnote 62: _Med. Centralblatt_, 1875, pp. 675-677.]

HEMORRHAGE.--Loss of blood may be the cause of impaired vision from
transient anæmia of the retina or of the cerebral centres, but not
{746} unfrequently, in some manner which we are not yet able
satisfactorily to account for, it gives rise to permanent blindness.
This failure of sight may come on immediately after the hemorrhage, but
it is usually noticed at periods varying from two to fourteen days
after the loss of blood. Fries[63] has written an admirable monograph
on the subject, and gives 26 cases collected from various authors.
According to his tables, 35½ per cent. of the cases are due to
hemorrhage from the stomach or intestines; 25 per cent. to uterine
hemorrhage; 25 per cent. to abstraction of blood; 7.3 per cent. to
epistaxis; 52 per cent. to bleeding from wounds; and 1 per cent. each
to hæmoptysis and urethral hemorrhage. Many of these cases are
preopthalmoscopic, and consequently the exact pathological changes in
the retina and optic nerve are necessarily matters of conjecture.
Jaeger has given us two most interesting cases of blue degeneration of
the optic nerve, with comparatively little change in the calibre of the
main vessels of the disc and retina.[64] In both, the loss of blood
occurred during labor; in the first, two births happened without
accident; at the third and fourth labor there was severe hemorrhage,
each followed by considerable and lasting impairment of vision, leaving
ability to read Jaeg. No. iii. for a short time, and only by close
approximation. In the other case there were four confinements, all
accompanied by hemorrhage, each leaving the vision more and more
impaired, until after the fourth labor there was no light-perception.
At this time the ophthalmoscope showed only blue discoloration of the
nerve, followed six years subsequently (after recurrent headaches from
taking cold) by a more complete atrophy of the disc and retina, the
former appearing of a dirty-green color and having acquired a
saucer-like excavation, whilst the retinal vessels had undergone great
diminution in their calibre. In most recorded cases no examination of
the fundus has been made until long after failure of sight, and then
there has generally been found some stage of atrophy; but when the
ophthalmoscope has been used early in the case the eye-ground seems to
have presented various appearances. Thus, Jaeger[65] says that soon
after the hemorrhage the eye-ground presents a diminution in the
calibre of the veins and arteries, with a light-blue discoloration of
the optic disc, without any other demonstrable tissue-change.
Graefe[66] saw slight diminution of the calibre of the retinal arteries
and an increased pallor of the disc in a case where blood was vomited
and passed by stool fourteen days after the occurrence of the
blindness. On the other hand, Schweigger[67] (in two cases), Nagel,[68]
Hirschberg,[69] Nägeli,[70] Horner,[71] and Landesberg[72] have all
noted the occurrence of neuritis.

[Footnote 63: Sigmund Fries, "Diss. Inaug." in _Klin. Monatsblätter f.
Augenheilkunde_, 1878.]

[Footnote 64: _Ergebnisse der Untersuchung mit dem Augenspiegel_, 1876,
p. 87.]

[Footnote 65: _Loc. cit._, 1876, p. 87.]

[Footnote 66: _Arch. f. Ophth._, vol. vii., part 2, p. 146.]

[Footnote 67: _Handbuch der Augenheilkunde_, 1875 (3d ed.), p. 522.]

[Footnote 68: _Behandlung der Amaurose und Amblyopie mit Strychnine_,
1871, p. 51.]

[Footnote 69: _Bericht über die zehrite Vorsammlung der Ophth.
Gessellschaft Heidelberg_, 1871, pp. 53-60.]

[Footnote 70: _Jahrbuch f. Ophthalmologie Literatur_, 1879, p. 253.]

[Footnote 71: _Klin. Monatsblätter f. Augenheilkunde_, 1877
(supplement), pp. 53-60.]

[Footnote 72: _Ibid._, 1875, pp. 98, 99.]

PROGNOSIS.--The prognosis is very unfavorable, and but few cases are
recorded where there has been any improvement of sight.

PATHOLOGY.--The pathology of the affection is not well made out.
Samelsohn,[73] who has reported a number of interesting cases, supposes
{747} that where there is a great loss of blood the brain becomes
anæmic and occupies less room in the skull, and serum exudes from the
blood-vessels to fill the vacuum. As the patient regains strength and
blood is re-formed, the increased intracranial pressure drives the
fluid into the subvaginal space of the optic nerves and causes
neuritis. In other cases a hemorrhage into the sheath of the nerve is
assumed as the cause. For those very exceptional cases where, after
slight loss of blood, there is sudden and complete blindness without
marked changes in the optic nerves and retinæ (and prompt reaction of
the pupils to light), we are obliged to assume some lesion of the optic
centres. Samelsohn[74] attempts to explain it by comparison with the
observations of Lussana, Brown-Séquard, Ebstein, and Schiff, who found
that wounds of the brain involving the anterior prominences of the
corpora quadrigemina and the thalamus opticus may cause hemorrhage into
the mucous membrane of the stomach; consequently, he assumes a central
lesion which produces simultaneously the blindness and the hemorrhage.
All this is, however, but ingenious speculation, and the true pathology
is still to be made out by careful autopsies.

[Footnote 73: _A. f. O._, xviii., 2, pp. 225-235.]

[Footnote 74: _A. f. O._, xxi., 1, pp. 150-178.]

The study of the eye-ground after death is difficult; for, apart from
any hindrances due to the position of the body or to social customs,
Nature soon interposes an efficient barrier to such examination by the
rapidity with which cloudiness of the corneal epithelium and of the
lens substance sets in. These optical hindrances advance sufficiently
soon to make it impossible to focus accurately any object in the
eye-ground. Poncet[75] asserts that this may be remedied to a certain
extent by dropping water into the conjunctival sac, which will render
the cloudy epithelium sufficiently transparent to permit examination
from two to five hours after death. Most observers agree that in the
human eye there is an immediate blanching of the disc and choroid,
causing the latter to assume a pale-yellowish hue with a faint tint of
rose, and that the arteries (by promptly emptying themselves) escape
observation, while the veins retain for a time a considerable amount of
their contents, the blood-columns often being discontinuous and broken.
Later, these changes are followed by a gradually increasing haze of the
retina, which gives the appearance of a bluish-white veil spread over
the fundus. Schreiber[76] gives an instructive picture of the eye of a
patient dying of phthisis, and another of the same eye five minutes
after death. Gayat, who had the opportunity of studying this subject in
the eyes of five individuals recently decapitated by the guillotine,
describes the formation of a small red spot at the fovea centralis
similar to that seen in embolism of the central artery.[77] On the
other hand, Becker[78] thinks that the emptying of the vessels after
death is rather the exception than the rule, basing his observations
not on ophthalmoscopic examinations, but on the fact that in opening
freshly enucleated glaucomatous eyes, and in the eyes of those who had
been hung, he had observed all the vessels, arteries as well as veins,
full of {748} blood. Weber[79] also, while admitting that the vessels
both in men and animals usually empty themselves soon after death,
describes as an exception a case in which there was no visible change
in the blood-columns of the retinæ of the eyes of a patient with brain
tumor, and a consequent optic neuritis, who was gradually dying of
paralysis of the organs of respiration. This circumstance, in the
opinion of the narrator, was very probably due to the obstruction to
the escape of blood from the eye which would naturally be caused by the
swollen and prominent optic nerve. Landolt and Nuel[80] assert that
there is an increase in the refraction in rabbits' eyes after death,
causing any existing hypermetropia to approach emmetropia. They call
attention to the difficulty of such determinations, owing to
rapidly-forming haze on the corneal epithelium and to more or less
complete emptiness of the retinal vessels.

[Footnote 75: _Archives générales de Médecine_, Série 6, t. xv., 1870,
pp. 408-424.]

[Footnote 76: Separat Abdruck aus dem _Deutschen Arch. f. klin. Med._,
Bd. xxi. pp. 100, 101, Plates vii. and viii.]

[Footnote 77: _Annales d'Oculistique_, 1875, pp. 1-14.]

[Footnote 78: "Sitzungsbericht der Ophth. Gesellschaft," in _Klin.
Monatsblätter f. Augenheilk._, 1871, p. 385.]

[Footnote 79: _Klin. Monats. f. Augenheilk._, pp. 383-385.]

[Footnote 80: _A. f. O._, xix. 3, pp. 303, 304.]


Diseases of the Organs of Respiration.

Diseases of the organs of respiration appear to have little direct
influence upon the nutrition of the eye, except in so far as they cause
venous stasis by obstruction of the circulation through the lungs.
Jaeger was the first to call attention to this fact in cases of
pneumonia and pleurisy. The stasis manifests itself by an increase in
the calibre of the veins, with a broadening of the light-reflex from
them and a marked change in the color of the blood, causing the venous
columns to become dark bluish-red. The writer has often seen this
condition well marked in cases where there was not sufficient
interference with the oxidation of the blood to cause an appreciable
cyanosis of the skin. A higher degree of impeded circulation in the
lung doubtless gives rise to the retinal hemorrhages, which, according
to Foerster, are not infrequent in emphysema. Schreiber[81] mentions
that in the hectic fever of phthisis the dilatation of the retinal
vessels causes a congested appearance of the eye-ground, in marked
contrast with the anæmic pallor of the skin of the patients. In 1871,
Horner[82] published 31 cases of herpes corneæ occurring either during
the course of severe catarrhal affections of the respiratory organs or
immediately following such attacks. The eruption, which first appeared
upon the lips, and then upon the eyeball, usually took place after the
culmination of the febrile symptoms. The progress of the affection is
slow, the ulcers left by the bursting of the vesicles healing in a
period varying from two to six weeks. The herpes was monolateral,
except in one case of double pneumonia in a drunkard, where the
eruption occupied the entire central area of both corneæ. In
preophthalmoscopic times Sichel called attention to blindness after
pneumonia and bronchial catarrh, which he thought was due to cerebral
congestions occurring in the height of these diseases.[83] He
considered these congestions harmless so long as the patients remained
quiet under antiphlogistic treatment, but deemed them noxious in their
influence upon the eye as soon as freedom was allowed. Seidel[84]
relates {749} cases of amblyopia with contracted pupils and eyeballs
which were painful on the slightest pressure. He says that coincident
with croupous pneumonia on the fifth day there was color-blindness,
followed two days later by a disappearance of the amblyopia, with a
return of the pupils to their normal size.

[Footnote 81: _Veränderungen des Augenhinter-qrundes bei Internen
Erkrankungen_, 1878, p. 87.]

[Footnote 82: "Bericht der Ophth. Gesellschaft," in _Klin.
Monatsblätt._, 1871, pp. 326-328.]

[Footnote 83: Zehender, _Handbuch der Augenheilkunde_, vol. ii. pp.
188, 189.]

[Footnote 84: "Sehstörungen bei der Pneumonie," _Deutsches Klinik_,
1862, No. 27.]


Affections of the Eye caused by Diseases of the Digestive Organs.

TEETH.--Ophthalmic literature furnishes many instances of diseases of
the eye said to be caused by affections of the teeth. These vary in
severity from slight conjunctivitis and photophobia, or temporary
failure of accommodation, to absolute amaurosis. It is natural to
suppose that affections of the dental division of the trigeminus might
readily give rise to reflex disorders in parts supplied by branches of
the same main trunk. Although the writer has been on the lookout for
such affections, he has seen very few cases of eye disease which could
be logically attributed to disease of the teeth, and has known at least
two sound teeth which were uselessly sacrificed to mistaken theories of
pathology. Perhaps the most noteworthy effort to assign dental
neuralgia as a cause of amaurosis is the well-known paper of Jonathan
Hutchinson in the _Royal London Ophthalmic Hospital Reports_ for 1865.
An attentive study of the interesting cases there recorded shows that
but few of them can be considered as affording convincing evidence of
the point which he desires to prove, and few are probably more keenly
aware of this fact than the distinguished surgeon himself when he
writes: "I am quite alive to some of the sources of mistake which
attend the attempt to prove the occurrence of paralysis from reflex
irritation consequent on a peripheral cause: chief among them we have,
of course, the possibility that the neuralgia itself may have been due
to central disease, and that the extension of the latter may have
complicated other nerves."[85] That amaurosis does, however, sometimes
follow dental irritation is proved by Hutchinson's first case in the
above-quoted paper, where neuralgia of the eyeball with great
intolerance of light was cured by extraction of a carious molar tooth.
Perhaps the most striking case on record is that of Galezowski,[86]
where a small fragment of wood which had entered the cavity of a
carious tooth (probably from picking the teeth with a wooden
toothpick), lodged at the extremity of one of the fangs, is said to
have caused absolute blindness of the eye, with dilatation of the pupil
on the same side. After a blindness of eleven months the tooth with the
foreign body was extracted, causing the evacuation of a few drops of
thin pus from the antrum; after which the patient improved and vision
gradually returned, so that on the ninth day after the operation he
could see with the affected eye as well as with the other. Schmidt,
after an examination of 96 patients with carious teeth, formulates the
following conclusions: "1. That we may have a more or less considerable
limitation of the accommodation {750} in consequence of pathological
irritation of the dental branches of the trigeminus. 2. This may occur
on both sides. Where the affection is one-sided, it is always on the
side of the affected tooth. 3. It is usually an affection of the young,
very seldom or never occurring in old age. 4. That the diminution of
the power of accommodation is due to increased intraocular pressure
caused by reflected irritation of the vaso-motor nerves of the eye."
These conclusions are interesting, but cannot be considered absolutely
correct, in consequence of the fact that there are no recorded tests
for astigmatism or insufficiency, and that accurate examination of the
state of refraction was impossible through want of a mydriatic which
may in measure have accounted for the existent diminution of
accommodation. More extended and minute investigations of the subject
are desirable.

[Footnote 85: "A Group of Cases illustrating the Occasional Connection
between Neuralgia of the Dental Nerves and Amaurosis," by Jonathan
Hutchinson, F.R.C.S., _R. L. O. H. Rep._, vol. iv. pp. 381-388.]

[Footnote 86: _Archives générales de Médecine_, t. xxiii. pp. 261-264.]

STOMACH, INTESTINES, AND LIVER.--Amblyopia and amaurosis with severe
gastric symptoms are not very uncommon, but, although such cases are
made much worse by the ingestion of indigestible substances,
constipation, etc., it has nevertheless always appeared to the writer
that the primary lesion lay in the nervous system. Galezowski, however,
lays stress on this subject, and discriminates between a true and false
locomotor ataxia; the latter being, according to this author,
symptomatic of stomachic and intestinal lesions. Many of the older
writers relate cases of amaurosis from worms in the intestines. Thus
Laurence[87] gives an instance of sluggishness and partial dilatation
of the pupils with dim vision which promptly disappeared after the
evacuation of seat-worms consequent on an enema of turpentine. Hays
calls attention[88] to a case recorded by Welsh of Massachusetts where
complete amaurosis in a child instantly ceased on a worm being puked
up. Many similar instances might be adduced which in modern books are
either passed over in silence or looked at with a shrug of incredulity.
Although the writer has had no personal experience with such cases, he
can readily understand that in children the irritation of worms might
easily give rise to enough reflex disorder of the spinal cord and brain
as to cause impairment of the accommodation and partial dilatation of
the pupils. (The effects of hæmatemesis and hemorrhage from the bowels
have been already discussed.)

[Footnote 87: Amer. ed. by Hays, 1847, p. 554.]

[Footnote 88: _Ibid._, 1847, p. 555.]

That jaundice shows readily in the conjunctiva is well known to all
practitioners, and yellow vision is described as an occasional symptom
of severe icterus, Jaeger calls attention to a light-yellow color of
the eye-ground and retinal vessels under these circumstances.
Junge,[89] Stricker,[90] and Buchwald[91] have all recorded cases of
retinal hemorrhage in cases of grave disease of the liver. Litten[92]
says that for ten years he has examined every case of liver disease
under his charge with the ophthalmoscope, and found retinal hemorrhages
only in fifteen cases. These occur only when icterus is present, but
are not due, as Traube assumes, to the action of the biliary acids on
the blood-corpuscles. If they were so, we should have blood-stained
lymphatic sheaths instead of corpuscular diapedesis and massing of the
exuded blood. Of these 15 cases, 4 were cases of congestive jaundice, 4
of carcinoma, 1 each of acute fatty {751} degeneration and
phosphorus-poisoning, 1 of abscess, 2 of cirrhosis, 1 of hydrops
cystides filleæ. The hemorrhages were usually in the nuclear layers,
and seldom presented white centres, as in leucocythæmia. In the case of
phosphorus-poisoning there were large white plaques with marginal
inflammation. Litten considers that the pigment-spots reported in the
retina in cases of liver disease (his own cases and Landolt's) are due
not to cirrhosis hepatis, but to a congenital or acquired disposition
to connective-tissue hyperplasia [syphilis?]. Foerster[93] has called
attention to a group of cases which he ascribes to hyperæmia of the
liver and plethora abdominalis, where we find discomfort in the use of
the eyes from the accompanying retinal hyperæmia and diminution of the
range of accommodation, and where the ophthalmoscope frequently shows
premature senile degeneration of the lens, manifested by striæ
occurring in the extreme periphery. Every careful observer will
doubtless agree to the accuracy of this description, and to the
advantages of proper hygiene, exercise, and the alterative mineral
waters (Karlsbad, Saratoga) in such cases.

[Footnote 89: _Heinrich Müller's Gesammelte Schriften_, pp. 331-335.]

[Footnote 90: _Berliner klin. Wochenschrift_.]

[Footnote 91: Foerster, _loc. cit._]

[Footnote 92: _Deutsche med. Wochenschrift_, 25 März, 1882, pp.
179-182.]

[Footnote 93: _G. u. S._, vol. vii. p. 74.]

SPLEEN.--The effect of disease of the spleen in causing disease of the
eye has already been alluded to in the discussion of leucæmic
retinitis.

Xanthopsia appears to be a very infrequent complication of liver
disease. Moxon,[94] who records seven cases of fatal obstructive
jaundice, has never seen it. He remarks that in these cases the
vitreous and lens remained perfectly clear, while the blood-serum was
saffron-yellow and the sclerotic deeply stained (yellow or
olive-green). Rose[95] gives the only case with which the writer is
familiar, in which it was carefully studied and demonstrated with the
spectroscope. Here the violet end of the spectrum was shortened as in
poisoning by santonin, and the blue blindness was so marked that a few
days before his admission to the hospital the patient had excited the
astonishment of his fellow-workmen by mistaking the color of a door
which had been freshly painted blue. The autopsy showed here also that
the vitreous and aqueous were colorless, but the cornea was clearly
yellow. This Rose thinks insufficient to have caused the xanthopsia,
and therefore attributes it to the effect of the jaundice in the
nerve-centres.

[Footnote 94: "Clinical Remarks on Xanthopsia and the Distribution of
Bile-Pigment in Jaundice," _Lancet_, Jan. 25, 1873. p. 130.]

[Footnote 95: "Die Gesichtsläuschungen im Icterus," _Virchow's Archiv_,
vol. xxx. pp. 442-447.]

HEMERALOPIA.--The curious affection hemeralopia, which we well know to
be a constant accompaniment of some forms of congenital nerve-atrophy
(retinitis pigmentosa), and also to affect, at times, considerable
numbers of persons exposed to the glare, overwork, and exposure of an
active campaign, is probably always due to some form of malnutrition or
disorder of the digestive apparatus, and in many cases it is associated
with jaundice and disease of the liver. That glare of light is not
necessary to its production is shown by its development in convalescent
hospitals. Reymond of Turin reports it as developing in an individual
affected by pellagra on whom he had operated for cataract, and who
during the four weeks subsequent had never been out of his room.
Cornillon[96] reports 5 cases of hemeralopia during jaundice, and of
these 4 came under his observation {752} in a single winter in the
hospital in Vichy. It never appeared early in the congestion of the
liver, but always after jaundice had existed for some time, and
disappeared without special treatment--often to recur when the disease
of the liver became more marked. Parinaud[97] has reported 4 such cases
in all, with jaundice, the conjunctiva being yellow, but the media not
tinged. There were no ophthalmoscopic changes. One of these cases was
malarial hepatitis, the other three probably cirrhosis. A curious
change in the ocular conjunctiva has been noted in many of these cases
of hemeralopia, and attention was first called to it by Bitot.[98] He
observed 29 cases at the Hospice des Enfants Assistés at Bordeaux. The
bulbar conjunctiva in the palpebral fissure, usually at the outside of
the cornea, becomes dry and anæsthetic (epithelial xerosis), and a
number of minute points form in it, and the little patch becomes like
mother-of-pearl, iridescent and silvery. They become paler before they
disappear, and come and go with the advent and cessation of the
hemeralopia. Pressing on the conjunctiva over the spot by rubbing the
lids over it often causes little fragments of the dry patch to crumble
off. The adjoining conjunctiva is dry and less pliant, more like
parchment. The extensive occurrence of hemeralopia during the severe
Easter fasts of the Greek Church has been noted by Blessig. There is
frequently diarrhoea associated with this condition. Teuscher also
speaks of conjunctival xerosis and hypopyon keratitis in the young
slave-children in the Brazilian coffee-plantations, associated with
gastric catarrh and diarrhoea.

[Footnote 96: _Le Progrès médicale_, No. 9, Fèvrier 26, 1881, pp.
157-159.]

[Footnote 97: _Archives générales de Médecine_, April, 1881, pp.
403-414.]

[Footnote 98: _Gaz. méd. de Paris_, No. 27, 4 Juillet, 1863.]


Diseases of the Kidneys and Skin.

DISEASES OF THE KIDNEYS.--As has been abundantly proved by careful
autopsies, inflammation of the retina may be developed during any form
of _Bright's disease_, either with the enlarged mottled kidney of acute
parenchymatous nephritis, the large white kidney, the amyloid kidney,
or the cirrhotic kidney of chronic disease. In the vast majority of
cases the retinal inflammation appears during the later stages of the
last-named form of disease, and seems to be in some way dependent upon
blood-poisoning, which has been caused by the degenerating kidney.

The retinitis presents various aspects, not only in different cases,
but also in the different stages of its development in the same case,
and distinguishes itself mainly from other forms of inflammation of the
retina by its marked tendency to fatty degeneration. As seen at an eye
hospital the disease usually presents a type quite different to that
which predominates in the wards of a general hospital. In the former
class of cases the blood-poisoning seems to fall with peculiar
intensity on the nervous system, and the patients come complaining of
headache, dizziness, and dim vision, these being the only marked
symptoms of the malady, while the anæmia, dropsy, and other symptoms
are either absent or present in so slight a degree that the patients
have not supposed themselves to be suffering from any constitutional
malady or to need any medical advice. In the walking cases the retinal
changes are usually very extensive (and those in the cerebrum would
possibly be found equally developed if we {753} had only as accurate a
method of investigating them), whilst among hospital inmates we often
see only a few white splotches in the retina, either with or without
hemorrhages, and occasionally only a slight atrophy of the optic disc
due to a previous retinitis. In the wards of a general hospital we have
a much better opportunity to study the early development of the
retinitis, and it is there most frequently encountered among those
suffering from dropsy and dyspnoea--patients whose waxy skin and
general appearance indicate at a glance how seriously their nutrition
has been impaired by the ravages of the disease. When the individual
lives and is not markedly relieved by the rest and treatment adopted,
we frequently have an opportunity of seeing the development to a
greater or less degree of the typical form of the affection.

In typical cases the retinal changes commence with slight oedema of the
disc and surrounding retina, associated with a few irregular white
splotches and striated hemorrhages in the fibre-layer. These white
patches multiply and extend, but are usually confined within an area of
two or three disc-diameters from the optic entrance. In high grades of
the affection they coalesce and form a broad zone around the disc,
which is itself swollen and prominent, its outlines being hidden by the
opaque nerve-fibres which diverge from it. From time to time fresh
hemorrhages occur, which are striated when in the fibre-layer, and of
irregularly rounded outline when they invade the deeper portions of the
retina. These were formerly supposed to be absolutely characteristic of
the disease, but it is now asserted by several good observers that
similar appearances have been seen in the neuro-retinitis caused by
brain tumor or by basilar meningitis where there was no accompanying
disease of the kidney. Graefe,[99] Schmidt and Wegner,[100]
Magnus,[101] Leber,[102] Carter,[103] and Eales[104] have each reported
such cases. The hemorrhages are usually either entirely absorbed or
leave behind them a fatty clot, which adds an additional white patch to
the splotches already existing in the retina. In many cases occurring
in the last stages of the disease, a remarkably yellowish tint of the
fundus is observed, together with decided alteration in the color of
the blood-columns in the retinal blood-vessels, the blood in the
arteries being too yellow, and that in the veins presenting too little
of its usually pronounced red-purple tint. In short, there is a state
of affairs approximating in some degree to that which we find in cases
of pernicious anæmia.

[Footnote 99: _A f. O._, xii. 2.]

[Footnote 100: _Ibid._, xv. 3.]

[Footnote 101: _Ophth. Atlas_, Taf. vi. Fig. 2.]

[Footnote 102: _Graefe und Saemisch_, Bd. v. p. 581.]

[Footnote 103: _Diseases of the Eye_ (Am. ed.), p. 382.]

[Footnote 104: H. Eales, _Birmingham Med. Review_, Jan., 1880, p. 47.]

Exceptional forms of albuminuric retinitis have been recorded where the
only change seen in the fundus oculi was a pronounced choking of the
disc similar to that with which we are familiar in cases of brain
tumor. The writer has seen cases which at the start could not be
diagnosticated by the ophthalmoscope from cases of retinal hemorrhage
due to other causes. Magnus has published similar cases.

In the course of Bright's disease uræmic amaurosis is much more rarely
encountered than albuminuric retinitis. It is, however, occasionally
developed in cases in which albuminuric retinitis already exists. It is
rapid in its development, and in its subsidence is without retinal
changes, the blindness being evidently due to some transient affection
of the cerebral centres.

{754} DISEASES OF THE SKIN.--The _eczema_ of the lower lid, nose, angle
of the mouth, and external meatus of the ear which so frequently
accompanies the phlyctenular conjunctivitis of scrofulous children is
probably the most common example of coincident skin and eye disease.
Lepra is a frequent cause of severe affections of the eye in localities
where it is endemic. Bull and Hansen[105] assert that the cornea is
frequently attacked. They divide the manifestations of the disease upon
this membrane into two varieties--the one in which there is a diffuse
infiltration of the tissue, and the other where there is a formation of
tubers. The first variety is a gray opacity limited to the border of
the cornea, not separated from its circumference by any such clear area
as is found in arcus senilis. This opacity becomes vascularized, and
may remain quiet for years till another attack of hyperæmia occurs,
which, also in time receding, leaves the tissue more opaque than
before. In the second there are nodes which appear to start at the
margin of the cornea and to accompany either its superficial or its
deep layer of vessel-loops: this latter form is more dangerous to
vision. The paralysis of the orbicularis muscle which is a frequent
attendant upon the smooth form of the disease allows an exposure of the
membrane to irritants which often produce a third form of inflammation.
The iris also exhibits the smooth and the tuberous forms of the
disease. Iritis occurring in lepra is, however, by no means
pathognomonic; 50 per cent. of all cases exhibiting synechiæ are the
result of extensions of corneal inflammations due to orbicular
paralysis. The superciliæ and the eyelashes are said to be frequent
seats of leprous tubercules. In the lids the first symptom is the
falling of the eyelashes, which is dependent upon the formation of the
tubers before they become manifest to sight and touch. Mooren[106]
maintains that chronic skin eruptions favor the development of cataract
by causing creeping inflammatory processes which alter the character of
the exudations into the vitreous humor, and moreover claims that when
such skin eruptions have their seat in the scalp they favor the
occurrence of retinitis by maintaining a constant hyperæmia of the
meninges. He further cites a case where he observed a decrease in the
acuity of vision corresponding with the breaking out of a skin
eruption, and an increase in the power of vision coincident with the
disappearance of the eruption. Foerster[107] agrees with Mooren in the
statement that cataract may be formed in cases where chronic skin
affections favor the development of marasmus. Rothmund[108] reports a
noteworthy curiosity to the effect that cataract followed a peculiar
degeneration of the skin in three families living in separate villages
in the Urarlberg. The skin of these patients showed a fatty
degeneration of the rete Malpighii and of the papillæ, with consecutive
thinning and atrophy of the epidermis: this was most marked on the
cheeks, chin, and the outer surfaces of the arms and legs. In the
individuals thus affected the skin disease commenced between the third
and sixth months of life, whilst the cataract appeared in both eyes
between the third and sixth years. Rothmund thinks that the same
congenital predisposition to disease exists in both organs, because the
lens is developed out of an unfolding of the external skin.

[Footnote 105: _The Leprous Diseases of the Eye_, Christiana, 1873.]

[Footnote 106: _Ophthalmologische Mittheilungen_, 1874, p. 93.]

[Footnote 107: _Graefe und Saemisch's Handb._, vol. vii. p. 152.]

[Footnote 108: _A. f. O._, xiv., 1, p. 159.]


{755} Disturbances of Vision caused by Disease of the Sexual Organs.

The eyes and their appendages frequently exhibit the effects of
perverted function or diseased conditions of the sexual organs. As
might be expected, these ocular effects are most marked in the female,
whose generative apparatus is so much more complex and extensive. While
it is true that there are thousands of women with grave disease or
derangement of these organs who are free from any uncomfortable eye
symptoms, still, clinical experience shows that there are crowds of
others who present eye lesions due entirely to such causes. Still more
frequently do we see some slight optical defect (previously scarcely
noticed) become so unbearable that the patient is unfitted for any
useful employment. In fact, at most eye hospitals, and still more
markedly in private practice, we find an excess of female over male
patients. This excess becomes more palpable when we throw out of
consideration the large number of male patients who are under treatment
for injuries of all sorts the result of mechanical occupations not
pursued by females, and the inflammations due to direct exposure to
storm, cold, and intense heat.

MENSTRUATION.--When menstruation is profuse its effects are with
difficulty distinguished from those of anæmia and loss of blood, but
where it is retarded, irregular, or scanty the effects are more readily
traced. All surgeons of experience are agreed that it is undesirable to
perform operations for cataract or to make iridectomy at the menstrual
period, and it is well known that eyes which have been progressing
favorably after operations become congested and irritable during the
monthly period. In trachomatous eyes retardation of the catamenia often
causes the eruption of a fresh crop of granules, while in cases of
phlyctenular and interstitial keratitis there are still more frequently
relapse and exacerbation of the disease. Vaso-motor disturbances
connected with the period of puberty and with that of cessation of the
menses are of daily occurrence: we constantly see cases at these epochs
where some slight astigmatism or hypermetropia, which has previously
given no practical annoyance to the patient, becomes absolutely
unbearable. The eyes become watery and sensitive to light; there is
marked congestion of the retina with tortuosity of its veins, together
with serous infiltration and swelling often sufficient to obscure the
margins of the disc. These symptoms frequently entirely disappear when
the menses have either become established or have permanently ceased.
In some rare cases the symptoms are anomalous and striking: thus the
writer has seen vicarious menstruation from the lachrymal caruncle, and
a case of pemphigus of the upper lid occurring regularly at each
menstrual period for some months. In another patient menstruation came
on during the thirteenth year with intense headache, epistaxis, and
photophobia, and for a long time afterward there was utter inability to
use the eyes for school-work even during the catamenial interval. At
almost every menstrual epoch during a period of eight years there has
been a recurrence of these symptoms, although they subside sufficiently
in the interval to allow the patient to use her eyes for a very limited
amount of near work. At the first examination the ophthalmoscope showed
that the retinal fibres were swollen and oedematous, hiding the
outlines of the discs, while the lymph-sheaths of the retinal vessels
at {756} their point of emergence from the disc presented an almost
snow-white appearance. The discs and the retinæ have never quite
resumed a normal appearance.

Disturbances in the circulation of the eye and its appendages are
frequently associated with the menopause. The writer recalls a case
where for years there was headache with intense congestion of the
palpebral and bulbar conjunctiva, with a fulness and pressure on the
orbits at each menstrual period, all these symptoms disappearing with
the cessation of the menses. The most striking examples of the
influence of the menses on the eyesight are those where the flow has
been suddenly checked. Rejecting examples from the older authors, where
the want of exact helps to diagnosis might leave room for a different
interpretation of the symptoms, we will content ourselves with two
examples where the testing of the eyesight and the ophthalmoscopic
examination were made by skilled observers. Thus, Mooren--to whom we
are indebted for a careful discussion of the relations between uterine
disease and disturbances of sight--recites[109] the case of a
peasant-woman aged twenty-three years who had complete stoppage of the
menstrual flow from exposure to wet during the catamenial period: this
was accompanied by high fever and delirium, with pain in the region of
the right ovary. When these symptoms subsided, she noticed that there
was absolute loss of sight in the right eye, and so great a diminution
of it on the left that she could only distinguish movements of the
hand. The ophthalmoscope showed in the right side a multiple detachment
of the retina, and on the left an intense neuro-retinitis. Rest in bed,
inunctions of mercurial ointment, and cataplasms over the region of the
ovaries, with leeches to the septum of the nose and the neck of the
uterus, gradually brought about amelioration of the symptoms, with
restoration of the eyesight in the left eye. As might be expected, the
retinal detachment and consequent loss of vision in the right eye
remained permanent. In confirmation of this case, but in contrast with
it as regards the retinal symptoms, is the one related by
Samelsohn.[110] The patient (a peasant-girl) by standing in a cold
running brook while at work had her menses suddenly stopped. There was
no marked uterine or abdominal pain. The patient complained of a
feeling of pressure on the orbits, and experienced a gradual failure of
sight with contraction of the field of vision. In five days there was
absolute amaurosis of both eyes (no sensation of light and no
phosphenes to be obtained by pressure). The sight gradually returned in
each eye, this being preceded by a copious flow of tears, so that in
sixteen days the patient could read small print fluently. In seven
weeks the menses returned. There were no ophthalmoscopic symptoms: each
eye, both during the attack and subsequent to it, showed only striation
of the retina and tortuosity of its veins, the calibre of the retinal
arteries being unchanged. Unfortunately, any pupillary changes that
might have been recognized were annihilated by previous instillation of
atropine into the eye. In the first case there was every probability in
favor of a serous effusion into the subarachnoidal and the intravaginal
spaces. The latter case is more difficult to explain: if it were due to
orbital or intracranial neuritis, why should there not have been some
ophthalmoscopic changes during the {757} time that the patient was
under observation? If to effusion within the cranium or to local
circulatory disturbances in either the corpora quadrigemina or the
occipital lobes, why were there not other symptoms of intracranial
disturbance?

[Footnote 109: _Arch. f. Augenheilkunde_, Bd. x., 1881.]

[Footnote 110: _Berliner klin. Wochenschrift_, Jan., 1878, pp. 27-30.]

In further illustration of the effects of a stoppage of menstruation,
Mooren[111] cites the case of a peasant-woman aged thirty-one who had
complete suppression of the menses after the birth of her fourth child,
and where subsequently an almost continuous headache, dimness of
vision, and eventually epileptiform attacks, followed. The
ophthalmoscope showed a double neuritis so intense as to lead to the
supposition of a possible cerebral tumor. Mercurial inunctions with
seton to the back of the neck were resorted to without result.
Emmenagogues also failed to give relief. An examination of the uterus
was now made, which showed great enlargement and hyperplasia,
especially of its mouth and neck, for which scarifications and
sitz-baths were employed with good result. The headache and epileptoid
attacks disappeared, and the vision improved so far that the patient
(who when admitted to the hospital could only decipher Jaeger No.
xviii.) could read fluently Jaeger No. iii.

[Footnote 111: _Loc. cit._, p. 551.]

DISPLACEMENTS OF THE UTERUS.--Anteflexion and retroversion of the
uterus are frequent causes of retinal hyperæsthesia. In this connection
we may quote from the same author two cases, as showing how slight
mechanical irritations of the uterus may cause eye disturbance--one
where a patient had an episcleritis and a chronic metritis with
malposition of the uterus, in whom there was an exacerbation of the
ciliary neuralgia and of the local eye inflammation every time that the
ulcerated os uteri was cauterized or a pessary introduced; and a second
with an adhesive kolpitis, in whom the introduction of a pessary caused
unpleasant feelings about the head and oppression in the cardiac
region, accompanied on two separate occasions by capillary hemorrhages
into the retina, all of these symptoms disappearing rapidly after the
removal of the pessary. Mooren[112] has also seen a double
neuro-retinitis caused by retroversion of the uterus. The sight was so
much impaired that the patient could with difficulty decipher Jr. No.
xx.; but it was entirely regained within a few months after the uterus
had been replaced in its proper position. No other treatment was
employed.

[Footnote 112: _Ophthalmologische Mittheilungen_, 1878, p. 97.]

PELVIC CELLULITIS.--Still more frequently are the reflex eye
disturbances caused by parametritis and the various forms of pelvic
cellulitis. Every practitioner has had abundant opportunity of studying
the easy fatigue of the eye, the burning and stinging conjunctival
sensations, the orbital and periorbital pains, the retinal
hyperæsthesia and sensitiveness to artificial light, which characterize
the early stages of the affection, accompanied later on by symptoms of
retinal anæsthesia. Inasmuch as the cause of these symptoms is
irremediable, we find in the majority of cases that it is impossible to
relieve the sufferings of the patient; this cause consisting in the
cicatricial shrinking of the parametrium and the pelvic connective
tissue. Sleep gives relief only so long as it lasts, and the patients
upon awakening, instead of feeling rested, often experience their
greatest pain and discomfort. Foerster[113] and Freund, who were the
first to demonstrate this {758} form of parametritis, call special
attention to the fact that the patients have their good and bad days
entirely independent of any use of the eyes. In many of the milder
cases, however, we find that the sufferings of the patients are
enhanced and aggravated by the presence of some defect, such as
astigmatism, hypermetropia, or insufficiency. Although the careful
correction of such defects will give considerable relief and enable the
patients to use their eyes for near work for a much longer period,
nevertheless the pain and discomfort are out of all proportion to the
amount of error. Of course, we are very far from having converted such
eyes into useful instruments for every-day work or for long-continued
labor, but we have removed an appreciable source of irritation from an
oversensitive nervous system, and done much to relieve the toedium vitæ
in cases which perhaps for months previously have been unable to amuse
or occupy themselves by the use of their eyes in either reading,
writing, or sewing.

[Footnote 113: "Allgemein-Leiden und Veränderungen des Sehorgans," in
_Graefe und Saemisch_, vol. vii. pp. 88-96.]

MASTURBATION is also an occasional cause of reflex eye disturbances.
Mooren[114] relates two aggravated cases in women who for years had
been excessively addicted to the vice. In both of these there were
accommodative asthenopia and tenderness in the ciliary region, dread
even of moderate illumination, which increased from year to year. In
both cases there were attacks of dyspnoea and other disturbance of
innervation of the pneumogastric nerve. Cohn has also published a
number of cases of eye disease in the male sex due to the same cause.
The main symptoms were a feeling of pressure on the eyes, bright dots
moving before them, and a sensation as if the air between the patient
and the object looked at was wavy and trembling. In some of the
individuals a discontinuance of onanism and a moderate indulgence in
sexual intercourse effected a complete cure. Travers[115] gives a case
of loss of sight from excessive venery, and another from masturbation.
Mackenzie[116] quotes Dupuytren as relating the case of a man who lost
his sight on the day after his wedding, but where it was promptly
restored by the use of a cold bath with stimulants and the application
of counter-irritation to the skin of the lumbar region. Foerster[117]
has recorded a case of kopiopia hysterica in a man where, from the eye
symptoms alone, he diagnosticated disease of the genital organs, and
where it was afterward proved that there was inability to copulate, the
patient having extremely small testicles and there being a thin
whey-like discharge from the urethra.

[Footnote 114: _Loc. cit._]

[Footnote 115: _Synopsis of Diseases of the Eye_, 1820, p. 145.]

[Footnote 116: _Diseases of the Eye_, 1854, p. 1075.]

[Footnote 117: _G. u. S. Handb._, vol. vii. p. 95.]

CONGESTION AND INFLAMMATION OF THE OVARIES.--Disease of the ovaries is
frequently associated with retinal oedema and hyperæsthesia. In women
complaining of weak and painful eyes pressure in the ovarian region
often causes pain. Where only one ovary is tender to the touch, we
often notice that the patient complains more of the corresponding eye,
although there may be no difference or abnormality in the
ophthalmoscopic appearance of the two eyes. Under this head may be
appropriately mentioned the eye symptoms of patients affected with
hystero-epilepsy, a disease which is always associated with ovarian
trouble, of which Charcot has given us so graphic a picture. He says
that previous to the attack the patient experiences an aura which
starts from the abdomen. The convulsion is ushered in by a loud cry,
which {759} is accompanied by pallor of the face and loss of
consciousness. These symptoms are succeeded by twitching and rigidity
of the face-muscles, with foaming at the mouth, followed by contortions
of the muscles of the trunk, abdomen, and lower limbs, the paroxysm
terminating with sobbing, weeping, and laughing. Landolt has given us a
careful description of the eye symptoms in such cases, and groups them
into four stages. In the first, the outer and inner tunics of the eye
appear healthy and the acuity of vision is normal, but there is a
contraction of the form- and color-folds, always more marked on the
affected side. In the second group the acuity of vision begins to fail,
and the symptoms become more marked on the hitherto sound side. In the
third with the more affected eye fingers can scarcely be counted, while
the field of vision is limited to a few degrees from the fixation
point; at this stage the ophthalmoscope shows a serous swelling of the
retina, with fulness and tortuosity of its veins. In the fourth stage
there is a partial atrophy of the optic nerve on both sides.

PREGNANCY.--Cases of amaurosis occurring during pregnancy, in which the
vision was impaired after delivery, are recorded by Beer,
Ramsbotham,[118] and other writers of the preophthalmoscopic period.
Some of them, at least, may probably be accounted for by the occurrence
of albuminuric retinitis in the puerperal state, but no such
interpretation can be put on the more recent cases reported by
Lawson[119] and Eastlake,[120] which in their main features strongly
recall the amaurosis after loss of blood, although there is no history
of any similar hemorrhages. In Lawson's case, we have an amaurosis
which commenced during the gestation of the eighth child, and recurred
during the ninth and tenth pregnancies. After the eighth labor the
patient recovered sufficient sight to be able to sew; the amount of
vision being gradually lessened after each gestation until finally
complete atrophy of the optic nerve ensued. In Eastlake's case, the
patient (æt. thirty-four) had borne nine children at full time. The
labors were normal in character, and the amount of blood lost was not
excessive. On the second or third days after the second and each
subsequent delivery, sudden loss of vision occurred, and the woman
became insensible. On recovering her consciousness, her sight did not
at once return, the amaurosis remaining from three to five weeks. After
the last labor there was complete and permanent loss of sight in both
eyes: Z. Laurence examined this case with the ophthalmoscope, and
reports only a slight contraction of the retinal arteries, without
other positive lesion. Zehender,[121] in treating of the subject,
remarks that "almost every busy eye-surgeon has encountered similar sad
cases."

[Footnote 118: _Med. Times and Gazette_, March 7, 1834.]

[Footnote 119: _R. L. O. Hos. Rep._, vol. iv. pp. 65, 66.]

[Footnote 120: _Obstet. Trans._, vol. v. p. 79 (1864).]

[Footnote 121: _Handbuch der Augenheilkunde_, vol. ii. p. 180.]

PUERPERAL PHLEBITIC OPHTHALMITIS.--According to Mackenzie, this dread
malady, which, as a rule, causes the death of the patient, may develop
at any time from the third to the thirtieth day after delivery. It
frequently attacks both eyes, and in those cases which do not terminate
fatally eyesight is usually lost. Hall and Higginsbottom,[122]
Mackenzie,[123] Fischer,[124] {760} Arlt,[125] and Hirschberg[126] have
all given good clinical descriptions of the disease, with careful
autopsies. As in other forms of metastasis, it is ushered in with a
chill. Soon after, transient darting pains are felt in the eye, which
are sometimes associated with photopsies and followed by serous
infiltration of the conjunctiva bulbi. Later, owing to effusion in the
capsule of Tenon and to the swelling of the orbital tissues, the eye
projects forward and its motility is impaired, these symptoms being
accompanied by a clouding of the cornea and the formation of pus in the
anterior chamber. If the patient lives, we may have either discharge of
pus through the cornea or sclera, or its gradual absorption: in either
case, the eyeball shrinks to a small stump. Anatomical examination
shows that the starting-point of these symptoms is a septic embolism of
either the choroidal or central retinal blood-vessels. According to
Hirschberg, "In other pyæmic affections in which the eye is attacked
with septic embolism life is dangerously threatened, but there is a
larger percentage of recovery with permanent blindness (single or
double) than in the puerperal form."

[Footnote 122: _Medico-Chirurgical Transactions_, 1829, vol. xv. p.
120.]

[Footnote 123: _Treatise on Diseases of the Eye_, London, 1854.]

[Footnote 124: _Lehrbuch der Entzündungen und Organischen Krankheiten
des Menschlichen Auges_, 1866, p. 285.]

[Footnote 125: _Die Krankheiten des Auges_, 1863, Bd. ii. pp. 167,
269.]

[Footnote 126: _Archives of Ophthalmology_, 1880, vol. ix. p. 177.]

Influence of Lactation.--The asthenopia, feeble accommodation,
photophobia, and obstinate phlyctenular inflammations of the
conjunctiva and cornea which occur during prolonged lactation are
subjects of daily observation to every ophthalmic surgeon. They
unfrequently fail to yield to appropriate remedies so long as the
patients continue to nurse their children. Besides these symptoms,
Critchett[127] has called attention to the sudden unilateral affection
of sight which occurs during lactation, and is due to hemorrhage
situated either in or behind the retina. This author has frequently
seen such cases coming on without pain.

[Footnote 127: _Medical Times and Gazette_, 1858, p. 118.]

PATHOLOGY.--As regards the pathology of these affections we are still
very much in the dark. Mooren in his elaborate paper (previously
quoted) considers that the reflex disturbances of the retina and optic
nerve may either be transmitted directly, or may cause primarily a
spinal myelitis, which in its turn affects the eyes. He points out that
the subperitoneal connective tissue of the pelvis and the uterus is so
rich in blood-vessels, lymphatics, and nerves that Rouget has likened
it to cavernous tissue. He asserts that the uterine and pelvic nerves
re-enter the lumbar cord, while the veins anastomose freely with the
veins of the spinal column; and quotes Röhrig to show that electric
stimulation of the ovary causes a rise in the general blood-pressure
and a diminution of the heart's action--effects which he attributes to
irritation of the vagus. He further maintains that any long-standing or
often-repeated congestion of the visual centres, of the optic nerve, or
of the retina would cause increase of connective tissue and a
subsequent tendency to contraction, while the lymph which is poured
out, acting on the cylinder axis of the nerves, causes them first to
swell, and finally to absorb (Rumpf,[128] Kuhnt[129]).

[Footnote 128: _Untersuchungen am d. Physiol. Institut. d. Univ.
Heidelberg_, Bd. ii. Heft 2.]

[Footnote 129: _Ueber Erkrankung der Sehnerven bei Gehirnleiden_,
1879.]


{761} Febrile and Post-febrile Ophthalmitis.

VARIOLA.--Various affections of the eye which at times impair its
functions, and at others destroy vision, frequently arise during the
course as well as during the subsidence of smallpox. When pocks form in
the skin of the eyelids, they cause the lids to swell to such an extent
as to completely close the eye: many patients so affected relate how,
after being blind for a week or ten days, they again recovered their
eyesight. The cicatricial processes which ensue often produce falling
of the eyelashes with incurvation of the tarsus, which changes the
direction of the ciliæ and causes the lashes to rub against the
eyeball. During the first stage of the disease there is always flushing
and congestion of the conjunctiva, frequently associated with increased
flow of tears and sensitiveness to strong light. In some cases we find
small elevated yellowish spots, often in groups of two or three,
surmounted by an area of vascularization on the edges of the lids and
in the tarsal conjunctiva. Similar efflorescences are at times seen in
the conjunctiva bulbi and on the limbus corneæ. These coincide in the
time of their appearance with the eruption on the skin, and are
probably of the same nature, although from the difference in the
anatomical structures they do not present the same appearance as the
pocks in the skin. Hebra, who has observed and analyzed twelve thousand
cases, says that 1 per cent. of the total number presented
efflorescences in the conjunctiva. Neumann, Knecht, Schely, Buck, and
other German authorities describe them; and Adler in his able monograph
(_On Eye Diseases during and after Variola_) gives an accurate account
of them. In opposition to the above statement it should be mentioned
that Gregory maintains that no mucous membranes except those of the
fauces, larynx, and trachea are capable of taking on variolous
inflammation. Marson[130] also, who from his position at the London
Smallpox Hospital had unusual opportunities for witnessing the disease,
maintains "that pustules never form on the conjunctiva;" Coccius[131]
is also of the same opinion. These authors call attention to the fact
that the well-known abscesses of the cornea which occur during the
drying and desquamation of the eruption, and which have frequently been
described as pocks by the older authors, cannot in any sense be
considered as pocks. Beer, however, while calling these formations
pocks, distinctly states[132] that they occur during the suppurative or
drying stage. There seems to be no good reason why the above-described
conjunctival efflorescences, which come on simultaneously with the
skin, should not be considered as analogous in their natures, although
from the absence of the corium in the conjunctiva they cannot assume
the well-known form of the skin eruption. At times the conjunctivitis
becomes catarrhal, and even purulent, leaving in some cases an acute
dacryo-cystitis (Adler), and more frequently a low grade of blenorrhoea
of the lachrymal duct. Beer states that "those authorities may be right
who suppose that there is a real eruption of pocks in the mucous
membrane of the tear-sac, because no other sort of inflammation of it
is so apt to cause complete closure in its entire length."[133] The
cornea may present either diffuse or interstitial keratitis. Malacia or
abscesses are more {762} frequent in the severe cases, where there are
evidences of metastases to other organs. They usually form in the outer
quadrant of the cornea, and are accompanied by marked ciliary
injection, the patients complaining of stitches in the ball with
frontal and temporal neuralgia. Prolapse of the iris and often the
formation of a staphyloma are produced by the perforation of resultant
ulcers; sometimes the entire cornea is swept away. Marson declares that
he has seen this last condition occur within forty-eight hours from the
time of the commencement of the corneal affection. Iritis is a less
frequent complication. It is of the seroplastic variety, and, according
to Adler, comes on only after the twelfth day and in cases where the
progress of the disease is slow and insidious. It is always accompanied
by some degree of cyclitis and by vitreous opacities. Four cases of
glaucoma are on record as occurring during variola; and one (that of
Adler) is noteworthy from the fact that the prodroma of glaucoma
coincided with those of the smallpox. It was successfully operated on,
notwithstanding the fact that the incision was made difficult by the
necessity of avoiding a pock on the limbus of the cornea. Fortunately,
the present generation has rarely an opportunity of seeing great
numbers of eye affections from smallpox, and when they do occur, the
partial protection from previous vaccination often modifies their
severity. In these days of antivaccination societies, it is interesting
to turn back to the accounts of the disease given by those who were in
active practice at the time of Jenner's great discovery, and to see how
serious the matter appeared when viewed through their spectacles. Thus,
Andreæ says, "No disease is so dangerous to the eyesight as the
smallpox, and before the introduction of vaccination it caused as much
blindness as all other eye inflammations put together."[134]
Benedict[135] also bears testimony to the great diminution in the
intensity of variolous ophthalmia after the introduction of
vaccination.

[Footnote 130: _London Med. Gazette_, 1838-39, pp. 204-207.]

[Footnote 131: _De Morbis Oculi humani que e Variolis exedi, etc._,
Leipzig, 1871.]

[Footnote 132: _Lehre von den Augenkrankheiten_, vol. i. p. 527.]

[Footnote 133: _Op. cit._, p. 525.]

[Footnote 134: August Andreæ, _Grundriss der Gesammten Augenheilkunde_,
vol. ii. p. 260.]

[Footnote 135: P. W. G. Benedict, _De Morbis Oculi humani
inflammatorii_, lib. iii. p. 367.]

Writing later, Himly[136] says: "Smallpox, formerly a rich source of
all eye diseases by which the doctor was most busied, is at present
only feebly represented by the varioloids (_i.e._ smallpox modified by
cowpox)." Mackenzie[137] states that "in former times smallpox proved
but too often the cause of serious injury to the eyes, and even of
entire loss of sight. It was by far the most frequent cause of partial
and total staphyloma." Dumont in his work on blindness, the result of
his own observations at the Hospice des Quinze-Vingts at Paris, and
from its extensive statistics in previous years, records that out of a
total of 2056 blind, 262 were blind from variola (or 12.64 per cent.);
and, further, that the old records of the hospice showed 17.9 per
cent., whilst at present (1856) it was 12 per cent. amongst the older
inmates, and but 7 per cent. amongst the more recently admitted. He
quotes Carron du Villars as giving the ratio before Jenner at 35 per
cent. From immunity we become careless, so that when an epidemic breaks
out (as that in Mayence in 1871) we have a state of suffering which
forcibly brings back our remembrance of old times. Thus, Manz asserts
that "the pestilences of the last (Franco-German) war have revived the
remembrance of a disease which in the {763} beginning of this century
was a terror to humanity, but which in the last decade was so rare that
many now living physicians know it only by the writings of the older
authors: the late epidemics, however, have enlarged their experience,
and added a new contingent to the almost extinct army of the
smallpox-scarred blind."[138]

[Footnote 136: _Krankheiten u. Missbildungen des Auges_, Berlin, 1843,
p. 481.]

[Footnote 137: _Diseases of the Eye_, p. 500.]

[Footnote 138: _Jahresbericht f. Ophth._, 1873, pp. 178-183.]

RUBEOLA.--Preceding the outbreak of the skin eruption, or coincident
with it, every case of measles presents a greater or less degree of
catarrhal conjunctivitis, often accompanied by lachrymation, itching,
and burning of the lids, slight pain, and photophobia. In from two to
three weeks the catarrh usually disappears of itself, but in many cases
leaves behind it an asthenopia and sensitiveness to light which often
lasts for months. In some fortunately rare cases the catarrh increases,
and we have a severe muco-purulent inflammation of the eyes, causing
partial or total sloughing of the cornea, and thus leading either to
the formation of a staphyloma or to the total loss of the eye.
Moreover, we often have the development of phlyctenular keratitis as
one of the sequelæ, especially among the weak and badly nourished. Some
authors (Rilliet and Barthez, Mason, Schmidt-Rempler, De Schweinitz,
etc.) relate cases where diphtheritic conjunctivitis, with all of its
well-known symptoms--yellow, ropy-like secretion, great bulbar
chemosis, and hard board-like infiltration of the lids--set in during
the course of the disease. Kerato-malacia (a rapid sloughing of the
cornea with marked anæsthesia of the ball, without swelling of the
lids) was probably first observed as a consequence of measles by
Fischer.[139] He had seen three cases, each accompanied by suppression
of the skin eruption, severe fever, and delirium. The corneæ were
entirely destroyed in twenty-four to forty-eight hours, and the
children died soon after the development of the eye affection. Beger
and Begold (Leber) have each reported similar cases. Sometimes in the
course of this disease, amaurosis, either permanent or transient, is
doubtful. Graefe[140] gives a case where failure of sight came on
during convalescence, and where for a week there was absolute loss of
perception of light, without any other ophthalmoscopic appearances than
a slight neuritis, the patient gradually recovering his eyesight. In an
epidemic of measles with severe cerebral symptoms, Nagel[141] records a
case of a child where on the third day sopor, convulsions,
opisthotonos, and dilatation of the pupils set in. The patient remained
soporose for ten days, and then, on regaining consciousness, was found
to be entirely blind. On the twenty-fifth day from the setting in of
the convulsions, perception of light was dubious, and the pupils, which
remained insensitive to the reflection from the ophthalmoscopic mirror,
contracted slightly on exposure to the full glare of daylight. There
was eventually complete recovery both of health and eyesight, the
return of the latter being apparently hastened by the use of strychnia.
The same author relates two other cases, in one of which the
ophthalmoscope showed neuritis. One of them was fatal, the other
terminated in recovery, and in neither was there any return of
eyesight. In some cases of measles where Bright's disease of the
kidneys is pre-existent or sets in during the {764} attack, there may
be the development of the characteristic form of retinitis albuminuria.

[Footnote 139: J. N. Fischer, _Lehrbuch der Entzündungen und
Organischen Krankheiten des Menschlichen Auges_, Prag, 1846, p. 275.]

[Footnote 140: _A. f. O._, xii., 2, p. 138.]

[Footnote 141: _Behandlung der Amaurosen_, pp. 24-30.]

SCARLATINA.--In scarlatina we have usually a hyperæmia of the
conjunctiva coincident with the skin eruption. Inflammatory affections
of this membrane and of the cornea are much less frequent than in
measles. Martini[142] remarks that only in one case in twenty is there
any inflammation of the eye. Beer[143] informs us that the tears are
more irritating than in morbillous ophthalmia, and that the photophobia
is more persistent. When ichorous ulcers form, they attack not only the
cornea, but also the white of the eye, and spread much more rapidly in
this situation than in the conjunctival leaflet of the cornea.
Kerato-malacia occurs more frequently than in rubeola. Bonman[144]
relates that in a severe epidemic of scarlet fever five boys in one
family were taken sick, and that two of them lost their sight from
sloughing of the cornea within a week of their seizure. Of these, one
died, and the other was brought to him with a shrunken globe and
without light-perception. The eyes of the other three children were not
affected. Arlt in the first volume of his work on diseases of the
eye[145] has given us a clinical description of this form of
kerato-malacia. The patient, a boy of four and a half years, was first
seen by him on the eighth day of the disease. The child was very
pallid, with a burning-hot skin, hoarse voice, slight diarrhoea, and
flat abdomen. The right cornea was evenly clouded throughout, swollen,
and softened, while the left had lost its brilliancy and was slightly
clouded, presenting the appearance of an eye thirty-six hours after
death. The conjunctivæ of both eyes were white, with a few vessels and
ecchymotic spots in their lower parts. On the tenth day, the right
cornea was converted into a mass as soft as schmeer-käse, and was
beginning to be thrown off on the centre, where there was a hernia of
the hitherto unaffected membrane of Descemet. Both eyes eventually had
the cornea completely destroyed, and the patient died on the
seventeenth day. Iritis is more frequent than after measles.

[Footnote 142: _Von dem Einflusse des Secretions Flussigkeiten_, vol.
ii. pp. 267, 268.]

[Footnote 143: _Lehre von dem Augenkrankheiten_, Bd. i. pp. 536, 537.]

[Footnote 144: _Lectures on the Parts concerned in the Operations in
the Eye_, London, 1870, p. 110.]

[Footnote 145: _Krankheiten des Auges_, vol. i. pp. 211-213.]

Considering the frequency of acute nephritis in this disease, the
retinal lesions are comparatively rare. Schreiber[146] gives two
interesting plates of chorio-retinitis after scarlatina. Ebert[147] at
a meeting of the Berlin Medical Society in 1867 called attention to
some cases of transient blindness in the course of scarlatina without
ophthalmoscopic changes; and Graefe, who presided at the meeting,
remarked that in all these cases of absolute blindness there was still
reaction of the pupil to the light, and that therefore there could be
no neuritis or decided lesion between the corpora quadrigemina. He
considered the prognosis favorable so long as there was pupillary
reaction, and not necessarily bad where it was wanting. Although this
is the rule, the prognosis is certainly more favorable when the pupil
reacts promptly and to moderate light. Hirschberg[148] has recorded a
case of blindness following meningitis, where light-perception failed
to return, although the pupillary reaction lasted several weeks.

[Footnote 146: _Veränderungen des Augenhinter-grundes_, Plates iii. and
iv., Figs. 7 and 8.]

[Footnote 147: _Berliner klin. Wochenschrift_, Jan. 15, 1868, pp.
21-23.]

[Footnote 148: _Ibid._, 1869, p. 387.]

{765} Relapsing typhus fever is frequently followed by amblyopia and
inflammation of one or both eyes. Considerable variety in the intensity
and in the symptoms of the disease has been manifested in different
epidemics, and the ratio of the percentage of eye cases has greatly
varied. In most outbreaks of relapsing typhus fever amblyopia is
followed by inflammation. This was the sequence of the symptoms in the
epidemic in Dublin in 1826, in Glasgow in 1845, and in Finland in 1865,
although in the last-mentioned the inflammatory symptoms were less
prominent and severe than in the first two. The eye symptoms rarely
develop during the first attack of the fever, but usually occur after a
second or third attack or during convalescence. The earliest careful
study of the eye symptoms in a severe epidemic is that of Wallace,[149]
who tells us that "there is often that haggard and worn aspect, that
sickly, mottled, pallid hue of skin, that sleepy, exhausted, and
oppressed appearance of the eye, which is more easily observed than
described. The patient only half opens the lids of the affected organ.
They are of a purplish-red color and humid. Their subcutaneous vessels
are preternaturally enlarged. The vascularity of the sclerotic and
conjunctiva is greatly increased. The vessels of the former describe a
reticulated zone round the cornea, and those of the latter run in a
direction more or less straight to the edge of this membrane, and
sometimes appear to pass on the edge. The hue of the redness is
peculiar; it is a dark brick-red. The pupil is generally much
contracted, and its edge thickened and irregular. The iris is altered
in color, generally greenish, and incapable of motion. There exists
dimness of the cornea, which may be compared to the appearance glass
assumes when it has been breathed upon. There is often a turbidness of
the aqueous humor, and a pearly appearance of the parts behind the iris
may be observed by looking through the pupil. There is great
intolerance of light, and a copious, hot lachrymal discharge. The
vision will be found for the most part so extremely imperfect that the
patient can merely distinguish light from darkness, and he is often
tormented by flashes of light which shoot across his eye, and these
occur more particularly in dark places; or he is troubled by brilliant
spectres or by the constant presence of muscæ volitantes. There is very
considerable pain, which returns in paroxysms, and these are almost
always more severe at night. The pain is sometimes referred to the ball
of the eye, sometimes to one of the lids, sometimes to the temple or to
the circumference of the orbit." Mackenzie agrees in the main with the
foregoing description: his cases were also accompanied by severe
inflammation, with hypopyon and copious precipitates in the membrane of
Descemet and on the anterior capsule of the lens. He also called
attention to the diminution of the intraocular tension and the
consequent flabbiness of the eyeball, and states that out of 1877 cases
of fever admitted to the Glasgow Infirmary during the epidemic of 1843,
261 (one-seventh) were attacked by the disease of the eye.
Anderson,[150] who describes the same epidemic later in the course,
takes exception to Wallace's statement that there is always an
amaurotic stage at the outset of the disease. He computes these cases
at two-thirds of the entire number, and tabulates five cases of
inflammation without {766} amaurosis. He also describes and gives
plates which show opacities of the vitreous, posterior synechia,
pigment on the anterior capsule, posterior polar cataract, and other
forms of lenticular degeneration; these conditions ensuing not only in
this disease, but in all other affections where the circulation in the
ciliary body and the constitution of the vitreous are profoundly
involved. Schweigger, in describing an epidemic in Berlin, says that in
one-third of the cases of ophthalmia there was simple unilateral
iritis, and that in a second third there was diffuse punctiform or
flocculent vitreous opacities without any trace of iritis or external
symptoms of disease; while in the remaining third there was iritis with
vitreous opacities in common: when it ensues in its usual form the
effects of annular synechiæ or detachment of the retina; rarely from
suppuration of the corneæ. Although of late years the Russian writers
have materially added to our knowledge of the affection, nevertheless
in most essentials their observations agree with those above quoted.
Thus, Blessig[151] gives an account of an epidemic in St. Petersburg,
while Logetschnikow[152] describes an epidemic in Moscow in which he
encountered over 700 cases of this form of ophthalmia. Larionow[153]
relates the history of a mild epidemic in the Russian army of the
Caucasus, and tabulates 767 cases of the fever, in which are also
included a number of cases of exanthematic typhus and a few cases of
typhoid fever. Exclusive of the ischæmia of the retina and feebleness
of the accommodation which were present in every case during
convalescence, there were 3 cases of serous retinitis, 2 of
hemeralopia, and only 3 of iritis; while in 10 per cent. of these there
were vitreous opacities. He did not see a single case of genuine
irido-choroiditis in the entire number. Estlander[154] has given a
masterly description of two epidemics which he observed at Helsingfors
in Finland, both of which occurred after a failure of the crops and
consequent famine. In the first of these epidemics, which was of a mild
type, only 3 out of 222 patients died, and the concomitant eye
affections were few in number; while in the latter, 18 out of 242
patients died, and extensive vitreous opacities with severe
inflammation of the eyes were frequent. He agrees with Mackenzie that
the fever attacks few children under ten years of age, and says that
although the disease is much more liable to attack people between
twenty and thirty years of age, here it is less frequent than it is in
patients between ten and twenty years of age, where it exists in one
half of the cases. Arlt[155] agrees with this, and says that it is due
to the fact that hunger and malnutrition are in general much worse
borne by adolescents than by adults. As regards the period of the
disease at which the eye symptoms come on, Estlander says that out of
28 carefully observed cases it developed 6 times during the fever or a
week after its cessation, 11 times between the second and fourth week,
5 times in the second month, and 6 times from the third to the fifth
month. These figures agree well with those given by Mackenzie, and show
that there is both a feeble state of constitution and a prolonged
convalescence from {767} this severe fever. Pepper,[156] in a previous
volume of this work, has given an interesting account of an epidemic in
this city in which he states that eye affections were of rare
occurrence.

[Footnote 149: "An Essay on a Peculiar Inflammatory Disease of the Eye,
and its Mode of Treatment," _Trans. Med.-Chir. Soc. of London_ (read
Dec. 11, 1827).]

[Footnote 150: "Post-febrile Ophthalmitis," _Monthly Journ. Med. Sci._,
1845, pp. 723-729.]

[Footnote 151: _Congrès internationale d'Ophthalmologie_, Paris, 1868,
pp. 114-117.]

[Footnote 152: "Entzündung der Vorderen Abschnitten der Choroidea als
Nachkrankheit der Febris Recurrens," _A. f. O._, Bd. xvi., 1, S.
352-363.]

[Footnote 153: _Klinische Monatsblätter f. Augenheilkunde_, 1878, pp.
487-497.]

[Footnote 154: _A. f. O._, xv. 2, pp. 108-143.]

[Footnote 155: _Klin. Darstellung der Krankheiten des Auges_, 1881, pp.
289-291.]

[Footnote 156: Vol. I. p. 399.]

Exanthematous typhus fever is occasionally followed by the same train
of symptoms as pointed out in discussing Larionow's statistics, who
gives vitreous opacities as the most frequent forms of the eye
affection. Out of a total of 57 fever patients with typhus
exanthematicus, he found 1 case each of iritis, keratitis, and
neuro-retinitis, 2 cases of contraction of the field of vision, 5 of
subconjunctival ecchymosis, and 2 of conjunctival catarrh.

Abdominal Typhoid Fever.--Severe eye complications are less frequent in
this disease than in either of the foregoing affections. During
convalescence from this, as from all other exhausting diseases, there
is usually feebleness of the accommodation, and occasionally the
development of vitreous opacities, with or without the formation of
cataract. The most common eye affections show as an optic neuritis or
paralysis of some of the muscles supplied by the third pair of nerves,
and are due to a complicating meningitis.

Yellow Fever.--In this disease most writers have called attention to
the accompanying ocular symptoms--flushing and injection of the
conjunctiva with increase of lachrymation, followed later by a change
of the color of this membrane to a yellow hue, which precedes a similar
change of the color of the skin of the face and other parts of the
body. The first epidemic of the disease in Philadelphia occurred in
1762. Redman,[157] in describing it, says: "The patients were generally
seized with a sudden and severe pain in the head and eyeballs, which
were, I think, often, though not always, a little inflamed or had a
reddish cast." Another severe epidemic of the disease visited the city
in 1793, of which Rush[158] has given us a valuable account. Among the
premonitory signs he enumerated "a dull-watery-brilliant, yellow or red
eye, dim and imperfect vision;" and he defines his meaning by saying
that the dull eye was found among the severe cases, and the brilliant
one where the poison was less intense. Later in the disease there was
"preternatural dilatation of the pupil," and in one case "a squinting
which marks a high degree of morbid affection of the brain." There were
hemorrhages, chiefly from the nose and uterus, and in but one case "a
dropping of blood from the inner canthus." A dimness of sight was very
common in the beginning of the disease, and many were affected with
temporary blindness. In some there was a loss of sight in consequence
of gutta serena or a total destruction of the substance of the eye. The
eyes seldom escaped the yellow tinge. There were a number of cases of
uncommon malignity without this symptom, but sometimes the yellow color
appeared on the neck and breast before it invaded the eyes. Wood,[159]
who witnessed a later epidemic (also in Philadelphia), says that even
in the earliest period of the disease the white of the eye is often
reddened and turbid, and in bad cases appears sometimes as if
bloodshot. As before stated, in the course of the disease {768} this
redness yields to a yellow or orange color. Féraud,[160] in speaking of
the symptoms of the second stage, lays great stress on the brilliancy
of the eyes, their lachrymose condition, the fulness and nicety of the
conjunctival injection, the dilatation of the pupil, and the presence
of photophobia; adding that this congestion is diminished during the
remission of the fever if the attack is not severe, but that if the
conjunctiva darkens and assumes an icteric aspect, which becomes more
and more intense, the case is undoubtedly severe. He adds that ocular
hemorrhages occur in some grave cases during the second stage,
producing subconjunctival suffusion and a flow of blood from the
neighborhood of the commissure of the lids. Such "hemorrhages have
frequently caused conjunctivitis, keratitis, and even such an accident
as phlegmon." Fernandez[161] gives three cases of delirium, suppression
of urine, and loss of vision. One of these cases was examined with the
ophthalmoscope, but no changes were found in the eye-ground. One case
recovered, having entirely regained his eyesight; the other two died.

[Footnote 157: "An Account of the Yellow Fever of 1762," by John
Redman, M.D. (read before the College of Physicians of Philadelphia,
Sept. 7, 1793).]

[Footnote 158: _An Account of the Bilious Remitting Yellow Fever as it
appeared in the City of Philadelphia in the Year 1793_, by Benjamin
Rush, M.D., Philada., 1794.]

[Footnote 159: G. B. Wood, _Treatise on the Practice of Medicine_, vol.
i. p. 321, 1858.]

[Footnote 160: Béranger-Féraud, "La Fièvre jaune à la Martinique,"
quoted by Juan Santos Fernandez, _Archiv. of Ophthalmology_, x., 4,
1881, pp. 440-445.]

[Footnote 161: _Loc. cit._]

Intermittent Fever.--Intermittent ophthalmia is but rarely encountered
in countries where only a mild form of intermittent fever is present;
in fact, it was so rare in Scotland that Mackenzie in the earlier
editions of his work denied its existence, but a larger experience
enabled him (in 1854) to give three cases. In 1828 and 1829 it was so
infrequent in Marburg that Hueter devoted two papers to its study--one
of a case of the quotidian type, and the second of the septan form of
the ophthalmia. In countries where the malarial poison exists in more
intense form, we have quite a different state of affairs; thus
Levrier[162] describes it as of common occurrence in the district of
Landes in France, and says that its most frequent form is a periorbital
and ocular neuralgia, accompanied by intense congestion of the
conjunctiva, with increased flow of tears and a greater or less degree
of photophobia, occurring in those who have had frequent attacks of
intermittent fever. Wehle, whose observations were made in Hungary,
describes an erysipelatous swelling of the lids with small hemorrhages
in the palpebral conjunctiva, redness and swelling of the bulbar
conjunctiva with intense photophobia, and occasional clouding of the
cornea. Arlt[163] relates eight cases of chronic interstitial
keratitis, all occurring in emaciated patients who had had severe
malarial fevers, in Slavonia and Hungary. Only three of these stayed
for prolonged treatment, which consisted of the use of Karlsbad water,
followed by the preparations of quinine and iron; all of these
recovered, and their eyes cleared, leaving only the faintest trace of
corneal opacity. Galezowski[164] gives a case of malarial keratitis,
and Griesinger,[165] after describing the usual symptoms of the disease
(similar to that noted by Levrier), speaks of cases of long duration
accompanied by clouding of the cornea and atrophy of the eyeball. He
has also encountered an intermittent form of iritis. Mackenzie
describes a case of it (one of those above referred to) which
eventually ended in amaurosis. While affections of the retina and optic
{769} nerve from malarial fever would seem to be rare in temperate
latitudes, Guéneau de Mussy,[166] however, relates a case of optic
perineuritis with retinal apoplexies. Macnamara, observing in India,
says the serous retinitis is not uncommon in malarial fever, and that
in severe cases of this disease amaurosis is not infrequent. Galezowski
and Kohn each reports a case of atrophy of the optic nerves after a
severe attack of intermittent fever, but it is not quite evident from
the clinical history whether the blindness might not be attributed to
the large doses of sulphate of quinia which had been administered.

[Footnote 162: J. F. Levrier, _Thèse de Paris_, 1879, "Des Accidents
oculaires dans les Fièvres intermittentes," p. 56.]

[Footnote 163: _Klinische Darstellung der Krankheiten des Auges_, 1881,
pp. 121, 122.]

[Footnote 164: Quoted by Levrier, _loc. cit._, p. 39.]

[Footnote 165: _Traité des Maladies infectueuses_.]

[Footnote 166: _Journal d'Ophthalmologie_, p. 1, 1872.]

ERYSIPELAS.--Erysipelas of the face and head frequently causes swelling
of the lids and chemosis of the bulbar conjunctiva, and occasionally
gives rise to an orbital cellulitis which by its effects on the optic
nerve impairs or destroys sight. Beer[167] speaks of an idiopathic
erysipelatous conjunctivitis which may not be accompanied by swelling
of the lids. The conjunctiva is of a pale, somewhat livid-red hue, in
which no distinct vessels are visible, there being numerous bright-red
ecchymotic spots in the subconjunctival tissue. Vesicular prominences
form around the cornea, and become so large as to project between the
lids. The folds and interstices of this swollen membrane are covered
with thin mucus, which often adheres so closely to the cornea as to
make it look hazy, but which can be washed off, leaving the corneal
surface as brilliant as in its normal state. The conjunctival swelling
finally subsides, and the membrane again adheres to the sclerotic. Even
after there is apparent absorption of the ecchymoses, the places where
there were extravasations of blood are slow in adhering to the sclera,
and often roll into folds with every motion of the eye. Mackenzie
describes the conjunctiva as of a pale yellowish-red color: it rises in
soft vesicles around the cornea, and these change in shape with every
motion of the eye. There is slight photophobia and a pricking
sensation, with a large quantity of white mucus, which is secreted by
the conjunctiva and the Meibomian glands. Where a low grade of orbital
cellulitis ensues we may have only slight prominence of the eye and
some interference with its motions, in which a complete subsidence of
the symptoms without any failure of eyesight may take place. We may
encounter more severe cases, where the intense swelling and
inflammation of the orbital tissues so impair the functions of the
optic nerve and retina as to permanently destroy the eyesight, and at
times destroy life by the extension of the inflammation to the
meninges. The cellulitis may attack one or both orbits. Poland[168] has
recorded a case of protrusion of both eyes where, after death, the
ophthalmic veins and the cavernous sinuses were found full of pus;
while Cohn[169] has reported another fatal case of double erysipelatous
cellulitis, in which post-mortem showed purulent phlebitis of the orbit
and brain with embolic infarcta in the lungs. All cases of double
exophthalmos from erysipelas do not end as fatally: Jaeger has recorded
two cases of recovery, where in each one eye remained permanently
blind, while the other was restored to sight. He has given us accurate
and beautiful ophthalmoscopic plates of the {770} lesions in the blind
eyes, these plates showing atrophy of the optic nerve, with great
thickening of walls of the retinal vessels, which in some places
totally hide their contents, while in others the blood-columns are
still faintly visible. In one case the inflammation of the lids had
been so severe that they had grown together in the middle of the
palpebral fissure and had also formed an attachment to the eyeball.
These cicatricial bands were divided with the knife, only to find a
blind eye with dilated pupil. In one of Jaeger's cases there were
pigment-masses in the choroid. Coggin[170] describes a case of double
exophthalmos with blindness where the corneæ were so denuded of
epithelium that no ophthalmoscopic examination was practicable. Three
weeks later the media were clear and the discs atrophic, the vessels
being visible as empty white cords. These effects be attributed to
thrombosis. Knapp[171] has recorded a most interesting case of
erysipelas where there was severe fever with high temperature (104.8°)
and marked protrusion of both eyes, in which he had an opportunity of
observing the eye-grounds in all stages of the disease. On the ninth
day ophthalmoscopic examination showed that the yellow spot and disc
were both invisible, and that their localities could only be determined
by the radiation of the tortuous veins, which were gorged with blood so
dark as almost to be black, the retinal arteries being invisible. The
posterior portion of the eye-ground was milky white, while the anterior
was reddish white: numerous hemorrhages were scattered through the
retina, more or less linear in shape in the posterior part and
irregularly rounded in the anterior portion. Two days later the orbital
swelling was less, and the arteries were visible, though much reduced
in size, and the eye-ground was beginning to resume its normal color.
About a month after seizure the patient was convalescent and he could
go out. At this time the disc was atrophic, and there was a whitish
cloud in the region of the yellow spot, with numerous hemorrhages: both
arteries and veins presented isolated areas of perivasculitis,
accompanied by snow-white patches of greater or less extent, which were
of the same calibre as the adjacent dark-red blood-columns in each of
them. Two months later, the disc was still atrophic, the hemorrhages
had been absorbed, the blood-vessels were mostly visible as white
cords--one of them presenting the usual appearance, while two showed
blood-contents for a short distance surrounded by dense white walls.
The white intercalary portions of the vessels seen in the examination
two months after the onset of the disease are considered by Knapp to be
thrombi. Arlt, Jr., reports a case of gangrenous erysipelas of the lids
with loss of the eye, and mentions that his father had seen several
similar cases.

[Footnote 167: J. J. Beer, _Lehre von den Augenkrankheiten_, vol. i.
398, 399. (He also gives a colored plate of the appearance, Taf. 1, p.
3.)]

[Footnote 168: _R. L. O. H. Rep._, vol. i., pp. 26-31, 1857.]

[Footnote 169: _Klinik der Embolischen Gefärskrankheiten_, 1860, p.
196.]

[Footnote 170: D. Coggin, _Trans. Amer. Oph. Soc._, vol. ii. pp.
570-572 (session 1878).]

[Footnote 171: _Trans. Amer. Oph. Soc._, 1883, and _Arch. of
Ophthalmology_, 1884 (with plates and lithographs).]

       *       *       *       *       *

{771} DISEASES OF THE NERVOUS SYSTEM.[172]

[Footnote 172: In the foregoing sections the relationship between
definite diseases and their concomitant eye symptoms have been dealt
with; whereas in this division of the subject this has been found so
impracticable that it had to be discarded in favor of an anatomical
basis upon which to place the various affections. This change has
necessitated the disuse of the representative headings of names of
disease, and the substitution of absolute physical conditions with
their hypothetical causes.]

Symptoms of impaired function in the eyes and their appendages have
always been regarded as valuable indices of disease of the nervous
system; and when it is considered that six of the twelve pairs of
cranial nerves send branches to these organs, and that the second,
third, fourth, and sixth pairs are distributed exclusively to them, and
that they are further supplied with twigs from the cervical and
cerebral sympathetic nerves, it can be readily appreciated that a vast
variety of nerve lesions, interfering with some of these connections
either at their origins or in their course, may produce either impaired
vision in the eye or loss of power in some of its appendages. Moreover,
the retina and optic nerve originate as sprouts from the anterior
cerebral vesicle, and retain respectively the structure of a ganglion
and of a cerebral commissure. From these circumstances, as well as from
the close connection of their blood and lymph circulations with those
of the cerebrum, they frequently become delicate exponents of
intracranial changes.


Affections of the Second Pair (Nervi Optici).

NEURITIS.--Five years after the discovery of the ophthalmoscope Graefe
called attention to the fact that in many cases of intracranial disease
the intraocular ends of the optic nerve presented marked changes. He
had already discovered that when these changes were inflammatory in
character they presented two main varieties--the one in which there was
intense swelling of the intraocular end of the nerve (designated by him
stasis papilla); and the other, in which there was a dull-red suffusion
of the disc. In the first variety, which he attributed to increased
intracranial pressure from tumor or other cause, the disc projected
into the eye and formed a small tumor, often prominent to an extent
equal to its own diameter, the oedematous and opaque nerve-fibre being
permeated by tortuous, enlarged, and often newly-formed capillary
vessels, which hide the arteries and allow only the projecting branches
or lips of the tortuous and dilated retinal veins to be perceived as
they slope down in the swollen papilla to regain their normal level in
the retina; the other, which he thought was due to meningitis spreading
along the nerve, was characterized by a slightly swollen disc of a
dull-red color, with opacity of its nerve-fibre sufficient to
completely hide its normal boundaries, associated with tortuous veins
and arteries that were often diminished in size. Since that time
volumes have been written on the subject, and it has given rise to most
extended and searching discussion, causing researches to be instituted
which have added much to the knowledge of the anatomy and pathology of
the central connections, circulation, and lymph-supply of the optic
nerves. To-day the first variety is usually designated {772} as choked
disc or papillitis, and the second as interstitial or descending
neuritis. When typical cases are seen at the height of the disease, it
is easy to make a distinction between the two varieties, but usually
they shade off so imperceptibly, the one into the other, and the
consecutive atrophies present so absolutely the same appearance, that
no experienced observer would at all times claim an ability to
distinguish between them. In the choked disc the intense swelling is
limited to the intraocular end of the nerve, and therefore vision is
little interfered with until the swelling becomes so great, or the
contraction of the subsequent cicatrization so decided, that by
pressure on the nerve-fibre they become atrophic and incapable of
reporting the retinal image to the brain-centres, while in interstitial
neuritis, owing to the primary interference with conduction, vision is
impaired from the beginning. The choked disc usually develops slowly,
requiring a period varying from a few days to two, three, or four weeks
to attain its maximum, and it may exist unchanged for a long time
before atrophy sets in. The writer once had an opportunity of observing
a case in which the choking was produced by a cerebral gumma, and where
for nearly a year the discs remained swollen and vision was still 6/8;
and another of intense swelling, where the discs projected at least
from one and a half dioptrics (one millimeter), in which for a period
of three months vision was 6/6 and the field almost normal.
Mauthner,[173] Blessig, and Schiess-Gemuseus[174] each record cases of
marked choking of the discs lasting for some time, where the patients
retained perfect central vision to the day of their death. Double
choked discs are almost always a symptom of grave intracranial disease
when all local causes in the eyes or orbits have been excluded. Even in
the very exceptional cases where they form part of the symptoms of
Bright's disease they are probably indicative of intracranial effusion.
The lower grades of inflammation of the optic nerve are apt to be
accompanied by marked proliferation of the connective tissue between
the nerve-bundles. There are many cases of congestive atrophic change
of the optic nerve where at first central vision is but little
affected. In judging of the appearance of neuritis the observer should
be sufficiently familiar with the changes in the eye-grounds of healthy
individuals which occur from local causes not to allow himself to be
led astray by the often very decided neuro-retinitis constantly
encountered in hard-worked eyes with uncorrected astigmatism and slight
degrees of ametropia; and not to mistake these changes, which are
simply an expression of that local congestion which leads ultimately to
softening and elongation of the eyeballs, for changes due to incipient
cerebral disease, although each is accompanied by neuralgia. While,
after careful study of the various forms of neuritis optici during the
last few years, it is acknowledged that increased intracranial pressure
is apt to cause choking of the disc, and that basilar meningitis
frequently gives rise to interstitial neuritis, we are still far from
having such a clear comprehension of the subject as to render the
profession unanimous as regards its pathology; some observers claiming
that choked disc is essentially a vaso-motor paralysis of the affected
part, while others maintain that it is caused by infiltration of the
disc and optic nerve with abnormal fluids which have been secreted
within the cranium, and by increased intracranial pressure have been
{773} forced between the sheaths of the optic nerve and between it and
its pial envelope. The ingenious explanation proposed by Graefe, that
stasis papilla is produced by the damming up of the return blood in the
cerebral sinuses, thus causing impeded circulation with increased
blood-pressure in the ophthalmic vein and its branch (the central
retinal vein), has generally been abandoned since the investigations of
Sesemann and Merkel have demonstrated the free anastomosis between the
facial and the orbital veins in whatever method the primary congestion
may be brought about. The latter part of his explanation, in which he
compared the rigid tissue of the lamina cribrosa to a multiplier, by
its construction tending to augment any existing plethora in the head
of the nerve, is still worthy of consideration. While the theory of
vaso-motor paralysis is a most enticing one, it is, however, difficult
to understand why paralysis of any of the fibres of the sympathetic
should always be accompanied by such a limited local congestion without
affecting the retinal tissue in their peripheral parts or without any
branch leading to the iris, ciliary body, or choroid. Granting that
there is some special filament of the carotid plexus distributed to
this region of the nerve, it is hard to comprehend how it can be acted
upon by tumors of almost any size or consistence situated in the most
varied parts of the brain, and also why pressure on the various
portions of the intracranial nerve, chiasm, and optic tracts (which so
frequently cause hemianopia and partial atrophies) should not be
associated with choking of the disc.

[Footnote 173: _Ophthalmoscopie_, p. 293, 1868.]

[Footnote 174: _Klinische Monatsblätter f. Augenheilkunde_, 1870, p.
100.]

THE LYMPH-SPACE THEORY--Since the anatomical researches of Schwalbe and
of Retzius have given us a clear understanding of the lymphatic
circulation in the eye, the effusions into the sheaths of the optic
nerve that have been found in many cases of choked disc that have been
examined post-mortem have been shown to be due to the effects of
blocking up of the lymph-channels and of the effusion of cerebral
fluids (lymph-pus and blood) in the intervaginal space of the nerve or
between it and its pital sheath. In support of this, Manz in 1870
showed that injection of fluid into the cranial cavity of rabbits would
produce a marked neuritis which was readily demonstrable by the
ophthalmoscope; while Schmidt proved that the spaces of the lamina
cribrosa of the optic nerves of the calf could be distended by fluid
thus injected. In experiments on the human cadaver the writer has
repeatedly seen that colored fluids could be readily driven between the
sheaths of the optic nerve by injections from the subarachnoid and
subdural spaces, and also that when high pressure was used and the
injection made directly into the intravaginal space of the nerve, the
fluid found its way from the subdural into the perichoroidal space. He
once obtained traces of the colored fluid in the lamina cribrosa of the
nerve. Since this mode of communication between the cavity of the
cranium and the eye has been duly appreciated, a large number of
autopsies have shown that choking of the disc has been accompanied by
dilatation of the outer sheath of the nerve by lymph-pus or blood which
has found its way down from the cranial cavity. It has also been
demonstrated that proliferation of the intravaginal (arachnoid) tissue,
and the formation of tumors (psammoma and tubercle) at the distal end
of the nerve will produce choking of the disc by causing local
accumulations of fluid. On the other hand, there are cases where this
distension of the sheaths has been {774} carefully looked for and not
found; and those who hold the _vaso-motor theory_ consider that it is
in any case an accompanying accident, and not the cause, of the choking
of the disc. The experiments of Rumpf and Kuhnt, however, add to its
probability, by which the deleterious influence of lymph on the
axis-cylinder of nerves adds to the probability of the above theory;
moreover, even if it is granted that this accumulation of lymph or
other fluid within the sheaths of the optic nerve is the cause of
choking of the disc, it seems very unreasonable to the writer to expect
to find it in all stages of the complaint. It is everywhere admitted
that a cerebral tumor may exist for a long time without causing
papillitis, and also that inflammation of the discs may exist for
months or years, until they have become entirely atrophic, before the
brain disease shall have caused death. Choking of the disc is
essentially a temporary symptom. Although severe cerebral irritation
may cause a great transient increase of cerebro-spinal fluids, which in
their turn may produce the most intense inflammation of the intraocular
end of the nerve, yet when the atrophied nerve comes to be examined
months or years later they leave no traces sufficiently lasting to
positively prove their previous existence. Whatever theory may be
adopted as to the mode of production of optic neuritis, its clinical
importance is admitted by all. Where it exists on both sides, and is
accompanied by other cerebral symptoms, it usually points to increased
intracranial pressure.

Since the earliest times, impaired vision and other ocular symptoms
have been recognized as accompaniments of diseases of the brain. In
more recent, but still preophthalmoscopic, times the statistics showing
the percentage of blindness in brain tumor are most interesting: thus,
Abercrombie noted failure of vision in 17 (38-5/10 per cent.) out of 44
cases, while Ladame, in a study of 331 cases, estimated that there is
disturbance of vision in about 50 per cent. This percentage represents
the cases of atrophy consequent upon neuritis only. It must be
remembered, however, that many die of the brain disease while the disc
is still choked, and that this state of the eye-nerve may exist for a
long time without any appreciable failure of vision, making it evident
that should we look for choked disc with the ophthalmoscope while there
are as yet no symptoms of failing sight, the above percentages would
still be higher. In support of this we find that there is a rise of
double optic neuritis to 93 per cent. in a series of 88 cases of brain
tumor, 43 of which have been recorded by Annuske[175] and 45 by
Reich,[176] these being here adduced because in all of them there was a
careful ophthalmoscopic examination. Gowers thinks that this is an
over-estimate, but admits that optic neuritis occurs in four-fifths (or
80 per cent.) of all cases of cerebral tumor. In considering this
question we cannot too carefully keep in view the facts so well stated
by Hughlings-Jackson,[177] that optic neuritis is essentially a
transient symptom, and that, although it often occurs early in the
disease, it may in some cases be developed only in the latter stages of
the complaint. Jackson states that he frequently examined a case with
the ophthalmoscope in which there was no appearance of choked disc till
six weeks before the patient's death, when marked papillitis developed,
the {775} autopsy showing a tumor in the left cerebral hemisphere. In
fact, where the tumor does not occupy the cortical sight-centres, the
intercalary ganglia, or press on the tractus opticus or chiasm, it may
exist a long time without producing any affection of the optic nerve or
deterioration of vision. No neuritis will take place by increase of
intracranial pressure so long as the growth of the tumor is slow and
there is a corresponding absorption of brain-substance; but should the
growth of the tumor be rapid, or any other cause exist by which
increased pressure, with consequent irritation and effusion, would take
place, infiltration of the nerve and its sheaths with lymph or
inflammatory products would ensue, and give rise to swelling and
increased growth of connective tissue. In cases of cerebral tumor,
however, and where the growth presses on the intracranial portion of
the optic nerves, or where the chiasm is compressed and atrophied by
the protuberant and bulging floor of the third ventricle, as in the two
cases recorded by Foerster,[178] optic atrophy may be produced without
the occurrence of previous choked disc.

[Footnote 175: _A. f. O._, xix., 3, pp. 165, 300.]

[Footnote 176: _Klin. Monatsblätter f. Augenheilkunde_, 1874, pp. 274,
275.]

[Footnote 177: _Med. Times and Gazette_, Sept. 4, 1875.]

[Footnote 178: _G. u. S._, vol. vii. p. 141.]

HEMIANOPIA (HEMIOPIA, HEMIANOPSIA).--We may, however, have serious
affections of the sense of sight without any marked alteration in the
retina or optic nerve. Careful study of the various forms of hemianopia
and other symmetrical defects in the field of vision will often
surprise us by the extent of the defect which it reveals, and sometimes
serve as a guide to the localization of the cerebral lesion which
produces the defect. Hemianopia (or the not-seeing of half an object)
is usually of the homonymous lateral variety, in which, if the centre
of any object be fixed by the macula lutea of each eye, then either all
parts of the object lying to the right-hand side of the points of
fixation or else all parts lying to the left of that point become
invisible. There may also be temporal hemianopia (hemianopia
heteronymous lateralis),[179] in which the nasal side of each retina is
blind, and the temporal field of each eye consequently abolished. In
such case the right eye sees nothing to the right of the
fixation-point, and the left eye nothing to the left of it. The
external half of each retina may be blind, in which case there is loss
of the nasal field of each eye and of the entire binocular field of
vision. In all of these cases the dividing-line between the blind and
seeing parts of the retina is a more or less vertical one, but there
are also cases where the dividing-line is horizontal, and we thus have
an upper or lower hemianopia. From a clinical standpoint the
first-named variety (homonymous lateral hemianopia) is markedly
distinguished from the others by its usual more rapid development, and
by the absolutely sharp dividing-line which runs vertically through the
retina at the macula; this field of vision retaining its form without
subsequent development of zigzags or other irregularities. All other
varieties of hemianopia develop more slowly, and their
boundaries--which are usually not perfectly vertical or horizontal, and
do not generally extend to the fixation-point--may vary from time to
time. The homonymous lateral variety is of far more frequent occurrence
than the other forms: out of 30 cases carefully observed by Foerster,
where perimetric measurements {776} of the fields were taken, 23 were
of this variety, while the remaining 7 presented the heteronymous
temporal form. The subject of homonymous lateral hemianopia is so
important clinically, and so interesting as regards the probable course
of the fibres in the optic nerves, chiasm, and cerebral centres, that
it appears desirable to state briefly a few of the most decisive facts
in regard to it which have been substantiated by careful autopsies.

[Footnote 179: If we retain the word hemiopia (half-seeing), then this
variety is termed medial hemiopia, because the lateral halves of the
retina are still intact and vision is practicable in the median or
nasal field of each eye.]

1. In 1875, Hirschberg[180] published a case of right-sided homonymous
hemianopia with perfect central vision. At first there was no paralysis
of sensation or motion, but subsequently aphasia and right hemiplegia
set in. The autopsy showed a large sarcomatous tumor which had caused
atrophy of the left tractus opticus.

[Footnote 180: _Virch. Arch._, Bd. lxv.]

2. Hughlings-Jackson and Gowers[181] (1875) relate a case of left
homonymous hemianopia with hemianæsthesia and hemiplegia of the same
side. The autopsy showed softening of the posterior part of the right
thalamus opticus without other lesion.

[Footnote 181: _R. L. O. H. Rep._, vol. viii. p. 330.]

3. Curschmann[182] (1879) gives the case of a patient who drank
sulphuric acid, which corroded the oesophagus and affected the aorta,
causing embolus of the right brachial artery. On the day following
there was complete left hemianopia. The autopsy showed a large area of
cerebral softening in the right occipital lobe without other lesions.
In the discussion of this case at the session of the Berlin Society of
Psychiatry and Nerve Diseases, Westphal[183] related a case of
unilateral convulsions without loss of consciousness where there was
homonymous hemianopia, and in which the autopsy showed a large area of
softening in the white substance of the occipital lobe in the side
opposite to the defect in the field of vision.

[Footnote 182: _Centralblatt f. Augenheilkunde_, 1879, p. 256.]

[Footnote 183: _Loc. cit._, p. 181.]

These cases might be multiplied, but the writer has selected them
because they were made by careful and competent observers, and the
lesions were so marked and limited in character as not to allow of any
other interpretation than that given. If we admit the validity of the
evidence, we have proved conclusively that, from a clinical and a
pathological standpoint, binocular homonymous lateral hemianopia may be
produced by lesions of the optic tract, of the posterior part of the
thalamus opticus, and of the occipital lobe of the brain of the side
opposite to the defect in the field of vision; and that, therefore,
there must be a partial, and not a total, crossing of the fibres of the
optic tracts at the chiasm. Moreover, as Foerster has most pertinently
remarked, such a state of affairs does not violate the physiological
law of the total crossing of other nerves, because in the binocular
field of vision the partial crossing causes all objects to the right of
the point of fixation to be seen by the left hemisphere, while those to
the left of it are seen with the right hemisphere. While this problem
appears sufficiently plain, and the view above advocated is adopted by
the majority of writers of the present day, it is by no means equally
satisfactory when looked at from a purely anatomical or physiological
standpoint. Newton[184] in 1704 had already appreciated the importance
and difficulty of the subject, and in {777} the hope that others might
further investigate it asked the question whether the fibres from the
right sides of both retinæ do not so unite at the chiasm as to go
together to the right side of the brain, those from the left side of
each retina pursuing a similar course to the left hemisphere. He
further remarks that "if he is correctly informed that the optic nerves
of such animals as have a binocular field of vision join at the chiasm,
while those of the animals who have no binocular vision, such as the
chameleon and some fishes, do not so join."[185] Since his day the
majority of authors have adhered to this view, until Biesiadecki,[186]
by careful anatomical studies and lectures, attempted to prove that in
both men and lower animals there is a total crossing of the fibres at
the chiasm. Twelve years later Mandelstamm,[187] by clinical
observations of nasal hemiopia and dissections of the chiasm,
maintained the same view. In the same year Michel[188] supported the
same doctrine, and since then Schwalbe[189] and Scheel[190] have each
advanced the same view. However, Von Gudden,[191] also basing his
opinions upon dissections, takes the opposite ground, and has since
endeavored by a series of experiments, in which he enucleated one eye
of young rabbits and dogs, to prove[192] that if the animals were
allowed to live until central atrophy set in there is a partial atrophy
of both optic tracts, more marked on the side opposite to that of the
enucleated eye, because the crossed bundle is by far larger than the
direct.

[Footnote 184: _Optiks_, London, 1704, p. 136.]

[Footnote 185: _Loc. cit._]

[Footnote 186: "Chiasma Nervorum Opticorum der Menschen und der
Thiere," _Sitzungsberichte der Wiener Akadamie_.]

[Footnote 187: _A. f. O._, xix., 2, pp. 39-58.]

[Footnote 188: _Ibid._, xix., 2, pp. 59-84.]

[Footnote 189: _G. u. S._, vol. ii. p. 324.]

[Footnote 190: _Klin. Monatsblätter f. Augenheilkunde_ (extra number
2), 1874.]

[Footnote 191: _Arch. f. Psychiatrie_, vol. ii. p. 21.]

[Footnote 192: _A. f. O._, xx., 2, p. 226, and also _Ibid._, xxv., 1,
p. 1, 1879.]

From similar experiments on rabbits, Mandelstamm[193] maintains that
there is a total crossing at the chiasm, and Michel,[194] who repeated
Von Gudden's experiments, arrived at the same conclusion.
Brown-Séquard[195] asserted that a medial cut of the chiasm in rabbits
produces amaurosis of both eyes, which would indicate that there is
total crossing, while Nicati[196] a year later showed that a median
section of the chiasma in young cats did not produce blindness of each
eye, the animal following with the eye and the head the movements of a
light held at a considerable distance from the eyes.[197] The condition
of the optic nerve and brain obtained from the human subject, where by
accident or by disease one of the eyes has been destroyed long before
death, seems in the main to speak for partial decussation. Thus,
Biesiadecki, while maintaining total decussation, could only conclude
from such specimens of degenerated nerves and tracts that the greater
part of the fibres of the atrophic nerve went to the tract of the
opposite side. Woinow[198] demonstrated preparations to the Ophthalmic
Society at Heidelberg where the left eye had been blind for forty
years, and the atrophy, which had travelled up the left nerve, was
plainly visible in both optic tracts. Schmidt-Rimpler[199] also showed
atrophy of both tracts {778} more marked in that of the opposite side,
and Manz[200] found atrophy of both tracts after atrophy of the nerve
of one side; Plink[201] reports a similar state of affairs; while
Popp[202] and Michel[203] from analogous specimens draw conclusions
favorable to the total crossing.

[Footnote 193: _Ibid._, xix., 2, p. 47.]

[Footnote 194: _Ibid._, xxiii., 2, p. 227.]

[Footnote 195: _Archiv de Physiologie_, 1872, p. 261, and 1877, p.
656.]

[Footnote 196: _Ibid._, 1878, p. 658.]

[Footnote 197: Cats have a larger binocular field of vision, and are
better subjects for experiments than rabbits.]

[Footnote 198: _Klin. Monatsblätter f. Augenheilkunde_, 1875, p. 425.]

[Footnote 199: _Ibid._, 1877, "Bericht der Ophth. Gesellschaft," pp.
44-48.]

[Footnote 200: _Klin. Monatsblätter f. Augenheilkunde_, 1877, "Bericht
der Gesellschaft," pp. 49, 50.]

[Footnote 201: _Arch. f. Augenh. und Ohrenheilkunde_, vol. v.]

[Footnote 202: Inaug. Diss., _Embolie der Art. Centralis_, Regensberg,
1875, p. 20.]

[Footnote 203: _A. f. O._, xxiii., 2, p. 243.]

The above cases are amongst the most decisive which have been reported,
and are quite sufficient to show how great the conflict of opinions is
among good observers. The observations and experiments on the subject
of sight-centres in the cortex cerebri are also conflicting: thus,
while Ferrier places the cortical sight-centre in the angular gyrus,
and maintains that its destruction will produce blindness, Luciani and
Tamburini agree as to the locality of the sight-centre, but maintain
that its destruction produces hemianopia; while Munk places the
sight-centre in the occipital lobe, and asserts that its loss causes
hemianopia and not contra-lateral blindness. In the case of hemianopia
reported by Keen and Thomson,[204] where a bullet wound of the left
occipital lobe produced right hemianopia without other apparent lesion,
the writer has had an opportunity of personally examining it and of
confirming their conclusions. The conclusions which he arrived at,
associated with the knowledge which he obtained in Stricker's
laboratory by witnessing experiments upon dogs and apes, where portions
of the occipital lobes were destroyed, have convinced him that cortical
lesions of the occipital lobes produce hemianopia. On the other hand,
chiefly on clinical grounds and from the study of hystero-epilepsy,
Charcot concludes that the band of uncrossed fibres in the chiasm bends
again somewhere in the region of the geniculate bodies to join the
crossed bundle once more in the cortical centre. According to this
theory, destruction of the cortical centre should produce total
amaurosis of the opposite eye, and lesions between the chiasm and
geniculate bodies would produce homonymous hemianopia, while pressure
in the crossing-point of those fibres (which in the chiasma are
uncovered and run from the geniculate bodies to the opposite cortical
centre) would give paralysis of the temporal halves of both retinæ.

[Footnote 204: _Trans. A. O. Soc._, 1871.]

As regards pure crossed amblyopia, the scheme of Charcot is scarcely
borne out by his clinical facts. The latest theories of those cases
which were investigated by Landolt and himself showed, as they
reported, marked amblyopia on the opposite side from the lesion, but
associated with contraction of the field of vision in the eye of the
same side. The question, however, is so vast, and so much remains to be
learned concerning the brain-centres and their communications with the
optic tracts, that it can scarcely be considered sufficiently ripe for
an exhaustive discussion in a paper like the present.

According to Foerster, temporal hemianopia always develops slowly
without any concomitant paralytic symptoms: it does not have constant
boundaries, and is now progressive and again retrogressive. He cites
cases which he has observed for years where at first small negative
scotoma appeared just outside of the fixation-point, and increased till
there was a total loss of the temporal fields. The line of division
between the blind and seeing sides of the field of vision is not
sharply defined and {779} not accurately vertical. In some cases there
is a gradual invasion of the sound side. Although it is usually assumed
that some pressure in the anterior or in the posterior angle of the
chiasm is the cause, yet the writer does not know of any post-mortem
examination of a case. Mauthner[205] gives short histories of 23 cases
of temporal hemianopia, besides 11 cases relating to nasal hemianopia
(or, according to his classification, hemianopia heteronyma medialis)
from various authors, in most of which the ophthalmoscope showed either
the presence of a neuritis or an atrophy of the nerve. There were two
autopsies in the cases of nasal hemianopia related by Mauthner--those
of Schule and Knapp--one of which showed an enlargement of the third
ventricle and infundibulum, with atrophy of the nerves, and the other a
high degree of ætheromatous degeneration of arteries at the base of the
brain. Any cause which would produce simultaneous pressure on the outer
angles of the commissure would give rise to nasal hemianopia. Little is
known regarding hemianopia above or below the horizontal line: both
Mackenzie and Graefe mention its occurrence, and Knapp, Schoen, and
Mauthner give interesting cases. The writer has seen a case in a woman
of fifty-five years otherwise apparently in good health. The upper part
of each field was wanting, and the line of division ran slightly above
the fixation-point, it being nearly horizontal. The optic nerves did
not present any marked departure from their normal appearance, and
central vision was fair (20/x1). The only autopsy of a case of superior
hemianopia with which the writer is familiar is that reported by
Russell,[206] in which there was a tumor involving the bones of the
base of the cranium. The patient had upper hemianopia, confined to the
right eye, followed by total blindness, coming on first in the right
and then in the left eye. Genuine binocular hemianopia of the superior
or inferior variety is probably produced by some symmetrical affection
of the optic nerves between the chiasm and the eyes.

[Footnote 205: _Gehirn und Auge_, 1881, pp. 373-381.]

[Footnote 206: _Med. Times and Gazette_, No. 47, 1873 (rep. _Nagel's
Jahresbericht_, 1873, p. 361.)]

In apparently healthy individuals transient hemianopia is not an
unfrequent occurrence, and may either develop with or without other
cerebral symptoms. It is usually followed or accompanied by headache,
or more rarely by vertigo, tinnitus aurium, difficulty of speech, etc.
Even in intelligent patients, who have not been drilled by their
medical adviser to carefully analyze their symptoms, it is not
recognized as half-vision, but here, as in the permanent variety of the
affection, it is described as a dimness or blindness of the eye on the
side in which the field of vision is defective. Some cases of transient
hemianopia are accompanied by peculiar zigzag flickerings of light in
the defective portions of the field of vision, which have given it the
name of scotoma scintillans. We are fortunate in having an accurate
description of this form of the affection by so competent an observer
as Foerster, who has frequently experienced it in his own person. In
his case the phenomena last from fifteen to twenty-five minutes, and
commence with the appearance of dimness in both eyes, which gradually
increases to a defect of the field of vision lying to one side of the
fixation-point. This is soon followed by a flickering which commences
in a zone around the scotoma, and increases centrifugally until it
assumes the form of an arc with the convexity outward, {780} the
flickering rarely extending beyond the vertical line which separates
the two halves of the field of vision. When it has reached the outer
limits of the field, it generally diminishes and fades away. From a
consideration of the celebrated case of Wollaston, it is probable that
transient hemianopia may be caused by some temporary congestion of a
brain tumor, but in the majority of instances it is certainly allied to
functional disorders like migraine. Transient hemianopia has been
observed in several members of the family of one of the writer's
patients, all of whom are subjects of consecutive neuralgic headaches.
Leber has observed the same thing. Brewster and Quaglino have
attributed it to a retinal anæmia, but a careful ophthalmoscopic
examination in two well-marked cases (that of Foerster and one related
by Mauthner) failed to show any retinal changes. In some cases the
well-marked hemianopic character of the attack speaks for its
intracranial origin, which may be temporary derangement of the
circulation, possibly in the optic tracts. Dianoux tells us that in his
case the attack could be cut short by keeping the head down between the
legs. In some of the cases which the writer has seen it may be cut
short by a liberal dose of whiskey.


Affections of the Third Pair.

While a few words on the pathology of the third and sixth nerves tend
to throw light on our knowledge of cerebral localization, they will
also spare a good deal of needless repetition in the detailed
discussion of the eye symptoms which accompany many well-marked
diseases. Complete paralysis of the third nerve may be caused by
pressure on its filaments at the base of the brain without other
symptoms. Where it occurs with hemiplegia of the opposite side of the
body and other cerebral symptoms, it is usually due to pressure on the
nerve where it runs beneath the cerebral peduncle: according to
Nothnagel,[207] this localization of the disease is still more certain
when paralysis of the facial and hypoglossal nerves exists on the same
side as the hemiplegia (that is, on the side opposite to the third-pair
paralysis). Hughlings-Jackson[208] remarks that the symptoms are only
positively diagnostic of a lesion in the neighborhood of the peduncle
when they appear simultaneously, but when they are concentric to each
other they may be due to an affection of the cranium. Ollivier and
Little[209] have each related a case where this group of symptoms has
not originated in any lesion in the peduncle, but has been caused by an
abscess of the middle and posterior lobes, which secondarily involved
these parts.

[Footnote 207: _Topische Diagnostik der Gehirnkrankheiten_, p. 198,
1879.]

[Footnote 208: In Russell Reynolds's _System of Medicine_, vol. ii.,
1872.]

[Footnote 209: Robin, _Des Troubles oculaires dans les Maladies de
l'Encephale_, p. 95.]

DOUBLE THIRD-PAIR PARALYSIS.--Double third-pair paralysis is rare, but
might be produced by any cause acting on both peduncles. Kohts gives a
case where such paralysis was caused by a tumor of the size of a
cherrystone limited exactly to the posterior tubercles of the
quadrigeminal body. Nothnagel remarks that paralysis of corresponding
branches of the third pair point to the corpora quadrigemina as the
seat of lesion. On the other hand, Panas[210] relates a case of
absolute {781} immobility of the eyes where the only demonstrable
lesion at the autopsy was a meningo-encephalitis in the lower part of
the cerebellum. Robin describes a case of double third-pair paralysis
where there were ptosis and dilatation of the pupils, with a loss of
all power to move the eyes except downward and outward. The diagnosis
was that of an interpeduncular syphilitic gumma: there was complete
recovery. In the above case it is interesting to note that while the
paralysis of the left eye occurred previous to that of the right, the
eye last attacked was the first to regain its motions.

[Footnote 210: Cited by Robin, _loc. cit._, p. 74.]

PTOSIS.--Paralysis of the branch of the third pair which supplies the
levator palpebræ, when it exists without any lesion of the other
branches or where it is coincident with hemiplegia of the opposite
side, is frequently held to indicate a cerebral lesion, which may be
either cortical or have its seat in the nucleus of the nerve. According
to Grasset,[211] when the lesion is cortical it is situated in the
parietal lobe in advance of the angular gyrus. The localization is by
no means well made out. Coignt[212] has shown that it is not always
crossed, for in 5 out of 20 cases mentioned by him it existed on the
same side as the paralysis. Steffen[213] gives a case of double ptosis
with sluggish pupils where there was complete control over the muscles
moving the globe, the autopsy showing a tubercle in the tubercular
quadrigemina which had entirely effaced their normal structure.

[Footnote 211: Robin, p. 104.]

[Footnote 212: _Thèse de Paris_.]

[Footnote 213: _Berliner klin. Wochenschrift_, No. 20, 1884.]

OPHTHALMOPLEGIA INTERNA.--In those cases where affection of the orbital
ophthalmic ganglia can be excluded, paralysis of the pupillary and
ciliary branches of the third pair is, according to Jonathan
Hutchinson, due to an affection of the twig which runs through the
lenticular nucleus in the striated body. It is frequently associated
with paralysis of the internal rectus, and may be accompanied by
paralysis of the ciliary muscle. After diphtheritis there is often
paralysis of the ciliary muscle, with prompt reaction of the iris. The
writer is not aware of any recorded instance of apoplexy or other
sudden onset of disease which would enable us to localize exactly the
centre for pupillary contraction. According to Hughlings-Jackson, we
may have in apoplexy the most varied states of the pupil (normal,
dilated, or contracted) independent of the seat of lesion: he further
states that upon calling loudly to the patient there will sometimes be
a transient pupillary dilatation. When we look at the state of the
pupils as part of general symptomatology, we find a most perplexing
confusion and contradiction: in fact, notwithstanding the quantity of
material both in ancient and modern literature, we are far from having
any satisfactory account of the subject. This is partly due to our
imperfect knowledge of the anatomy of the brain and to the great
difficulty of estimating exactly pupillary changes, and partly
carelessness and want of a proper system of observation. The data have
for the most part been hastily compiled, without a minute statement of
concomitant symptoms or the stage of the disease in which they are
developed. Usually, they have been made without any proper means for
illuminating the pupil or apparatus for correctly magnifying and
observing its motions. In most cases the want of knowledge of the more
common sources of error, such as a difference in the size of the pupils
owing to difference in the refraction of {782} the eyes, posterior
synechiæ, or other intraocular changes, has invalidated the results.

ASSOCIATED MOVEMENTS OF THE HEAD AND EYES.--In many central lesions,
associated movements of the head and eyes are present, and, although
the exact channels through which they are propagated are for the most
part unknown, yet certain groups of these clinical symptoms are of so
frequent occurrence as to be recognized and admitted by almost all
observers. Vulpian and Prévost were the first to enter into a minute
study of these movements. Vulpian in his lessons on the physiology of
the nervous system (1866) states that "in cases of unilateral cerebral
lesion, whether it be situated in the cerebral hemispheres, the
striated bodies, the thalami optici, the cerebellum, or in the
different parts of the isthmus cerebri, whether the lesion be softening
or hemorrhage, there is often, immediately after the attack, a
deviation of the eyes at the time of development of the hemiplegia. The
deviation is in general transient, and may last either a few minutes or
hours or several days. The eyes are usually turned in a direction
opposed to that of the hemiplegia; thus, if the right side is
paralyzed, both eyes are turned toward the left. On regaining
consciousness the patient, if he tries to turn his eyes to the right,
may either be entirely unable to move them, or, what is more usual, may
succeed in bringing them to the middle of the palpebral aperture
without being able to turn them farther in that direction. Does this
phenomenon depend on a paralysis of the muscles which cause conjugate
motion of the eyes, or on a spasmodic contraction of their opponents,
over which they are unable to triumph?" He further states: "I incline
strongly to the latter view, as it is in accordance with what we
observe in animals. The analogy of the phenomena goes still farther:
often the head of the patient has made a more or less marked movement
of rotation on the neck--a movement as the result of which the face is
turned toward the non-paralyzed shoulder, and in the cases where we
cannot observe a deviation by turning back the head into its normal
position, an action which can often be only brought about by
considerable effort."

Prévost[214] has since formulated the following laws for cases of
hemiplegia: "I. When the hemiplegic looks toward his lesion and away
from his paralyzed side, the lesion is hemispherical. II. If he looks
toward his paralyzed side, the latter is situated in the
mesencephalon." This statement coincides with the facts reported by
Hughlings-Jackson, Charcot, and many other observers. Nothnagel[215]
admits that this is the rule, but quotes as an exception to it a case
of his own where, with right hemiplegia and head turned to the right,
the eyes were turned to the left, the autopsy showing an extensive
patch of softening in the left hemisphere which involved the frontal
convolutions, the central convolution, and the adjacent white
substance. In addition, he cites Bernhardt as giving other exceptional
cases which, in his own judgment, "considerably diminishes the
diagnostic value of the phenomenon." Landouzy and Coignt[216] have
attempted to define still more clearly the diagnostic value of the
associated movements of the head and eyes, and, while they admit the
correctness of these laws of hemiplegic paralysis, they add that in
convulsive {783} cases in which there are symptoms of irritative
lesions the above rules are reversed. To explain such cases they lay
down the following rules: first, that if the patient looks toward his
convulsed side the lesion is situated in the hemisphere of the opposite
side; and second, if he looks away from his convulsed side (or toward
the lesion) there is an irritant lesion of the mesencephalon.

[Footnote 214: _Thèse de Paris_.]

[Footnote 215: _Topische Diagnostik der Gehirnkrankheiten_, p. 580,
1879.]

[Footnote 216: _Thèse de Paris_, 1878.]

NYSTAGMUS.--This is a term applied to a periodic type of involuntary
oscillatory or rotatory movements of the eyeballs. The oscillatory are
due to rapid alternate contraction of the straight muscles, while the
rotatory indicate either similar actions of the oblique muscles alone
or in conjunction with the straight. The oscillatory motions are
usually horizontal, but instances of vertical nystagmus occur, as in
the case recorded by Soelberg Wells.[217] Nystagmus may be either
congenital or acquired; the latter variety being much the more frequent
form of the affection. Congenital nystagmus is usually associated
either with cataract or imperfect development of the optic nerve and
retina. It is a very frequent accompaniment of albinism and pigmentary
retinitis. We often see the acquired form arise during the first few
months of life, when the child in its effort to see is hindered by
corneal or lenticular opacities resulting from ophthalmia neonatorum.
One of the most interesting of the acquired forms is that which occurs
amongst coal-miners, rendering a considerable number of those thus
affected unfit for work. At first the symptoms are that the lights in
the mines and the objects on which the patients endeavor to fix their
attention begin to dance, this being accompanied by a sensation of
dizziness and discomfort. In the first part of the attack they
disappear when work is stopped, and the miners come up into the
daylight; but if work be persisted in they become permanent and
exaggerated. When the nystagmic motions have ceased, they may often be
called into activity by placing the patient in a dark room and getting
him to direct his eyes to a candle held above the horizontal line of
the field of vision. The motions are usually lateral, or in some cases
the centre of the cornea describes an ellipse or circle which causes
the patient to see a ring of light. It has been observed to occur much
more frequently in those working in shafts where there is a good deal
of fire-damp; which has caused some writers to assert that the
nystagmus has been dependent upon the action of the gas. This view
would seem to receive some support from an instance reported by Bright
of nystagmus, in a case of suffocation from the fumes of burning coals,
which he attributed to cerebral pressure. In these cases it is more
probably due to fatigue of the eye and its nerve-centres in the
endeavor to see in the dim light and strained position which the miner
is often obliged to maintain, which is intensified by the enfeeblement
of the nerve-centres due to the action of the gas: these, associated
with the diminution of the light caused by the wire gauze of the
safety-lamp, would further increase the strain in those obliged to work
in the shafts pervaded with fire-damp. The statements of Dransart,[218]
founded on the examination of a large number of miners, probably give a
correct idea as to the frequency of the affection. He states that among
12,000 workmen employed by one company, there were 30 under treatment
for nystagmus, which would give about two and a half patients per
thousand. In any form of nystagmus the motions of {784} the eyes
usually become more rapid when they are used for near work. According
to Nagel,[219] excessive convergence will at times cause a temporary
cessation of all nystagmic motion; and he further proved this by
putting extra strain on the interni by means of prisms with their base
out. The true pathology of the various forms of nystagmus is still
imperfectly known. Arlt[220] supposes that there is a rapid repetition
of reflex movements in the endeavor to attain distinct vision in those
forms which develop on account of corneal and lenticular opacities. He
explains this by the supposition that the retinal impression is
strengthened by the same retinal areas being rapidly and repeatedly
subjected to the action of the rays of light from the same object,
while a longer period of fixation would cause retinal fatigue and blur;
showing the same principle by reminding us that our perceptive powers
for a test object, upon first being brought into view at the periphery
of the field of vision, are much stronger when the object is shaken
than when it is brought quietly toward the fixation-point. Some forms
of the affection, however, are manifestly due to fatigue of the
nerve-centres, and have been by some authors placed in the same
category as writers' cramp. For its causation we would naturally look
for the anatomical changes either in the cortical centres for the
eye-muscles or in the nuclei of the third and sixth pairs. Vulpian[221]
states that wounds of the medulla in dogs cause nystagmus, and Schiff
asserts that wounds of the white substance of the cerebellum near the
peduncles give rise to the same phenomenon; while Ferrier has produced
it by the influence of electricity on the cerebellum of apes. Cohn[222]
records a case of gunshot wound of the right parietal bone (near the
angular gyrus) which produced nystagmus. Merkel's case, occurring in a
patient with embolism of the artery of the fissure of Sylvius, would
also point to lesion near the angular gyrus. Stintzing[223] gives a
case where there was thrombosis of the basilar and Sylvian arteries.
Oglesby[224] relates two cases where nystagmus came on suddenly with
dilatation of the pupils, the autopsies showing a clot which pressed on
the medulla. Fienzal[225] also gives a case where there was a tumor in
the left peduncle of the brain. It is often seen during epileptic
convulsions. According to Raehlmann,[226] the motions of both eyes are
under the control of psychic centres which regulate them according to
the necessities of vision: for Willbrand[227] it is a sign of weakness
of the voluntary cortical centres which fail to regulate the reflex
activity of the middle brain and cerebellum. The latter author shows
that the extent of the field of vision is increased in the direction of
the oscillations in those cases where direct vision is not much
impaired, while there is marked contraction of the field in cases where
the direct visual acuity is much diminished. He also states that there
is contraction of the field in the nystagmus of miners, which is
greater during the intervals of the paroxysm than during their
occurrence, and, further, that the contraction is greater where the
case is one of long standing.

[Footnote 217: _Lancet_, 1871, p. 662.]

[Footnote 218: _Annales d'Oculistique_, 7, 82, p. 177.]

[Footnote 219: _Graefe u. Saemisch_, vol. vi. p. 226.]

[Footnote 220: _Krankheiten des Auges_, Bd. iii. p. 335.]

[Footnote 221: _Comptes Rendus de la Société de Biologie_, 1861 (quoted
by Robin, p. 157).]

[Footnote 222: _Schussvorletzungen des Auges_, p. 19.]

[Footnote 223: _Jahresbericht f. Ophth._, vol. xiv. p. 306.]

[Footnote 224: _Brain_, vol. iii., 1880.]

[Footnote 225: _Trans. Internat. Congress_, at Milan, 1881, p. 126.]

[Footnote 226: "Nystagmus und seine Aetiologie," _A. f. O._, xxiv., 4,
p. 237 (1878).]

[Footnote 227: _Klin. Monatsblätter f. Augenheilkunde_, vol. xvii.,
1879, pp. 419-438 and 461-480.]

{785} In some rare cases nystagmus may be produced at will.
Raehlmann,[228] Lawson,[229] Benson,[230] all report cases of the
voluntary type. In one of those given by Lawson the patient (a
gentleman in good health) "first made his eyes steady, and then set
both into rapid lateral motion--so rapid that the outline of the cornea
was completely lost to view." Zehender[231] observed it in a case of a
twelve-year-old boy, where he was able to produce it by the
instillation of a strong solution of eserine. Charcot states that
ordinary nystagmus is a valuable symptom of disseminate sclerosis, and
that it is present in about half of these cases, while it is
exceptional in locomotor ataxy. "In some patients the look is vague
until the eyes are made to fix some object, when the nystagmus
develops."

[Footnote 228: _Loc. cit._]

[Footnote 229: _R. L. O. H. Reports_, vol. x. p. 203.]

[Footnote 230: _Ibid._, vol. v. p. 343.]

[Footnote 231: _Klin. Monatsblätter f. Augenheilkunde_, vol. xviii.,
1879, p. 127 (note).]

According to Hammond, in disseminate sclerosis, nystagmus may be the
only symptom for the period of a year before other symptoms develop.
Moos[232] speaks of oscillatory movements of the eyes in Menière's
disease, and Schwalbach[233] describes them in a case of purulent
catarrh of the middle ear where they could be produced either by
syringing or by pressure on the mastoid process.

[Footnote 232: _Arch. f. Augenheilkunde und Ohrenheilkunde_, vii. 2, p.
508.]

[Footnote 233: _Deutsches Zeitschrift f. prakt. Med._, No. 2, 1878.]


Affections of the Fifth Pair.

HERPES FACIALIS.--Herpes facialis frequently appears on the lips and
angles of the mouth, and occasionally in the eye and its appendages.
When upon the conjunctiva or cornea, it commences as clear watery
vesicles, usually in groups, which soon burst and leave open ulcers
looking very much like abrasions or scratches of this membrane. They
usually occur in successive crops after fevers, especially pneumonia,
although at times they may appear without any assignable cause. They
are also slow to heal, but are not dangerous to the eyesight, except
where they give rise to purulent infiltration leading to hypopyon.

HERPES ZOSTER OPHTHALMICUS.--Herpes zoster ophthalmicus is a far more
formidable affection. The eruption, as is well known, follows the
distribution of the divisions of the ophthalmic branch of the
trigeminus, and when the eyeball is affected the sight is always
threatened. Clear watery blisters form on the cornea, which soon burst,
the exposed tissue taking on purulent infiltration, while pus is not
infrequently deposited in the anterior chamber. These ulcers are slow
to heal under the most careful treatment, which, as a rule, consists in
washing with disinfecting solutions and applying a bandage, etc. There
is almost always iritis, as evidenced by the sluggish pupil and at
times by marked synechiæ.

The burning and pricking pain at the seat of eruption is marked, and
there is severe neuralgia in the temple, forehead, and side of the
nose. The intensity of the iritis varies considerably in different
cases, and, although some terminate favorably, having had but few and
slight symptoms, yet the one case reported by Noyes, where it led to
cyclitis, followed by shrinking of the eyeball, which ultimately gave
rise to {786} sympathetic irritation of the fellow-eye, shows how
serious its consequences may be. Permanent opacities of the cornea are
not infrequent. The disease is, fortunately, a rare one. It usually
comes on either in middle or declining life, although Wadsworth has
reported a case in a child four years old. The cornea becomes
anæsthetic, both in the ulcers and over the rest of its surface, a long
time often elapsing before any of its sensibility is regained.
Horner[234] was the first to demonstrate that the corneal ulcers
originated in vesicles, and the very great diminution of intraocular
pressure in the affected eyeball, and also to show the marked
difference in the temperature of the skin of the two sides. The
temperature on the affected side is usually one and a half to two
degrees higher than on the other side, while the cutaneous sensibility
is markedly diminished; as, for instance, the æsthesiometer might give
twelve lines on the healthy forehead as against twenty-two lines on the
diseased side, and the superciliary ridges and the upper eyelid on the
normal side might give respectively nine and five lines as against
seventeen and seven lines on the affected side. In the cases which the
writer has had an opportunity of studying he has found similar
variations in intraocular tension, temperature, and sensibility.
Hutchinson[235] thinks that the affection of the nasal branch is always
accompanied by inflammation of the eyeball, and says: "Thus far, I have
never seen inflammation of the whole side of the nose without
witnessing inflammation of the eye;" while Bowman[236] says that he has
"not found affections of the eyeball to occur, especially in those
cases of ophthalmic zoster in which the eruption followed the course of
the nasal branch." Wadsworth[237] gives a case where the entire side of
the nose was involved, the eyeball and conjunctivæ not being affected.
He suggests that possibly the explanation in these cases is an anomaly
of distribution described by Turner, where the side of the nose is
supplied by a long, slender infratrochlear branch. Bowman,[238]
although realizing that peripheral excitement of sensory nerves may
originate in a central or reflected source, and induce tenderness and
redness in the parts supplied by them, yet nevertheless holds that
ophthalmic zoster is a peripheral disease, having its primary seat in
the branches of common sensation, the nerves probably becoming inflamed
in the more superficial portions of their trunks, as the eruption
succeeding as an extension of vascular excitement to the cutaneous
tissue: he thus explains the tenderness of the skin before it reddens
and the often lasting alteration of sensibility. In reference to
whether the neuritis causing the eruption is an ascending or descending
one, the only two careful autopsies that give answer with which the
writer is familiar are those of Wyss and of Weidner, where both show
extensive changes in the nerve-centres. The latter, made five years
after the attack, showed cicatricial shrinking of the ganglion of
Gasser and of the root of the nerve between it and the medulla; while
that of Wyss, made within two weeks of the outbreak of the affection,
showed that the entire ophthalmic branch of the trigeminus was
thickened, reddened, softened, and surrounded by extravasation of blood
from the entrance of the orbit up to the ganglion of Gasser; while the
other branches of the trigeminus were normal in size and {787}
appearance. The Gasserian ganglion itself was enlarged and bright red,
while that of the other side of the head was yellowish-white. As is
well known, zoster in other parts of the body not infrequently affects
the two sides simultaneously; and there are recorded cases where it has
twice attacked the same locality, but the writer is not familiar with
any such facts as regards ophthalmic zoster.

[Footnote 234: _Klinische Monatsblätter f. Augenheilkunde_, 1871, p.
321.]

[Footnote 235: _R. L. O. H. Rep._, 1866, pp. 191-215.]

[Footnote 236: _Ibid._, 1867.]

[Footnote 237: _Trans. of Amer. Oph. Soc._, 1874.]

[Footnote 238: _Loc. cit._]

NEURO-PARALYTIC OPHTHALMIA.--In 1822, Herbert Mayo[239] showed that
section of the fifth nerve within the cranium produces insensibility of
the eye; and Charles Bell[240] in 1830, while recognizing this fact,
maintained that "when that sensibility is destroyed, although the
motions of the eyelids remain, they are not made to close the eye, to
wash and clear it, and consequently inflammation and destruction of
that organ follow." Since that time the subject has been a favorite
theme with both clinicians and physiologists, but opinions as to its
cause have been a good deal divided. While, perhaps, a majority, with
Bell,[241] Snellen,[242] Kondracki,[243] Gudden,[244] Senftleben,[245]
and others, hold that the inflammation of the cornea is of traumatic
origin, many writers--amongst whom may be mentioned Longet,[246]
Graefe,[247] Meissner,[248] Schiff,[249] and Eckhard[250]--assert that
it is caused by the impaired action of the trophic fibres of the nerve;
and again others, such as Ferrier,[251] Balogh,[252] and Buchmann,[253]
maintain that the inflammation is peripheral, consequent upon the
drying of parts of the cornea. Clinically, soon after the occurrence of
complete palsy of the trigeminus, there is an interstitial punctate
keratitis, which makes the cornea so cloudy that the motions of the
iris are with difficulty observed, this being accompanied by
conjunctival and ciliary injection. The symptoms, especially where the
paralysis is incomplete, are often much alleviated by maintenance of
careful closure of the lids and repeated washing of the eye, which
protects the enfeebled tissue from the action of foreign bodies.
Success is not, however, always obtainable, for occasionally, even with
the most complete protection of the eye, eventual sloughing of the
cornea cannot be prevented. This is not a usually-accepted doctrine,
but the writer is convinced[254] of its truth by a case seen within a
week of the commencement of the disease, in which the cornea was not
yet ulcerated, where the most sedulous care in cleansing the eye and
protecting it from external irritants did not prevent the necrosis and
perforation of the central part of the cornea. Since then other cases
of similar import have been published. Quaglino[255] gives an instance
where complete ptosis shielded the eye from all gross insults, but
where, nevertheless, a central slough of the cornea formed.
Laqueur[256] also found {788} that the cornea sloughed in spite of the
most careful protection. In all other cases where the cornea is exposed
to air and external irritants, as in lagophthalmos or excessive
exophthalmos, the case is quite different, the consequent inflammation
being much better borne. While this is a fact more or less familiar to
all clinicians, it is nowhere better shown than in the case of
Horner,[257] where there was caries of the petrous portion of the
temporal bone and complete paralysis of the facial nerve. Two years
later the trigeminus was attacked, and then for the first time
ulceration occurred in the hitherto sound cornea. Hirschberg[258]
describes neuroparalytic keratitis and panophthalmitis consequent upon
a neurectomy of the infraorbital nerve, and quotes Langenbeck as
relating a similar case after section of the supraorbital nerve.

[Footnote 239: _Anat. and Physiol. Commentaries_, London, 1822, No. 2,
p. 5.]

[Footnote 240: _Nervous System of the Human Body_, London, 1830, p.
207.]

[Footnote 241: _Loc. cit._]

[Footnote 242: _Virchow's Archiv_, Bd. xiii. S. 107, 1850.]

[Footnote 243: _Nagel's Jahresbericht_ (Lit. 1873), p. 266.]

[Footnote 244: _Idem._]

[Footnote 245: _Virchow's Archiv_, Bd. lxv. Heft. 1, pp. 69-99.]

[Footnote 246: _Anatomie et Physiologie du Système nerveux_, t. ii. p.
161, Paris, 1842.]

[Footnote 247: _Arch. f. Ophthalmologie_, Bd. i. Abth. i. S. 306-315.]

[Footnote 248: _Henle und Pfeuffer's Zeitschrift_ (3), xxix. p. 96
(quoted by Soelberg Wells).]

[Footnote 249: _Ibid._, p. 217 (also quoted by Wells).]

[Footnote 250: _Centralblatt f. Med. Wiss._ (cited by Nagel,
Literature, 1873).]

[Footnote 251: _Nagel's Jahresbericht_, (Lit. 1876), p. 51.]

[Footnote 252: _Ibid._]

[Footnote 253: _Ibid._, 1883, p. 153.]

[Footnote 254: Norris, "Case of Paralysis of the Trigeminus, followed
by Sloughing of the Cornea," _Trans. Amer. Ophth. Soc._, 1871, pp.
138-141.]

[Footnote 255: _Nagel's Jahresbericht_ (Lit. 1874), p. 26.]

[Footnote 256: _Klinische Monatsblätter f. Augenheilkunde_, 1877, p.
228.]

[Footnote 257: _Nagel's Jahresbericht_ (Lit. 1873), p. 267.]

[Footnote 258: _Berliner klinische Wochenschrift_, 1880, S. 169;
_Sitzung der Gesell. f. Psych. und Nervenkrankheiten_, 10 März, 1879.]

INJURIES OF THE FIFTH PAIR.--Although daily clinical experience shows
us how promptly irritation of the sensitive branches of the trigeminus
are followed by symptoms of reflex action in the eye--as, for instance,
a cinder in the conjunctiva will cause contraction of the pupil, or a
sharp pinch of the temple will at times cause pupillary
dilatation--nevertheless, instances of impairment of the eyesight due
to injury of the branches of the infraorbital or supraorbital nerves,
and to this alone, are of rare occurrence. Sympathetic ophthalmia is
the exception in which we too frequently see inflammation of one eye
cause severe and often irreparable damage to its fellow. Scattered
through ancient and modern surgical works there are many interesting
and well-attested cases of impaired vision, some of which should be
excluded on account of the want of proper evidence, which is now
obtained from testing of the acuity and field of vision and
ophthalmoscopic examination. Erichsen[259] cites cases from
Hippocrates, Fabricius Hildanus, and La Motte where amaurosis was
produced by a wound of the brow. Chelius[260] gives a case from similar
injury, while Wardrop[261] narrates three instances--one of wound of
forehead, one from a blow on it with a ramrod, and one from an injury
by a fragment of shell. The same author calls attention to the fact
that amaurosis is more readily caused by wounds and injuries of the
supraorbital and infraorbital nerves than from complete division of
them. The various neurotomies and neurectomies performed upon the
supraorbital branch since his day bear witness to the accuracy of his
deduction. The same author quotes Morgagni as saying that Valsalva has
seen amaurosis follow a wound of the lower lid which has been inflicted
by the spur of a cock. Morgagni relates a similar case where the injury
was inflicted by the broken glass from the windows of an upset
carriage; and Beer reports a similar case of amaurosis from wound of
the cheek. Guthrie[262] remarks that "when the eye becomes amaurotic
from a lesion of the first branch of the fifth pair of nerves, the
pupil does not become dilated; the iris retains its usual action,
although the retina may be insensible and the vision destroyed." More
recently, Rondeau[263] {789} gives two cases, one of which caused
lachrymation, photophobia, and eventual atrophy of the eye on the
affected side, followed, fifteen years later, by loss of the fellow-eye
from sympathetic ophthalmia, which had been produced by degenerative
changes taking place in the shrunken bulb; and a second, in which a
wound of the left brow became painful eight days after the receipt of
the injury, and where pains became more severe as the wound cicatrized:
in this latter case the left eye became foggy in three weeks, and soon
sight was entirely lost, whilst six weeks after the accident there was
dull pain in the right eye, with a sensation of cloudiness and a
gradual development of photophobia in it. By local bloodletting, which
caused the photophobia to rapidly yield, and a derivative and alterant
treatment, the patient's right eye was so far improved that fifteen
days later he could find his way about with the left eye, and could see
to read with the right. Ophthalmoscopic examination showed in the left
eye a serous swelling of the retina which entirely obscured the margin
of the discs and gave the whole fundus a grayish tint, the veins being
much enlarged and very tortuous. The right eye showed similar changes,
though less developed.

[Footnote 259: _Loc. cit._, pp. 233-261.]

[Footnote 260: South's translation of Chelius's _System of Surgery_,
vol. i. p. 430.]

[Footnote 261: _Morbid Anatomy of the Human Eye_, vol. ii. pp. 180,
181, London, 1818.]

[Footnote 262: Quoted by White-Cooper, _Injuries of the Eyes_, London,
1859, p. 92.]

[Footnote 263: _Des Affections oculaires Reflexes_, Paris, 1866, pp.
53, 54.]


Affections of the Sixth Pair.

The extremely limited distribution of the sixth pair of cranial nerves
renders the clinical study of their pathology comparatively simple. The
eye supplied by the paralyzed muscle turns inward to an extent
corresponding to the degree of loss of power in the paretic muscle plus
the energy of its opponent rectus internus. The image of the object
fixed by it falls, therefore, to the inner side of the macula lutea,
and, being projected outward, causes a double vision, in which the
image of the deviated eye appears to be in the temporal field of the
affected eye (homonymous diplopia). When the healthy eye is covered and
the patient endeavors to fix any near object with the paralyzed eye, it
will be found that (as in all other cases of peripheral paralysis
affecting any of the extra-ocular muscles) the secondary deviation of
the sound eye is considerably greater than the primary deviation of the
affected one; this being accounted for by the fact that the amount of
consentaneous innervation which is sufficient to cause a small motion
in the paretic muscle will produce a marked effect in the sound one.

Paralysis of the external rectus is quite common, and is either
transient or permanent. The former variety is often put down as
rheumatic, when it is really a symptom of tabes dorsalis. The permanent
paralysis is frequently an accompaniment of the affections of the base
of the brain: when these are located in the middle fossa of the skull
it is often associated with paralysis of the facial. If hemiplegia be
present, the lesion is usually situated farther back toward the exit of
the nerve from the pons. Graux[264] and Ferréol have called attention
to a form of paresis which results from disease of the nucleus of the
sixth pair. In this form, owing to the affection of the filament which
the nucleus of the sixth nerve gives to the nucleus of the third nerve,
which is distributed to the internal rectus of the other side, the
amount of the secondary deviation is much {790} diminished, and there
is more or less the appearance of an ordinary concomitant convergent
squint (where, as is well known, the excursions of the two eyes are
nearly equal). In one case, where the autopsy showed that a small
tubercle had been developed at the junction of the medulla and pons,
just beneath the surface of the fourth ventricle, there was no other
symptom than this conjugate deviation of the eyes. In another case, in
which there was hemiplegia (hemiplégie alterne), a tubercle was found
higher up in the pons, bulging into the fourth ventricle. In addition
to the conjugate deviation of the eyes already mentioned, Graux and
Ferréol believe that this central form of paralysis is distinguished by
its gradual access, slow development, and persistence. They say that in
pure cases of lesion of the nucleus it is characterized by the absence
of all other symptoms, and still further assert that in those cases in
which it is but partially involved the accompanying symptoms are either
complete facial paralysis or alternate hemiplegia.

[Footnote 264: _Thèse de Paris_.]


Affections of the Seventh Pair.

Loss of power in the orbicularis palpebrarum, and consequent
lagophthalmos, is frequently encountered as part of paralysis of the
facial nerve. Where the paralysis is complete, it prevents closure of
the eyelids. Variation in the size of the palpebral fissure is,
however, by no means abolished, for, owing to relaxation of the levator
palpebrarum, the fissure diminishes when the patient looks down, but is
increased by the activity of this muscle when he looks up.

BLEPHAROSPASM.--Spasmodic closure of the lids is frequent in
phlyctenular conjunctivitis and in many corneal and conjunctival
affections. It is evidently reflex in its origin, and often entirely
out of proportion to the amount of conjunctival or corneal disease. A
foreign body under the lids will frequently give rise to a similar
state of reflex spasm. We also encounter a greater or less degree of
twitching of the lids as part of general or local chorea.


Affections of the Twelfth Pair.

BULBAR PARALYSIS, LABIO-GLOSSAL LARYNGEAL PARALYSIS.--Affections of the
eye and its appendages are rather exceptional in this form of disease.
In one case Galezowski describes unilateral atrophy of the optic nerve,
and Dianoux[265] bilateral atrophy in another. In the latter the
atrophy came on after partial paralysis of the lips and of the muscles
of deglutition, it being preceded by paralysis of the right external
rectus. Hallopeau[266] quotes a case from Wachsmuth where there was
partial paralysis of the facial which rendered the face immobile and
effaced its wrinkles, allowing the lower lid to fall. He cites also a
case of Hérard in which there was amblyopia and partial ptosis. He
justly remarks that such phenomena indicate an extension of the lesion
from the nucleus of the twelfth pair to other parts of the central
nervous system. {791} The pupils are sometimes described as contracted,
more rarely as dilated. Leeser quotes Leube[267] to the effect that
"paralytic myosis, when it occurs in bulbar paralysis, is generally a
sign that it is complicated either by progressive muscular atrophy or
with sclerosis of the brain and spinal cord."

[Footnote 265: Quoted by Robin, _Troubles oculaires dans les Maladies
de l'Encephale_, p. 335.]

[Footnote 266: _Des Paralysies bulbaires_, Paris, 1875, p. 41.]

[Footnote 267: _Deutsches Archiv f. klin. Med._, Bd. viii. pp. 1-19,
quoted by Leeser, p. 94.]


Mental Affections.

It is admitted by all observers that affections of the pupillary branch
of the third pair, such as mydriasis, myosis, and inequality of the
pupils, are of comparatively frequent occurrence among all classes of
the insane. There is the widest difference of opinion as to the
percentage of cases in which it occurs: thus, Nasse out of 229 cases
found 146 (64 per cent.) with difference in the size of the pupils,
while Wernicke found 24 per cent. in the Leubus Asylum, and only 13 per
cent. in the Breslau Institute. The latter author has attempted to
classify the pupillary lesions into three groups:

I. Mydriasis, with loss of accommodation, where the pupil does not
react to light nor with increased convergence of the eyes.

II. Where the pupillary difference is slight and the irides less prompt
than normal in reaction to light, all difference of the pupils
disappearing upon convergence of the eyes.

III. In which the irregularity is still less, the narrower pupil being
absolutely insensitive to light, but prompt in responding to
convergence, while the more dilated pupil acts promptly in obedience to
both light and convergence.

In the first group there is some lesion in the course of the third
pair; in the second, some lesion of the sympathetic either in the
cilio-spinal centre or in its unknown intracranial distribution; whilst
in the third, which is not so readily explained, there is possibly an
affection of those fibres which pass from the third pair to the optic
nerve. Foerster[268] states that he has frequently seen cases where at
different times the same pupil under similar circumstances showed
different diameters; also asserting that variation in the relative
sizes of the two pupils sometimes occurred within a few days or weeks.
He also maintains that in many cases the occurrence of inequality in
the pupils precedes and presages the occurrence of insanity; and as a
marked example of it he quotes the case of a friend and colleague who
observed this phenomenon in himself. This person was well aware of the
theories on the subject, and while yet of sound mind jokingly remarked
that on account of this inequality of pupils having set in, he thought
of taking up his quarters in an insane hospital. A few years later he
actually died insane in the Leubus Asylum. Myosis is said to be
frequent in states of mental exaltation. Seifert asserts that when it
is accompanied by acute mania general paralysis will sooner or later
ensue. Griesinger asserts that the same thing occurs in chronic mania.
As regards the changes in the optic discs in the insane, we find
usually recorded either a low grade of neuritis or of atrophy:
according to Leber[269] this atrophy is histologically similar to that
occurring in gray degeneration of the nerves. The outer strands are
{792} usually those most affected. Indeed, as far as these obscure
diseases are at present understood, there is no good reason why any
changes should be found in the optic nerves except the congestion which
accompanies acute or subacute mental disease and the nerve-degeneration
of various grades which might be expected to be found in all worn-out
lunatics. Illusions and hallucinations referable to the sense of sight
are not uncommon in the insane, and are perhaps due to degenerative
changes in the visual centres. In classifying such cases for study of
the intraocular changes most writers place them under the following
heads--viz.: general paralysis, dementia, mania, and melancholia,[270]
the account of the changes in the eye-ground and the proportion of
cases in which they occur being found to vary greatly.

[Footnote 268: _G. u. S._, vol. vii. p. 227.]

[Footnote 269: _A. f. O._, xiv., 2, p. 203.]

[Footnote 270: Noyes, "Ophthalmoscopic Examination of Sixty Insane
Patients in the State Asylum at Utica," pp. 6 (extra copy from _Amer.
Journ. of Insanity_, Jan., 1872).]

GENERAL PARALYSIS.--Almost all agree that in this form of the disease
we frequently have gray degeneration of the optic nerve, with pupillary
symptoms which strongly resemble those found in tabes dorsalis, in some
instances the autopsy showing the same location of spinal changes which
characterizes the changes seen in locomotor ataxia.

DEMENTIA.--In chronic dementia Albutt found either hyperæmic or
atrophic changes in the disc in 23 out of 38 cases. Noyes[271] found
hyperæmia in 18 cases, and infiltration of the optic nerve and retina
in 12. Jehn and Klein were unable to find changes in the discs of any
of the cases which they examined.

[Footnote 271: _Idem._]

MANIA.--Albutt found the discs hyperæmic except in one case examined
during a paroxysm, in which they were pale. Out of 20 cases of acute
mania, Noyes[272] found 14 which showed hyperæmia of the discs; the
discs of the remaining 6 were either anæmic or normal, these latter
cases all being of short duration (less than three months); the 6 cases
of chronic mania had eye-grounds which showed no lesion, while the
other 3 exhibited hyperæmic or inflammatory changes.

[Footnote 272: _Loc. cit._]

MELANCHOLIA.--In Noyes's examination 4 out of 5 cases had healthy
eye-ground, and 1 moderate hyperæmia and striation. Jehn found
hyperæmia in every one of 40 cases examined, 2 of these having decided
neuritis, which he supposed to be due to meningeal change.


Spinal Cord.

INJURIES TO THE SPINE.--Physiologists have frequently shown that
pupillary and other eye-symptoms may be produced by experimental injury
to the spinal cord of animals, which would lead us to naturally expect
analogous results in man in cases of spinal fracture and injury. This
subject has received great attention in England, where spinal injury
from railway accidents appears unusually frequent. Albutt[273] tells us
that it is tolerably certain that disturbance of the optic nerve and
its neighborhood is seen to follow disturbance of the spine with
sufficient frequency and uniformity to establish the probability of a
causal relation between the two events. Erichsen,[274] who has
collected his large clinical experience {793} into a book on
_Concussion of the Spine_, after citing Plutarch to show how Alexander
the Great was in danger of losing his eyesight from the blow of a heavy
stone on the back of the neck, gives 53 cases (not tabulated with this
view by the author), of which 49 were apparently undoubted cases of
spinal injuries: of these, 13 (36 per cent.) showed decided
eye-symptoms. Erichsen says: "My experience accords fully with that of
Albutt. I found that in the vast majority of cases of spinal concussion
unattended by fracture or dislocation of the vertebral column there
occurred within a few weeks distinct evidence of impairment of vision."
As enumerated by this author, these symptoms consist of difficulty of
seeing in dim light, blurring and running together of the letters, and
at times (in the early stages) slight diplopia. Later, there is
photophobia, with contraction of the brow, which gives a peculiar
frown, and at times an injection of the conjunctiva; these symptoms
often being accompanied by muscæ volitantes and photopsia. He agrees
with Albutt in attributing these to an ascending meningitis, while
Wharton Jones considers that the eye symptoms are better accounted for
by the action of the cilio-spinal centre and the sympathetic filaments
springing from the dorsal and cervical cord. Wharton Jones[275] lays
stress upon the undue retention of after-images and upon the small
amount of comfort which a positive (convex) glass gives the patients,
and "to the pain extending from the bottom of the orbit to the occiput,
which is always a symptom belonging to deep-seated disturbance in the
circulation of the optic apparatus." Rondeau[276] gives an interesting
example of severe affection of the eyesight from apparently slight
injury to the spine. The patient, seventeen years old, fell on the
staircase, striking the neck and shoulders. There was complete loss of
sight. Light-perception returned in a month, and four years after he
could distinguish large objects in front of him, but vision remained
stationary at that point. Albutt informs us that the percentage of
visual affections is greater in proportion to the height of the seat of
the injury in the spine.

[Footnote 273: _Use of the Ophthalmoscope_, London, 1871.]

[Footnote 274: _Concussion of the Spine_, by John Eric Erichsen,
London, 1875.]

[Footnote 275: _Failure of Sight after Railway and Other Injuries of
the Spine and Head_, London, 1869.]

[Footnote 276: _Affections oculaires Reflexes_, Paris, 1866.]

TABES DORSALIS.--That affections of the eye are common in this grave
malady is admitted by all writers, but as to their frequency and nature
at the different stages of the disease, there is wide diversity of
opinion: this is probably in part due to the fact that from the chronic
nature of the disease, which extends usually over a period of several
years, it is rare that the case remains from beginning to end under
care of the same observer. The symptoms are of three varieties--viz.
firstly, transient paralyses of the external muscles of the eye;
secondly, changes in the iris and ciliary body; and, thirdly,
affections of the optic nerve. The first-named symptoms are frequent in
the early stages of the disease. Sometimes they affect the external
muscles supplied by the third pair, and at others the rectus externus.
Their transient character and frequency, while admitted by all
observers, have as yet received no adequate explanation, it being
indeed difficult to see why transient affections of the motor nerves
should be so common in a disease which has its seat in the posterior
sensory columns of the spinal cord, and which presents such formidable
and irreparable lesions. The pupillary symptoms are, as a rule, those
of myosis, sometimes mydriasis, and at times the so-called
Argyll-Robertson {794} symptom (viz. a moderate myosis, with diminished
reaction to light, but prompt response to convergence and
accommodation). The last symptom is by no means present in all cases
and at all stages of the complaint; but where it exists there is a
remarkable resistance to the action of mydriatics. Trousseau was
probably the first to call attention to this state of affairs. The
writer has repeatedly seen cases where a strong solution of sulphate of
atropia failed to produce any more than one-third of the usual
dilatation produced by the same amount of the drug. Trousseau and
Duchenne have both observed that during attacks of violent pain the
pupils of ataxic patients will sometimes undergo temporary dilatation.
Atrophy of the optic nerve (either partial or complete) is a frequent,
and often an early, symptom of tabes dorsalis, and even may precede by
many years the development of spinal symptoms. Foerster relates a case
where complete optic atrophy preceded the development of all other
symptoms by a period of three years, he having seen a number of other
instances when atrophy preceded the other symptoms for a less period.
Charcot records a case where the interval was ten years, and states
that sooner or later locomotor ataxia develops in the majority of cases
of optic atrophy in his wards in the Salpêtrière. Gowers gives two
interesting cases, in one of which blindness came on fifteen years
before the development of the other symptoms, the interval in the
second being twenty years. Buzzard[277] also has recorded an
observation where blindness and lightning pains manifested themselves
fifteen years before the development of the other ataxic symptoms. If
we were to estimate the frequency of optic atrophy as a symptom of
early development of tabes dorsalis by the cases seen at ophthalmic
hospitals, we should probably much overrate its proportion, inasmuch as
those cases in which atrophy is a more marked and early symptom alone
resort to such places. Leber found that 13 (26 per cent.) out of 87
cases at his clinic had spinal symptoms, while Gowers gives 20 per
cent. as a relation existing between degeneration of the optic nerves
and tabes. The latter author thinks that the ratio should really be
stated as 15 per cent., because 5 per cent. was due to cases which had
been sent to him for examination by his colleagues. Nettleship
classifies 76 cases of optic atrophy as follows: 38 as presenting
undoubted symptoms of locomotor ataxia; 11 as showing mixed spinal and
cerebral symptoms (as in general paralysis of the insane); 9 with other
forms of spinal degeneration without brain lesions, these associated
with reflex iridoplegia without other symptoms of spinal or cerebral
disease; and 15 only in which there was no manifest disorder of other
parts of the nervous system. In the earlier stages of degeneration of
the optic nerve in tabes dorsalis the discs are usually of a dull
reddish-gray tint, and, while they are still capillary superficially,
their deeper layers next to the lamina cribrosa have a decidedly
diminished blood-circulation, and appear of a marked and more neutral
gray color. The surface of the discs often looks more or less fluffy,
there being enough haze of the retinal fibres to veil, and at times to
hide, the scleral ring. Later, the superficial capillarity disappears
and the discs assume a pallid, filled-in aspect, being surrounded by a
scleral ring which is everywhere too broad: at this stage the main
stems of the retinal arteries and veins exhibit no marked change in
calibre, but later on we find them {795} shrinking, and the surface of
the disc becomes excavated, the nerve itself often assuming a greenish
tint. The earlier stages of such degenerations often exist for a long
time, and are demonstrable by the ophthalmoscope before the sight is
sufficiently impaired to prevent the patient from executing any
ordinary work; this being dependent upon the facts that at first there
is only a concentric diminution of the field for form and colors, while
central vision remains for a long time unaffected. According to
Foerster, this contraction of the field commences at the outer part. In
advanced cases there are often irregular sector-like defects. This
state of affairs makes it probable that while the number of cases in
which total blindness precedes the development of tabetic symptoms is
probably rated much too high, from the natural gathering of such cases
at ophthalmic hospitals, yet, nevertheless, the frequency of incomplete
gray degeneration of the optic nerves in the early stages of the
complaint is probably, as a rule, much underrated.

[Footnote 277: _Brain_, ii. 1878, p. 168.]

Foerster has most justly called attention to the remarkable mental
cheerfulness of persons laboring under this malady, and states that he
has frequently seen cases where the patients would insist that they
were improving, while examination of the acuity and of the field of
vision showed steady failure of the eyesight. The writer's personal
experience has on several occasions substantiated this statement.
According to Cyon,[278] tabes presents three varieties: First, tabes
dorsalis. This variety commences with paralyses of the eye-muscles and
amblyopia. The pupils are not contracted. The amblyopia progresses.
Cramp-like disturbances of innervation are always present, with a want
of co-ordination of movements and anæsthesia of the upper extremities,
while mental disturbances are often demonstrable. Second, tabes
cervicalis. Myosis, with intense boring pains in the extremities and
impotence, are its chief characteristics. Ataxia is rare, and
disturbances of vision develop only late in the course of the disease.
Third, a class which he considers the true form of tabes dorsalis, in
which there are marked anæsthesia, formication, bladder and rectal
symptoms, associated with motor disturbances which often end in
paralysis. In such cases there are no eye symptoms except occasional
dilatation of the pupil. The same writer has collected 203 cases
reported by various authors, and gives the following tables as showing
the relative frequency of eye symptoms:

  Amblyopia . . . . . . . . . . . . . . . . . . . . . . . . 33 times.
  Paralysis of eye-muscles  . . . . . . . . . . . . . . . . 30   "
  Mydriasis . . . . . . . . . . . . . . . . . . . . . . . .  3   "
  Myosis  . . . . . . . . . . . . . . . . . . . . . . . . .  9   "
                                                            --
                                                            75

  Amaurosis with affections of eye-muscles  . . . . . . . . 16 times.
  Amaurosis with mydriasis  . . . . . . . . . . . . . . . .  8   "
      "      "   myosis . . . . . . . . . . . . . . . . . .  1   "
  Affections of the eye-muscles with mydriasis  . . . . . .  4   "
  Amaurosis with mydriasis and affection of the eye-muscles  2   "

He remarks[279] that the number of reported cases of mydriasis is
probably excessive, and says that dilatation has been improperly noted,
as, for instance, where one pupil is normal and the other contracted.
As regards the frequency of the Argyll-Robertson symptoms, Vincent[280]
found it {796} present in 40 cases out of 51, in which there were 7
cases of amaurosis with immobile pupils, 5 being marked exceptions to
the rule. Out of 51 cases of tabes, the same author found myosis in 27.
The statements of Vincent (as will be seen) differ materially from
those of Cyon. Erb[281] found that in 56 cases, there were only 7 in
which the optic nerves were affected (12½ per cent.), while in 17 there
were affections of the eye-muscles (30-3/10 per cent.). He considers
myosis a frequent symptom, but thinks that the stage at which it
develops is not yet determined. The anatomical cause of the want of
sensitiveness of the pupils to light, while they retain their movements
of convergence and accommodation, has not been well made out.
Vincent[282] attributes it to a paralysis of the excito-motor filaments
which supply the iris, and which he locates at the upper portion of the
spine; while Wernicke thinks it due to degeneration of the filaments
which go from the third pair to the optic nerve. Hughlings-Jackson[283]
tells us that the pupils which fail to react to light often act but
slightly with convergence, and in a note gives two cases of absolutely
immobile pupils where the accommodation was nearly normal for the age.
In fact, much remains to be accomplished in the study of the
innervation of the iris and ciliary muscle in tabes. The proportion of
cases in which cycloplegia occurs, and what relation it bears in point
of time and frequency to the presence of iridoplegia, are far from
being well made out. Jackson also insists that tabes does not
necessarily follow in all cases of long-standing optic atrophy. On a
basis of 72 cases Gowers says that some formal ophthalmoplegia interna
was present in 92 per cent. He groups these cases into three stages:
No. 1, where there is loss of knee-jerks, lightning pains, difficulty
of standing with toes out and heels together, there being a want of
ataxic gait; 2, where there is an ataxic gait, but the patient can
still walk by the aid of a stick; 3, where the patient cannot walk
without the assistance of another person. In 23 of his cases in the
first stage (84 per cent.) symptoms of palsy of some of the intraocular
muscles were found; in the second stage, 29 cases (93 per cent.); in
the third stage, 18 cases (100 per cent.). Erb has called attention to
the fact that reflex dilatation of the pupil from sharp stimulation of
the skin of the temple is usually absent where we have the
Argyll-Robertson pupil. Gowers admits that this is the rule, but has
seen several cases where, although there was no attempt at myosis on
exposure to light, yet there was marked dilatation on stimulating the
skin.

[Footnote 278: _Tabes Dorsalis_ Berlin, 1866, p. 43.]

[Footnote 279: _Loc. cit._, p. 71.]

[Footnote 280: _Thèse de Paris_, cited by Robin, p. 20.]

[Footnote 281: _Nagel's Jahresbericht der Ophthalmologie_, 1872, p.
150.]

[Footnote 282: _Thèse de Paris_.]

[Footnote 283: _Transactions of the Ophthalmological Society of the
United Kingdom_, vol. i. pp. 139-154.]


Unclassified Nerve Diseases.


DIABETES.[283]

[Footnote 283: This affection has been placed here for convenience of
classification, and because there is a form of the disease which is of
neurotic origin.]

DIABETES MELLITUS.--This disease, which affects so profoundly all
tissues of the body, necessarily manifests its influence on the tissues
of the eyes. It frequently impairs the nutrition of the vitreous and
causes the formation of cataract. The presence of grape-sugar is
readily detected in such lenses by chemical examination. Mitchell and
other {797} experimenters have produced cataract in frogs by placing
them in a solution of sugar. In such instances the lens tissue is said
to become transparent when the animal is removed from its sugar bath
and placed for a time in water; therefore, it is probable that the
cataract has been developed by the simple abstraction of water.
Diabetic cataracts are often extracted successfully, and the wound
usually heals well; but we occasionally have intraocular hemorrhage
during the course of healing. At times the nutrition of the patients is
so impaired that a slight accident is dangerous, such as happened in a
patient of the writer, where the striking of the hand against an iron
bedstead caused gangrene and death. Nettleship[285] has recorded an
analogous case, where accidental injury during convalescence caused
death from gangrene. At times marked retinitis and hemorrhages with
clear media have been encountered; thus, Jaeger in 1855 gave us an
admirable picture of such a case, in which there was retinal swelling
so great as to hide the outlines of the nerve, it being accompanied by
numerous hemorrhages and yellow splotches. In his description of the
case he also states that there was a marked central scotoma (a denser
inside of a lighter one) in the field, while the periphery of the
retina was so little affected that the patient could still decipher
large letters (No. 18 of Jaeger's test-types). We might perhaps think
that the scotomata are accidental and due to the location of the
retinal changes in the given case, but later researches seem to show
that we may have them in diabetes without retinal changes, Nettleship
and Edmunds describing two such cases. In one of these cases there
seems to be some doubt whether it was not a tobacco amblyopia which had
been developed in a diabetic subject; but in the other case there was
no such complication. The retinal changes which have been recorded in
some cases have much resembled those due to albuminuria, but these
alterations in the eye-ground have been seen in a number of cases where
no albumen in the urine could be obtained.

[Footnote 285: _Transactions of the Ophthalmological Society of the
United Kingdom_.]

Diabetes also may, by impairing the nutrition, diminish the power of
accommodation in the young and cause a rapid increase of presbyopia in
old persons (Graefe, Nagel, Foerster). Horner[286] proved that a
hypermetropia of 1/14 in a patient of fifty-five years of age rapidly
diminished to H. = 1/48, and the amount of presbyopia remained
unaltered, while the general health had improved and the quantity of
sugar had diminished. He attributes this rapid increase and subsequent
diminution of the hypermetropia to a change in the amount of the fluid
contents of the eye. Were this reporter any less careful an observer,
one might be inclined to suspect swelling of the lens; but he specially
mentions that there was no trace of cataract formation.

[Footnote 286: _Klin. Monatsbl. f. Augenheilkunde_, 1873, p. 490.]


EPILEPSY.

IDIOPATHIC EPILEPSY.--In idiopathic epilepsy--that is, in those cases
where no gross changes in the brain can be demonstrated by autopsy--the
eye symptoms are numerous and interesting. Wecker[287] tells us that at
the commencement of the spasm there is contraction of the pupils.
Usually, soon after the tonic spasm sets in or coincident with it, we
have marked dilatation of the pupil and an abolition of the
eye-reflexes, this {798} being shown by the want of contraction of the
orbicularis or of the pupil when the conjunctiva is touched. Reynolds,
Echeverria, Clouston, and Hammond have called attention to a
development of hippus (an alternate contraction and dilatation of the
pupil) at the end of the convulsive paroxysms; but this is exceptional.
The last author considers a state of alternate contraction and
dilatation of the pupils, or a contraction of one pupil with dilatation
of its fellow, to be characteristic of the convulsive stage. When the
convulsions are unilateral the head and eyes are often turned toward
the convulsed side. Although ophthalmoscopic examination is favored by
dilatation of the pupil, yet the convulsions make it so difficult that
we have quite conflicting accounts of the state of the disc and retina
during the paroxysm. Six cases have been accurately examined by Albutt
during the convulsion, in three of which there was congestion of the
disc, and pallor in the remainder. Jackson also reports cases of pallor
during the convulsion. More lately, Schreiber[288] has examined three
cases in which he found pallor in the convulsive stage, this being very
marked in one case, where the convulsion was violent. Gowers, on the
other hand, maintains that in convulsions which commence locally
without initial pallor of the face he was unable to perceive any
alteration of the calibre of an artery which he kept continuously in
view during the convulsion. The same author tells us that during the
stage of cyanosis the veins of the retina become distended and dark,
and that once in the status epilepticus he has seen a congestion of the
discs with oedema, which subsequently disappeared. He does not consider
that there is any abnormal appearance of the discs in the intervals
between the attacks, while both Albutt and Bouchut hold that they are
congested. In several of the chronic cases which the writer has had an
opportunity of examining there has been a low grade of atrophy of the
discs with concentric limitation of the field of vision. That this, at
least, is common in advanced cases is well shown by the observations of
Michel,[289] who in 1867 published careful examination of the
eye-ground, acuity, and field of vision of 58 epileptics. In 15 of
these cases there were no visible changes; in 10, hyperæmia; in 1,
hyperæmia with oedema; 1 of hyperæmia passing into atrophy; 10 of
unilateral atrophy (9 of the right nerve and 1 of the left); 13 cases
of atrophy of both optic nerves; the remaining cases showing changes in
the eye-ground which were probably attributable to other causes. Auræ
which affect the special senses have been recorded, and have been
usually described as flashes of light or balls of fire. Maisonneuve
(quoted by Robin) gives an instance where the auræ consisted in
convulsions of the eyelids. Gowers gives 119 cases of auræ which
affected the special senses, 84 of these being of the sense of sight.
He divides the latter into five classes: I. Sensation in the eyeball;
II. Diplopia; III. Apparent increase or diminution in the size of
objects; IV. Loss of eyesight; V. Distinct visual sensations,
consisting sometimes of flashes of light, colored spectra, and rarely
some more specialized sensation, such as an apparition. The only one of
these cases in which there was an autopsy appears to have been one of
symptomatic rather than idiopathic character, as there was found a
tumor of the occipital lobe which had extended as far forward as the
angular gyrus.

[Footnote 287: _G. u. S._, Bd. iv. p. 565.]

[Footnote 288: _Ueber Voränderungen des Augenhintergrundes, etc._, 1878
(S. 42).]

[Footnote 289: _Inaug. Diss._, von Dr. Julius Michel, Würzburg, 1867.]

{799} HYSTERO-EPILEPSY.--The remarkable co-ordinated convulsions which
are associated with hemianæsthesia, and which have been so minutely
described by Charcot as characteristic of this disease, are constantly
accompanied by subjective or objective disorders of the visual
apparatus. Visions of animals, such as rats, vipers, crows, cats, etc.,
frequently precede the convulsive seizure, followed by a transient loss
of sight; a return of the illusions (sometimes pleasant and gay, at
others erotic in their nature, or again sad or terror-striking) coming
on in a later stage. It is said that processions of animals are often
seen, which usually come and go on the hemianæsthetic side as the
attack passes off and the patient becomes quiet. The objective symptoms
have been carefully studied by Landolt in Charcot's wards. They were
found by him to consist in a diminution of the acuity of vision and a
concentric limitation of the field for form and color. All these
symptoms are bilateral, and much more marked on the anæsthetic side,
they occurring before any ophthalmoscopic changes are visible. These
are followed later by alterations in the eye-ground, which consist at
first of slight congestion and oedema of the discs, followed by partial
atrophy. The difference in the affection of the two eyes was so marked
that Charcot at first described it as a crossed amblyopia, but he
admits that the lesion is bilateral, as above described.[290]

[Footnote 290: _Leçons sur les Localisations dans les Mal. du Cerveau_,
vol. i. p. 119 (foot-note), Paris, 1876.]


EXOPHTHALMIC GOITRE.

GRAVE'S DISEASE; BASEDOW'S DISEASE.--The most prominent characteristics
of this affection are an irritability of the heart with increased
frequency of the pulse, and enlargement of the thyroid gland and a
swelling of the tissues of the orbit, which cause the eyeballs to
become prominent. The size of the goitre and the amount of protrusion
of the eyeball vary very much in different cases. Frequently there is a
symptom to which Graefe was the first to call attention--namely, a
disturbance of the usual consensual movements of the eyeball and upper
eyelid. When the patient looks downward below the horizontal line, the
lid no longer accompanies the eyeball in its motion, but halts in its
course. This derangement in the action of the lid is supposed to depend
upon some defect in the innervation of the orbicularis, as it is not
present in cases of equal prominence of the eyeball from other causes.
The amount of secretion from the tear-glands and from the conjunctival
surface is also at times much diminished. Owing to the prominence of
the eyes and the relaxation of the orbicularis, the fissure of the lids
is wider open than usual, and the eye has a peculiar stare. At times,
when the prominence of the eyes is very great, the lids fail to cover
the balls during sleep, and the cornea becomes inflamed and ulcerated
from exposure to air and dust. The disease rarely develops till after
puberty, and is more frequent in females than in males: in the former
it often develops after childbirth. It is so frequently accompanied by
disease of the reproductive organs that Foerster, in his paper on the
"Relation of Eye Diseases to General Disease,"[291] places it in the
section devoted to eye symptoms from diseases of the sexual organs.
Ophthalmoscopic examination usually shows a slight thickening of the
fibre-layer of the retina in and around the disc, with dilatation and
tortuosity of the veins--a state of affairs which may often {800} be
fairly attributed to venous stasis caused by the swelling tissues. In
addition to these symptoms there is sometimes, as Becker has pointed
out, a dilatation of the arteries, which may almost equal the veins in
calibre. At times there is an arterial pulse. As found by autopsies,
the anatomical changes are usually enlargement and dilatation of the
heart, hypertrophy and various degenerative changes in the thyroid
glands, and a state of hyperæmia at times associated with hypertrophy
of the fat tissue of both orbits.

[Footnote 291: _Graefe und Saemisch_, vol. vii. p. 97.]


Affections of the General System.

CHOLERA.--In this disease the eyelids are said to show an early
development of cyanosis, which becomes more marked as this symptom
develops in other parts of the body. The contents of the orbits shrink
and the eyes are drawn back in their sockets, there being an imperfect
closure of the lids, which leads at times to necrosis of the exposed
lower part of the cornea. There is a marked diminution in the secretion
of tears, and often a dilatation of the veins of the exposed part of
the conjunctiva bulbi, which are turgid with the black blood, this
state being at times accompanied by subconjunctival hemorrhages. The
pupils are usually contracted. The retinal arteries are much diminished
in size, and the veins although not dilated, are filled with blackish
blood. Owing to the great feebleness of the circulation, the slightest
pressure with the finger on the eyeball produces arterial pulse;
Graefe[292] in some cases describes a pulsating movement of interrupted
blood-columns in the veins, such as is sometimes seen in incomplete
embolism of the arteria centralis.

[Footnote 292: _A. f. O._, xii. 2, p. 210.]

RHEUMATISM AND GOUT.--In the older books on diseases of the eye we
constantly meet references to rheumatic and arthritic forms of
inflammation of that organ. In the later works on the subject the list
has been greatly reduced, partly because an anatomical classification
has been attempted, and partly because many such affections have been
attributed to other causes, such as syphilis, etc. Catarrho-rheumatic
ophthalmia, rheumatic iritis, rheumatic paralysis of the eye-muscles,
etc. have been so classified, not on account of their occurrence in the
course of attacks of acute rheumatism, but because the writers have
been unable to attribute them to any other source than that designated
as having taken cold. That recurrent attacks of iritis are frequent in
some individuals who have recurrent attacks of chronic inflammation of
the joints is a fact familiar to many practitioners, amply attested by
the cases published by Hutchinson[293] and by Foerster.[294] As regards
gout, the direct proofs of its relations to eye disease are still less
manifest, and most cases supposed to be attributed to this cause by
both the older and more modern writers are to be classed as primary or
secondary glaucoma.

[Footnote 293: "A Report on the Forms of Eye Disease which occur in
connection with Rheumatism and Gout," by Jonathan Hutchinson (_R. L. O.
H. Reps._, vol. vii. pp. 287-332; also vol. viii. pp. 191-216).]

[Footnote 294: "Beziehungen der Allgemein-Leiden, etc., zu
Veränderungen des Sehorgans," _Graefe u. Saemisch_, vol. vii. pp.
155-160.]

SYPHILIS.--All the tissues of the eyeball and eyelids may at times
manifest the signs of this dread and searching dyscrasia, although it
is {801} rarely so marked in its character as to be distinguished with
certainty from other forms of eye disease by its appearance alone.
Primary syphilis of the lid is rare, but when it occurs it is liable to
be mistaken for epithelioma, where there is absence of a distinct
history of infection. In the eyeball itself the uveal tract (iris,
ciliary body, and choroid) is the favorite seat of disease. Iritis is
said by Fournier[295] to be developed in from 3 to 4 per cent. of all
cases of syphilis, and, according to Coccius, 11-6/10 per cent. out of
7898 cases of eye disease in Leipzig were due to this cause. Syphilitic
iritis certainly constitutes a large proportion of the cases of
inflammation of the iris seen in hospital practice: Coccius places the
percentage at 46-6/10 per cent., while Wecker puts it at 50 to 60 per
cent. It usually develops during the subsidence of the secondary skin
affections, and is often to be distinguished by its insidious course
and the amount of plastic exudation which accompanies it. There is
ciliary injection and sluggishness of the pupil, with the formation of
synechiæ, before there is any very decided pain or photophobia, this
latter being usually strongly developed at a later period. The
formation of gummata in the iris, which are generally seen in the
smaller circle, is much rarer, generally developing in the tertiary
stage of the disease; occasionally they are developed in the ciliary
body. In the former situation they usually disappear under active
treatment, leaving fair vision in the eye, but when situated in the
latter place they usually lead to shrinking and atrophy of the eyeball,
even under the most vigorous treatment. When iritis occurs in infants
it is generally specific in origin. When they are born with posterior
synechiæ and complicate cataract, similar occurrences during
intra-uterine life may be suspected. Syphilitic choroiditis is
frequent, but its frequency is probably overrated on account of a
disposition to assume syphilis as a cause of cases of choroiditis in
which the pathology is not evident. Foerster has very properly pointed
out that a majority of the cases of disseminate choroiditis are not due
to this cause, and that the changes are developed slowly, and remain
stable for a long time even when not treated; while the usual form of
specific choroiditis shows rapid progress, with failure of the sight,
photopsies, vitreous opacities, hemeralopia, and zonular defects in the
field of vision. Opinion, however, is divided on this point: Wecker
thinks that two-thirds of the cases of disseminate choroiditis are due
to syphilis. In many of the chronic cases of syphilitic choroiditis
there is a wandering of the pigment out of the cells of the choroidal
epithelium, and a distribution of it into the lymph-sheaths of the
retinal vessels and capillaries, these changes producing
ophthalmoscopic appearances which closely resemble those of typical
pigmentary degeneration of the retina. Affections of the head of the
optic nerve and superficial layers of the retina, such as are
represented by Liebreich,[296] are much more rare, but the writer has
repeatedly seen them both at Liebreich's Paris clinic and in our own
hospitals. They are characteristic, and usually accompany the tertiary
symptoms. There is a dense haze which seems to lie partly in front of
the retina, and to extend around the disc for a space of one and a half
to two disc-diameters, generally including the macula lutea, and
rapidly diminishing as it approaches the equator. Vision is usually
much reduced, and even under persistent {802} antisyphilitic treatment
it is slow to clear up. Hereditary syphilis frequently manifests itself
in an interstitial keratitis, which begins with small
irregularly-rounded dots near the centre of the cornea. They gradually
become more numerous, and coalesce, until the membrane appears as if a
thin layer of ground glass had been imbedded in its tissue, leaving the
epithelium clear and bright. Although there is no ulceration, yet there
is a great tendency to the formation of new blood-vessels, which often
goes on until the entire cornea is permeated by them and becomes of a
dull venous blood-like red color. These vessels are continuous with
superficial and deeper shoots which pass in from the two layers,
normally forming loops in the corneal periphery. This form of keratitis
is usually accompanied by marked photophobia, pain, ciliary injection,
and low grades of iritis. The pathological processes which take place
in the cornea during the disease generally leave it more or less
clouded, and often much misshapen by softening and alteration of its
curvature.

[Footnote 295: Quoted by Foerster, _Graefe und Saemisch_, vol. vii. p.
189.]

[Footnote 296: Plate 10, Fig. 2, ed. 1863.]

TUBERCULOSIS.--Except in children, the eyeball is rarely the seat of a
deposit of tubercles, and even then it is much more likely to give
evidence of their seat in the membranes of the brain by its secondary
affection than to be itself directly affected by them. When they form
in the eye, they may affect the choroid, the intraocular end of the
optic nerve, the retina, or the iris. Jaeger was the first to call
attention to their ophthalmoscopic appearances. Their favorite seat, as
is well shown in one of Jaeger's plates, is the macular region and its
vicinity. They develop in the stroma of the choroid, and appear as
whitish-yellow spots varying from one-eighth the diameter of the optic
disc to the size of the disc itself, and by aggregation may form even
larger masses. They are usually seen in cases of well-marked acute
miliary tuberculosis, although doubtless they are often overlooked, on
account of not giving rise to any symptoms; besides, thorough
ophthalmoscopic examination of such sick and restless children is
difficult, and the general diagnosis is usually well made out from
other symptoms. They may, however, precede all other symptoms, as in
the cases reported by Steffen[297] and Fraenkel.[298] Development of
tubercular masses in the intraocular end of the opticus has been
described by Chiari,[299] Michel,[300] and Gowers.[301] In the case
cited by the last author the growth extended from the disc to the ora
serrata, which during life gave rise to the peculiar reflection from
the eye so often seen in intraocular tumor. According to Cohnheim,[302]
tubercle is to be found in the choroid in all cases of acute miliary
tuberculosis. Other observers, however, have not been able to support
him in this assertion: Albutt,[303] who repeatedly searched for them
both in living and dead subjects, failed to find them; Garlick[304]
during two years' experience at a children's hospital found them but
once; Heinzel[305] in ten cases of general tuberculosis in children was
at the autopsies unable to find any tubercles of the choroid. According
to Stricker, they may at times develop very rapidly, coming on in from
twelve to twenty-four hours. Tubercles have been {803} found in the
retina in the cases of papillary tuberculosis already referred to, and
also with cases of tubercle in the iris (Perls, Manfredi). At times,
tubercles in the iris occur in scrofulous and feeble children,
appearing as growths in all respects closely resembling syphilitic
gummata. As in the latter case, they are accompanied by severe iritis,
and at times with hypopyon. Tuberculosis of the conjunctiva is a very
rare affection. It is described as commencing with swelling of the
lids, and when these are everted exuberant granulations of the
conjunctiva are seen which are most frequently situated in the
retrotarsal folds. These granulations are at first of a grayish-red
color, but when they have existed for some time, superficial erosion of
their surface occurs, and uneven yellowish-red ulcers are formed. The
disease usually occurs in young people, and generally affects but one
eye. Haab[306] has given a description of six cases of it, with
reference to a few instances described by other authors.

[Footnote 297: _Jahresbericht f. Kinderheilkunde_, 1870 (Gowers).]

[Footnote 298: _Berliner klinisches Wochenschrift_, 1872, pp. 4-6
(Foerster).]

[Footnote 299: _Wien. Med. Jahrbucher_, 1877, p. 559.]

[Footnote 300: _Archiv der Heilkunde_, 1873.]

[Footnote 301: _Medical Ophthalmoscopy_, 1879, p. 250.]

[Footnote 302: _Virch. Arch._, 1867, Bd. xxxix. p. 49 (Foerster).]

[Footnote 303: Quoted by Gowers, p. 203.]

[Footnote 304: Quoted by Gowers, _Med. Ophth._, p. 200.]

[Footnote 305: Quoted by Foerster, p. 99, _Jahrbuch der
Kinderheilkunde_, Neue Folge, viii., 3, p. 331.]

[Footnote 306: "Die Tuberculose des Auges," _A. f. O._, xxv., 4, p.
163.]


Toxic Amblyopiæ.

TOBACCO AND ALCOHOL.--These two lesions strongly resemble each other,
and it is impossible to differentiate them when we find them in persons
who are addicted to the abuse of both of these drugs; consequently, for
a time, in Germany, there was a disposition to underrate the potent
destructive agency of the latter drug, but every practitioner of
experience in eye disease must have seen cases of tobacco amblyopia in
which there has been no abuse of alcohol. The best proof of the
deleterious influences of tobacco on the eyesight is the improvement
which results by simple abstinence from its use where the vision has
been seriously affected by its influence. In the earlier stages of both
forms of amblyopia there is a contracted pupil and a slight dimness of
vision, the patients claiming that they see better in feeble light and
twilight. The ophthalmoscope shows a slight oedema of the disc with
tortuosity of the veins, the rest of the eye-ground appearing normal.
Later, the usual appearances of blue-gray atrophy set in. In the
earlier stage there are often color scotomata, which are usually ovoid
in form and lie between the disc and the macula lutea. Unless carefully
looked for with color squares of one to two millimeters in diameter,
they are apt to be overlooked. Later, there is a marked reduction of
central vision. When the atrophy has progressed farther, there is
decided contraction of the field.

LEAD-POISONING.--The deleterious effects of lead on the eyesight are
undoubted, although rare in proportion to the cases of colic and
wrist-drop produced by this metal. When amaurosis develops, it is
usually either in acute lead-poisoning or after a gradual saturation of
the system, as is shown by repeated attacks of lead colic. In either
case the amaurosis is usually accompanied by dilatation of the pupils,
delirium, and convulsions. The amaurosis generally passes off, and the
pupils contract with the return of vision, although it may remain
permanent, and leaves the patient with atrophic nerves, as in a case
observed by Trousseau, where the patient was subsequently transferred
to the Salpêtrière. The only two cases which the writer has had an
opportunity of witnessing showed {804} marked choking of the discs and
severe cerebral symptoms. One of these cases died and one recovered:
both were results of the use of white lead as a cosmetic. Rognetta[307]
quotes Vater as reporting a case of hemianopia produced by
lead-poisoning, which recovered when the lead colic was cured.
Trousseau[308] quotes Andral as giving a case of diplopia due to the
same cause, and disappearing as the patient recovered.

[Footnote 307: _Recherches sur la Cause et la Siège d'Amaurose_.]

[Footnote 308: _Thèse de Concours_.]

QUININE.--Over-doses of quinine seriously impair the eyesight, and in
some cases have produced temporary but absolute blindness. The usual
symptoms are a deterioration of central vision and a contraction of the
field. The ophthalmoscopic examination reveals a pallid disc with
marked diminution in the size of the retinal arteries and veins. In
many of the reported cases it is difficult to decide positively how
much of the amaurosis is due to the quinine and how much to the disease
for which the patient is under treatment. This is especially true where
the patient has been suffering from severe intermittent fever or from
exhausting hemorrhages complicating uterine disease, which are well
known frequently to produce more or less complete atrophy, with
shrinking of the vessels. There are, however, a sufficient number of
well-observed cases on record to satisfactorily establish the lesion.
One of the most striking is a case of poisoning recorded by Giacomini,
where the patient took at one dose three drachms of sulphate of quinia
by mistake for cream of tartar. This was followed by severe headache,
pain in the stomach, dizziness, unconsciousness, with slow and scarcely
perceptible pulse and infrequent respiration. The pupils were widely
dilated. On regaining consciousness the patient found that he was
almost blind, the weakness of sight lasting a long time. As the
poisoning occurred in the preophthalmoscopic era, there is of course no
description of the eye-ground. In all recorded cases, while central
vision has been either partially or entirely regained, the field of
vision has remained permanently contracted.

SANTONIN.--In very large doses santonin produces dilatation of the
pupil, amblyopia, and complete color-blindness. Smaller doses produce a
shortening of the violet end of the spectrum and cause yellow vision.
The disturbance of vision usually lasts only a few hours. The poison
seems to be eliminated by the urine, as the sight is said to become
normal while traces of the drug can still be seen in the secretion of
the kidneys. Rose has given us a most careful study of this subject in
his papers entitled "Color-Blindness from Santonin"[309] and
"Hallucinations in Santonin Intoxication."[310]

[Footnote 309: _Virch. Arch._, Bd. xx., 1860 (Separat Abdruck, S. 48).]

[Footnote 310: _Ibid._, Bd. xxviii., 1863 (Separat Abdruck, S. 12).]

SALICYLATE OF SODIUM.--Gatti[311] reports a case of transient
amblyopia, due to the ingestion of one hundred and twenty grains of
salicylate of sodium, in a sixteen-year-old peasant-girl who had acute
articular rheumatism. There were no changes in the eye-ground except a
fulness of the veins, which persisted after the eyesight had returned.
There was mydriasis. No phosphenes could be produced. As the urine did
not present any traces of salicylate of sodium, it would seem to show
that it was not eliminated by the usual emunctories.

[Footnote 311: _Gaz. d. Ospital Milano_, p. 129, 1880; _Nagel's
Jahresbericht_, 1882 (Lit. 1880), p. 245.]




{805}

MEDICAL OTOLOGY.


{806}


{807}

MEDICAL OTOLOGY.

BY GEORGE STRAWBRIDGE, M.D.


In this article on Medical Otology it is proposed to include those
diseases of the ear that are frequently seen by the general
practitioner, and especially those that exist as sequelæ to some
general disease, and where the ear complication would be treated in
connection with the general disorder.


Examination of a Patient.

As nearly all ear patients are afflicted with varying degrees of
deafness, one of the first points of inquiry will be as to their
hearing power. There are three tests commonly employed for this
purpose: the ticking of a watch, the human voice, and the tuning-fork.

1st. The Watch.--By this method of examination the patient is placed
with closed eyelids, so as to exclude the visual power as a factor in
the examination, as it is a curious fact that many people are
apparently unable to distinguish between seeing a watch and hearing its
tick, and therefore so long as they can see the watch they will imagine
that they can hear it ticking. Bring the watch (held by the physician)
from a distance toward the patient until the tick is heard, and note
the distance in inches. The plan of holding the watch close to the ear,
and then slowly removing it until the extreme limit of hearing is
attained, gives an incorrect result as regards the distance that the
watch can be heard, due to the fact that the impressions produced on
the terminal endings of the auditory nerve by the watch-tick continue a
sensible time after the watch-tick has passed out of the nerve-limit,
and therefore the watch-tick can still be noted. Prout has prepared a
convenient method for recording the hearing power. Note the number of
inches that the watch-tick can be heard by a normal ear, and let this
serve as a denominator of a fraction, the numerator of which is the
number of inches that the same watch-tick can be heard by the ear of
the person under examination. For instance: a normal ear can
distinguish my watch-tick at a distance of twenty inches; if, now, the
patient's ear can perceive the same sound at only five inches, the
hearing power would be noted as 5/20. By this it is not meant that the
hearing power is one-fourth of normal hearing, as it would be only
one-sixteenth of normal hearing, as the volume of sound is inversely in
proportion to the square of the distance.

2d. The human voice tells more about the hearing power for practical
purposes than does the watch. There are many persons who can readily
{808} hear the watch-tick at several inches, and yet who hear very
imperfectly ordinary conversation, and also many who hear very well the
human voice and very badly the watch-tick. The method of examination is
to speak ordinary words in a tone that can be heard by the average ear
a given number of feet, and to note the distance in feet that the ear
under observation can detect the words that are spoken. In this way can
be noted the hearing power of the human voice, the numerator of the
fraction being the distance that the word can be heard by the observed
ear, the denominator being the distance that the word can be
distinguished by the normal ear.

The patient should always be examined with closed eyelids, as deaf
people quickly learn by watching the movements of the lips of the
speaker to know the words that are being spoken. Another precaution is
to have the ear to be tested directly opposite the mouth of the
observer, the other ear being firmly closed.

3d. The Tuning-Fork.--Bone-conduction of sound is used by this method.
The great use of the tuning-fork is in determining diseased conditions
of the auditory nerve and internal ear, and it enables one to make a
differential diagnosis as to whether deafness is due to a diseased
condition of the sound-conducting apparatus or whether the nerve
portion of the ear is at fault. For instance: a patient complains of
deafness. This may be due to some obstruction in the external auditory
canal, such as impacted cerumen, or it may be due to a diseased middle
ear, with thickening of its membranes, or it may be due to a diseased
internal ear. The watch and human voice would only show the ear to be
defective in its hearing power, and it may be from any of the
above-mentioned causes. The tuning-fork, in vibration, placed on an
incisor tooth or on the frontal bone, would bring out the fact that if
the deafness was due to a diseased middle ear or obstruction in the
external auditory canal, the tuning-fork would be heard best by the
defective ear; but if due to a disease of the internal ear, it would be
heard the least distinctly by the defective-hearing ear. Mack explains
this by the supposition that the sound-waves are prevented from freely
escaping through the sound-conducting apparatus, and are reflected back
on the auditory nerve-elements, and thus make a double impression.
Tuning-forks having the note C are best adapted for this examination.

EXAMINATION OF THE EXTERNAL CANAL AND TYMPANIC MEMBRANE.--This can be
done by direct or by reflected light, better by the latter. A mirror
and speculum are needed. The mirror should be concave, with a focal
distance of from 5"-7" and a diameter of 2½"-3", with a
ball-and-socket-joint and head-band, so as to allow of the two hands
being free, the head holding the mirror in the required position. The
mirror should have a central perforation of 2'''-3''', with a brass
back, rendering it less liable to break. As a light-source can be used
the light from an argand burner, but preferably sunlight reflected from
a cloud or white wall.

The Ear Speculum.--The Wilde or Gruber speculum answers equally well.
The Wilde speculum is cone-shaped, and best of German silver: it is
easily cleansed and has four sizes. The Gruber speculum has a larger
mouth and gives a large visual field. It has a parabolic curve, for the
purpose of admitting more light; there are also four sizes. The {809}
speculum should be warm when in use, and is to be held in position in
the canal by the thumb and forefinger of the left hand. Often in the
examination of an external canal an angular-toothed forceps is needed
to remove foreign substances.

The cotton-holder is a most important instrument, furnishing a means of
thoroughly drying the external canal of any fluid with the least
possible amount of irritation--much less than that caused by the use of
the ear-syringe. It is a slender steel rod 6" long, having a number of
serrations at one end to more easily allow cotton to be wrapped around
it; the other end has a convenient handle. In using this instrument a
small tuft of well-cleansed cotton is wrapped around the holder, so
that one half of the length of the cotton tuft projects beyond the end
of the instrument. By slight adaptation with the fingers the cotton
roll can be made soft or quite firm, and large or small in proportion
to the amount of cotton used. The cotton-holder should always be used
under the light from the head-mirror.

The curette is of the same length as the cotton-holder, but is made of
heavier steel, and terminates at one end in a small ring of a diameter
of from 2-3 mm. It is useful in removing scabs, etc. from the external
canal, also in loosening impacted cerumen.

Probes are also needful. A good middle-ear probe is made of a single
piece of silver, of the same length as the cotton-holder, and tapering
down to a slender shank with a small knob-like ending.

The ear syringe, a most excellent instrument, is now made of rubber,
holding two ounces of fluid, and has a bulbar extremity, so as to avoid
injuring the external canal or tympanic membrane. The syringe has a
finger-rest, with the piston ending in a ring, so as to admit of its
use with one hand. In using a syringe warm water should be always
employed, and at a temperature that the finger would indicate as being
quite warm. Also at first force the water very gently into the meatus,
so that the patient shall not be startled; also it is well to bear in
mind that many patients become very giddy under its use, necessitating
either very gentle use or its being abandoned for the time.

EXAMINATION OF THE EUSTACHIAN TUBE.--The main point is as to whether
the tube permits the free passage of air up to the middle ear. This can
be ascertained by three methods: 1. Valsalva's method; 2. Politzer's
method; 3. Catheterization of the tube.

Valsalva's method consists in forcing air through the tube by a forced
expiration, the mouth and nasal passages being at the same time firmly
closed. The patient can distinctly feel the air pressing against the
tympanic membrane, causing it to bulge outwardly, provided the tube is
open. This proceeding has certain disadvantages, sometimes causing head
congestions and giddiness.

Politzer's Method.--In this proceeding a gum air-bag is used as the
means of forcing air into the tube. In the act of swallowing the soft
palate is drawn against the posterior wall of the pharynx, and at the
same time the pharyngeal mouth of the tube is well opened, so that air
forced through the nasal passages at such a moment, being prevented
from passing downward by the up-drawn palate, is forced up through the
Eustachian tube into the middle ear. The success of this procedure
depends entirely upon the inflation being made at the same moment that
{810} the soft palate is drawn up against the pharyngeal wall;
otherwise the air would naturally pass by the widest passage, in this
case downward into the stomach. The usual plan of inflating at the
moment that the patient is told to swallow fails, from the fact that
patients differ so materially in the quickness with which they respond
to an order. Many in their anxiety will swallow before the word is
given, others will allow an appreciable time to pass before swallowing,
so that the inflation will fail. For this reason I have adopted the
following plan: It is well known that in the act of swallowing the
larynx is drawn forcibly upward, and also that the moment of the
extreme elevation is nearly coincident with the moment that the soft
palate is drawn against the wall of the pharynx. The prominence of the
thyroid cartilage (the so-called pomus Adami) enables one to easily
watch until the maximum elevation of the larynx is reached, and then
quickly, by a forcible contraction of the air-bag, to thoroughly
inflate the middle ear. The Politzer method so thoroughly accomplishes
the object, and with the least possible irritation, that the use of the
catheter in the majority of cases is no longer indicated. The method of
Politzer is as follows: The patient takes some water in the mouth; the
air-bag has attached to it a short piece of gum tubing ending in a
nose-piece in shape like an olive, or sometimes a small gum catheter is
attached to it. This is placed in the lower nasal passage and the nose
held firmly closed over it with one hand, the second hand grasping the
air-bag. The patient is then told to swallow, so as to cause elevation
of the soft palate (this can also be accomplished by the patient
speaking quickly some word like _hoc_), and the air-bag is forcibly
pressed. In this way the air is quickly driven, viâ the nasal passage
and Eustachian tube, into the middle ear. In little children it is
sufficient to quickly inflate, as the crying of the child elevates the
soft palate to a certain degree, and so cuts off the downward passage
into the stomach.


External Ear Diseases of the Auricle.

ECZEMA.--This disease occurs very frequently in infants during
dentition, where irritation of the dental branches of the fifth pair of
nerves causes irritation in other branches of the same nerve, including
those distributed to the skin of the face and auricle, causing acute
attacks of the disease. It is also frequently observed that successive
teeth penetrating the periosteum will cause fresh attacks of this skin
irritation, so that as long as the teething process continues, so long
is the eczema apt to continue, and treatment will probably prove only
palliative. Eczema occurs also in both the male and female approaching
the period of adolescence, a time when other forms of skin disease are
especially common.

The aged do not escape this annoying malady, where it is apt to occur
in the chronic form, and is due to want of nerve-force in the skin
branches of the nerves distributed to this part--a wise provision of
nature allowing nerve-power to fail first in the nerves distributed to
parts where the harm done is a minimum one, rather than in the
nerve-centres, where disease fatal to life would result. The treatment
in this class of cases would be radically different from the preceding
divisions, where nerve-irritation is the cause.

{811} DIAGNOSIS.--The acute form shows the same diagnostic appearance
as does eczema occurring elsewhere--the same redness and swelling of
skin, followed by the vesicular eruption with serous oozing and loss of
epithelium. In the chronic variety there is marked thickening of the
skin, and the auricle is often covered with crusts, but here and there
a deep fissure in the skin, from some one of which pus will exude.

Marked itching and burning and a sensation of fulness occur, both in
the acute and chronic forms.

COURSE.--The acute variety may last only a few days, but as a rule
tends to recur at frequent intervals. The chronic variety can last
almost any length of time, and will often prove to be most obstinate.

TREATMENT.--Acute Variety.--The first indication is to relieve the
burning and itching. This is often best done by the use of some mild
anodyne powder which protects the part from the air and tends to
relieve the existing skin irritation. Finely-powdered starch dusted
over the part is a good remedy. One of the best anodyne powders is that
of McCall Anderson:

  Rx. Pulv. camphoræ,   drachm iss;
      Pulv. zinci oxid. ounce ss;
      Pulv. amyli,      ounce j.

To be dusted over the inflamed surface.

Often there will be difficulty in preventing the powder from falling
off. When this is the case a very thin coating of the skin with the
oxide-of-zinc ointment furnishes an excellent ground for the powder to
adhere to. The oxide-of-zinc ointment alone is also an excellent
application.

In the chronic variety a more stimulating application is needful, and
some preparation of tar will prove valuable, such as--

  Rx. Ungt. picis liquidæ, drachm j-drachm iij;
      Ungt. zinci oxid.    ounce j.

The crusts that collect on the auricle are best removed by a poultice
of bread and milk, or a cotton pad moistened with olive oil can be
bound over it for a few hours, and will serve to cleanse the part. In
the very chronic cases, where points of suppuration are found, a
caustic application like nitrate of silver is needed. Careful
regulation of the diet and habits of the patient is indicated; an
outdoor life, abstinence from alcohol and tobacco, nutritious food,
will greatly aid. Iron, quinine, cod-liver oil can be used frequently
with good results, while in teething children incising of the gums will
sometimes give temporary relief.


Diseases of the External Auditory Canal.

IMPACTED CERUMEN.--This disease occurs very frequently, and, as a rule,
is considered a matter of very little moment by the profession at
large, whereas, in fact, it is often a symptom of grave disorders of
the middle ear. Roosa mentions that in 1448 cases observed by him in
private practice, only 101 were cases of inspissated cerumen alone, the
great majority showing in addition serious disorders of other parts of
the organ of hearing. The ceruminous glands are found chiefly in the
cartilaginous portion of the external canal, and, according to Kessel,
resemble the sweat-glands not only in the time and manner of their
development, {812} but also in their external form and minute
histology. This is also true of the contents of the ceruminous glands,
as far as the microscope allows us to judge, the only difference being
that in cerumen masses of very fine corpuscles of coloring matter are
found.[1] The ceruminous glands secrete but slowly, and the cerumen
tends to harden and become dark in color as it grows older. The removal
of the secretion is probably effected by several factors. Numerous
experiments prove that the epithelial lining of the external canal has
a constant motion from within outward; necessarily any substance
resting on it will move with it. Cerumen could in this way be
constantly extruded from the external canal; and the cerumen, becoming
dry and hard by exposure to the air, would tend to separate from the
skin by curling itself into small rolls, and so drop out from the
external meatus. The question naturally arises, Why does the cerumen
form such impacted masses as are met with? We submit the following
explanation:

In many of these cases the secretion is largely above the normal, and
catarrh of the naso-pharynx is found associated with it. Pomeroy first
noticed this connection, and suggested the probability that the
ceruminous function is greatly affected in catarrhal disease, on the
theory that the earlier stages of catarrh would result in hyperæmia,
and consequently augmented function, of the ceruminous glands, which if
continued may result in atrophy with abolition of function, precisely
as results in inflammation of the mucous membrane lining the fauces.[2]

[Footnote 1: Vide Stricher, _Textbook_, p. 951.]

[Footnote 2: _American Otological Soc. Trans._, 1872.]

The pneumogastric nerve by its pharyngeal branch is connected with the
pharynx, and by its auricular branch with the external auditory canal,
so that irritation of the pharyngeal branches of the nerve, as would
occur in pharyngeal catarrh, could readily excite reflex irritation in
the auricular branch, with increase of function of the parts to which
it is distributed, causing increase of the ceruminous secretion.
Conversely, atrophy of the nerve would be followed by atrophy of
function of correlated parts. The external canal often presents a sharp
angle in its course near the meatus, and this also would tend to cause
an accumulation of cerumen.

It is a well-established clinical fact that the great majority of cases
of impacted cerumen are found to be associated with serious diseased
conditions of the middle ear especially, and probably the diseased
middle ear is often an important factor in causing impaction to take
place; so that it frequently happens that the patient will experience
no increase of hearing after removal of such an impacted mass, owing to
the diseased middle ear that may be present. I remember one case where
the hearing was absolutely lessened after removal of a ceruminous plug;
doubtless in this case the solid conduction through such a mass was
better than through an air-filled auditory canal.

SYMPTOMS.--Sudden loss of hearing: this is due to the fact that the
mass grows slowly from the periphery toward the centre, and as long as
a small central opening remains the hearing power will remain good.
Some sudden jolt or misstep, or some quick-acting force, will cause
occlusion of this narrow passage, with consequent sudden loss of
hearing. The tuning-fork, placed on the incisor teeth, will be best
heard on the affected side by reason of vibrations being impeded by the
mass in their passage through the external canal.

{813} Tinnitus aurium and vertigo are often present, both being due to
the mass pressing inward the tympanic membrane, with consequent
increase of pressure on the labyrinthine fluid by the chain of small
bones pressing on the membrane of the foramen ovale. These symptoms are
sometimes alarming to the patient, as in his judgment indicative of
serious brain lesion.

DIAGNOSIS.--Examination of the external canal with the speculum and
reflected light reveals a dark amber-colored mass lying in the external
canal, which can be very hard, the result of exposure to the air for a
length of time, as well as the union with it of epithelial débris of
the skin of the canal; or it may be soft, like syrup, in its
consistence.

The PROGNOSIS is to be guarded until the condition of the middle ear is
known.

TREATMENT.--If the mass is hard in its character, its removal is best
effected by the forceps or curette or blunt hook, it being understood
that the external canal is well illuminated, so that the course of the
instrument can be carefully watched. The curette or blunt hook will
loosen the attachments of the mass to the sides of the canal, and then
it can be readily removed by the forceps, care being taken not to
injure the tympanic membrane. In such a way a hard plug can be removed
at one sitting that otherwise would require repeated efforts to
accomplish the same purpose.

If these instruments are not at hand, the next best method is to effect
the removal with the syringe and warm water. A caution is to be given
in the use of the syringe. There are a great number of people who are
not able to have the external ear syringed, even though gently, without
becoming giddy, and if the syringing is then continued the vertigo will
end in a fainting attack. My rule is to caution the patient of the
above fact, and always promptly stop at the first symptom of vertigo.
Sometimes a short rest will allow the operator to proceed, but often it
is necessary to postpone any further attempt at removal until a
succeeding day. Always use quite warm water. If in a fair trial with
the syringe it is found that the mass does not soften and break up, it
is better to make an application of olive oil to it, and at a
subsequent time repeat the attempt at removal. Soft masses of cerumen
are best removed by the use of warm water and the syringe.

In some few cases inflammation of the external auditory canal will
complicate the treatment, and the question will come up as to whether
it is best under such circumstances to attempt the removal of the
impacted mass. As a rule, the removal of the mass is the best means of
combating such an inflammation, and therefore an attempt at removal
should be made unless the inflammation is very acute, when treatment of
this complication would be in order, and the removal of the plug
deferred for the moment. In all cases the condition of the middle ear
and hard pharynx should be noted after the removal of the impacted
mass, and these parts often will need treatment.


Furuncle of External Auditory Canal (Acute Circumscribed Inflammation).

ETIOLOGY AND PATHOLOGY.--In a great number of cases furuncle is to be
regarded as an evidence of general bodily debility. For example, {814}
in the richer classes it is often a result of over-dissipation, while
in the poorer classes insufficient food, bad clothing, and such like
are important factors. Local irritations of the external canal may
cause the disease, such as rubbing the canal with a hairpin or
toothpick to relieve itching. The use of alum and nitrate-of-silver
washes in the canal will cause a furuncle in some cases. Furuncle
occurs in the outer third of the canal as a rule, and often develops
around a ceruminous gland, and will generally be followed by a number
of others.

SYMPTOMS.--Pain is the most marked one--in the beginning of the attack
of an intermittent character, with a tendency to increase toward and in
the night; but as the attack advances pain becomes more marked, and may
extend over the entire temporal region well down into the neck. The jaw
movement also becomes very painful. The furuncle will rupture at any
time, from the third day up to the tenth day, according to its
location. The more deeply seated it is, the slower will be its progress
toward maturity. The pain quickly disappears after the rupture, and
then a short interval of rest is followed too often by the recurrence
of the same disease. A varying degree of deafness is usually present,
due to partial closure of the canal by the swollen soft tissues, and
also it may be in rare cases through involvement of the tympanic cavity
in the inflammation. Fever is often present. The great objective
symptom will be the circumscribed swelling found in the cartilaginous
portion of the canal and often along its anterior wall, and will show
great increase of pain by but slight pressure. The swelling as it
matures becomes more circumscribed, and will end in a pus collection
and subsequent rupture.

DIAGNOSIS.--The disease most likely to be confounded with it would be
an acute middle-ear inflammation, with involvement of the periosteum of
the osseous part of the canal; but the history of the case would clear
up this point.

The PROGNOSIS is favorable as to hearing, but with great probability of
successive crops of the same disease.

TREATMENT.--The local application of heat and moisture is a remedy of
great value, and a good method of application is to bend the head into
a horizontal position, as by resting the side of the head on a table,
and then fill up the external canal with water as warm as the ear will
allow without causing pain; then quickly place over the auricle towels
that have been dipped in very warm water and wrung dry by being twisted
in a second towel, and over this a large pad of warm flannel or some
similar covering. The heat and moisture will be retained for quite a
time, and then the procedure can be repeated until relief from pain is
obtained. In the interval the auricle is to be covered with a pad of
cotton. A steam atomizer furnishes a convenient way of applying heat
and moisture. Dry heat is sometimes preferred: a flannel bag filled
with bran or hops and well warmed in a hot oven would carry out this
indication; also a hop pillow moistened by hot whiskey is a good
application.

An application of leeches affords great relief from pain. The best
point to place a leech (which should be a Swedish leech) is just in
front of the tragus. Two or three leeches can be applied at this place,
and by encouraging the after-bleeding by warm applications any desired
amount of blood can be taken. The after-bleeding can be readily
controlled by the use of styptic cotton.

{815} Incision of the Furuncle.--It is a mooted question as to whether
an incision is capable of giving relief, and when it should be done. My
own experience has been that the application of a leech has given
greater relief than the use of a knife in those cases when the furuncle
has been deep seated. Later on, when the swelling has become
circumscribed and shows evidence of pus, the incision is clearly
indicated.

General treatment is to be of a tonic character, and during the acute
stage, when the pain is severe, anodynes are indicated.


Foreign Bodies in the External Auditory Canal.

1. VEGETABLE PARASITES.--Aspergillus flavescens and Aspergillus
nigricans are found on the inner part of the canal and over the
external surface of the tympanic membrane. This growth largely depends
for its development upon a diseased condition of the epithelial layer
of the skin lining the external canal, such as is found in cases of
chronic middle-ear suppuration and in eczema of the skin of the
external canal, by furnishing a moist nidus for its development.

SYMPTOMS.--Intense itching in the external canal, with a sense of
fulness; also sometimes pain, with tinnitus and difficulty of hearing.
The growth is found in the inner part of the canal, or over the surface
of the tympanic membrane in the form of yellow or black flakes
according to the variety. It may be found in spots or may form a
complete covering to the canal-walls, so that when removed it forms a
mould of the canal, leaving a raw skin surface, on which the growth
rapidly reproduces itself. The disease is found in an acute and a
chronic form, and in a few days can attain full development; also there
exists a marked tendency to relapse as long as any portion remains
undestroyed.

PROGNOSIS.--Favorable.

TREATMENT.--The main point is to thoroughly remove the parasite. This
is best effected by the use of warm water and the syringe, carefully
picking off any small portion that may remain by the forceps or
curette. My practice is then to fill up the external canal with
alcohol, allowing it to remain a few moments, and then to carefully dry
the canal by the aid of styptic cotton. This procedure may have to be
repeated every second day for a number of times until the growth is
entirely destroyed. Wreden recommends the use of the hypochlorate of
lime in the strength of one or two grains to the ounce of water, the
salt to be freshly dissolved in water at each application. The
condition of the middle ear and the integument of the external canal is
to be considered after the removal of this growth, and treated as
indicated by the state of the case.

2. INSECTS IN THE EXTERNAL AUDITORY CANAL.--Cases of this character
occur frequently during the summer season to persons who by lying on
the ground give insects an opportunity to crawl into the external
canal. The common house-fly also affects an entrance into the canal
quite often; also during the summer it is not uncommon to find grubs or
larvæ in the canals of patients suffering from suppurative inflammation
of the middle ear resulting from the deposit by insects of their eggs
in the moist coverings of the canal. The movements of insects in the
sensitive {816} external ear cause great pain to the patient, and their
removal is sometimes difficult. For instance, the grub is provided with
two hooks, by means of which it adheres tenaciously to the skin, so
that it may be necessary to remove each one separately with the
forceps. The quickest method of removal, as a rule, is to wash out the
insect by the use of warm water and a syringe; and if this is not at
hand the insect can be drowned by filling the canal with water, olive
oil, or some demulcent liquid.

OTHER VARIETIES OF FOREIGN BODIES, such as grains of corn, beans, peas,
cherry-stones, beads, buttons, pieces of slate-pencil, are found in the
external canal, and the symptoms that are present arise partly from the
presence of the body, but more frequently from the irritation produced
by attempts at removal.

SUBJECTIVE SYMPTOMS.--Difficulty of hearing, often due to the foreign
body filling up the external canal and thus excluding all
sound-vibrations. Tinnitus aurium and vertigo are often present, and
caused by pressure of the body on the tympanic membrane with resulting
abnormal labyrinthine pressure; also a variety of reflex conditions are
noted as a result of the presence of a foreign body in the external
canal, such as coughing and vomiting, partial paralysis, etc.

OBJECTIVE SYMPTOMS.--The appearance of the external canal will depend
greatly upon the amount of pressure that the foreign body has exerted.
For instance, a body loosely lying in the canal will irritate but
little; on the contrary, a hard body like a cherry-stone firmly
impacted in the canal will quickly cause a severe inflammation.

DIAGNOSIS.--As a rule, the foreign body can be readily seen with the
aid of the mirror and speculum, unless the canal has become swollen to
such an extent as to hide the body from sight. Probing and such-like
procedures are not advisable.

TREATMENT.--The question comes up if it is good practice to make an
attempt at immediate removal of a foreign body if the external canal is
in a condition of acute inflammation. Unless grave head symptoms are
present it is often good practice to delay, and reduce the inflammation
by proper treatment, and then remove the foreign body. In other words,
there is more risk by a forcible removal during a stage of acute
inflammation than to permit the foreign body to remain until the
inflammatory stage is past. Numbers of cases are on record where
foreign bodies have remained for years in the external canal without
causing serious sequelæ. Also, be sure a foreign body really exists in
the canal, as it is not uncommon for patients to come with the
statement that such is the case, and yet no foreign body has been
discovered.

The majority of foreign bodies can be removed by the use of the syringe
and warm water. The impacted bodies--and particularly those having a
hard, smooth surface--present the greatest difficulties. A good plan is
to try first the syringe and warm water, and if not successful try with
a toothed angular forceps to grasp the body. If, as is often the case,
it is found that the forceps slips off the body, then the curved blunt
hook is to be used. This can be passed by the body and then turned on
its axis, so that the hook is firmly placed behind it, and then a slow
upward movement will often dislodge the body. On some occasions I have
used two hooks, holding the body between them, and thus dragging it
out. It is also better to desist after a fair trial until a succeeding
day, rather {817} than make excessive efforts at removal, which will
often cause violent inflammation to follow. After the body is dislodged
examine the condition of the tympanic membrane, as this is often found
to be perforated by the foreign body.


Diseases of the Middle Ear.

ANATOMY.--The cavity of the middle ear is of small dimensions:
antero-posterior diameter, 13 mm.; vertical diameter at the anterior
part, 5.8 mm.; vertical diameter at the posterior part, 15 mm.;
transverse diameter at the anterior part, 3-4.5 mm.; transverse
diameter at the opposite drumhead, 2 mm. (Von Tröltsch). It is situated
in the petrous portion of the temporal bone and surrounded by bony
walls, with the exception of the opening covered by tympanic membrane
and the opening of the Eustachian tube, having a mucous periosteal
covering, very thin, transparent, and colorless. This membrane covers
not only the tympanic cavity, but is reflected over the chain of small
bones and tendons of the tensor tympani and stapedius muscles. It is
essentially a mucous membrane, and may be considered a continuation of
the naso-pharyngeal mucous membrane reflected through the Eustachian
tube to the middle-ear cavity; also subject to the same pathological
changes as other mucous membranes.

The tympanic cavity normally is an air-filled cavity, and allows of
free vibration of the tympanic membrane and its ossicles, as well as
the membrane covering the oval and round foramina; and it is readily
understood that any interference with the vibration of this
sound-conducting apparatus will at once affect the hearing.

Its arterial blood is supplied from the middle meningeal,
stylo-mastoid, ascendant pharyngeal, posterior auricular, tympanic, and
internal carotid arteries. These freely anastomose with each other. The
veins pass internally through minute openings of the petrosal squamous
fissure to the veins of the dura mater, and thence into the superior
petrosal sinus, and also externally into the venous ring surrounding
the tympanic membrane, and also to the veins of the meatus (Schwartze).
This is important to bear in mind, as furnishing an easy passage for
the extension of middle-ear inflammation to the brain membranes.

The nerves forming the tympanic plexus are as follows: The mucous
membrane is supplied by the tympanic plexus, formed from the tympanic
branch of the petrous ganglion of the glosso-pharyngeal nerve--from the
branch of the superficial petrosal and branches of the sympathetic
nerve. The otic ganglion receives fibres from the inferior maxillary
nerve, from the auriculo-temporal nerve, and from the sympathetic
plexus, and it is distributed to the tensor tympani and tensor palati
muscles.

The mastoid cells lead directly from the tympanum. They consist of one
large opening, the antrum, and the lower mastoid cells. These cells
consist of a large number of varying-sized cavities, and are enclosed
by a dense layer of bone. The mucous membrane lining these cells is a
direct extension of the tympanic membrane, and liable to the same
pathological conditions as that mucous membrane.

{818} The Eustachian tube connects the cavity of the tympanum with that
of the naso-pharynx, and is mainly intended for the introduction of air
into the tympanic cavity. It has a length of 35 mm., partly bone (11
mm. in length), partly cartilaginous (24 mm. in length). The pharyngeal
opening is 8 mm. high and 5 mm. wide; the tympanic orifice, 5 mm. high
and 3 mm. wide (Schwartze). The mucous membrane lining this canal is a
continuation of that of the naso-pharynx, and affords an easy way for
the transmission of disease from the naso-pharynx to the middle ear.
The Eustachian tube at rest is probably closed, although this is a
matter still discussed; but it is essential for normal hearing that the
air-pressure exerted on the tympanic membrane through the external
auditory canal should be equalized by that exerted through the
Eustachian tube. This necessitates the opening of the tube from time to
time for free admission of air into the tympanic cavity. This is
accomplished by the action of the musculus dilator tubæ, the tensor
veli palatini, and the salpino-pharyngeus muscle. In the act of
swallowing the tube opens; also, if the nostrils are closed and the act
of swallowing is performed, air will be pumped out of the middle ear;
on the contrary, if the nostrils are open air will be forced into the
middle ear.

Diseases of the middle ear can involve the superficial layers of the
middle-ear mucous membrane only, and may be of a catarrhal character.
Hyperæmia and swelling of the epithelial cells, with increased mucous
secretion, will be found. Later on, if the inflammation assumes a
higher degree, a serous fluid will be profusely poured out, with
lessening of the mucous secretion. When the deeper epithelial cells are
involved, then pus-cells often appear, and a suppurative process
becomes established, with frequent destruction of the soft tissues of
the middle ear.

These different grades of inflammation are seldom found distinct, but
run one into another. A case can start as a pure catarrhal
inflammation; this, after attaining its acme, may end in recovery or
degenerate into a chronic catarrh; or, on the contrary, it may advance
into an acute purulent inflammation with a subsequent chronic stage.

CAUSES OF INFLAMMATION OF THE MIDDLE EAR.--Change of temperature,
causing a sudden cooling of the body, is a frequent cause of this
disease; for instance, exposure to wind from a partly-open window, a
sudden rush of cold water into the external canal, as in surf-bathing,
etc. Irritating foreign bodies in the external auditory canal may also
cause this disease.

But inflammation of the middle ear occurs most frequently as a sequela
of diseases affecting the general body. Among these may be mentioned,
in order of their relative importance--

1. Scarlet Fever.--This disease is apt to cause the purulent form of
middle-ear inflammation, and often of a very grave character. The ear
complication can occur during the existence of the rash or immediately
after its cessation (Thomas), and may run a rapid course, causing
destruction of the tympanic membrane and middle-ear ossicles.
Destruction of the facial nerve in its passage through its bony canal
is not infrequent. Wendt has noticed in severe cases that the
periosteum of the mastoid process, also that of the squamous and
petrous portions, may participate in the purulent process, and end in
subsequent caries of the bone. The severity of the ear complication
will largely depend upon the condition {819} of the naso-pharyngeal
mucous membrane. Light attacks of scarlet fever with slight throat
symptoms would most probably cause slight irritation of the middle-ear
mucous membrane, while the anginose variety would cause most violent
inflammatory sequelæ.

2. Measles is apt to cause the catarrhal variety of middle-ear
inflammation rather than the purulent form. It occurs during and
immediately after this eruption, and is a direct continuation of the
naso-pharyngeal inflammation viâ the Eustachian tube. Hearing, as a
rule, is diminished, due to the swollen mucous membrane of the
Eustachian tube and middle ear, and also to fluid accumulations that
often exist in the middle ear. Wendt[3] draws attention to the fact
that chronic affections of the auditory apparatus, such as formation of
adhesions between the ossicles or between the tympanic membrane and
wall of the tympanum, may arise while the soft parts are in a swollen
condition, and often chronic catarrhal sequelæ may be traced to this
cause.

[Footnote 3: _Ziemssen_, ii. 112.]

3. Tuberculosis is often associated with the catarrhal and purulent
varieties of middle-ear inflammation, having, as a rule, a subacute
course, the patient's attention sometimes only being drawn to his ear
by the escape of pus from the middle ear into the external canal, the
medium of communication being the mucous membrane of the pharynx viâ
the Eustachian tube. Wendt[4] states that as yet the presence of
tubercles has not been authenticated, although the clinical
observations of rapid destruction, especially of the tympanic membrane,
would seem to indicate it.

[Footnote 4: _Ibid._, vii. 77.]

4. Retro-nasal catarrh is a frequent cause of middle-ear inflammation,
the disease being communicated along the mucous membrane of the
Eustachian tube. All degrees of inflammation are found, the catarrhal
variety being the most frequent, while acute nasal catarrh is a cause
of a large number of ear complications. Chronic retro-nasal catarrh is
apt to cause a chronic middle-ear catarrh, that progresses insidiously,
and almost unnoticed by the patient until the deafness begins to
interfere with the ordinary affairs of life.

5. Scrofulosis causes most frequently the catarrhal form of middle-ear
inflammation; and this is a direct continuation of the catarrhal
affections of the naso-pharyngeal mucous membrane viâ the Eustachian
tube. Birch-Hirschfeld[5] asserts that scrofulosis is the cause of the
largest number of those cases in which weakening or destruction of the
function of hearing has occurred during childhood; also, that the large
number of scrofulous individuals found in deaf-and-dumb asylums is
explained in this way; and that after the scrofulosis is cured the
deafness remains as a result of permanent pathological middle-ear
changes produced by the former disease.

[Footnote 5: _Ibid._, xvi. 794.]

6. Smallpox may cause several varieties of middle-ear hyperæmia, and
frequently also a hemorrhagic catarrhal process is met with. Not seldom
is found a suppurative inflammation, with extensive destruction of the
soft tissues and ossicles, with permanent subsequent deafness. There is
probably no reason to doubt that a pustule itself can develop in the
middle-ear mucous membrane, just as is found in the cornea, and cause
an acute inflammatory process; but, as a rule, the middle-ear mucous
membrane is secondarily involved as a consequence of inflammatory
process existing in the naso-pharyngeal mucous membrane.

{820} 7. Diphtheria is a cause of middle-ear inflammation. Wendt[6]
states that in a fifth of the entire number of cases of croup and
diphtheria; and in two-fifths of those cases in which the
naso-pharyngeal space participated, but in no case without immediate
connection with the corresponding affections of this space, he found an
extension of the specific process into the middle ear. In some cases
the tubal prominences were covered with membrane terminating at their
orifices; in other cases a membranous cast of the cartilaginous portion
of the tube was found. As a rule, the pathological changes noted were
hyperæmia of the mucous membrane of the middle ear and catarrhal and
purulent inflammation.

[Footnote 6: _Ziemssen_, vii. 71.]

8. Syphilis causes most frequently the catarrhal variety of middle-ear
inflammation; the purulent variety is also met with, but much less
frequently, the disease of the naso-pharyngeal mucous membrane
determining largely the grade of inflammation. Hereditary syphilis may
cause this complication, as well as the primary disease, but not so
frequently. Hutchinson has observed some cases of deafness in which the
disease was situated either in the labyrinth or auditory nerve, the
middle ear being healthy. Also, deafness may be caused by syphilitic
affections of the external auditory canal, causing obstructions to
sound-vibrations passing through it.

9. Typhoid fever may cause either the catarrhal or purulent form of
middle-ear inflammation. For instance, Hoffmann[7] found fourteen cases
of deep-seated disturbance of the faucial mucous membrane; he also met
with perforation of the tympanic membrane four times--twice in
connection with caries of the mastoid process.

[Footnote 7: _Ibid._, i. p. 159.]

It is easy to understand why middle-ear complications should complicate
such a disease as typhoid fever, where the mucous membranes generally
are the favorite seat of inflammation. Disease of the internal ear and
auditory nerve are not uncommon after typhoid fever.

10. Bright's disease is a cause of hemorrhage into the middle ear.
Schwartze reports in the year 1869 the case[8] of a young man who
suffered from albuminuria with retinal hemorrhages; also, enlargement
of the liver and spleen existed. He suddenly complained of pain in the
right ear. The tympanic membrane was of a red color and devoid of
concavity. Three days later an abundant serous discharge existed, with
a small blood-coagulum, the patient dying a few days later of the
kidney disease. Examination showed a hemorrhagic inflammation of the
mucous membrane of the right tympanic cavity, which was also found
filled with a bloody purulent fluid. The left tympanic cavity also was
found filled with a similar fluid. A number of other similar cases are
reported.

[Footnote 8: _Archiv für Ohren Heilkunde_, Bd. iv. p. 12.]

11. Whooping cough has been noted in several cases to have caused
hemorrhage into the middle ear, with perforation of the tympanic
membrane, with subsequent partial deafness.

The two principal types of acute middle-ear inflammation are the
catarrhal and purulent; and these up to a certain stage have similar
symptoms, but when pus has formed it gives rise to conditions that must
be described as peculiar to purulent inflammation alone.


{821} Acute Catarrh of the Middle Ear.

This may be described as acute catarrh of the mucous membrane lining
the middle-ear cavity. The prominent symptoms are as follows:

1. Pain.--This is, as a rule, of the most violent character. It is
described as a boring or tearing pain situated in the ear itself, and
often extending over the entire temporal region: any muscular exertion
like swallowing or sneezing causes increase of it. The external ear
becomes swollen, and so exquisitely tender to the touch that the least
pressure over the tragus causes the patient to flinch very markedly.
The pain tends to increase during the night up to the early morning
hours, and to lessen during the day. The immediate effect of a
middle-ear inflammation is to render the entire region of that side of
the face tender, so that any movement of the jaws or neck becomes
painful. It is also not uncommon to find the sympathetic glands of the
neck becoming enlarged and tender, and they may go on to suppuration.
The adult will complain most vigorously of the pain, so that there will
be no difficulty in locating it; but in the infant or young child the
greatest difficulty may be experienced in determining its precise seat,
owing to its inability to express in language its suffering. Two points
may be mentioned as aids in the diagnosis: (_a_) the cry of a young
child suffering from an acute inflammation of the middle ear has a
peculiar shrill, continuous character, an intermission sufficient only
to inspire being noticed; (_b_) pressure over the tragus of an inflamed
middle ear will cause a quick shrinking away of the little sufferer,
thus showing the seat of the disease.

2. Loss of Hearing Power.--This depends partly on a lessening of the
vibratory power of the conducting apparatus, partly due to a thickened
tympanic membrane, and also to the fact that the mucous membrane
covering the middle ear and chain of small bones becomes swollen, and
so clogs their movements. Again, the tympanum may be filled with a
mucous or muco-serous fluid, instead of being an air-chamber, as in the
normal condition, so that vibrations of the conducting apparatus may
cease entirely, while at the same time increase of intra-labyrinthine
pressure takes place. A tuning-fork placed on the incisor teeth or on
the forehead is heard more distinctly on the deaf side, due to the
sound-vibrations being retarded in their outward passage through the
diseased middle ear; also, the voice of the patient is heard by himself
with increased resonance, due to the same cause (retarded
sound-vibrations), and the patient unconsciously lowers the voice below
its normal tone.

3. Giddiness is not uncommon, due partly to increase of labyrinthine
pressure, and in some cases to a sympathetic irritation and congestion
of the vessels of the basilar brain membrane. Fever is always to be
looked for in acute middle-ear disease.

4. Noises in the ear (tinnitus aurium), resembling the noise produced
by the escape of steam or the singing of crickets, etc., are common,
and are due to a variety of causes. For instance, a large number of
these noises (according to Theobold's theory) depend upon muscle and
blood-vessel movements, causing vibrations that in a normal condition
pass out through the external auditory canal without being noticed; but
if their outward passage is impeded by obstructions existing in the
middle ear, like thickened tissue or the existence of fluids, as mucus
or pus, or by {822} obstructions in the external auditory canal itself,
such as impacted cerumen, etc., then these vibrations are thrown back
and impress for a second time the auditory nerve-endings, and thus
become noticeable sounds. (A familiar example is to shut the external
auditory canal by closing the meatus: a tidal noise is at once
noticed.) A crackling noise is often caused by air entering the middle
ear and bubbling up through the confined fluids.

OBJECTIVE SYMPTOMS.--The tympanic membrane is at first slightly
injected, particularly along the manubrium and the anterior and
posterior folds; but as the inflammation advances the entire membrane
becomes intensely injected and red. The cone of light is either very
small or may be entirely absent, due to the membrane having lost its
high reflective power. At this stage exudations into the middle ear
frequently show themselves, and if of sufficient quantity may cause an
outward bulging of the membrane: frequently the tympanic membrane at
its lower third becomes less transparent, and in some cases fluid
collections show a dark border-line stretching across the tympanic
membrane, and movable by change of position of the head.

DIAGNOSIS.--This disease can be hardly mistaken: the only difficulty
that can arise is whether the case is one of simple acute catarrh or is
one of commencing purulent inflammation, as the symptoms are identical
in each up to the formation and escape of pus, when no doubt can arise.

TREATMENT.--This must be directed against the acute inflammation that
exists, then as quickly as possible to restore the mucous membrane to
its normal condition and return to the sound-conducting apparatus its
normal vibrating power.

Local bleeding is to be considered among the most important remedies,
and therefore is taken first. This is best done by the use of the
Swedish leech, applied to the tragus, as at this point the blood is
most easily drawn from the tympanic cavity, in number from one to
three; and if the taking of a larger quantity of blood is desired, this
can be accomplished by encouraging the after-bleeding by hot
fomentations. When great pain exists, when the auricle is tender and
pressure on the tragus produces marked increase of pain, the
application of a leech is indicated. In children it is best to refrain
from the use of leeches.

The use of heat and moisture is most valuable. An effective method of
application is as follows: Place the head of the patient in a
horizontal position, with the affected ear turned upward, and fill the
external auditory canal with water at the temperature, say, of 100°
Fahr. Place quickly over the auricle towels that have been dipped in
very hot water and wrung out as dry as possible, and over these a large
flannel pad. This makes an excellent dressing, and one retaining the
heat and moisture for a length of time. When it cools repeat the same
proceeding until relief is obtained, when a large dry cotton pad can
take the place of the previous dressing. Patients suffering from acute
catarrh of the middle ear should be confined to the house, and, still
better, to bed. All physical exercise aggravates this disease, and a
suitable anodyne may be given to procure sleep if it be found
necessary. Paracentesis of the tympanic membrane is sometimes indicated
in those cases where the membrane shows distinct bulging and
perforation is clearly close at hand; also in some cases where,
notwithstanding previous treatment, the pain still {823} continues with
great severity. This operation is best done by incising the posterior
half of the membrane by means of a broad paracentesis needle. The
incision should be made at a point midway between the periphery of the
membrane and the handle of the hammer, and on the dividing-line of the
upper and lower posterior quadrants, the cut to be made downward.
Paracentesis of the membrane is to be done while the head of the
patient is well supported and the membrane illuminated by means of a
light reflected from the head-mirror. Immediately after the operation
wet hot flannels should be applied to the ear to relieve the pain.

The condition of the pharyngeal and nasal mucous membrane should be
thoroughly attended to, as from this source a large number of cases of
acute middle-ear catarrh have their origin. Nitrate-of-silver solutions
are often of great service as a local application to the naso-pharynx.
Tannic acid makes a good astringent gargle, and is more particularly
adapted to those cases where a pure astringent effect is needed.
Chlorate of potash is an excellent gargle, and often proves of great
service. It may not be out of place to state that the use of alcohol
and tobacco tends to keep up an irritated condition of the
naso-pharyngeal mucous membrane, and they should be dispensed with. As
part of the treatment inflations of the middle ear are used to aid in
the removal of abnormal secretions from the tympanic cavity and to
restore the sound-conducting apparatus to its normal condition. This
can be thoroughly carried out by the Politzer proceeding. This consists
in forcing air (by compressing a rubber hand-bag, Politzer's air-bag,
so called) through the lower nasal passage up the Eustachian tube, and
so into the middle ear. The patient holds a small quantity of water in
the mouth. The nasal end of the tubing connected with the air-bag is
placed in one of the lower nasal passages, and the nose tightly closed
over it. The patient is then told to swallow, and at the same moment
the air-bag is forcibly compressed, and the air is thus compelled to
travel along the nasal passage and up the Eustachian tube into the
middle ear. The act of swallowing causes the soft palate to be forcibly
pressed up against the posterior pharyngeal wall, and at the same time
causes the Eustachian tube orifice to open widely. A column of air thus
used will expel large accumulations of mucus from the Eustachian tube,
and to some extent from the middle-ear cavity, and at the same time the
thorough distension of this cavity throws into motion the tympanic
membrane and chain of small bones--a most desirable proceeding. In
acute conditions the inflation should be made only after all pain has
ceased, and then at first very gently; but in a short time a thorough
inflation two or three times repeated, say every two or three days, is
most beneficial. The inflation of the middle ear by the use of the
Eustachian catheter is a more irritating procedure, and does not
accomplish the purpose any more completely than the Politzer method.
Therefore the latter is to be preferred in adults, while in children it
is the only available method that can be used.


Chronic Catarrh of the Middle Ear.

Various classifications of this disease have been made by different
authors: I prefer the division that Buck has used in his textbook. The
following summary will give an idea of it:

{824} Chronic catarrh is a name that has been given to a class of cases
where deafness and tinnitus are prominent symptoms, and where no
suppurative action in the middle ear has existed at any previous time,
and where the internal ear is supposed to be in a healthy condition. In
some of these cases there will be found a marked hypertrophy of the
mucous membrane, and sometimes of the submucous connective tissue,
accompanied with excess of secretion, with the same condition existing
in the naso-pharyngeal membrane. The tympanic membrane often becomes
sunken, and therefore strongly concave outwardly. The short process of
the malleus is very prominent, and the handle of the malleus, by being
drawn forcibly backward, becomes apparently shortened (foreshortening
of the malleus handle, so called).

The membrane loses its vibratory power to some extent, and the cone of
light is either very small or is entirely absent. The color of the
membrane changes to a more or less opaque white, with often a line of
vascularity along the manubrium, or it may assume the color of ground
glass; white calcareous deposits are not seldom met with; marked
evidences of catarrhal inflammation exist in the naso-pharynx, such as
increase of mucoid secretion, with enlargements of the tonsils, and
often granular pharyngitis may be found. The mucous membrane of the
Eustachian tube is often involved in the process: marked swelling of
its mucoid tissue, with the tube filled with secretions, prevents free
entrance of air into the middle-ear cavity. In the nasal mucous
membrane, beyond the ordinary catarrhal conditions, polypoid formations
are common; also thickening of the mucoid and submucoid tissues
prevents the free passage of air.

In another class of cases coming under the head of chronic catarrh of
the middle ear a very different set of symptoms from the class first
described are noticeable. In these cases perhaps catarrhal symptoms
have at one time existed, but have completely passed away, and the
mucous membrane not only of the tympanic cavity, but also of the
pharynx and Eustachian tube, has undergone a fibroid degeneration,
causing destruction of the glandular elements and ending in an
atrophied mucous membrane (the so-called proliferous degeneration of
some authors). The tympanic membrane in these cases is abnormally thin
and very transparent, sometimes much sunken, no doubt due to
connective-tissue adhesions in the middle-ear cavity. The external
auditory canal is devoid of cerumen and hair; also the same change in
the mucous membrane of the naso-pharynx and Eustachian tube gives a
smooth, transparent appearance to their surface. In this class of cases
in post-mortem examinations there have been found the stapes firmly
ankylosed to the margin of the fenestra ovalis; the chain of small
bones firmly ankylosed; fibroid adhesions in the mastoid cells; and
adhesions between the tympanic membrane and the labyrinthine wall.

CAUSES.--A percentage of cases result from a previous acute middle-ear
catarrh. Others apparently originate as a chronic condition and slowly
advance. Beyond all doubt, a large percentage are inherited, as the
same disease can be traced back through several generations, where
signs of the disease were noted in early youth, with slow advance as
years go on. It is also a matter of interest to note that these cases
are apt to show sensible advance in women at the birth of a child.

{825} PROGNOSIS, as a rule, bad, both as to the possibility of
preventing increase of deafness and of doing away with tinnitus--a most
annoying factor.

TREATMENT is successful in proportion to the catarrhal symptoms that
exist, and which are to be treated on the general plan laid down for
catarrhal inflammation. A great number of these cases call for a tonic
plan of treatment, such as iron tonics, cod-liver oil, etc.

Local treatment consists in inflations of the middle ear by the
Politzer method. In those cases where a thin, sunken membrane exists
care should be observed not to use undue pressure, lest a rupture of
the membrane result. In those cases where tinnitus aurium is a
prominent factor a few drops of ether placed in the Politzer bag cause
a more stimulating effect from the inflation than the use of pure air,
and is sometimes of service in lessening this annoyance. It is an
important part of the treatment that the general health should be in
the most vigorous possible condition.


Acute Purulent Inflammation of the Middle Ear.

The disease proceeds very frequently from some inflammation in the
naso-pharyngeal cavity, the mucous membrane of the Eustachian tube
furnishing a ready way of communication between the pharynx and middle
ear.

The exanthematous diseases furnish a large proportion of these cases.
Scarlet fever stands first on the list, as causing the largest number
of these cases, and also those of the most serious character. Measles,
smallpox, diphtheria, the different forms of fever, such as typhus and
typhoid, cerebro-spinal meningitis, pneumonia, bronchitis, etc., are
complicated by this form of inflammation, and the ear disease
represents simply a continuation of the naso-pharyngeal inflammation
which occurs so frequently in the above-mentioned diseases. Another set
of causes come under the head of change of temperature, such as
exposure to draughts of air and sea-bathing, where the cold water
entering the external auditory canal acts directly upon the tympanic
membrane. Some few cases occur as the result of injury, such as blows
upon the ear or direct injuries to the tympanic membrane.

COURSE.--The same pathological conditions are to be noted here as in
the acute catarrhal attack, with the difference that the inflammation
goes on to a higher grade--namely, pus-formation. In this form of
disease there exists marked hyperæmia and swelling, not only of the
superficial but also of the deep-seated tissue, with pus-formation, and
generally perforation of the tympanic membrane, with occasional
ulceration and destruction of other parts of the middle ear. The
neighboring cavities of the antrum and mastoid cells participate more
or less, while blood-vessels penetrating the superior wall of the
middle ear furnish a ready means of communication between the inflamed
middle-ear tissues and the brain-membrane, so that the wonder is not
that brain complications result, but that they occur so seldom.

The changes in the tympanic membrane in the first stage are marked
hyperæmia and swelling of the tissue, so that it often assumes a
uniform red appearance, without a trace of the malleus or cone of
light. {826} Pus-formation in the middle ear is quickly followed by
bulging of the tympanic membrane, due to increase of middle-ear
pressure; and this in the great majority of cases is followed by
perforation of the tympanic membrane, due not only to increase of
pressure, but also to a destructive ulcerative process in the membrane
itself. The latter process is seen in those cases of great destruction
of the tympanic membrane that occurs in scarlet fever, where almost
entire destruction of the membrane is often found. Perforation may
occur at any part of the membrane.

SYMPTOMS AND COURSE.--These are very much the same, up to a certain
point, pus-formation, as have been described under the head of Acute
Catarrh--namely, the great pain, deafness, tinnitus, headache,
tenderness on pressure over the tragus, increase of pain by movement of
the jaw, followed often by quick relief by perforation of the membrane
and escape of pus through the external auditory canal, with a
subsequent subsidence of inflammation and restoration of the tympanic
membrane. A moderate attack may run a course of from two to six weeks,
and end in entire recovery, or it may end in a chronic suppuration with
its sequelæ.

DIAGNOSIS.--It often will be difficult at the outset to know if the
case is one of acute catarrh or whether it will advance to a purulent
inflammation; but as the disease goes on to pus-development and
subsequent drum-perforation, no doubt can exist as to its true
character. The perforation can often be seen, and air may be forced
through it with a whistling sound by a forcible expiration of the
patient. In regard to whether complications exist, such as mastoid or
brain involvement, several points can be given as aids in the
diagnosis. When mastoid involvement exists, the soft tissues over it
become swollen, very tender on pressure, with pain in that part of the
bone; also, often swelling of the posterior upper wall of the external
auditory canal, a part adjacent to the mastoid process.

In those cases where the inflammation tends toward the cranial cavity,
the pain spreads over the entire side of the head, and often becomes
marked in the occipital and frontal regions, and is of a peculiar
lancinating character. Vertigo is also present, even if the head is in
a quiet horizontal position, but greatly increased by movement of the
head. The body-temperature in acute purulent inflammation in adults is
not altered as a rule, but in children it is raised.

PROGNOSIS.--An uncomplicated case if properly treated will generally
result in a good recovery, and often with but slight impairment of the
hearing power. If allowed to run its course, it may cause serious and
permanent changes in the middle ear destructive to hearing, and may end
either in a chronic purulent inflammation with bone destruction or in
involvement of brain membranes or brain tissue proper.

TREATMENT.--In the early stages absolutely the same treatment as
recommended for acute catarrh is indicated--the use of leeches,
hot-water applications, rest in bed, anodynes, etc. When pus has formed
and the tympanic membrane is bulging, paracentesis is indicated (method
of operation, vide p. 917), to be quickly followed by the use of hot
water to relieve the pain of the operation; the gentle use of the
syringe and warm water will keep the canal free of pus during the
suppurative process; also the external ear is to be kept covered by a
cotton pad or some other like application as long as pain and
tenderness exist.

{827} In young children suffering from scarlet fever it is of the
utmost importance to cleanse frequently the pharynx of its
muco-purulent secretions. This can be done by means of a probang or
cotton wrapped on a curved end of whalebone, and afterward some
detergent wash can be used, such as a strong decoction of green tea
containing alum or a solution of common salt. The muriated tincture of
iron, one part to five parts of water, is an excellent local
application to be applied with a camel's-hair brush. Chlorate of potash
makes a valuable gargle. In young children Meigs suggests the use of a
powder containing one part of chlorate of potash to six parts of sugar,
and a pinch of this placed on the tongue and allowed to dissolve.

By such a plan of treatment an acute purulent case will be best carried
over the acute stage, and in many instances will end in entire recovery
without the necessity of local treatment; but in some cases the
purulent discharge from the middle ear will continue, and it remains to
consider the best local remedies for checking this discharge and when
they are to be used. It is with me an absolute rule that no remedy is
to be used with a view of checking a purulent discharge until
absolutely all pain has passed away and no pain is caused by pressure
on the tragus or over the mastoid. During the interval the local
treatment will consist of cleansing the external canal from the
contained pus by the use of the syringe and warm water, the canal being
afterward dried by cotton on a cotton-holder. If the discharge is small
in quantity, the use of cotton on a cotton-holder will be sufficient to
cleanse the canal, and causes less irritation than the syringe and warm
water. The frequency with which the ear is to be cleansed will depend
upon the amount of the discharge, as it should be done as little as is
consistent with keeping the external canal free from pus. It is also
useful for the patient by the Valsalva method of self-inflation to
cleanse the middle ear from the therein-contained pus just before the
time of using the syringe. If this is not feasible, the Politzer method
of inflation answers the same purpose. When all pain has passed away,
and if the discharge still continues, it will be proper to make a local
application. My favorite one is insufflation of a small quantity of
finely-powdered boracic acid (a convenient rubber blower is made for
this purpose). This application answers well also in chronic purulent
middle-ear affections. In applying this powder a very small portion
only is to be used, so that there can be no danger of blocking the
discharge by the powder obstructing its passage through the middle-ear
cavity. A small portion is to be placed in an insufflator and blown in,
the application to be repeated every few days. I would also mention the
great importance of keeping the external canal closed by a wad of
absorbent cotton, which not only absorbs the pus as it slowly escapes,
but also prevents the immediate contact of air with the middle-ear
cavity--a most desirable aid in the cure.


Chronic Purulent Inflammation of the Middle Ear.

Urbantschitsch[9] calls attention to two distinct pathological
conditions that are to be noted in this disease--the one a swelling and
hypertrophy, {828} the other a thinning, of the mucous and submucous
tissues. The thickening consists in an infiltration, with subsequent
connective-tissue development, either in the submucous or over the free
surface of the mucous membrane, causing in the first case a diffuse
tissue hypertrophy; in the latter case forming a circumscribed
connective-tissue formation, papillary excrescences, and nodes. The
condition accompanied with thinning of the tissue is to be considered a
higher grade of purulent inflammation, by which it results that a
portion of the normally existing tissue disappears, and is not again
reproduced, while the newly-developed inflammatory products do not
advance to organization, but are thrown off in the purulent discharge.
In this way can be explained why at one time, by examination through
the external canal and perforated tympanic membrane, there is found a
swollen connective tissue, while at another time the bone can be seen
through the thinned membrane.

[Footnote 9: Vide _Textbook_, p. 351.]

CAUSES.--As a rule, it is a sequela of a previous acute attack. And it
is also safe to say that a large number of chronic purulent cases are
the result of bad treatment or non-treatment of the acute attack. To
mention the causes of chronic suppuration is to repeat those causing
the acute variety, such as diseases of the naso-pharynx resulting from
scarlatina, variola, measles, typhus, tuberculosis, bronchitis,
syphilis, etc.; also the external irritating causes, effect of change
of temperature, as by draughts of air, cold water entering the external
auditory canal, etc.

SUBJECTIVE SYMPTOMS.--Difficulty of hearing is always present. This is
often caused by masses of granulations or collections of pus, filling
up largely the tympanic cavity. These with a hypertrophied mucous
membrane could sensibly interrupt sound-vibrations; and it will not be
out of place to remark that the recovery of hearing will depend largely
on what amount of change can be effected in these different conditions.
Tinnitus aurium is not a constant factor; a few patients suffer from
discomfort caused by pus passing down the pharynx, causing nausea.

OBJECTIVE SYMPTOMS.--More or less swelling of the external canal, while
the constant passage of purulent fluids over the skin results in
exfoliation of its epithelial layer and a subsequent weeping from the
skin tissue. The secretion varies from an abundant discharge to a
minimum of a few drops per day. It may be watery or muco-purulent, or
of a thick, creamy, tenacious consistence. Odor is common, and if the
bone is involved of a most disagreeable character. The perforation in
the tympanic membrane may vary in size from that of a pin-head to a
loss of the greater part of the entire membrane; also, the membrane is
found thickened, with an occasional calcareous deposit in its fibrous
layer. Granulations and polypoid growths are found in the external
canal and middle-ear cavity. The mucous membrane of the naso-pharynx
will show the various changes that are found associated with the
different diseases that cause this complication.

DIAGNOSIS.--This is without difficulty as a rule. The discharge, the
perforation that often can be seen, the whistling caused by the air
being forced through the middle ear and the perforation in the tympanic
membrane by the Valsalva or Politzer method of inflation, are very
significant of middle-ear suppuration. The pulsation often noticed at
the bottom of the external auditory canal, and which has been
considered indicative of perforation, is caused by a thin surface of
fluid in contact with a {829} pulsating blood-vessel, and therefore is
not necessarily a sign of perforation of the tympanic membrane, as
fluids are found in the external auditory canal from inflammation of
its coats, and in such a case pulsation might occur; but this is but
seldom the case, and the removal of the fluid would remove any doubt as
to whether the fluid was a result of external-ear inflammation or
caused by purulent middle-ear disease.

The course of a chronic purulent inflammation is very variable. In many
cases under proper treatment healing and restoration of tissue go on
rapidly. The secretion grows daily less and of a thicker consistence,
and the mucous membrane of the middle ear rapidly returns to a normal
condition. The perforation in the tympanic membrane becomes smaller,
and often entirely closes, so that in a young person the restoration
may be so complete that it is difficult to know where the seat of
perforation has been. In one case in my practice in a child of ten
years, where the membrane had been destroyed to at least three-fourths
of its extent, a full restoration took place. In another class of cases
the course is not so favorable. The tympanic membrane is largely
destroyed, and is not regenerated. The chain of small bones may be
either partly or entirely lost. Granulations form in the mucous
membrane of the middle ear, and the bony walls of the tympanum undergo
partial necrosis, the pus appearing as an acrid, irritating fluid with
more or less odor. The graver complications of purulent inflammation
are apt to occur in those cases of chronic purulent inflammation where
there has been a stoppage of the free discharge of pus from the middle
ear, causing it to collect in the antrum and mastoid cells.

TREATMENT.--The first indication is to cleanse as thoroughly as
possible the middle-ear cavity of the muco-purulent fluid that may have
collected. This is best accomplished by forcing air up the Eustachian
tube and through the middle ear by either the Politzer or Valsalva
method of inflation. The fluids thus forced out into the external canal
can be removed by the use either of warm water and the syringe if large
in amount, or by cotton on a cotton-holder if small in quantity: the
latter plan is less irritating, and also completely dries the external
canal. No local application ought to be made as long as any pain
exists.

The local applications that my experience has shown to give the best
results consist of boracic acid and iodoform. (The latter is
objectionable on account of its odor.) The powder-insufflator furnishes
a convenient method of applying these powders, and only small
quantities should be used, so that no possible plugging of the middle
ear can take place. Some authorities prefer fluid applications instead
of powder. Weak solutions of sulphate of zinc, from one to four grains
to the ounce, are frequently used: a few drops, warmed, are poured into
the external canal and allowed to remain a short time, and then removed
by a twisted tuft of cotton on a cotton-holder. Nitrate-of-silver
solutions are to be used on a cotton-holder; and if a very strong
solution is used it should be neutralized with salt and water.

The frequency of application of any remedy will depend upon the amount
of discharge; but as the discharge lessens, so should the remedy be
less frequently applied. The same rule applies to the cleansing of the
ear, as I have no doubt that excessive use of the syringe often tends
to re-establish and increase the discharge. In some cases, where the
discharge has {830} become very small in quantity, a thick scab will
form over the tympanic perforation, and restoration of the tympanic
membrane will rapidly advance under such a covering, showing that it is
good practice not to remove such a scab, provided pus is not thereby
prevented from escaping. A cotton plug should always be worn in the
external canal of a purulent ear, as it acts as an absorbent of the
purulent secretions, as well as protects the middle ear from the
irritating contact of the air.

The naso-pharyngeal cavities are to be considered and appropriately
treated; also, a general tonic treatment is often indicated.

SEQUELÆ OF PURULENT INFLAMMATION.--I. Brain involvement, either of the
meninges or its substance proper: _a_, purulent meningitis; _b_,
abscess of the brain; _c_, phlebitis with thrombosis of the sinuses.
II. Mastoid disease.


I. Brain Involvement.

It will be proper for a clear understanding of the subject to briefly
consider the anatomy of the middle-ear cavity with reference to this
complication. The middle-ear cavity is practically surrounded by bony
walls, with the exception of the foramen closed by the tympanic
membrane and the opening of the Eustachian tube. The roof of the middle
ear is of varying thickness, and is perforated by a number of canals
for the passage of blood-vessels, forming a direct communication
between the circulation of the middle ear and the meninges of the
brain; also, the petro-squamous suture in the earlier years of life
before complete ossification has set in provides a way for spreading of
the inflammatory process from the tympanum to the brain tissue; also,
cases are recorded where caries has formed actual openings in this bony
roof, through which pus has entered into the brain cavity. The floor of
the tympanic cavity is very thin, and forms a fossa in which lies the
jugular vein, so that involvement of this vein in the inflammatory
process could occur by the close apposition of these parts. The
anterior wall is formed in part by the carotid canal, and cases are
noted where defects in this bony wall are found. Under such
circumstances the coats of the artery would lie in direct contact with
the middle-ear membranes. Also, it is to be noted that small twigs from
the carotid artery pass through its bony canal and anastomose with
vessels of the middle ear, furnishing a way for the spread of
inflammation from the middle ear to the carotid artery that may result
in thickening of its walls.

The superior and posterior surfaces of the petrous bone are in direct
contact with the brain membranes. The posterior wail contains the
passage into the mastoid cells by way of the antrum, through which
middle-ear inflammations spread and involve the mastoid cell cavities,
and may result in some cases in thrombosis of the transverse sinus.

The inner wall presents two weak points--the one the round foramen,
covered with membrane; the other, the oval foramen, covered with the
stirrup and the annular ligament. Inflammation can cause destruction of
these coverings and give free access of pus through their foramina into
the labyrinth, and thence through the internal auditory canal into the
brain cavity. It is not difficult, therefore, with so many ways of
{831} communication between the middle ear and brain cavity to have
easy spread of inflammation between these two regions.

(_a_) PURULENT MENINGITIS may arise from continuance of the
inflammation along the veins which penetrate the roof of the tympanic
cavity in their passage from the middle ear to anastomose with the
blood-vessels of the meninges, or may in rare instances be caused by
pus entering the brain cavity by way of the internal ear, or it can
result from caries of the petrous portion of the temporal bone.

SYMPTOMS.--Fever will be present; distressing headache; vertigo, a most
significant symptom, and often present even when the head is quiet and
in a horizontal position, but greatly increased by the vertical
position and motion; pain of a lancinating character, shooting over the
entire affected side and even down the neck; the occiput and vertex are
favorite points for pain to locate. Nausea and hiccough are present.
Abdomen depressed; pupils reacting to light but feebly; slow pulse; and
in some cases paralytic symptoms are prominent. Post-mortem appearance:
meninges congested, and lymph and pus often found at various points.
Dura mater over the diseased petrous bone will be found thick,
congested, and pus may be found between it and the bone. Caries of the
petrous bone also is found in some cases.

(_b_) ABSCESS OF THE BRAIN.--With the exception of wounds and injuries,
chronic purulent middle-ear inflammation is the most frequent cause of
brain abscess. Meyer, in a collection of 89 cases of brain abscess
tabulates the causes as follows: Typhus, 1; intercranial tumor, 2;
disease of nasal mucous membrane, 3; disease of the blood-vessels, 5;
inflammation of neighboring parts of the brain, 5; unknown causes, 11;
suppuration of distant organs, especially the lungs, 19; caries of the
petrous bone, 20; injuries, 21. Lebert collected 80 cases of brain
abscess, and found that one-fourth were caused by purulent middle-ear
inflammation, caries of the petrous bone being frequently present; in
one-seventh of the cases the brain abscess appeared before puberty, in
the remaining cases mostly between the sixteenth and thirtieth years;
also, that in some cases the abscess developed in the part of the brain
lying over the bony roof of the middle ear; in other cases it was found
in a distant part of the brain or the cerebellum, probably developing
as a metastatic abscess. Toynbee considered the retention of purulent
products in the middle ear or mastoid cells as the chief cause of brain
complications from ear sources: he also endeavored to show that an
inflammation of the external auditory canal will tend to implicate the
cerebellum and lateral sinus--that inflammation of the middle-ear
cavity would extend to the cerebrum, and that of the labyrinth to the
medulla oblongata. But, practically, such a rule will not hold good,
and Gull has modified Toynbee's law as follows: The cerebellum and
lateral sinus may suffer from mastoid disease, while the cerebrum is
threatened by caries of the roof of the tympanic cavity.

Brain abscess is generally located in the medullary substance, very
rarely in the cortex. The middle portion of the brain hemisphere is the
most frequent seat of abscess, and very often in that part adjacent to
the diseased ear. The abscess may be located directly over the diseased
bone, so that the dura mater forms its covering on one side and the
brain tissue on the other, or it may be located in the brain parenchyma
with perfectly healthy brain tissue between it and the diseased bone.
Meyer traces the {832} origin of a brain abscess from ear disease in
this manner: A chronic catarrh of the middle-ear mucous membrane
results in an hypertrophy of the mucosa on one side and a chronic
inflammation of the neighboring bone on the other side. Caries of the
petrous bone, so caused, produces inflammation and adhesion of the dura
mater, and from here as a starting-point the inflammation spreads into
the brain tissue. In rare cases the brain abscess has been found
connected by a fistulous tract with the diseased bone.

SYMPTOMS.--Headache is generally present in varying degree, often of a
lancinating character. Vertigo frequently present. Fever generally
present, with or without chill. Convulsions frequent, with loss of
consciousness and unsteadiness of gait, and often paralysis of
different parts of the body. The pupils are often contracted, and not
unfrequently this disease may closely resemble typhus fever. Lebert
noticed in his cases that failure of the intellect was not the rule,
but paralysis of sensibility occurred in two-thirds of them. It is also
to be noted that cases occur where all these symptoms are absent. This
disease can run an acute or chronic course. In the acute condition a
fatal termination is caused by the great destruction of brain tissue
involved in the suppurative process. In the chronic cases the abscess
becomes encapsulated, but finally terminates by rupture of the abscess
and escape of pus into the ventricles or over the surface of the brain.
In Lebert's cases the fatal termination occurred in half of them during
the first month, in one-third of the remainder toward the end of the
second month, and in the remaining cases in a varying time between the
third and eighth months.

(_c_) PHLEBITIS WITH THROMBOSIS.--This sequela of middle-ear
suppuration is not infrequent. Von Dusch in 32 cases of phlebitis with
thrombosis found that purulent middle-ear disease was the cause of 20
of them. It is frequently found in the venous sinuses in proximity to
the petrous portion of the temporal bone, especially in the lateral and
petrosal sinuses, and often caused by caries of the petrous bone.

Phlebitis with thrombosis of the lateral sinus is characterized by a
swelling of the mastoid region which extends downward into the neck,
due to an extension of the phlebitis from the lateral sinus along the
veins leading from that sinus through the mastoid process to the
exterior of the skull. Giddiness and unsteady gait are often present.
If the inflammation involves also the superior longitudinal sinus, it
will cause symptoms such as epileptic convulsions and violent
hemorrhage from the nose. Wreden considers that the epileptic seizure
is due to a capillary hemorrhage in the cortical substance of the
posterior cerebral lobes, caused by obstruction of the veins passing
over the brain substance. The nose-bleeding is due to the fact that a
part of the blood circulating through the veins of the nasal passages,
and then through the superior longitudinal sinus, is hindered by the
sinus obstruction and accumulates in the veins of the nasal passages,
and finally causes a rupture in some part.

Phlebitis with Thrombosis of the Cavernous Sinus.--Urbantschitsch gives
the following summary of this complication:[10] A thrombosis of the
cavernous sinus can be caused by a thrombus in the internal jugular or
facial veins or by a clot passing from the superior petrosal sinus into
the {833} cavernous sinus, or, finally, by inflammation and thrombosis
in the venous circulation of the carotid canals.

[Footnote 10: Vide _Textbook_, p. 367.]

PROMINENT SYMPTOMS.--Retro-bulbar oedema and exophthalmos, caused by
stoppage of the blood from passing from the orbit into the cavernous
sinus. This may result in a mechanical compression of the retinal
vessels and temporary blindness; also, occasionally swellings appear
about the eyelids and nose. Compression of the oculo-motor and abducens
nerves as they pass along the outer wall of this sinus may cause
paralysis of these nerves, and consequent inward turning of the eye,
with ptosis of the eyelids; also, pressure on a branch of the fifth
pair of nerves as it passes along the outer wall of the sinus may cause
neuralgia in the parts supplied by the branch, or neuralgia in the
supraorbital region.

Phlebitis with thrombosis of the internal jugular vein is marked by a
well-defined swelling extending from the angle of the jaw downward
along the line of the sterno-cleido-mastoid muscle, painful on
pressure, with marked distension of the veins of the face and neck,
especially the external jugular vein. Later on, when the collateral
circulation is established, the superficial veins are apt to return to
their former calibre. If the inflammation extends downward, it can
involve the vena cava; and if upward, the facial veins, causing a
swelling of the cheeks and eyelids. The process can also extend from
the facial to the orbital veins, and thence into the cavernous sinus.
Pressure of the thromboid mass on the internal jugular vein, on the
glosso-pharyngeal hypoglossus and pneumo-gastric nerves at the opening
of the jugular foramen, will cause nervous symptoms corresponding to
the nerve involved.

PROGNOSIS of a phlebitis with thrombosis, as a rule, is unfavorable.
Chronic middle-ear suppuration can also form a starting-point of
metastatic abscess, also of tubercular formations in the lungs and
other organs of the body. I have also been much impressed with the
frequent occurrence of kidney complications, such as granular
nephritis, in this disease. A gradual absorption of pus will develop a
general bodily weakness, and it is a fairly well established fact that,
as a rule, patients suffering from chronic middle-ear suppuration are
not apt to be long lived: many life insurance companies now order that
this disease will prevent the case from being considered a first-class
risk.


II. Mastoid Disease.

The mastoid process of the temporal bone presents an outer convex with
an inner concave surface. On the upper and posterior borders of the
bone are found several canals, through which the external vessels form
a union with those of the dura mater; also, by which the outer cranial
veins form a union with the transverse sinus. There is also an
important suture--the petro-squamous suture, which admits of the
passage of blood- and lymph-vessels. These vessels furnish a channel
for the spread of inflammation from the antrum outwardly, involving the
tissues of the neck, and inwardly to the brain membranes and brain
tissue proper; phlebitis with thrombosis of the lateral sinus can also
occur. The interior of the mastoid process contains one large opening,
the antrum, with numerous communicating air-cells, and all lined with
{834} an extension of the tympanic mucous membrane. Inflammation of the
mastoid process, as a rule, is an extension of inflammation from the
middle ear. The cause will be found in an obstruction to the free
escape of the purulent products from the antrum out through the middle
ear. It is also found that in a great number of cases of purulent
middle-ear inflammation the air-cells are closed by a process of
sclerosis. There are two forms of mastoid disease--1, periostitis of
the bone; 2, inflammation of the mucous membrane of the mastoid cells.

1. Periostitis of the Mastoid Bone is caused either by external
injuries, or more frequently by inflammation extending from the mastoid
cells outwardly to the periosteum.

SYMPTOMS.--Pain, severe in character, also fever. Redness over the
mastoid and great sensibility to the touch, followed by marked
swelling, which may extend far down the neck, involving the lymphatic
glands. Later, pus will be found between the periosteum and bone, and
in a few cases caries of the bone.

2. Inflammation of the Mucous Membrane of the Mastoid Cells is caused
generally by extension of inflammation from the middle-ear cavity,
either of a catarrhal or purulent character, causing the cell-cavities
to quickly fill up with the inflammatory products which escape through
the antrum and middle-ear cavity into the external canal. If this way
is closed, the fluids accumulate in the mastoid cells and form
conditions favorable to involvement of the internal organs.

SYMPTOMS.--Severe pain, tenderness, and redness of skin over mastoid,
but not the marked swelling that is found in periostitis. During such
an inflammation facial paralysis may develop, showing that the
inflammation has extended into the bone itself. Delirium is
occasionally met with, probably due to a more or less circumscribed
meningitis; coma is also occasionally noted, caused by effusion into
the lateral ventricles. In many cases of antrum inflammation there is a
marked swelling of the upper and posterior cutaneous covering of the
osseous part of the external canal, making it a valuable symptom in
determining the degree of the inflammatory action.

Caries and necrosis of the mastoid bone are resultants of the
above-described conditions, and are especially found in early
childhood, and generally caused by retention of pus in the mastoid
cells and breaking down of their walls. This process can be limited to
the cell portion of the bone or can also involve the cortex, with
formation of an external fistulous opening.

TREATMENT.--Use of heat and moisture, either by hot-water fomentations
or warm poultices, like flaxseed, over the entire temporal region of
the head on which the diseased mastoid is located. The flaxseed
poultice is to be covered with oil silk and changed as often as needful
to keep it warm. The use of leeches to the mastoid is indicated by
tenderness of the part to the touch, with heat and swelling of the
tissue covering the bone. Two or three foreign leeches can be used, and
if the abstraction of more blood is desired the after-bleeding is to be
encouraged by warm moist applications. If the disease advances
notwithstanding this treatment, an opening down to the bone is
indicated. The incision is usually described as the Wilde incision. The
length of the cut is to be from a half to one inch, down to the bone,
the point of the knife entering the {835} skin on a level with the
upper wall of the auditory canal, about half an inch behind the
auricle. Occasionally the posterior auricular artery is cut, but
hemorrhage is readily controlled by pressure over the artery. During
the entire treatment the external auditory canal is to be cleansed from
time to time of the purulent secretions, so as to facilitate the
discharge of pent-up fluids from the middle ear and antrum. Also, the
condition of the pharynx is to be noted, and treated if needful.
Finally, if all these measures fail to relieve, and the patient shows
signs of meningeal or brain involvement, together with marked redness,
tenderness, and swelling over the mastoid bone, showing that pus is
being retained in the mastoid cells, there only remains the making of
an opening into the mastoid process and antrum by means of a bone-drill
or gouge. This is best done by a free vertical incision through the
skin and periosteum covering the mastoid process. Examine then the
bone, and a fistulous opening may be found which can be enlarged by a
probe, and so allow the free escape of pus. If such does not exist,
apply a drill to the bone at a point a quarter of an inch posterior to
the external canal and just below a horizontal line drawn tangent to
its upper wall. The instrument is to have a direction inward, upward,
and slightly forward. The depth to which it should penetrate varies:
usually cell-structure is reached at a slight depth, when the drill
should be withdrawn. If sclerosis of bone exists, it will be necessary
to go deeper, but never more than three-quarters of an inch, or about
20 millimeters. This is Buck's rule. Schwarze says, never go deeper
than 25 millimeters, otherwise there is risk of plunging the drill into
the labyrinth. Also, during the drilling process Buck recommends
keeping the fore finger of the operating hand constantly pressed
against the neighboring bone, so as by counter-pressure to reduce to a
minimum the risk of wounding the lateral sinus if it should lie in an
abnormal position in the path of the drill. After-treatment consists in
keeping the canal open by gentle washing. The use of a bone-gouge is
preferred by some to the drill, as being a less dangerous instrument.


Diseases of the Internal Ear.

ANATOMY.--The internal ear consists of a central cavity, from one end
of which arise the semicircular canals, and from the other the cochlea.
The interior of these contains the membranous portion and fluids of the
internal ear. The cochlea contains the most important part--namely, the
terminal endings of the auditory nerve. Sound-vibrations pass through
the external canal and strike against the tympanic membrane, throwing
it into vibration. The vibrations of this membrane are carried across
the middle ear by the chain of small bones to the membrane closing the
foramen ovale of the internal ear, throwing this and the labyrinthine
fluid also into vibration, and these latter vibrations, impinging on
the terminal endings of the auditory nerve in a way as yet unknown,
produce sound.

Vessels of the Labyrinth.--The labyrinth obtains its blood partly from
the arteria auditiva interna, a branch from the basilar artery which
comes from the vertebral, and partly through vessels communicating with
the middle ear viâ the round and oval windows, and through others
passing {836} through the long walls themselves. The arteria auditiva
interna divides in the internal meatus into a vestibular and cochlear
branch. The former is distributed to the soft structures of the
vestibule and semicircular canals. The cochlear branch is distributed
to the modiolus and layers of the lamina spiralis. The venæ auditivæ
internæ empty into the inferior petrosal sinus or the lateral sinus;
other branches empty into the superior petrosal sinus.

The auditory nerve or portio mollis of the seventh nerve arises by two
roots in the medulla oblongata. One ganglionic nucleus of origin is in
the floor of the fourth ventricle, the other is in the crus cerebelli
ad medullam (Stieda). The nerve winds around the restiform body, and
passes into the meatus auditorius internus, and finally divides into a
vestibular and cochlear branch. The vestibular branch divides into
three branches: the superior is distributed to the utricle and ampullæ
of the superior vertical and horizontal semicircular canals; the middle
to the sacculis, and the inferior to the ampulla of the inferior
vertical semicircular canal. The cochlear branch enters the modiolus
and breaks up into smaller branches, which radiate fan-shaped into the
lamina spiralis, and are then distributed between the two plates of the
lamina spiralis through all its turns.

TINNITUS AURIUM.--It may be assumed that the normal ear is filled with
continuous sound. The blood flowing through the large arteries and
veins in close proximity to it (such as the carotid arteries and
jugular vein), as well as the blood flowing through the vessels of the
internal ear, will give rise to sound by throwing into vibration the
soft tissues surrounding them, including also the walls of the vessels
themselves. This motion is sufficient to excite the auditory
nerve-elements by causing vibrations of the intra-labyrinthine fluids,
and so produce sound; which, being a normal condition, and one to which
the ear is accustomed, will remain unnoticed.[11]

[Footnote 11: To Theobald we are indebted for the vascular theory of
sound.]

The arterial system of the body throws the neighboring tissue into
vibration, but this is not recognized unless our attention is
particularly directed to it; or, in other words, the entire body is
filled with movement as a normal condition, and therefore attracts no
attention. But let this movement be increased--for instance, by violent
muscular exertion, increasing the arterial action--or lessened, as in
syncope, and at once an abnormal condition draws our attention to it.

In the same way the ear is filled with continuous sound as a normal
condition, and therefore it is not perceived, these sound-vibrations
escaping out through the middle ear and external canal. This can be
readily proved. Let the external auditory canal be obstructed
artificially, either by the finger or by a cork. At once a tidal
tinnitus, so called, is produced, this being caused by the normal
sound-vibrations being impeded in their outward passage and being
thrown back again to impress the nerve-elements for a second time.
This, being an abnormal condition, is at once recognized.

Different Varieties of Tinnitus Aurium.--I. Tinnitus caused by
obstruction of the normal sound-vibrations in their outward passage
through the middle ear and external canal; tidal tinnitus, so called
from a resemblance to the noise of the ocean. Such obstructions may
exist in the middle-ear {837} cavity, as thickening of the soft tissues
of the middle ear, exudations and adhesions, as found in chronic
catarrh, or in the external canal, as impacted cerumen, a swollen
canal, etc. The effect of such obstruction would be to interrupt the
normal sound-vibrations and cause them to be reflected back again to
impress for a second time the auditory nerve-elements, causing an
abnormal and therefore recognized condition. This is the most frequent
variety of tinnitus, and for the reason that it is produced by the more
ordinary ear diseases.

II. Tinnitus caused by abnormal sound-vibrations produced either by
increase or by decrease of intra-labyrinthine pressure. In a normal
condition the auditory nerve-elements are subjected to a given
intra-labyrinthine pressure; now, if this pressure be altered (either
by being increased or diminished) an abnormal condition ensues, and is
noted as such.

_a_. Tinnitus produced by increased intra-labyrinthine pressure may be
caused by increase of the intra-labyrinthine fluids (by effusions,
hemorrhages, etc., as in Menière's disease), or can be caused by
increase in the amount of blood flowing through the arteries and veins
of the internal ear. In either case there will result an increase of
pressure that is exerted on the auditory nerve-elements. Also, another
result of such increase of pressure on the arteries of the labyrinth
would be to throw them into more active pulsation, and so cause greater
movement on the intra-labyrinthine fluids. These abnormal vibrations
impinging on the auditory nerve-endings would be noticed as such, and
give rise to tinnitus of a pulsating character corresponding to the
movements of the pulsating vessels. Such a condition is noticed in an
eyeball afflicted by glaucoma, or can be artificially produced by
finger-pressure on a normal eye. The veins of the retina will be first
thrown into movement, and as the pressure increases the arteries will
show marked pulsation. Why should not a similar set of conditions in
the internal ear produce similar results?

_b_. Tinnitus produced by a lessened intra-labyrinthine pressure may be
caused either by loss of intra-labyrinthine fluid or by a lessened
blood-supply to the internal ear. The latter cause being the most
frequent, a familiar example of this would be the tinnitus experienced
by a fainting person, a common sensation being a swimming head
accompanied with strange whizzing noises in the ears. The tinnitus of
anæmia is of this class, and frequently of the pulsating variety.
Another explanation might be given: an anæmic heart murmur might be
conveyed along the blood-vessels as through a speaking-tube, and in
that way impress the auditory nerve. In this variety of tinnitus it is
supposed that the sound-conducting apparatus of the middle and external
ear is normal; if any obstruction exists, it would cause increase of
tinnitus of this variety.

III. Tinnitus caused by a diseased condition of the auditory nerve,
either in the part lying between the internal ear and brain or in the
brain-centre itself--pure subjective tinnitus. Here we enter upon a
subject obscure from the fact that so little pathological research has
been made in this direction; but, reasoning from analogy, why cannot
the auditory nerve be subject to as many diseased conditions as the
optic nerve, where the ophthalmoscope has clearly shown the existence
of neuritis, atrophy, and many other pathological changes, caused, it
may {838} be, by disease of the retina, or it may exist as an
inflammation of the nerve itself exterior to the eyeball, or it may be
due to a brain tumor pressing on the optic nerve or optic tracts, also
basilar meningitis? Gummata, osseous growths, etc. have in turn caused
optic neuritis; finally, lesions at the optic nerve-endings in the
brain itself have caused well-defined pathological changes in the optic
nerve, which by the aid of the ophthalmoscope are recognized. Now, if
these changes exist in the optic nerve, why may not the same conditions
be present in connection with the auditory nerve, although from its
anatomical location they are not capable of demonstration, as in the
case of the optic nerve? And, as in the latter phosphene symptoms are
common, due to nerve-irritation, so in irritation of the auditory nerve
tinnitus would be developed, but of a subjective character. (In this
connection it is not out of place to remark that in obscure internal
ear disease examination of the optic nerve will often give valuable
information toward clearing up the ear complication.) This variety of
tinnitus may in some cases be due to a reflex nerve-irritation.

Finally, tinnitus may be noticed in cases of inflammation of the middle
ear where fluid has collected, and is caused by the bursting of
air-bubbles in their passage through this fluid, the air gaining access
to the middle ear by way of the Eustachian tube. Tinnitus so produced
resembles a bubbling or crackling sound. Hinton draws attention to
certain cases where the tympanic membrane has lost its normal
elasticity and become stiff, any movement of such a membrane causing a
crackling sound. Also, there are some cases of tinnitus produced by
foreign bodies being deposited on the tympanic membrane, such as
cerumen, pieces of hair, etc., making a rustling or rasping noise.

Tinnitus produced by abnormal contractions of the tensor tympani or
stapedius muscles has been thought to exist. Tinnitus may be
intermittent or continuous. It also has an endless variety of sound,
from one almost unrecognizable to a roar so loud as to render the
patient nearly distracted.

Location of the Tinnitus.--Those varieties due to a diseased external
or middle ear locate the sound, as a rule, in the ear itself.
Subjective tinnitus is often located in the frontal and occipital
regions; often also in the ear itself. It is also to be noted that
marked tinnitus may be associated with a low degree of deafness, and
the converse is true: slight tinnitus may be associated with a high
degree of deafness.

PROGNOSIS.--The removal of tinnitus depends entirely upon the cause of
it and the possibility of its removal. Continuous tinnitus is always to
be regarded as a more pronounced symptom than the intermittent form.

The TREATMENT will be directed to the removal of the cause. If the
disease is located in the external canal or middle ear, or in a
diseased condition of the naso-pharynx, these irritating causes should
be removed by treatment already laid down in previous pages. The
treatment of subjective tinnitus will be guided by the same principles.
Determine the cause and seek for its removal. As to whether any
particular drugs exist peculiarly adapted to the removal of tinnitus, I
would say that in tinnitus of a subjective character or due to
nerve-irritation the bromides are indicated in appropriate doses.
Inflation of the middle ear with air impregnated with ether (a few
drops of ether dropped into a Politzer air-bag {839} and the inflation
made by the Politzer method), at intervals of three or four days, in
some cases proves of benefit.


Deafness after Cerebro-Spinal Meningitis, Scarlet Fever, Mumps, etc.

This opens up a chapter in which our knowledge derived from post-mortem
examination is very limited. In a given number of such cases the
inflammation probably extends from the brain to the labyrinth; in
others the changes that are found exist chiefly in the middle ear, so
that it must be supposed that the inflammation in such cases has
originated in the middle ear, and has secondarily invaded the
labyrinth. In some cases, such as deafness after mumps, Toynbee is of
the opinion that the peculiar poison of that disease affects the
nervous apparatus of the ear, as the deafness comes on suddenly, and is
usually complete, without evidence of disease in any other part of the
ear. In this class of cases the prominent symptoms are deafness--which
is total--and staggering gait, with vertigo. This symptom may last many
weeks, and then cease. As a rule, examination of the tympanic membrane
is negative, and the seat of disease is to be sought for in the
labyrinth, whether it may be an inflammation of the soft structures or
an effusion, causing increased intra-labyrinthine pressure. In many
cases the suddenness of the attack would point to an effusion as the
more probable cause.

Brunner in a comparison of five cases of deafness after mumps[12] gives
the following symptoms and course of the disease: 1. The nervous
deafness after mumps can be one-sided or double-sided, the former being
more frequent. 2. It is complete, and, according to past experience,
incurable. 3. It develops rapidly, with vertigo and subjective noises,
the later symptom lasting a long time. 4. There is little or no fever.
5. Pain is never or very seldom present. 6. Consciousness is not lost;
excessive vertigo a prominent symptom. 7. It happens both in children
and adults.

[Footnote 12: _Archiv Otology_, vol. xi., No. 2, p. 103.]


Menière's Disease.

A. Guye of Amsterdam has published a very full summary of the history
of this disease.[13] The following is extracted from it: Under the head
of Menière's disease is included those cases of inflammatory processes
in the semicircular canals or in the middle ear producing vertigo,
which is either continuous, or caused by normal movements of the head,
or appearing only at intervals of weeks or months; also, that this
disease is of a secondary nature, and is due to inflammatory processes
in the tympanum or antrum. In typical cases the vertigo is accompanied
by sensations of rotation: first a sense of rotation about a vertical
axis and toward the affected side; this is followed by a sensation of
rotation about a transverse axis forward and backward. The vertigo then
becomes complete, and is followed by fainting, with or without loss of
consciousness and vomiting. The attack in some cases may last for a few
minutes to a half hour; in others every movement will tend to produce
vertigo for {840} several days. In chronic cases the feeling of vertigo
to a slight degree persists between the attacks. Guye considers the
causes of middle-ear catarrh as the factors most likely to cause
Menière's disease. Syphilis is also noted in some cases.

[Footnote 13: _Ibid._, vol. ix., No. 3.]

TREATMENT.--In some cases an alterative treatment is most serviceable,
such as iodide of potassium, also the bromide of potassium; quinine is
also by some recommended. The use of alcohol and tobacco is to be
forbidden.

The disease known as boiler-makers' deafness, because generally found
among men laboring in machine-shops, where they are subjected to loud
noises connected with the work they are engaged on, is thought to be
due to a paralysis of the terminal endings of the auditory nerve due to
concussion. The middle ear sometimes shows some thickening of the
tympanic membrane. Treatment is without avail.

In internal-ear diseases a few common symptoms can be noted. All cases
show deafness, and in most of them of an absolute degree. And here is
where the tuning-fork proves a valuable aid in diagnosis of deafness
due to middle-ear disease, in which cases the tuning-fork is heard best
on the deaf side, and to deafness due to internal-ear disease, where
the tuning-fork is heard the least on the deaf side. Vertigo and a
staggering gait are quite common symptoms, probably due to irritation
of the semicircular canals. Prognosis as a rule is bad, as far as
recovery is concerned, and an alterative treatment is often indicated.
Electricity, I would state, in my experience has not proved to be of
any avail.


Deaf-Mutism

may be either congenital or acquired. Two-thirds of all cases will come
under the first class, and often depend upon a mal-development of some
part of the central nervous system or the ear itself, or may be due to
intra-uterine disease of the ear. There is a strong tendency for this
disease to be inherited, and particularly in children where there
exists a blood-relationship between the parents. The acquired cases may
arise from defects in the central nervous system or in the internal
ear, or may be due to diseases affecting the middle ear, such as
purulent inflammation; and this latter cause is to be noted, as no
doubt proper treatment of the middle-ear disease in many cases would
have prevented such a result.

All deaf cases become mute, unless the disease has occurred in adult
life, when the patient has already acquired the power of language. A
deaf-mute does not speak, because he cannot hear, and therefore speech
is an unknown quantity.

The TREATMENT would consist in treating any middle-ear disease that
might exist, such as the sequelæ of purulent inflammation, and the
instruction of the patient in acquiring the power of intercommunication
either by the methods long employed of finger-reading, or, much better,
by the lip method, so called, where the power of speech is given to the
patient. Such cases should attend schools where such instruction is
given, commencing at five years of age, and many cases now attest the
value of the latter method of instruction.

DIFFERENT METHODS OF DETECTING FEIGNED DEAFNESS.--The {841} Moos
Method.--Stop the external canal of the sound ear with a cork; place a
vibrating tuning-fork on the head. If the person under examination
declares that he does not hear the fork with either ear, he is feigning
deafness, as it would be heard well by the sound ear.

The Urbantschitsch method makes use of the human voice. First determine
that good hearing power exists in the sound ear; then shut the external
canal of this ear with a cork and address the individual with a few
loudly-spoken words. If he denies hearing at all, he is feigning, as a
good hearing ear, by simple closure of the external canal, will be
still able to hear loudly-spoken words.

Another method is to determine the distance at which the person can
hear certain words and repeat them correctly. Then have the patient
close the eyes and let the examiner try by lengthening and shortening
the distance, and note the result. Often he will hear and repeat words
spoken at long distances, and apparently not be able to repeat words
spoken at short distances.

Müller's Method.--Speak into the sound ear through a tube or paper roll
different words as softly and quickly as the examined person can
repeat; then let a second examiner repeat the same in the deaf ear. Of
course nothing will be heard by the person feigning. Then let the first
examiner repeat his performance; the feigner will quickly repeat after
him. Suddenly begins the second examiner to softly and quickly speak in
the deaf ear, but choosing different words from the first examiner. A
really one-sided deaf person will repeat the words spoken into the
sound ear only, while the feigner will be in doubt, and will not be
able to separate the words heard by both ears, so as only to repeat the
words heard by the sound ear.

{842}




{843}

INDEX TO VOLUME IV.


A.

ABORTION, 467
  Changes in maternal system, 474
  Changes in uterus and pelvic viscera, 475
  Classification, 467
  Criminal, causes of, 493
  Course of, 497
  Diagnosis, 505
  Duration, 503
  Hemorrhage, 516
  Morbid anatomy of, 494
  Pain, 516
  Pathology of, 494
  Preliminary symptoms, 499
  Prognosis, 508
  Symptomatology, 497
  Symptoms of, 500
  Termination, 504
  Treatment of, 509
    Abortion which is thoroughly inaugurated, 516
    After-treatment, 523
    Anæsthetics, 514
    Antiseptics in, 510
      by tampons, 517
    Dressing-forceps, use of, 513
      in cases of retention of ovum, 519
    Instruments, 512
    Medication, 512
    Preparations for, 509
    Preventive, 515
  Definition of, 467
  Development of ovum, 477
  Etiology, 479
    Amnion, the, 491
    Chorion, 490
    Decidua, 488
    Exciting causes, 481
    Hemorrhage, 490
    Local causes, 488
    Ovum, the, 489
    Placenta, the, 490
    Predisposing causes, 480
    Umbilical, the, 491
    Uterine mucosa, 488
  Frequency, 468
  History, 470
  Importance, 468
  Physiology of early pregnancy, 474
  Synonyms, 467
  Uterine mucosa, 476

Abscess of the brain as a sequel of chronic inflammation of middle ear,
        832

Absence of one kidney, 21
  of pain in fibroma of skin, 686

Acanthia lectularia, 733

Accidents and complications of ovariotomy, 336

Acne, 641
  rosacea, 647

Aconite in the treatment of parametritis, 221

Acquired anteflexion of uterus, 177

Actual cautery in the treatment of the pedicle after ovariotomy, 326

Acute catarrh of middle ear, 821
  cystitis, 126
  diffuse nephritis, 82
  nephritis of scarlatina, 84
  endocarditis in pregnancy, 430
  endometritis, 460
  infectious diseases of pregnancy, 424, 425
  lobar pneumonia in pregnancy, 430
  metritis, 447
  ovaritis, 283
  parenchymatous nephritis, 78
  pleuritis in pregnancy, 431
  purulent inflammation of middle ear, 825
  urethritis in women, 353
  vaginitis in prolapse of uterus, 158

Affections of the eye caused by diseases of the digestive system, 749
  of fifth pair of cranial nerves, 785
  of second pair of cranial nerves, 771
  of seventh pair of cranial nerves, 790
  of third pair of cranial nerves, 780
  of twelfth pair of cranial nerves, 790

After-treatment in anterior elytrorrhaphy for prolapse of uterus, 163
  of abortion, 523

Age in epithelioma, 709
  in progressive muscular atrophy, 542
  of menstruation, 182

Albinismus, 676

Albumen in the urine as a symptom of acute diffuse nephritis, 82
      of chronic parenchymatous nephritis, 81

Albuminoids in albuminuria, 35

Albuminuria, 34
  as a symptom of congestion of kidney, 70
  in Bright's disease of kidneys, 73, 75
  in calculous pyelitis, 47
  in chronic diffuse nephritis, 96
  of nervous affections, 40
  of pregnancy, 40

Alcohol as a cause of toxic amblyopia, 803
  effects of, on the eye, 803

Aleppo bouton as a variety of furunculus, 606

Alimentary canal, disorders of, during the menopause, 440
      in pregnancy, 408

Alkalies in treatment of acute cystitis, 127
      of chronic cystitis, 131

Alopecia, 678
  areata, 680

Alterations in condition of blood as a disorder of pregnancy, 405
  in nutrition during menopause, 437
  in secretion of kidneys during menopause, 437
  of functions of skin during menopause, 435

Alteratives in local treatment of chronic metritis, 459

Alum in the treatment of dilatation of the urethra in women, 359

Amenorrhoea, 183
  atrophy of uterus in, 186
  chlorosis in, 186

Ammonia hydrochlorate in the treatment of fibrous tumors of the uterus,
        259

Amnion, the, as a local cause of abortion, 491

Anidrosis as a disorder of secretion in diseases of skin, 584

Anæmia, pernicious, as a disorder of pregnancy, 406

Anatomical characteristics of seminal incontinence, 141

Anatomy, course, pathology, and termination of parametritis, 210
  of internal ear, 835
  of middle ear, 817
  of syphiloderma bullosum, 705
  of vagina, 367
  of vulva, 388
  pathological, of progressive muscular atrophy, 543

Anæsthetics in treatment of abortion, 512

Aneurism, retinal, 743

Angioma of the skin, 688

Anodynes in acute cystitis, 127

Anomalies of kidneys, 19

Anteflexion of uterus, 176, 177

Ante-locations of uterus, 153

Anterior elytrorrhaphy for prolapse of uterus, 161

Anteversion of uterus, 174

Antiseptics in treatment of abortion, 510

Apiol in treatment of amenorrhoea, 190

Applications in treatment of seborrhoea, 589

Arrangement of tables in ovariotomy, 320

Arsenic as a cause of dermatitis medicamentosa, 602
  in the constitutional treatment of eczema, 632
  in the treatment of lichen ruber, 624

Articles needed for operation of ovariotomy, 318

Ascites in the diagnosis of cystic tumors of ovary, 305

Aspiration in the treatment of ovarian cysts, 308
      of pelvic abscess, 225

Assistants in ovariotomy, 320

Associated movements of head and eyes in affections of third pair of
        cranial nerves, 782

Astringents in treatment of albuminuria, 42

Atony of bladder, 133

Atresia, 373
  hymenalis, 374
  vaginal, 376
  vulvæ, 373

Atrophia cutis, 683
  pilorum propria, 682
  unguis, 683

Atrophied tubules in congestion of kidney, 69

Atrophies of skin, 676

Atrophy of bladder in women, 348
  of uterus in amenorrhoea, 186
  progressive muscular, 540

Atropia as a cause of dermatitis medicamentosa, 602
  in polyuria, 34
  in treatment of seminal incontinence, 146

Autopsies in nystagmus, 784
  of cases of pseudo-hypertrophic paralysis, 558

Axis of arteries, 148


B.

Baldness in tinea tonsurans, 720

Basedow's disease in medical ophthalmology, 799

Baths in the treatment of lichen ruber, 624

Battey's operation, 290

Bearing-down feeling in prolapse of uterus, 158
    in retroversion of uterus, 166

Belladonna as a cause of dermatitis medicamentosa, 602
  in acute cystitis, 127

Bimanual replacement of retroflexed uterus, 170
    of retroverted uterus, 170

Biskra bouton as a variety of furunculus, 606

BLADDER, DISEASES OF, 123
  Atony, 133
    Causes of, 133
    Treatment of, 134
      Catheterization, 134
      Electricity, 134
      Strychnia, 134
    Catarrh, 128
  Catarrh of, in prolapse of uterus, 157
  Cystitis, acute, 126
    Causes of, 126
    Prognosis of, 127
    Symptoms of, 126
      Epididymitis as a symptom, 127
    Treatment of, 127
      Alkalies in, 127
      Anodynes in, 127
      Belladonna in, 127
      Hyoscyamus, 127
      Opium, 127
      Sitz-baths in, 127
  Cystitis, chronic, 128
    Causes of, 128
    Pathology of, 130
    Prognosis, 130
    Symptoms, 129
      Degrees of, 129
      Severe pain in, 129
    Treatment of, 131
      Alkalies in, 131
      Clothing in, 131
      Emptying bladder, 132
  Hemorrhage from, 134
    Diagnosis of, 135
    Treatment of, 135
      Gallic acid, 135
      Ice, 135
      Iron, 135
      Nitrate of silver, 135
      Opium, 135
      Tannic acid, 135
  Inflammation, 123
    Pathology of, 124
    Symptoms of, 124
    Treatment of, 125
      Marriage as a, 125
      Ointments in, 125
      Passing sound as, 125
    Varieties of, 123
  New growths of, 136
  Neurosis of, 132
  Prognosis, 133
  Treatment of, 133
  Organic diseases of, in wound, 339
  Paralysis of (see _Atony of_), 133

Blepharospasm, 790

Blindness after pneumonia, 748

Blistering in the treatment of parametritis, 222

Blisters in the treatment of chronic perimetritis, 236

Blood in Bright's disease of kidneys, 77

Bloody urine as a symptom of acute diffuse nephritis, 82

Boil or evil as a variety of furunculus, 606

Boric acid in treatment of chronic purulent inflammation of middle ear,
        829

Boracic acid in the treatment of pyelitis, 55

Borax and water in the treatment of cystitis in women, 346

Bougies in the treatment of seminal incontinence, 144

Brain abscesses as a sequel of chronic purulent inflammation of middle
        ear, 832

Bright's disease of the kidneys, 72
    as a cause of inflammation of middle ear, 820

Bromides as a cause of dermatitis medicamentosa, 602
  of potash in the treatment of seminal incontinence, 145

Bromidrosis as a disorder of secretion in diseases of skin, 584

Bulbar paralysis, 790
    in medical ophthalmology, 790


C.

Caffeine in treatment of chronic congestion of kidneys, 72

Callositas, 662

Calorica, 601

Canal of Nuck, cysts of, 397

Cancer of the vagina, 382
  of the vulva, 402

Canities, 678

Cannabis as a cause of dermatitis medicamentosa, 602

Cantharidal collodion in treatment of seminal incontinence, 145

Carbolic acid for instruments, 321
    in the treatment of pyelitis, 55
    spray in ovariotomy, 320

Carbunculus, 606

Carcinoma of the uterus, 274

Cardiac disease in congestion of kidney, 71
  diseases in pregnancy, 429

Caruncle, urethral, 403

Cases of hemianopia, 776
  of parametritis, 217

Castration for the cure of chronic metritis, 459

Casts as a symptom of congestion of kidney, 70
  in calculous pyelitis, 451
  in urine in chronic diffuse nephritis, 96

Catarrh of bladder, 128
    in prolapse of uterus, 157
  of middle ear, acute, 821

Cathartics in the treatment of diseases of kidneys in pregnancy, 419

Catheterization in the treatment of atony of bladder, 134

Cause of elephantiasis, 674
  of scabies, 726
  of tinea versicolor, 725

Causes of abortion, exciting, 481
    local, 488
    predisposing, 480
  of acute cystitis, 126
  of alopecia areata, 681
  of albuminuria, 39
  of amenorrhoea, 183
  of atony of bladder, 133
  of carbunculus, 607
  of chloasma, 659
  of chronic catarrh of middle ear, 824
  of chronic cystitis, 128
  of chronic purulent inflammation of middle ear, 828
  of criminal abortion, 493
  of death after ovariotomy, 314
    of foetus in pregnancy, 424, 425
  of dermatitis medicamentosa, 602
  of ecthyma, 653
  of erythema nodosum, 596
  of herpes zoster, 610
  of hypertrichosis, 670
  of inflammation of middle ear, 818
  of impacted cerumen in the external auditory canal, 812
  of impetigo contagiosa, 652
  of inversion of urethral mucous membrane in women, 362
  of keratosis pilaris, 660
  of lupus erythematosus, 690
  of menorrhagia, 201
  of molluscum epitheliale, 661
  of myalgia, exciting, 530
  of myalgia, predisposing, 530
  of ophthalmitis, febrile, 761
  of pelvic hæmatocele, 241
  of progressive muscular atrophy, 541
  of pruritus, 712
  of pyelitis, 53
  of pyelo-nephritis, 99
  of scleroderma, 672
  of sudamen as a disease of the skin, 586

Caustic potash in the treatment of lupus vulgaris, 696

Caustics in treatment of angioma of the skin, 688
    of hypertrichosis, 670
    of verruca, 664

Cauterization in the treatment of angioma of the skin, 688

Cautery, actual, in the treatment of pedicle after ovariotomy, 326

Cephalodynia as a symptom of myalgia, 531

Cerebral hyperæmia during the menopause, 443
  symptoms of acute diffuse nephritis, 82

Cerebro-spinal meningitis, deafness after, 839

Cerumen, impacted, in the external auditory canal, 812

Cervix, enlargement of, in prolapse of uterus, 157
  erosion of, in prolapse of uterus, 157

Cessation of menstruation, date of, 432

Change in quantity of urine as a symptom of nephritis, 81
  in specific gravity of urine as a symptom of nephritis, 81

Changes in dermatitis herpetiformis, 613
  in eye-ground and its appendages due to diseases of circulatory
        apparatus--heart, blood-vessels, and blood, 738
  in maternal system in early pregnancy, 474
  in uterus and pelvic viscera in early pregnancy, 475

Chloasma, 659

Chloral as a cause of dermatitis medicamentosa, 602
  in the treatment of vaginitis, acute, 372

Chlorosis as a cause of amenorrhoea, 185
  and hydræmia as a disorder of pregnancy, 405

Choked disc, 772

Cholera, effects of, in medical ophthalmology, 800
  in pregnancy, 428
  in relation to diseases of the eye, 800

Chorea in pregnancy, 422

Chorion as a local cause of abortion, 490

Chromidrosis as a disorder of secretion in diseases of skin, 585

Chronic catarrhal endometritis, 462
  catarrh of middle ear, 823
  congestion of kidney, 69
  cystitis, 128
  diffuse nephritis, 84
  endometritis, 461
  heart disease in pregnancy, 430
  metritis, 450
  ovaritis, 284
  parenchymatous nephritis, 80
  purulent inflammation of middle ear, 827

Cicatrices, 380

Circulatory disturbances in pregnancy, 407

Circumscribed urethritis in women, 355

Clamp in treatment of pedicle after ovariotomy, 325

Classification of abortion, 467
  of seminal incontinence, 137

Clavus, 663

Climacteric neuroses during the menopause, 442

Clinical history of epithelioma of uterus, 279
    of fibrous tumors of uterus, 250
    of seminal incontinence, 138

Clothing in treatment of chronic cystitis, 131

COLIC, RENAL, 42
    Diagnosis, 44
    Prognosis, 45
    Symptoms of, 43
    Treatment of, 45

Coma as a symptom of chronic congestion of kidney, 70

Comedo as a disorder of secretion in diseases of skin, 589

Complications of chronic diffuse nephritis, 94
  of myalgia, 534
  of ovariotomy, 336
  of parametritis, 210
  of pelvic hæmatocele, 243
  of progressive muscular atrophy, 552
  of vaginismus, 384

Congestion and inflammation of ovaries as a cause of disturbed vision,
        758
  of kidney, 69

Connective tissue in pathological anatomy of pseudo-hypertrophic
        paralysis, 571

Constipation during menopause, 440
  in amenorrhoea, 189
  in pregnancy, 413
  in retroversion of uterus, 166

Constituents of urine in chyluria, 115

Constitutional treatment of eczema, 632

Contraindications for ovariotomy, 316

Convallaria in treatment of chronic congestion of kidney, 72

Convulsions as a symptom of diseases of kidneys in pregnancy, 418

Copaiba as a cause of dermatitis medicamentosa, 602

Cornu cutaneum, 663

Corrosive sublimate in the treatment of lupus vulgaris, 696

Course and prognosis of pseudo-hypertrophic paralysis, 568
  and symptoms of chorea in pregnancy, 422
  of acute purulent inflammation of middle ear, 825
  of angioma of the skin, 688
  of congestion of kidney, 71
  of criminal abortion, 497
  of eczema erythematosum, 626
      of the auricle, 811
  of myalgia, 533
  of pelvic hæmatocele, 243
  of perimetritis, 229
  of pityriasis rosea, 621
      rubra, 622
  of polyuria, 30
  of prolapse of uterus, 158
  of pruritus vulvæ, 393
  of retroversion of uterus, 166
  of tinea circinata, 717
  of vaginismus, 384
  of vomiting of pregnancy, 409
  of vulvitis, 389

Criminal abortion, course of, 497

Cubebs as a cause of dermatitis medicamentosa, 603

Culex, 733

Culex lectularius, 733

Cupping, dry, in retroflexion of uterus, 168

Cups, dry, in treatment of nephritis, 83

Curative treatment of chronic endometritis, 465

Curette, use of, in treatment of epithelioma, 710
      of lupus erythematosus, 692

Cystic tumors of ovary, 301
    of vagina, 381

Cysticercus cellulosæ, 732

Cystitis, acute, 126
  chronic, 128
  in pyelo-nephritis, 100
  in women, 341

Cystocele in prolapse of uterus, 158
  vaginalis, 377

Cysto-vaginal hernia, 377

Cysts of canal of Nuck, 397
  of kidney, 63
  of parovarium, 293
  of terminal vesicle of oviduct, 296


D.

Date of cessation of menstruation, 432

Deaf-mutism, 840

Deafness after mumps, 839
    scarlet fever, 839
  in acute catarrh of middle ear 821
  of cerebro-spinal meningitis, scarlet fever, and mumps, 839

Decidua as the local cause of abortion, 488

Decubitus in treatment of vaginitis, 371

Definition and synonyms of parametritis, 209
    of pelvic hæmatocele, 240
  of abortion, 467
  of acne, 641
  of acne rosacea, 647
  of albinismus, 676
  of albuminuria, 34
  of angioma of the skin, 688
  of atresia, 373
  of atrophia cutis, 683
  of atrophia pilorum propria, 682
  of callositas, 662
  of carbunculus, 606
  of chloasma, 659
  of chronic diffuse nephritis, 85
    metritis, 450
    parenchymatous nephritis, 80
  of chyluria, 114
  of clavus, 663
  of cornu cutaneum, 663
  of cysts of canal of Nuck, 397
  of dermatitis herpetiformis, 611
  of dermatolysis, 675
  of displacements of uterus, 150
  of ecthyma, 653
  of eczema vesiculosum, 627
  of elephantiasis, 674
      of the vulva, 399
  of erythema nodosum, 596
  of fibroma of the skin, 686
  of functional disorders in connection with the menopause, 432
  of furuncles of labia, 392
  of furunculus, 604
  of hæmatoma, 401
  of herpes iris, 609
    simplex, 607
    zoster, 610
  of hypertrichosis, 669
  of impetigo, 651
    contagiosa, 652
  of keloid, 685
  of keratosis pilaris, 660
  of lentigo, 658
  of lichen ruber, 623
  of lupus erythematosus, 689
    vulgaris, 693
  of miliaria, 654
  of morphoea, 672
  of myalgia, 529
  of nævus pigmentosus, 666
  of nystagmus, 783
  of onychauxis, 669
  of ovariotomy, 313
  of pemphigus, 656
  of perimetritis, 227
  of phlegmonous inflammation of the labia majora, 391
  of pityriasis rosea, 621
    rubra, 622
  of pompholyx, 655
  of progressive muscular atrophy, 540
  of prolapsus vaginæ, 376
  of prurigo, 639
  of pruritus, 711
    hiemalis, 714
    vulvæ, 392
  of psoriasis, 614
  of pseudo-hypertrophic paralysis, 557
  of pudendal hernia, 398
  of sarcoma of the skin, 710
  of scabies, 726
  of sclerema neonatorum, 671
  of scleroderma, 671
  of scrofuloderma, 698
  of seborrhoea, 586
  of seminal incontinence, 134
  of sycosis, 649
  of syphilis cutanea, 699
  of tinea circinata, 717
    favosa, 715
    sycosis, 723
    tonsurans, 720
    tricophytina, 717
    versicolor, 724
  of urethral caruncle, 403
  of urticaria, 597
  of vaginitis, 368
  of verruca, 664
  of vitiligo, 677
  of vulvitis, 389

Degrees of prolapse of uterus, 154

Delhi boil as a variety of furunculus, 606

Dementia in ophthalmology, 792

Demodex folliculorum, 732

Depletion in the treatment of chronic metritis, 458

Dermatalgia, 711

Dermatitis, 600
  exfoliativa, 623
  gangrenosa, 604
  herpetiformis, 611
  traumatica, 600
  venenata, 600

Dermatolysis, 675

Dermoid cysts of ovary, 299

Descent of uterus, 154

Description of alopecia areata, 680
  of cystic tumors of ovary, 301
  of dilatation of the uterus in women, 355
  of dislocation of the urethra in women, 360
  of erythema multiforme, 595
  of inflammation of urethral glands in women, 354
  of kidneys, 19
  of milium as a disease of skin, 592
  of ovaries and oviducts, 282

Development of the ovum, 477

Diabetes insipidus (see _Polyuria_), 27
  mellitus, effects of, in medical ophthalmology, 796
    in pregnancy, 416
    in relation to diseases of the eye, 796

Diagnosis of abortion, 505
  of acne, 642
  of acne rosacea, 647
  of acute catarrh of middle ear, 822
    endometritis, 461
    metritis, 449
    purulent inflammation of middle ear, 826
    urethritis in women, 353
  of alopecia areata, 681
  of anteflexion of uterus (acquired), 177
  of anteversion of uterus (pathological), 175
  of atrophia pilorum propria, 683
  of atrophia unguis, 683
  of calculous pyelitis, 49
  of cancer of the vagina, 383
  of carcinoma of the uterus, 276
  of chronic endometritis, 464
    metritis, 456
    purulent inflammation of middle ear, 828
  of cystic tumors of the ovary, 304
  of cystitis in wound, 344
  of cysts of parovarium, 295
  of dermatitis herpetiformis, 612
  of dilatation of urethra in women, 358
  of dislocations of the urethra in women, 361
  of disorders of function of uterus, 186
  of displacements of uterus, 151
  of dysmenorrhoea, 194, 195
  of ecthyma, 653
  of eczema, 629
  of eczema of auricle, 811
  of epilepsy in pregnancy, 423
  of epithelioma of the uterus, 279
  of fibroid tumors of the ovary, 297
  of fibrous tumors of the uterus, 252
  of floating kidney, 24
  of foreign bodies in the external ear, 816
  of furuncle of the external auditory canal, 814
  of furunculus, 605
  of hæmatoma, 401
  of hemorrhage from bladder, 135
  of herpes iris, 609
    zoster, 611
  of hyperæmia of bladder in women, 339
  of hypertrophy of the bladder in women, 348
  of impacted cerumen in the external auditory canal, 813
  of imperforate hymen, 374
  of impetigo contagiosa, 652
  of lichen ruber, 624
    scrofulosus, 625
  of lupus erythematosus, 690
    vulgaris, 694
  of malformations of ovaries and oviducts, 283
  miliaria, 654
  of malignant icterus in pregnancy, 415
    tumors of the ovary, 298
  of molluscum epitheliale, 662
  of morphoea, 673
  of myalgia, 537
  of parametritis, 215
  of pemphigus, 657
  of perimetritis, 231
  of phlegmonous inflammation of the labia majora, 391
  of pityriasis rosea, 621
  of polyuria, 31
  of progressive muscular atrophy, 552
  of prolapse of ovary, 288
    of uterus, 159
  of prurigo, 640
  of pruritus, 712
  of pseudo-hypertrophic paralysis, 578
  of psoriasis, 616
  of pyelitis, 84
  of renal colic, 44
  of retroversion of uterus, 166
  of sarcoma of the skin, 710
  of sarcomatous tumors of the uterus, 272
      of the vagina, 382
  of scabies, 727
  of seminal incontinence, 141
  of stricture of the urethra in women, 364
  of sycosis, 650
  of syphiloderma erythematosus, 700
  of tinea circinata, 718
    favosa, 716
    tonsurans, 721
    versicolor, 725
  of tuberculosis of kidney, 65
  of urethral caruncle, 403
  of vaginismus, 385
  of vaginitis, 371
  of verruca, 665
  of the vomiting of pregnancy, 410

Diarrhoea during the menopause, 439, 440
  in pregnancy, 414

Diet in hygienic treatment of vomiting of pregnancy, 410
  in preparation of the patient for ovariotomy, 317

Differential diagnosis of parametritis, 215

Difficulties in diagnosis of floating kidney, 25

Digital uterine examinations, 152
  touch in retroflexion of uterus, 168

Digitalis as a cause of dermatitis medicamentosa, 603
  in treatment of chronic congestion of kidney, 72

Dilatation of the urethra in women, 355

Dilators in the treatment of vaginismus, 386

Diphtheria as a cause of inflammation of middle ear, 819

Diseases of bladder, 123
    in women, organic, 339
  of digestive system, effects on eye, 749
  of ear, see _Otology_.
  of eye, see _Ophthalmology_.
  of external auditory canal, 811
  of internal ear, 835
  of kidneys and skin, affecting eyes, 752
      in pregnancy, 416
  of liver in pregnancy, 414
  of lungs in pregnancy, 430
  of middle ear, 817
  of nervous system, affecting eye, 771
  of organs of respiration, effects of, on eye, 748
  of ovaries and oviducts, 282
  of parenchyma of uterus, 447
  of skin, 583
    in pregnancy, 420
  of uterus, 67
  of urinary organs in women, 339
  of vagina and vulva, 367
  of vulva, 388

Dislocations of the urethra in women, 360

Disorders of alimentary canal during menopause, 440
      in pregnancy, 408
  of function during menopause, 432

Disordered functions of uterus, 182

Disorders of liver during menopause, 441
  of secretion, 583
  of special senses in pregnancy, 423

Displacements of uterus, 150
    as a cause of disturbed vision, 757

Distribution, geographical, of chyluria, 115

Disturbances in circulation in pregnancy, 408
  of vision caused by diseases of sexual organs, 755

Diuretics in treatment of calculous pyelitis, 51
  in medical treatment of diseases of kidneys in pregnancy, 449

Diurnal pollutions in sexual incontinence, 138

Dividing cervix for anteflexion, 179

Dorsodynia as a symptom of myalgia, 532

Double vagina, 380

Douches, vaginal, in retroflexion of uterus, 168

Dover's powder in the treatment of wounds, 346

Dragging sensation in pathological anteversion of uterus, 175

Drainage-tubes after ovariotomy, 332

Dressing-forceps in treatment of abortion, 513
  of wound after ovariotomy, 331

Dressings in treatment of carbunculus, 607

Dropsy as a symptom of acute diffuse nephritis, 82
    of chronic congestion of kidney, 70
    of nephritis, 81
    of scarlatina, 84
      time of occurrence, 84
  Fallopian, 295
  in calculous pyelitis, 51

Drugs in preparation of the patient for ovariotomy, 317
  in treatment of pruritus, 712

Dry cupping in retroflexion of uterus, 168

Duration of abortion, 503
  of acute parenchymatous nephritis, 79
  of chronic parenchymatous nephritis, 81
  of congestion of kidney, 72
  of myalgia, 533
  of pelvic hæmatocele, 243
  of psoriasis, 614
  of vaginismus, 384
  of vulvitis, 389

Dysmenorrhoea, 192
  membranacea in chronic endometritis, 463

Dyspnoea as a symptom of chronic congestion of kidney, 70
      of nephritis, 81
    in congestion of kidney, 71


E.

Ear, diseases of, deaf-mutism, 840
      Treatment, 840
  Examination of, 807
  External, diseases of, 810
      Eczema, 810
        Course, 811
        Diagnosis, 811
        Treatment, 811
      Foreign bodies in, 815
        Insects, 815
        Other varieties of, 816
          Diagnosis, 816
          Objective symptoms, 816
          Subjective symptoms, 816
          Treatment, 816
        Vegetable parasites, 815
          Prognosis, 815
          Symptoms, 815
          Treatment, 815
      Furuncle, 813
        Diagnosis, 814
        Etiology and pathology, 813
        Prognosis, 814
        Symptoms, 814
        Treatment, 814
      Impacted cerumen, 811
        Diagnosis, 813
        Prognosis, 813
        Symptoms, 812
        Treatment, 813
  Feigned deafness, methods of detecting, 840
  Internal, anatomy of, 835
    Diseases of, 835
      Tinnitus, 836
        Varieties, 836-838
        Location, 838
        Prognosis, 838
        Treatment, 838
      Post-febrile deafness, 839
      Menière's disease, 839
  Middle, anatomy of, 817
    Diseases of, 818
      Acute catarrh, 821
        Diagnosis, 822
        Symptoms, 821
          Giddiness, 821
          Loss of hearing-power, 821
          Noises in, 821
          Objective, 822
          Pain, 821
        Treatment, 822
      Acute purulent inflammation, 825
        Course, 825
        Diagnosis, 826
        Prognosis, 826
        Symptoms, 826
        Treatment, 826
      Chronic catarrh, 823
        Causes, 824
        Classification, 823
        Prognosis, 825
        Treatment, 825
      Chronic purulent inflammation, 827
        Causes, 828
        Diagnosis, 828
        Symptoms, objective, 828
          Subjective, 828
        Treatment, 829
        Sequelæ, 830
          Brain involvement, 830
            Abscess of brain, 831
              Symptoms, 832
            Phlebitis with thrombosis, 832
              Prognosis, 833
              Symptoms, 833
            Purulent meningitis, 830
              Symptoms, 831
          Mastoid diseases, 833
            Periostitis, 834
              Symptoms, 834
            Inflammation of mucous membrane of mastoid cells, 834
              Symptoms, 834
              Treatment, 834
      Inflammation, causes of, 820
          Bright's disease, 820
          Diphtheria, 820
          Measles, 819
          Retro-nasal catarrh, 819
          Scarlet fever, 818
          Scrofulosis, 819
          Smallpox, 819
          Syphilis, 820
          Tuberculosis, 819
          Typhoid fever, 820
          Whooping cough, 820

Ecthyma, 653

Eczema, 625
  erythematosum, 626
  of auricle, 810
  papulosum, 627
  pustulosum, 627
  squamosum, 628
  vesiculosum, 627

Effects of high temperature on foetus in acute infectious diseases of
        pregnancy, 424
  of oöphorectomy, 293
  of hemorrhage on eye, 745

Electrical reactions as a symptom of pseudo-hypertrophic paralysis, 560

Electricity in treatment of amenorrhoea, 191
      of atony of bladder, 134
      of paralysis of bladder in women, 351
      of progressive muscular atrophy, 551
      of pseudo-hypertrophic paralysis, 579

Electrolysis in radical treatment of ovarian cysts, 313
  in the treatment of angioma of skin, 689

Elephantiasis, 399, 674

Elytrorrhaphy anterior, 161

Emptying the bladder in chronic cystitis, 132

Endocarditis, acute, in pregnancy, 430

Endometritis, 447, 460, 461
  acute, 460
  chronic, 461

Enterocele vaginalis, 378

Entero-vaginal hernia, 378

Epididymitis as a symptom of acute cystitis, 127

Epilepsy during menopause, 445
  effects of, in medical ophthalmology, 797
  in pregnancy, 423
  in relation to diseases of the eye, 797

Epithelioma, 707
  of the uterus, 278

Ergot in polyuria, 34
  in treatment of chronic metritis, 460
  in treatment of fibrous tumors of uterus, 259

Erosion of the cervix in prolapse of uterus, 157

Erysipelas as a cause of ophthalmitis, 769

Erythema intertrigo, 594
  multiforme, 595
  nodosum, 596
  simplex, 593

Ether in treatment of chronic congestion of kidney, 72

Etiology and pathology of diseases of kidneys in pregnancy, 418
    of furuncle of external auditory canal, 813
    of malignant uterus in pregnancy, 415
  of abortion, 479
  of acute diffuse nephritis, 82
  of acute endometritis, 460
  of acute parenchymatous nephritis, 79
  of chronic diffuse nephritis, 87
    endometritis, 462
    metritis, 450
    parenchymatous nephritis, 81
  of chlorosis and hydræmia as a disorder of pregnancy, 406
  of chorea in pregnancy, 422
  of chyluria, 116
  of congestion of kidney, 69
  of cystitis in women, 341
  of dilatation of urethra in women, 357
  of dislocation of urethra in women, 361
  of eczema, 629
  of elephantiasis of vulva, 399
  of fibrous tumors of uterus, 250
  of hæmatoma, 401
  of hyperæmia of bladder in women, 339
  of hypertrophy of bladder in women, 348
  of lichen ruber, 624
  of medullary cancer of uterus, 274
  of metritis, acute, 447
  of myalgia, 530
  of parametritis, 209
  of pathological anteflexion of uterus, 176
  of pathological anteversion of uterus, 174
  of perimetritis, 228
  of perinephritis, 102
  of pityriasis rubra, 622
  of progressive muscular atrophy, 541
  of prolapse of uterus, 154
  of prolapsus vaginæ, 377
  of pruritus vulvæ, 392
  of pudendal hernia, 398
  of pyelo-nephritis, 100
  of retroflexion of the uterus, 166
  of retroversion of the uterus, 166
  of seminal incontinence, 140
  of simple icterus in pregnancy, 414
  of urethral caruncle, 403
  of vaginismus, 384
  of vaginitis, 368
  of verruca, 665
  of vulvitis, 389

Estimation of albumen in albuminuria, 38

Eustachian tube, examination of, 809

Examination in medical otology, 807
      by tuning-fork, 808
      by voice, 807
      by watch, 807
      of Eustachian tube, 809
      of external auditory canal and tympanic membrane, 807
  of urine in calculous pyelitis, 49

Examinations of uterus, 151

Excision in treatment of dilatation of the urethra in women, 359

Exciting causes of abortion, 481
    of myalgia, 530

Exophthalmic goitre in relation to diseases of the eye, 799

Explorations of uterus, 152

Exposure as a cause of amenorrhoea, 187

External auditory canal, examination of, 807
  treatment of alopecia areata, 681
    of eczema, 634
    of psoriasis, 617
    of urticaria, 599

Eye, 737
  Affections of, from diseases of the digestive organs, 749
    from diseases of intestines, 750
      of liver, 750
      of spleen, 751
      of stomach, 750
      of teeth, 749
    Hemeralopia, 751
  Affections of the fifth pair, 785
      Herpes facialis, 785
        zoster ophthalmicus, 787
      Injuries of, 788
      Neuro-paralytic ophthalmia, 787
        Symptoms, 787
  Affections of, from diseases of the general system, 800
      from cholera, 800
      from gout, 800
      from rheumatism, 800
      from syphilis, 800
      from tuberculosis, 802
  Affections of, from diseases of respiratory organs, 748
  Affections of the second pair, 771
      Choked disc, 772
      Hemianopia, 775
        Cases of, 775
        Symptoms of, 778
      Neuritis, 771
      The lymph-space theory, 773
  Affections of the seventh pair, 790
        Blepharospasm, 790
  Affections of, from diseases of the sexual organs, 755
  Affections of the sixth pair, 789
      Symptoms, 789
  Affections of the third pair, 780
    Associated movements of the head and eyes, 782
    Double third-pair paralysis, 780
    Nystagmus, 783
      Autopsies in, 784
      Definition, 783
      Frequency, 783
      Pathology, 784
      Symptoms, 783
    Ophthalmoplegia interna, 781
      Description of, 781
      Paralysis of, 781
      Ptosis, 781
  Affections of the twelfth pair, 790
    Bulbar paralysis, 790
    Labio-glosso-laryngeal paralysis, 790
  Mental affections, 791
    Dementia, 792
    General paralysis, 792
    Mania, 792
    Melancholia, 792
  Spinal cord, 792
    Injuries to, 792
    Tabes dorsalis, 793
  Unclassified nervous affections, 796
    Basedow's disease, effects of, 799
    Diabetes mellitus, effects of, 796
    Epilepsy, idiopathic, effects of, 797
    Exophthalmic goitre, effects of, 799
    Graves' disease, effects of, 799
    Toxic amblyopia, 803
      Alcohol, 803
      Lead-poisoning, 803
      Quinine, 804
      Salicylate of sodium, 804
      Santonin, 804
      Tobacco, 803
    Blindness after pneumonia, 748
    Congestion and inflammation of ovaries, 758
      Displacement of uterus, 757
      Lactation, 760
      Masturbation, 758
      Menstruation, 755
      Pathology, 660
      Pelvic cellulitis, 757
      Pregnancy, 759
      Puerperal phlebitic ophthalmitis, 759
    In relation to diseases of the skin and kidneys, 752
  Diseases of, febrile and post-febrile ophthalmitis, 761
      Erysipelas, 769
      Intermittent fever, 768
      Relapsing typhus, 765
      Rubeola, 763
      Scarlatina, 764
      Typhoid fever, 767
      Variola, 761
      Yellow fever, 767
  Effects of diseases of kidneys and skin on, 752

Eye-ground, changes in, due to diseases of circulatory apparatus, 738
  Effects of hemorrhage on, 745
    Leukæmic retinitis, 744
    Pathology, 746
    Pernicious anæmia, 745
    Retinal aneurism, 743


F.

Factitia, 604

Fallopian dropsy, 295

Febrile and post-febrile ophthalmitis, 761

Feigned deafness, methods of detecting, 840

Ferrocyanide of potash as a test for albumen in albuminuria, 37

Fever as a symptom of progressive muscular atrophy, 552
  relapsing, in pregnancy, 427
  scarlet, in pregnancy, 426
  typhoid, in pregnancy, 426
  typhus, in pregnancy, 427

Fibroid tumors of ovary, 297

Fibroma of skin, 686

Fibrous tumors of uterus, 245
    of vagina, 381

Fifth pair of cranial nerves, affections of, 785

Filaria as a cause of elephantiasis, 674
  medinensis, 732

Flexions of uterus, 166, 174, 176, 177

Floating kidney, 21

Forceps for arresting hemorrhage in ovariotomy, 322

Foreign bodies in external ear, 815

Frequency of abortion, 468
  of acne, 642
  of floating kidney in sex, 22
  of herpes iris, 609
  of lichen scrofulosis, 625
  of nystagmus, 783
  of pelvic hæmatocele, 240
  of sarcoma of the skin, 710
  of tinea circinata, 718
    favosa, 715
    sycosis, 724
    tonsurans, 720

Functional disorders of bladder in women, 349
    in connection with menopause, 432

Functions of uterus, disordered, 182

Furuncle of external auditory canal, 813

Furuncles of labia, 392

Furunculus, 604


G.

Gallic acid in treatment of hemorrhage from bladder, 135

Galvanism in the treatment of chronic perimetritis, 237

General paralysis of the insane in relation to diseases of the eye, 792
  treatment of chronic metritis, 459

Geographical distribution of chyluria, 115

Giddiness in acute catarrh of middle ear, 821

Glycerin tampons in treatment of chronic metritis, 458

Goitre, exophthalmic, in medical ophthalmology, 799

Gout, effects of, in medical ophthalmology, 800

Graves' disease, in medical ophthalmology, 799

Great thirst as a symptom of polyuria, 29

Growths in the vagina, 381

Gymnastics in treatment of progressive muscular atrophy, 555
      of seminal incontinence, 143

Gynæcological treatment of vomiting of pregnancy, 412


H.

Hæmatoma, 401

Hæmaturia, 104

Hæmoglobinuria, 104
  in albuminuria, 35

Hæmophilia as a disorder of pregnancy, 407

Hæmostatics in treatment of hemorrhage from bladder in women, 340

Hair in tinea tonsurans, 720

Headache as a symptom of polyuria, 30

Heart disease in pregnancy, 430

Hemeralopia, 751

Hemianopia, 775

Hemianopsia, 775

Hemiopia, 775

Hemorrhage, arresting of, in ovariotomy, 322
  as a local cause of abortion, 490
  during menopause, 438
  from bladder, 134
    in women, 340
  its effects on the eye, 745

Heredity of lupus vulgaris, 693

Hernia of ovary, 289
  pudendal, 398

Herpes facialis, 785
    as an affection of fifth pair of cranial nerves, 785
  iris, 609
  simplex, 607
  zoster, 610
    ophthalmicus, 785
      as an affection of fifth pair of cranial nerves, 785

High temperature, effects on foetus in acute infectious diseases of
        pregnancy, 424

Histology of progressive muscular atrophy, 543

History, natural, of change of life, 434
  of abortion, 470
  of Menière's disease, 839
  of myalgia, 529
  of ovariotomy, 313
  of progressive muscular atrophy, 540
  of pseudo-hypertrophic paralysis, 557
  of retroversion of uterus, 166

Horseshoe kidney, 20

Hot-water douche in treatment of chronic metritis, 457
  in treatment of parametritis, 220

Hyaline casts in pyelitis, 54

Hydræmia as a disorder of pregnancy, 405

Hydrocele in women, 397

Hydro-nephrosis, 56
  Causes of, 56
  Diagnosis, 58
  Effects of, 58
  Treatment of, 59

Hygienic treatment of diseases of kidneys in pregnancy, 419
    of vomiting of pregnancy, 410

Hyoscyamus in acute cystitis, 127

Hyperæmia as a cause of chronic metritis, 451
  of bladder in women, 339

Hyperidrosis as a disorder of secretion in diseases of skin, 583

Hypertrichosis, 669

Hypertrophies of skin, 658

Hypertrophy of bladder in women, 348
  of vulva, 398

Hysterical diathesis as a cause of polyuria, 31

Hysteria during menopause, 443

Hystero-epilepsy in relation to diseases of eye, 799


I.

Ice in treatment of hemorrhage from bladder, 135

Ichthyosis, 666

Icterus in pregnancy, 414
  malignant, in pregnancy, 415

Impacted cerumen in the external auditory canal, 811

Imperforate hymen, 374

Impetigo, 651
  contagiosa, 652

Importance of abortion, 468

Incision in treatment of furuncle in external auditory canal, 815
    stricture of the urethra in women, 364
  line of, in ovariotomy, 322

Indications for ovariotomy, 316

Infectious diseases in pregnancy, acute, 424

Inflammation of bladder, 123
  of middle ear, causes of, 818
  of ovaries as a cause of disturbed vision, 758
  of ovary, 283

INFLAMMATION OF THE PELVIC CELLULAR TISSUE AND PELVIC
        PERITONEUM--General considerations, 208
    Parametritis, 209
      Anatomy, course, 210
      Cases of, 217
      Complications, 210
      Course, 210
      Definitions and symptoms, 209
      Differential diagnosis, 215
      Etiology 209
        Parturition as a cause, 210
      Pathology and termination, 210
      Physical signs, 214
      Prognosis, 219
      Symptomatology, 213
      Treatment, 219
        Aconite in, 221
        Aspiration in, 225
        Blistering in, 222
        Hot water in, 220
        Iodine in, 221
        Medicinal, 227
        Morphia in, 220
        Operation, 223
    Perimetritis, 227
      Course, 229
      Definition of, 227
      Diagnosis, 231
      Etiology of, 228
      Pathology, 229
      Physical signs, 231
      Prognosis, 232
      Symptoms, 230
      Synonyms for, 227
      Termination, 229
      Treatment, 232
        Blisters in, 236
        Galvanism, 237
        Local, 234
        Of chronic perimetritis, 233
        Packing in, 236

Inflammation of the urethral glands in women, 354

Inflammations, 593

Injections in the treatment of vaginitis, acute, 372

Injuries of the fifth pair of cranial nerves, 788
  to the spinal cord in relation to diseases of the eye, 792
  to the spine in relation to diseases of the eye, 792

Insanity during the menopause, 445

Insects in the external ear, 815

Instruments for the examination of the external auditory canal, 809
  for the operation of ovariotomy, 319
  in treatment of abortion, 512

Intermittent fever as a cause of ophthalmitis, 768

Internal ear, 835
  treatment of alopecia areata, 681
    of psoriasis, 617
    of urticaria, 599

Inversion of urethral mucous membrane in women, 362

Iodide of potash in the treatment of fibrous tumors of the uterus, 259
      of syphiloderma bullosum, 707

Iodides as a cause of dermatitis medicamentosa, 603

Iodine in the treatment of parametritis, 221

Iron in the treatment of acute parenchymatous nephritis, 80
    of hemorrhage from bladder, 135
    of pernicious anæmia of pregnancy, 406

Irrigation in the treatment of vaginitis, acute, 372

Ixodes, 733


J.

Jaborandi in the treatment of nephritis, 83


K.

Keloid, 685

Keratosis pilaris, 660

Kidney, absence of one, 21
  Anomalies of, 19
  Horse-shoe, 20
    Description of, 19

Kidneys, alterations in functions of, during the menopause, 437

KIDNEYS, DISEASES OF THE--Albuminuria, 34
    Albuminoids in, 35
    Causes of, 39
    Definition of, 34
    Estimation of albumen in, 38
    Hæmoglobinuria in, 35
    In pregnancy, 416
    Nephrozymase in, 35
    Of nervous affections, 40
    Of pregnancy, 40
    Tests for albumen in, 35
      Ferrocyanide of potash, 37
      Nitric acid, 36
      Salt solution with hydrocyanic acid, 36
    Treatment of, 42
      Astringents in, 42
  Bright's disease, 72
    Albuminuria in, 75
    Blood in, 77
    Casts in urine in, 76
    Cerebral symptoms in, 77
    Dyspnoea in, 76
    Retinitis, 77
  Calculous pyelitis, 47
    Diagnosis of, 49
    Examination of urine in, 49
      Pus as an aid to, 49
      Thompson's method in, 49
    Symptoms of, 51
      Albuminuria in, 47
      Casts in, 51
      Dropsy in, 51
    Treatment of, 51
      Diuretics, 51
      Operative, 51
        Nephrectomy, 51
        Nephro-lithotomy, 51
      Palliative, 51
      Rest, 51
    Varieties of, 47
  Chyluria, 114
    Constituents of urine in, 115
    Definition of, 114
    Distribution, geographical, 115
    Etiology, 116
    Morbid anatomy of, 119
    Pathology of, 115
    Symptoms of, 119
    Treatment of, 120
  Congestion, chronic, 69
    Course of, 71
      Cardiac disease in, 71
      Dyspnoea in, 71
    Duration of, 72
    Etiology of, 69
    Lesions of, 69
      Atrophied tubercles, 69
      Unnatural hardness as a, 69
    Symptoms of, 70
      Albuminuria as a, 70
      Casts as a, 70
      Coma as a, 70
      Dropsy as a, 70
      Dyspnoea, 70
      Loss of flesh, 70
    Synonyms, 69
    Treatment of, 72
      Caffeine in, 72
      Convallaria in, 72
      Digitalis in, 72
      Ether in, 72
      Opium in, 72
  Cysts, 63
    Symptoms of, 63
    Varieties of, 63
  Malignant growths, 60
    Symptoms of, 61
    Treatment, 62
  Nephritis, 82
    Acute diffuse, 82
      Etiology of, 82
      Morbid anatomy of, 82
      Prognosis of, 83
      Symptoms of, 82
        Albumen in urine, 82
        Bloody urine, 82
        Cerebral, 82
        Dropsy, 82
        Micturition, painful, 82
        Pericarditis, 83
        Peritonitis, 83
        Pleurisy, 83
        Pneumonia, 83
      Treatment of, 83
        Dry cups, 83
        Jaborandi in, 83
        Purgatives in, 83
    Acute diffuse, of scarlatina, 84
      Prognosis, 84
      Symptoms of, 84
        Dropsy, 84
      Time of occurrence, 84
    Acute parenchymatous, 78
      Duration of, 79
      Etiology of, 79
      Pathological anatomy of, 78
      Prognosis of, 80
      Symptoms of, 79
      Treatment of, 80
        Iron, 80
        Milk diet, 80
        Oxygen, 80
        Pilocarpine, 80
        Sweating, 80
    Chronic diffuse, 84
      Albuminuria in, 96
      Casts in urine in, 96
      Complications of, 94
      Definition of, 85
      Etiology of, 87
      Lesions of, 86
      Morbid anatomy of, 85
        Large white kidney, 90
            with waxy infiltration, 92
      Symptoms of, 88
      Treatment of, 95
    Chronic parenchymatous, 80
      Definition, 80
      Duration of, 81
      Etiology of, 81
      Lesions of, 81
      Prognosis of 81
      Symptoms of, 81
        Albumen in urine, 81
        Change in specific gravity of urine, 81
          quantity of urine, 81
        Dropsy, 81
        Dyspnoea, 81
    Pyelo-, 99
      Causes of, 99
      Cystitis in, 100
      Etiology of, 100
      Prognosis, 101
      Treatment of, 101
      Symptoms of, 99
      Treatment of, 99, 101
      Varieties of, 99
  Parasites, 65
    Treatment of, 66
    Varieties of, 65
  Perinephritis, 102
    Etiology, 102
    Lesions, 102
    Symptoms of, 102
      Rupture of abscess into peritoneal cavity, 102
    Treatment of, 103
  Polyuria, 27
    Course of, 30
    Diagnosis, 32
    Large quantities of water consumed during, 30
    Origin of, 31
      After acute diseases, 30
      After meningitis, 31
      Hysterical diathesis in the, 31
      Sudden fright in the, 31
    Pathology, 31
      Nerve lesions, 31
    Symptoms, 27
      Dryness of skin, 29
      Great thirst, 29
      Headache, 30
      Phosphates in urine, 30
    Termination, 30
    Treatment, 33
      Atropia in, 34
      Ergot in, 34
      Nitric acid in, 33
      Opium in, 33
      Pilocarpine in, 34
      Sufficient food in, 33
        liquids in, 33
  Pyelitis, secondary, 53
    Causes of, 53
    Diagnosis of, 54
      Hyaline casts in, 54
      Muco-pus in, 54
      Pain in, 54
    Treatment of, 55
      Boric acid in the, 55
      Carbolic acid, 55
      Operative, 55
      Washing-out of bladder as a, 55
  Tuberculosis of, 64
    Diagnosis, 65
    Origin, 64
    Prognosis, 65
  Floating, 21
    Diagnosis, 24
      Difficulties in, 25
    Frequency in sexes, 22
    Symptomatology, 23
    Treatment, 25
  Palpation of, 20
  Position of, 20
  Supernumerary, 21


L.

Labio-glosso-laryngeal paralysis, 790
      in medical ophthalmology, 790

Lacerated cervix uteri as a cause of chronic metritis, 451

Lactation as a cause of disturbed vision, 760

Laparo-hysterectomy in treatment of fibrous tumors of the uterus, 269

Laparotomy in treatment of fibrous tumors of the uterus, 269

Large quantities of water consumed in polyuria, 30

Large white kidney, 90
      with waxy infiltration, 92

Lateral flexion of uterus, 174
  locations of uterus, 153
  versions of uterus, 174

Laxatives in constitutional treatment of eczema, 632

Lead-poisoning as a cause of toxic amblyopia, 803
  effects of, on the eye, 803

Left hand in uterine examinations, 152

Lentigo, 658

Leptus, 731

Lesions of chronic diffuse metritis, 86
      parenchymatous nephritis, 81
  of congestion of kidney, 69
  of perinephritis, 102

Leucorrhoea, 447, 455
  during the menopause, 439

Leukæmic retinitis, 744

Lichen ruber, 623
  scrofulosus, 624

Ligatures, silk, in the treatment of pedicle after ovariotomy, 326

Line of incision in ovariotomy, 322

Liver, diseases of, in pregnancy, 414
  disorders of, during the menopause, 441

Local causes of abortion, 488
  treatment of acne, 644
    of chronic endometritis, 465
    of metritis, 457
    of perimetritis, 234
    of psoriasis, 619
    of syphiloderma bullosum, 707

Location of nævus pigmentosus, 666

Locomotion in pseudo-hypertrophic paralysis, 563

Loss of flesh as a symptom of chronic congestion of kidney, 70

Lotions in external treatment of eczema, 635
  in treatment of lupus erythematosus, 691
    of vulvitis, 390

Lumbago as a symptom of myalgia, 533

Lungs, diseases of, in pregnancy, 430

Lupus erythematosus, 689
  vulgaris, 693

Lymphangioma of skin, 689

Lymph-space theory, 773


M.

Malarial fever in pregnancy, 427

Malformations of ovaries and oviducts, 282

Malignant growths of kidney, 60
  icterus in pregnancy, 415
  tumors of ovary, 298

Mammary glands, changes in, during menopause, 437

Mania in relation to diseases of eye, 792

Marriage, in treatment of inflammation of bladder, 125
      of seminal incontinence, 146

Massage in treatment of progressive muscular atrophy, 555

Mastoid disease, following chronic inflammation of middle ear, 833

Masturbation as a cause of disturbed vision, 758

Measles as a cause of inflammation of middle ear, 819
  in pregnancy, 426

Medical ophthalmology, see _Ophthalmology_.

Medical otology, see _Otology_.
  treatment of diseases of kidneys in pregnancy, 419
    of vomiting of pregnancy, 411

Medicated cotton pledgets in treatment of anteversion of uterus, 176

Medication in treatment of abortion, 512

Medicinal treatment of pelvic abscess, 227

Medullary cancer of uterus, 274

Melancholia in relation to diseases of eye, 792

Menière's disease, see _Otology_.

Meningitis, purulent, as a sequel of chronic inflammation of middle
        ear, 831

MENOPAUSE, FUNCTIONAL DISORDERS IN CONNECTION WITH, 432
    Alterations in functions of skin, 435
      in nutrition, 437
      in secretion by kidneys, 437
    Hemorrhages, 438
    Neuroses, 442
      Cerebral hyperæmia, 443
      Epilepsy, 445
      Hysteria, 443
      Insanity, 445
      Monomania, 445
      Pseudocyesis, 444
    Of alimentary canal, 440
      Constipation, 440
      Diarrhoea, 440
    Of liver, 441
    Serous and mucous discharges, 438
      Diarrhoea, 439
      Leucorrhoea, 439
  Date of cessation of menstruation, 432
  Definition of, 432
  Duration of, 432
  Mammary glands, changes in, 437
  Natural history of, 434
  Respiratory changes, 435
  Termination, 432

Menorrhagia, 200

Menstruation, 182
  age of, 185
  as a cause of disturbed vision, 755

Mental affections in relation to diseases of the eye, 791

Mercury as a cause of dermatitis medicamentosa, 603
  in treatment of syphiloderma bullosum, 706

Methods for detecting feigned deafness, 840
  of examination of Eustachian tube, 809

Metritis, acute, 447
  chronic, 450

Middle ear, acute catarrh of, 821
    anatomy of, 817
    diseases of, 817

Miliaria, 654

Milium, 592

Milk diet in treatment of acute parenchymatous nephritis, 80

Morbid anatomy of abortion, 494
    of acute diffuse nephritis, 82
    of chronic diffuse nephritis, 85
    of chyluria, 119
    of elephantiasis, 675
    of lupus vulgaris, 694
    of myalgia, 534

Molluscum epitheliale, 661

Monomania during menopause, 445

Morphia as a cause of dermatitis medicamentosa, 603
  in treatment of parametritis, 220
    of pelvic hæmatocele, 244
  suppositories in treatment of cystitis in women, 346

Morphoea, 672

Movements of uterus, normal, 149

Muco-pus in pyelitis, 84

Multiple fibroma of skin, 686

Mumps, deafness after, 839

Muscles affected in pseudo-hypertrophic paralysis, 560

Muscular atrophy, progressive, 540
  fibres in pathological anatomy of pseudo-hypertrophic paralysis, 570

Mutism, 840

MYALGIA, 529
  Complications, 534
  Course, 533
  Definition, 529
  Diagnosis, 537
  Duration, 533
  Etiology, 530
    Exciting causes, 530
    Predisposing causes, 530
  History, 529
  Morbid anatomy, 534
  Pathology, 534
  Prognosis, 538
  Sequels, 534
  Symptomatology, 531
    Cephalodynia, 532
    Dorsodynia, 532
    Lumbago, 533
    Omodynia, 532
    Pleurodynia, 532
    Scapulodynia, 532
    Torticollis, 532
  Synonyms, 529
  Termination, 533
  Treatment, 538

Myoma of skin, 687


N.

Nævus pigmentosus, 666

Natural history of change of life, 434

Nephrectomy in treatment of calculous pyelitis, 51

Nephro-lithotomy in treatment of calculous pyelitis, 51

Nephrozymase in albuminuria, 35

Nerve-centres in pathological anatomy of pseudo-hypertrophic paralysis,
        572

Nerve-lesions in polyuria, 31

Nerves, fifth pair, affections of, in relation to diseases of eye, 785
  seventh pair, affections of, in relation to diseases of eye, 790
  sixth pair, affections of, in relation to diseases of eye, 789
  third pair, in relation to diseases of the eye, 780
  twelfth pair, affections of, in relation to diseases of eye, 790

Nervi optici, neuritis of, 771

Nervous diseases, unclassified, in relation to diseases of eye, 796
  system, diseases of, affecting eye, 771

Neuritis of nervi optici, 771

Neuroma of skin, 686

Neuro-paralytic ophthalmia, 787

Neuroses during menopause, 442
  of bladder, 132
  of pregnancy, 421
  of skin, 711

New growths of bladder, 136
    of skin, 685

Nitrate of silver in treatment of acute urethritis in women, 353
      of chronic purulent inflammation of middle ear, 829
      of cystitis in women, 347
      of furuncles of labia, 392
      of hemorrhage from bladder, 135
      of lupus vulgaris, 696
      of seminal incontinence, 145

Nitric acid as a test for albumen in albuminuria, 36
    in polyuria, 33

Nocturnal pollutions in seminal incontinence, 137

Nomenclature of displacement of uterus, 150

Normal location of uterus, 147
  movements of uterus, 149
  supports of uterus, 150

Nutrition, alterations in, during the menopause, 437

Nystagmus, 783


O.

Objective symptoms of acute catarrh of middle ear, 822
    of purulent inflammation of middle ear, 828

Obstetrical treatment of vomiting of pregnancy, 412

Oestrus, 732

Ointments in external treatment of eczema, 635
  in treatment of angioma of skin, 688
    of inflammation of bladder, 125
    of lupus vulgaris, 697
    of pruritus, 713
    of seborrhoea, 589
    of tinea tonsurans, 722

Omodynia as a symptom of myalgia, 532

Onychauxis, 669

Oöphorectomy, 290
  dressings in, 292
  effects of, 293
  indications for, 290
  varieties of, 291

Operative treatment of calculous pyelitis, 51
    of chronic metritis, 459
    of lupus vulgaris, 697
    of pelvic abscess, 223
    of pelvic hæmatocele, 244
    of pyelitis, 55

Opium as a cause of dermatitis medicamentosa, 603
  in acute cystitis, 127
  in polyuria, 33
  in treatment of chronic congestion of kidney, 72
  in treatment of hemorrhage from bladder, 135

Ophthalmitis, puerperal phlebitic, 759

OPHTHALMOLOGY, MEDICAL, 737
  Affections of the eye from diseases of the digestive organs, 749
      of intestines, 750
      of liver, 750
      of spleen, 751
      of stomach, 750
      of teeth, 749
    Hemeralopia, 751
  Affections of the fifth pair, 785
    Herpes facialis, 785
        zoster ophthalmicus, 785
      Prognosis, 786
      Symptoms, 785
    Injuries of, 788
    Neuro-paralytic ophthalmia, 787
  Affections of the general system, 800
    Cholera, 800
    Gout, 800
    Rheumatism, 800
    Syphilis, 800
    Tuberculosis, 802
  Affections of the second pair, 771
    Choked disc, 772
    Lymph-space theory, 773
    Neuritis, 771
  Affections of the seventh pair, 790
    Blepharospasm, 790
  Affections of the sixth pair, 789
    Symptoms, 789
  Affections of the third pair, 780
    Associated movements of the head and eyes, 782
      Causes of, 782
    Nystagmus, 783
      Autopsies in, 784
      Definition, 783
      Frequency, 783
      Pathology, 784
      Symptoms, 783
    Ophthalmoplegia interna, 781
      Description of, 781
    Paralysis of, 780
    Ptosis, 781
  Affections of the twelfth pair, 790
    Bulbar paralysis, 790
    Labio-glossal-laryngeal paralysis, 790
  Blindness after pneumonia, 748
  Changes in eye-ground and its appendages due to diseases of the
        circulatory apparatus--heart, blood-vessels, and blood, 738
    Hemorrhage, 745
    Leukæmic retinitis, 744
    Pathology, 746
    Pernicious anæmia, 745
    Prognosis, 746
    Retinal aneurism, 743
  Diseases of kidneys and skin affecting the eyes, 752
    of the nervous system affecting the eyes, 771
    of the organs of respiration, 748
  Disturbances of vision caused by disease of the sexual organs, 755
    Menstruation, 755
    Congestion and inflammation of ovaries, 758
    Displacements of the uterus, 757
    Lactation, 760
    Masturbation, 758
    Pathology, 760
    Pelvic cellulitis, 757
    Pregnancy, 759
    Puerperal phlebitic ophthalmitis, 759
  Febrile and post-febrile ophthalmitis, 761
    Erysipelas, 769
    Intermittent fever, 768
    Relapsing typhus, 765
    Rubeola, 763
    Scarlatina, 764
    Typhoid fever, 767
    Variola, 761
    Yellow fever, 767
  Hemianopia, 775
    Cases of, 776
    Symptoms, 778
  Mental affections, 791
    Dementia, 792
    General paralysis, 792
    Mania, 792
    Melancholia, 792
  Nervous system, unclassified diseases of, affecting the eye, 799
        Basedow's disease, 799
        Diabetes, 796
        Epilepsy, idiopathic, 796
        Exophthalmic goitre, 799
        Graves' disease, 799
        Toxic amblyopia, 803
          Alcohol, 803
          Lead-poisoning, 803
          Quinine, 804
          Salicylate of sodium, 804
          Santonin, 804
          Tobacco, 803
        Spinal cord, 792
          Injuries to, 792
          Tabes dorsalis, 793
  Ophthalmoplegia interna, 781
    as an affection of third pair of cranial nerves, 781

Origin of polyuria, 31
  of tuberculosis of kidney, 64

OTOLOGY, MEDICAL, 805
  Diseases of external auditory canal, 811
    Impacted cerumen, 811
      Causes, 812
      Diagnosis, 813
      Prognosis, 813
      Symptoms, 812
      Treatment, 813
    Eczema of the auricle, 810
      Course, 811
      Diagnosis, 811
      Treatment, 811
    Examination of Eustachian tube, 809
          methods of, 809
      of external canal and tympanic membrane, 808
        by ear speculum, 808
        instruments in, 809
      of patients by the tuning-fork, 807
        by the voice, 807
        by the watch, 807
    Foreign bodies in the ear, 815
      Insects, 815
      Varieties of, 816
        Diagnosis, 816
        Symptoms, 816
        Treatment, 816
      Vegetable parasites, 815
        Prognosis, 815
        Symptoms, 815
        Treatment, 815
    Furuncle, 813
      Diagnosis, 814
      Etiology and pathology, 813
      Prognosis, 814
      Symptoms, 814
      Treatment, 814
  Internal ear, anatomy of, 835
    Diseases of, 835
      Deaf-mutism, 840
        Treatment, 840
      Deafness after cerebro-spinal meningitis and mumps, 839
      Menière's disease, 839
        Treatment, 840
      Tinnitus aurium, 836
        Prognosis, 838
        Treatment, 838
        Varieties, 836
  Methods for detecting feigned deafness, 840
  Middle ear, anatomy of, 817
    Diseases of, 817
      Acute catarrh, 821
        Diagnosis, 822
        Symptoms of 821
          Deafness, 821
          Giddiness, 821
          Objective, 822
          Pain, 821
          Tinnitus aurium, 821
        Treatment, 822
      Acute purulent inflammation, 825
        Course, 825
        Diagnosis, 826
        Prognosis, 826
        Symptoms, 826
        Treatment, 826
      Chronic catarrh, 823
        Classification, 823
        Causes, 824
        Description, 824
        Prognosis, 825
        Treatment, 825
      Chronic purulent inflammation, 827
        Causes, 828
        Diagnosis, 828
        Morbid anatomy, 828
        Sequelæ, 830
          Abscess of brain from, 831
            Location of, 831
            Symptoms, 832
          Brain involvement, 830
          Mastoid disease, 833
            Symptoms, 834
            Treatment, 834
          Phlebitis with thrombosis, 832
            Symptoms, 833
            Prognosis, 833
          Purulent meningitis, 831
            Symptoms, 831
        Symptoms, 828
        Treatment, 829
          Boric acid, 829
          Nitrate of silver, 829
      Inflammation, causes of, 818
        Bright's disease, 820
        Diphtheria, 820
        Measles, 819
        Retro-nasal catarrh, 819
        Scrofulosis, 819
        Smallpox, 819
        Syphilis, 820
        Tuberculosis, 819
        Typhoid fever, 820
        Whooping cough, 820

Ovarian cysts, treatment of, aspiration in the, 308
    Electrolysis in the, 313
    Radical surgical, 312
    Tapping in the, 308
    Use of trocar in the, 308

Ovarian tumors, 297
  Cystic, 301
    Causation of, 302
    Description, 301
    Diagnosis, 304
      Ascites in the, 305
      Obesity in the, 308
      Phantom tumors in the, 308
      Pregnancy in the, 306
      Renal cysts in the, 307
      Spina bifida in the, 307
      Uterine fibroids in the, 306
    History, 303
    Symptoms, 303
    Treatment of surgical, 308
      Palliative, surgical, 308
        Aspiration in the, 308
        Tapping through the abdominal wall, 310
          methods of, 310
        Tapping through the vagina, 311
        Use of the trocar in the, 308
      Radical, 312
        Electrolysis in the, 313
  Dermoid cystic, 299
    Description of, 299
    Symptoms of, 294
    Treatment of, 300
  Fibroid, 297
    Diagnosis, 297
    Prognosis, 297
    Recoveries in, 297
  Malignant, 298
    Description, 298
    Diagnosis, 298
    Treatment, 299

OVARIES AND OVIDUCTS, DISEASES OF, 282
  Cysts of the oviducts, 295
    Contents of, 295
    Diagnosis of, 295
    Treatment of, 295
  Cysts of the parovarium, 293
    Description, 293
    Differential diagnosis, 294
    Treatment, 295
  Cysts of terminal vesicle of the oviduct, 296
  Hernia, 289
    Treatment, 290
  Inflammation, 283
  Ovaritis, acute, 283
    Chronic, 284
      Causation of, 284
      Prognosis, 285
      Symptoms, 285
      Treatment, 285
        Bromide of potash in, 286
        Fowler's solution in, 286
        Rest-cure in, 286
        Suppositories in, 285
        Oöphorectomy in, 287
  Prolapse, causation of, 287
    Description, 287
    Diagnosis, 288
    Symptoms, 287
    Treatment, 288
      Knee-chest position in, 289
      Oöphorectomy in, 289
  Tumors of the round ligament, 296
    Description of, 282
    Malpositions of, 282
      Diagnosis, 283
      Treatment, 283
  Ovariotomy, 313
    Accidents and complications of, 336
    After-treatment of cases of, 333
    Arrangement of tables for, 320
    Articles needed for the operation of, 318
    Assistants in, 320
      Position of, 321
    Carbolic-acid spray in, 320
        for instruments, 321
    Causes of death after, 314
    Contraindications for, 316
    Counting the sponges after, 330
    Definition of, 313
    Drainage-tubes after, 332
    Dressing the wound after, 331
    History of, 313
    Indications for, 316
    Instruments, 319
      Cautery-irons, 319
      Forceps, 319
      Gauze, 319
      Needles, 319
      Sponges, 319
    Line of incision in, 322
    Performance of the operation of, 322
    Preparation of the patient for, 317, 321
      Diet in the, 317
      Drugs in the, 317
    Pressure-forceps for arresting hemorrhage in, 322
    Statistics of, 314
    Surgical after-treatment of cases of, 335
    Time for the performance of, 318
    Treatment of pedicle after, 325
      By actual cautery, 326
      By clamp, 325
      Silk ligatures in, 326

Ovum, development of, 477
  as a local cause of abortion, 489

Oxygen in the treatment of acute parenchymatous nephritis, 80


P.

Pain in acute catarrh of the middle ear, 821
  in chronic cystitis, 129
  in pyelitis, 54

Painful micturition as a symptom of nephritis, 82

Palliative treatment of calculous pyelitis, 51

Palpation of kidney, 20

Paralysis, double, of third pair of nerves, 780
  of bladder, 133
    in women, 350
  of third pair of cranial nerves, 780
  pseudo-hypertrophic, 557

Parametritis, 209

Parasites in pathology of comedo, 590
  of kidney, 65
  of skin, 715
  vegetable, in the external ear, 815

Parasiticides in treatment of scabies, 728
  in treatment of tinea favosa, 716

Parenchyma of the uterus, diseases of, 447

Parenchymatous nephritis, acute, 78
  chronic, 80

Parturition in the etiology of parametritis, 210

Pathogeny of progressive muscular atrophy, 546
  of pseudo-hypertrophic paralysis, 576
  of seminal incontinence, 140

Pathological anatomy of acute endometritis, 461
  of acute metritis, 448
  of acute parenchymatous nephritis, 78
  of chronic endometritis, 462
  of chronic metritis, 452
  of progressive muscular atrophy, 543
  of prolapse of uterus, 157
  of pseudo-hypertrophic paralysis, 569
  anteflexion of uterus, 176
  anteversion of uterus, 174

Pathology and etiology of the vomiting of pregnancy, 409
  of abortion, 494
  of chronic cystitis, 130
  of chyluria, 115
  of comedo, 590
  of cystitis in women, 341
  of diseases of kidneys in pregnancy, 418
  of disturbed vision, 760
  of eczema, 629
  of elephantiasis of the vulva, 399
  of impetigo, 651
  of inflammation of bladder, 124
  of keloid, 685
  of lupus erythematosus, 690
  of malignant icterus in pregnancy, 415
  of milium, 592
  of molluscum epitheliale, 662
  of myalgia, 534
  of nystagmus, 784
  of parametritis, 210
  of pelvic hæmatocele, 240
  of perimetritis, 229
  of pernicious progressive anæmia of pregnancy, 406
  of polyuria, 31
  of prolapsus vaginæ, 377
  of prurigo, 640
  of retroflexion of uterus, 166
  of stricture of the urethra in women, 363
  of urethral caruncle, 403
  of urticaria, 598
  of vaginismus, 385

Pedicle, treatment of, after ovariotomy, 325

Pediculosis, 728
  capitis, 729
  corporis, 730

Pedunculus, 227

Pelvic abscess, treatment of, 222
  Cellular tissue, inflammation of, 208
  Cellulitis as a cause of disturbed vision, 757
    Causes, 241
    Complications, 243
    Course of, 243
    Definition and synonyms of, 240
    Differentiation, 243
    Duration, 243
    Frequency, 240
    Hæmatocele, 239
    History of, 239
    Pathology, 240
    Physical signs of, 242
    Prognosis, 243
    Symptoms, 242
    Termination, 243
    Treatment of, 243
      Morphia in the, 244
      Operative, 244
    Varieties, 241

Pemphigus, 656

Performance of anterior elytrorrhaphy for prolapse of uterus, 161

Pericarditis as a symptom of nephritis, 83

Perineorrhaphy for prolapse of uterus, 163

Perinephritis, 102

Peritoneum, pelvic, inflammation of, 208
  inflammation of, 208

Peritonitis as a symptom of nephritis, 83
  in prolapse of uterus, 158
  pelvic, in prolapse of uterus, 158

Permanganate of potash in treatment of amenorrhoea, 191

Pernicious anæmia, effects on the eye, 745

Pernicious progressive anæmia of pregnancy, 406

Pessaries in pathological anteversion of uterus, 176
  in prolapse of uterus, 160
  in retroflexion of uterus, 171
  in treatment of prolapse of uterus, 160

Phantom tumors in the diagnosis of cystic tumors of ovary, 308

Phlebitis with thrombosis following chronic inflammation of middle ear,
        832

Phlegmonous inflammation of the labia majora, 391

Phosphates in polyuria, 30

Phosphoric acid as a cause of dermatitis medicamentosa, 603

Phosphoridrosis as a disorder of secretion in diseases of skin, 585

Physical signs of chronic metritis, 454
    of parametritis, 214
    of pelvic hæmatocele, 242
    of perimetritis, 231

Physiology of early pregnancy, 474

Pilocarpine in polyuria, 34
  in treatment of acute parenchymatous nephritis, 80
    of diseases of kidneys in pregnancy, 419

Pityriasis rosea, 621
  rubra, 622

Placenta, the, as a local cause of abortion, 490

Plethora as a disorder of pregnancy, 407

Pleurisy as a symptom of nephritis, 83

Pleuritis, acute, in pregnancy, 431

Pleurodynia as a symptom of myalgia, 532

Pneumonia, blindness after, 748
  acute lobar, in pregnancy, 439

Polyuria, 27
  after acute diseases, 30
  after meningitis, 31

Pompholyx, 655

Position of assistants in ovariotomy, 322
  of kidney, 20

Poultices in treatment of carbunculus, 607

Predisposing causes of abortion, 480
    of myalgia, 530

Pregnancy as a cause of disturbed vision, 759

PREGNANCY, DISORDERS OF, 405
  Acute infectious diseases, 424
    Cholera, 428
    Effects of high temperature on the foetus, 424
    Malarial fever, 427
    Measles, 426
    Other causes of death of foetus in, 425
    Relapsing fever, 427
    Scarlet fever, 426
    Smallpox, 425
    Syphilis, 428
      Treatment, 429
    Typhoid fever, 426
    Typhus fever, 427
  Alterations in the condition of the blood, 405
    Chlorosis and hydræmia, 405
      Etiology, 406
      Treatment, 406
    Hæmophilia, 407
      Treatment, 407
    Plethora, 407
      Treatment, 407
    Progressive pernicious anæmia, 406
      Pathology, 406
      Prognosis, 406
      Treatment, 406
        Iron in, 406
  Cardiac diseases, 429
    Acute endocarditis, 430
    Chronic heart disease, 430
  Circulatory disturbances, 407
    Treatment, 408
  Diabetes mellitus, 416
    General consideration of, 416
    Prognosis, 416
    Treatment, 416
  Diseases of the kidneys, 416
    Etiology and pathology, 417
    Prognosis, 418
    Symptoms, 418
      Convulsions, 418
      Vertigo, 418
    Treatment, 418
      Hygienic, 419
      Medical, 419
        Cathartics, 419
        Diuretics, 419
        Pilocarpine, 419
  Diseases of the liver, 414
    Icterus, 414
      Etiology, 414
      Simple, 414
      Symptoms, 415
    Malignant, 415
      Diagnosis, 415
      Etiology, 415
      Pathology, 415
      Prognosis, 415
      Symptoms, 415
  Diseases of the lungs, 430
    Acute lobar pneumonia, 430
      Prognosis, 431
      Treatment, 431
    Acute pleuritis, 431
    Pulmonary tuberculosis, 431
  Diseases of the skin, 420
  Disorders of alimentary canal, 408
    Constipation, 413
    Diarrhoea, 414
    Ptyalism, 413
    Toothache, 413
    Vomiting, 408
      Course, 409
      Diagnosis, 410
      Pathology and etiology, 409
      Prognosis, 410
      Serious effects, 408
      Treatment, 410
        Gynæcological, 412
        Hygienic, 410
          diet in, 410
        Medical, 411
        Obstetrical, 412
  Disorders of special sense, 423
  Neuroses, 421
    Chorea, 422
      Course and symptoms, 422
      Etiology, 422
      Prognosis, 422
      Treatment, 423
    Epilepsy, 423
      Diagnosis, 423
    Tetanus, 421

Pregnancy, early physiology of, 474
  in the diagnosis of cystic tumors of the ovary, 306

Preparation of patient for ovariotomy, 317

Preparations for treatment of abortion, 509

Preventive treatment of abortion, 515

Prognosis of abortion, 508
  of acute cystitis, 127
      diffuse nephritis, 83
      endometritis, 461
      lobar pneumonia in pregnancy, 431
      metritis, 449
      parenchymatous nephritis, 80
      purulent inflammation of middle ear, 826
  of anteversion of uterus (pathological), 175
  of carcinoma of uterus, 277
  of chorea in pregnancy, 422
  of chronic catarrh of middle ear, 825
      cystitis, 130
      endometritis, 464
      metritis, 456
      ovaritis, 285
      parenchymatous nephritis, 81
  of diabetes mellitus in pregnancy, 416
  of dilatation of urethra in women, 359
  of diseases of kidneys in pregnancy, 418
  of dislocations of urethra in women, 361
  of dysmenorrhoea, 197
  of eczema, 631
  of epithelioma of uterus, 280
  of fibroid tumors of ovary, 297
  of fibrous tumors of uterus, 254
  of furuncle of external auditory canal, 814
  of herpes zoster ophthalmicus, 786
  of ichthyosis, 668
  of impacted cerumen in external auditory canal, 813
  of imperforate hymen, 375
  of inversion of urethral mucous membrane in women, 362
  of malignant icterus in pregnancy, 415
  of myalgia, 538
  of neurosis of bladder, 133
  of paralysis of bladder in women, 351
  of parametritis, 219
  of pelvic hæmatocele, 243
  of perimetritis, 232
  of pernicious progressive anæmia of pregnancy, 406
  of progressive muscular atrophy, 554
  of pyelo-nephritis, 101
  of renal colic, 45
  of retroversion of uterus, 165
  of sarcomatous tumors of uterus, 272
  of scarlatina in nephritis, 84
  of seminal incontinence, 142
  of stricture of urethra in women, 368
  of tinea tonsurans, 721
  of tinnitus aurium in diseases of internal ear, 838
  of tuberculosis of kidney, 65
  of vaginismus, 385
  of vaginitis, 371
  of vegetable parasites in external ear, 815
  of vomiting of pregnancy, 410

PROGRESSIVE MUSCULAR ATROPHY, 540
  Age, 542
  Complications, 552
  Definition, 540
  Diagnosis, 552
  Etiology, 541
  Histology, 543
  History, 540
  Pathogeny, 546
  Pathological anatomy, 543
  Prognosis, 554
  Sex, 542
  Symptoms, 547
    Fever as a, 552
  Synonyms, 540
  Treatment, 554
    Electricity, 554
    Gymnastics, 555
    Massage, 555

Progressive pernicious anæmia as a disorder of pregnancy, 406

Prolapse of ovary, 287
  of uterus, 154

Prolapsus vaginæ, 376

Prophylactic treatment of chronic endometritis, 464

Prophylaxis of prolapse of uterus, 159

Prurigo, 639

Pruritus, 711
  hiemalis, 714
  vulvæ, 392

Pseudo-cyesis during the menopause, 444

PSEUDO-HYPERTROPHIC PARALYSIS, 557
    Autopsies, 558
    Course and prognosis, 568
    Definition, 557
    Diagnosis, 578
    History, 557
    Pathogeny, 576
    Pathological anatomy, 569
      Central nervous organs, 572
      Connective tissue, 571
      Muscular fibres, 570
    Symptoms, 558
      Electrical reaction as a, 560
      In upper part of body, 565
      Locomotion, 563
      Muscles affected, 559
      Reflex excitability in, 561
    Synonyms, 557
    Treatment, 579
      Electricity in, 579

Psoriasis, 614

Psychical influences as a cause of amenorrhoea, 187

Ptosis, 781
  of third pair of cranial nerves, 781

Ptyalism in pregnancy, 413

Pudendal hernia, 398

Puerperal phlebitic ophthalmitis, 759

Pulex irritans, 733
  penetrans, 732

Pulmonary symptoms of abortion, 499
  tuberculosis as a cause of amenorrhoea, 186
    in pregnancy, 431

Purgatives in treatment of nephritis, 83

Purulent inflammation of middle ear, acute, 825
      chronic, 827
  meningitis as a sequel of chronic inflammation of middle ear, 831

Pus as an aid to diagnosis in calculous pyelitis, 49

Pyelitis, calculous, 47

Pyelo-nephritis, 99


Q.

Quinine as a cause of dermatitis medicamentosa, 603
    of toxic amblyopia, 804
  effects of, on the eye, 804


R.

Race in scrofuloderma, 699

Radical surgical treatment of ovarian cysts, 312

Recto-vaginal hernia, 378

Reflex excitability in pseudo-hypertrophic paralysis, 561

Relapsing fever as a cause of ophthalmitis, 765
    in pregnancy, 427
  typhus as a cause of ophthalmitis, 765

Removal of causes in treatment of seminal incontinence, 143

Renal colic, 42
  cysts in the diagnosis of cystic tumors of ovary, 307

Reposition in retroflexion of uterus, 170

Respiratory changes in connection with the menopause, 435

Rest-cure in treatment of chronic ovaritis, 286

Rest in treatment of calculous pyelitis, 51

Retinal aneurism, 743

Retinitis, 77
  leukæmic, 744

Retrocele in prolapse of uterus, 158
  vaginalis, 378

Retroflexion of uterus, 166

Retro-locations of uterus, 153

Rheumatism and gout in relation to diseases of the eye, 800

Rhinochoprion penetrans, 732

Round ligament, tumors of, 296

Rubeola as a cause of ophthalmitis, 763

Rue in treatment of amenorrhoea, 190

Rupture of abscesses into peritoneal cavity as a symptom of
        perinephritis, 102


S.

Saffron in treatment of amenorrhoea, 190

Salicylate of sodium as cause of toxic amblyopia, 804
    effects of, on the eye, 804

Salicylic acid as a cause of dermatitis medicamentosa, 603

Salt solution with hydrochloric acid as a test for albumen in
        albuminuria, 36

Santonin as a cause of dermatitis medicamentosa, 604
    of toxic amblyopia, 804
  effects of, on the eye, 804

Sarcoma of the skin, 710

Sarcomatous tumors of the vagina, 381

Savin in treatment of amenorrhoea, 190

Scabies, 726

Scapulodynia as a symptom of myalgia, 532

Scarlatina, acute diffuse nephritis of, 84
  as a cause of ophthalmitis, 764

Scarlet fever as a cause of inflammation of middle ear, 818
    deafness after, 839
    in pregnancy, 426

School-life as a cause of amenorrhoea, 188

Sclerema neonatorum, 671

Scleroderma, 671

Sclerosis as a cause of inflammation of middle ear, 819

Scrofuloderma, 698

Seat of eczema vesiculosum, 627

Seats of cornu cutaneum, 664
  of eczema erythematosum, 626
  of epithelioma, 708
  of keloid, 685
  of lupus erythematosus, 690
    vulgaris, 693
  of tinea versicolor, 725

Seborrhoea as a disorder of secretion in diseases of skin, 586

Secondary pyelitis, 53

Second pair of nerves, cranial, affections of, 771

SEMINAL INCONTINENCE, 137
    Anatomical characteristics of, 141
    Classification, 137
      Diurnal pollutions, 138
      Nocturnal pollutions, 137
      Spermorrhagia, 138
    Clinical history, 138
    Definition, 137
    Diagnosis, 141
    Etiology, 140
    Pathogeny, 140
    Prognosis in, 142
    Treatment of, 143
      Atropia, 146
      Bougies, 144
      Bromide of potash, 145
      Cantharidal collodion, 145
      Gymnastics, 143
      Marriage, 146
      Nitrate of silver, 145
      Removal of causes, 143
      Sitz-baths, 145

Sequelæ of chronic purulent inflammation of middle ear, 830

Sequels of myalgia, 534

Serious effects of vomiting of pregnancy, 408

Serous and mucous discharges during menopause, 438

Seventh pair of cranial nerves, affections of, 790

Sex in epithelioma, 709
  in progressive muscular atrophy, 542

Signs of parametritis, 214

Silk ligatures in treatment of pedicle of ovariotomy, 326

Simple icterus in pregnancy, 414

Sitz-baths in acute cystitis, 127
  in treatment of seminal incontinence, 145

Skin, alteration of functions of, during menopause, 435

SKIN, DISEASES OF (_classified_), 583
  _Atrophies_, 676
    Albinismus, 676
      Definition, 676
    Alopecia, 678
      areata, 680
        Causes, 681
        Description, 680
        Diagnosis, 681
        Symptoms, 680
        Treatment, 681
          External, 681
          Internal, 681
    Atrophia cutis, 683
        Definition, 683
      pilorum propria, 682
        Definition, 682
        Diagnosis, 683
      unguis, 683
        Diagnosis, 683
    Canities, 678
    Vitiligo, 677
      Definition, 677
      Synonyms, 677
      Treatment, 677
  _Hypertrophies_, 658
    Callositas, 662
      Definition, 662
      Symptoms, 662
      Synonyms, 662
      Treatment, 662
    Chloasma, 659
      Causes, 659
      Definition, 659
    Clavus, 663
      Definition, 663
      Treatment, 663
    Cornu cutaneum, 663
      Definition, 663
      Seats of, 664
      Treatment, 664
    Dermatolysis, 675
      Definition, 675
    Elephantiasis, 674
      Cause, 674
        Filaria as a, 674
      Definition, 674
      Morbid anatomy, 675
      Synonyms, 674
      Treatment, 675
    Hypertrichosis, 669
      Causes, 670
      Definition, 669
      Synonyms, 669
      Treatment, 670
        Caustics, 670
        Electrolysis, 670
    Ichthyosis, 666
      Prognosis, 668
      Symptoms, 667
      Synonyms, 666
      Treatment, 668
      Varieties of, 666
    Keratosis pilaris, 660
      Causes, 661
      Definition, 660
      Treatment, 661
    Lentigo, 658
      Definition, 658
    Molluscum epitheliale, 661
      Cause, 661
      Diagnosis, 662
      Pathology, 662
      Synonyms, 661
    Morphoea, 672
      Definition, 672
      Diagnosis, 673
      Treatment, 674
    Nævus pigmentosus, 666
      Definition, 666
      Locations, 666
      Treatment, 666
    Onychauxis, 669
      Definition, 669
      Symptoms, 669
      Synonyms, 669
      Treatment, 669
    Sclerema neonatorum, 671
      Definition, 671
    Scleroderma, 671
      Causes, 672
      Definition, 671
      Synonyms, 671
      Treatment, 672
    Verruca, 664
      Definition, 664
      Diagnosis, 665
      Etiology, 665
      Treatment, 665
        Caustics in, 665
  _Inflammations_, 593
    Acne, 641
        Definition, 641
        Diagnosis, 642
        Frequency, 642
        Treatment, 642
          Local, 644
        Varieties, 641
      rosacea, 647
        Definition, 647
        Diagnosis, 647
        Treatment, 648
          External, 648
          Internal, 648
    Carbunculus, 606
      Causes, 607
      Definition, 606
      Synonyms, 606
      Treatment, 607
        Dressings in, 607
        Poultices in, 607
    Dermatitis, 600
      calorica, 601
        Treatment, 601
      exfoliativa, 623
      factitia, 604
      gangrænosa, 604
      herpetiformis, 611
        Changes in, 613
        Definition, 611
        Diagnosis, 612
        Symptoms, 612
        Treatment, 613
        Varieties, 612
      medicamentosa, 601
        Causes, 602
          Arsenic, 602
          Atropia, 602
          Belladonna, 602
          Bromides, 602
          Cannabis indica, 602
          Chloral, 602
          Copaiba, 602
          Cubebs, 603
          Digitalis, 604
          Iodides, 603
          Mercury, 603
          Opium, 603
          Morphia, 603
          Phosphoric acid, 603
          Quinine, 603
          Salicylic acid, 603
          Santonine, 604
          Stramonium, 604
          Strychnia, 604
          Turpentine, 604
      traumatica, 600
      venenata, 600
        Treatment, 601
    Ecthyma, 653
      Causes, 653
      Definition, 653
      Diagnosis, 653
      Treatment, 654
    Eczema, 625
        Symptoms, 625
      erythematosum, 626
        Course, 626
        Seats of, 626
        Symptoms, 626
      papulosum, 627
      pustulosum, 627
        Symptoms, 627
      squamosum, 628
      vesiculosum, 627
        Definition, 627
        Symptoms, 627
    Eczemas in general, 629
      Diagnosis, 629
      Etiology, 629
      Pathology, 629
      Prognosis, 631
      Treatment, 632
        Constitutional, 632
          Arsenic, 632
          Laxatives, 632
        External, 634
          Lotions, 635
          Ointments, 635
    Erythema intertrigo, 594
        Treatment, 594
      multiforme, 595
        Description, 595
        Treatment, 596
      nodosum, 596
        Causes, 596
        Definition, 596
        Treatment, 597
      simplex, 593
        Treatment, 594
    Furunculus, 604
      Aleppo bouton, 606
      Biskra bouton, 606
      Boil or evil, 606
      Definition, 604
      Delhi boil, 606
      Diagnosis, 605
      Symptoms, 605
      Synonyms, 604
      Treatment, 606
    Herpes iris, 609
        Definition, 609
        Diagnosis, 609
        Frequency, 609
        Treatment, 609
      simplex, 607
        Definition, 607
        Varieties, 608
        Treatment, 608
      zoster, 610
        Causes, 610
        Definition, 610
        Diagnosis, 611
        Symptoms, 610
        Treatment, 611
    Impetigo, 651
        Definition, 651
        Pathology, 651
      contagiosa, 652
        Causes, 652
        Definition, 652
        Diagnosis, 652
        Symptoms, 652
        Treatment, 653
    Lichen ruber, 623
        Definition, 623
        Diagnosis, 624
        Etiology, 624
        Treatment, 624
          Arsenic, 624
          Baths, 624
          Tonics, 624
        Varieties, 623
      scrofulosus, 624
        Diagnosis, 625
    Miliaria, 654
      Definition, 654
      Diagnosis, 655
      Treatment, 655
    Pemphigus, 656
      Definition, 656
      Diagnosis, 657
      Treatment, 657
    Pityriasis rosea, 621
        Course, 621
        Definition, 621
        Diagnosis, 621
        Treatment, 621
      rubra, 622
        Course, 622
        Definition, 622
        Etiology, 622
        Symptoms, 622
        Treatment, 622
    Pompholyx, 655
      Definition, 655
      Treatment, 656
    Prurigo, 639
      Definition, 639
      Diagnosis, 640
      Pathology, 640
      Symptoms, 640
      Treatment, 641
    Psoriasis, 614
      Definition, 614
      Diagnosis, 616
      Duration, 614
      Symptoms, 614
      Treatment, 617
        Internal, 617
        External, 617
        Local, 619
      Varieties, 615
    Urticaria, 597
        Definition, 597
        Pathology, 598
        Treatment, 599
          External, 599
          Internal, 599
        Varieties, 598
      pigmentosa, 599
  _Neuroses_, 711
    Dermatalgia, 711
    Pruritus, 711
        Causes, 712
        Definition, 711
        Diagnosis, 712
        Treatment, 712
          Drugs in, 712
          Ointments in, 713
          Washes in, 713
      hiemalis, 714
        Definition, 714
        Treatment, 714
  _New Growths_, 685
    Angioma, 688
      Course, 688
      Definition, 688
      Treatment, 688
        Caustics, 688
        Cauterization, 688
        Electrolysis, 689
        Ointments, 688
    Epithelioma, 707
      Age in, 709
      Seats of, 708
      Sex in, 709
      Treatment, 709
        Caustics in, 709
        Curette in, 710
      Varieties, 707
    Fibroma, 686
      Absence of pain, 686
      Definition of, 686
      Multiple, 686
    Keloid, 685
      Definition, 685
      Pathology, 685
      Seats of, 685
      Treatment, 685
    Lupus erythematosus, 689
        Causes, 690
        Definition, 689
        Diagnosis, 691
        Pathology, 690
        Seats of, 690
        Symptoms, 689
        Treatment, 691
          Curette, use of, in, 692
          Lotions in, 692
      vulgaris, 693
        Definition, 693
        Diagnosis, 694
        Heredity, 693
        Morbid anatomy of, 694
        Seats of, 693
        Symptoms, 693
        Treatment, 695
          Caustic potash, 696
          Corrosive sublimate, 696
          Nitrate of silver, 696
          Ointments in, 697
          Operative, 697
    Lymphangioma, 689
    Myoma, 687
    Neuroma, 686
    Sarcoma, 710
      Definition of, 710
      Diagnosis, 710
      Frequency of, 710
      Symptoms, 710
    Scrofuloderma, 698
      Definition, 698
      Race in, 699
      Symptoms, 698
      Treatment, 699
      Varieties, 698
    Syphilis cutanea, 699
      Definition of, 699
    Syphiloderma bullosum, 705
        Anatomy, 705
        Treatment, 705
          Mercury, 706
          Iodide of potash, 707
          Local, 707
      erythematosum, 700
        Symptoms of, 700
        Diagnosis, 700
      gummatosum, 705
      papulosum, 701
        Varieties, 701
      pigmentosum, 701
      pustulosum, 703
        Varieties, 703
      tuberculosum, 704
      vesiculosum, 702
        Synonyms for, 702
    Xanthoma, 687
  _Parasites_, 715
    Acanthia lectularia, 733
    Cimex lectularius, 733
    Culex, 733
    Cysticercus cellulosæ, 732
    Demodex folliculosum, 732
    Filaria medinensis, 732
    Ixodes, 733
    Leptus, 731
      Varieties, 731
    Oestrus, 732
    Pediculosis, 728
        Synonyms, 728
        Varieties, 728
      capitis, 729
        Symptoms, 729
        Treatment, 729
      corporis, 730
        Cause, 730
        Description, 730
        Symptoms, 730
      pubis, 731
        Definition, 731
        Treatment, 731
    Pulex irritans, 733
      penetrans, 732
    Rhinochoprion penetrans, 732
    Scabies, 726
      Cause, 726
      Definition, 726
      Diagnosis, 727
      Symptoms, 726
      Treatment, 728
        Parasiticides, 728
    Tinea circinata, 717
        Course, 717
        Definition, 717
        Diagnosis, 718
        Frequency, 718
        Treatment, 719
      favosa, 715
        Definition, 715
        Diagnosis, 716
        Frequency, 715
        Symptoms, 715
        Treatment, 716
          Parasiticides in, 716
      sycosis, 723
        Definition, 723
        Frequency, 724
        Treatment, 724
      tonsurans, 720
        Baldness, 720
        Definition, 720
        Diagnosis, 721
        Frequency, 720
        Hair in, 720
        Prognosis, 721
        Treatment, 722
          Ointments in, 722
      trichophytina, 717
        Definition, 717
      versicolor, 724
        Cause, 725
        Definition, 724
        Diagnosis, 725
        Seats of, 725
        Treatment, 726
  _Secretion, Disorders of_, 583
    Anidrosis, 584
    Bromidrosis, 584
      Treatment, 585
    Chromidrosis, 585
    Comedo, 589
      Pathology, 590
        Parasites in, 590
      Treatment, 591
    Hyperidrosis, 583
      Treatment, 583
    Milium, 592
      Description of, 592
      Pathology of, 592
      Treatment of, 592
    Phosphoridrosis, 585
    Seborrhoea, 586
      Definition of, 586
      Treatment, 588
        Applications in, 589
        Ointment in, 589
      Varieties of, 587
    Steatoma, 592
      Treatment, 593
    Sudamen, 586
      Course of, 586
      Treatment of, 586
    Sycosis, 649
      Definition, 649
      Diagnosis, 650
      Synonyms, 649
      Treatment, 650
    Uridrosis, 585

Skin, diseases of (_unclassified_).
  Acanthia lectularia, 733
  Acarus, 732
  Acne, 641
    rosacea, 647
    vulgaris, 641
  Albinismus, 676
  Aleppo boil, 606
  Alopecia, 678
    areata, 680
  Angioma, 688
  Anidrosis, 584
  Anthrax, 606
  Atrophia pilorum propria, 682
    cutis, 683
    unguis, 683
  Bedbug, 733
  Biskra bouton, 606
  Boil, 604
  Bromidrosis, 584
  Callositas, 662
  Canities, 678
  Carbunculus, 606
  Chigoe, chigger, or jigger, 732
  Chloasma, 659
  Chromidrosis, 585
  Cimex lectularius, 733
  Clavus, 663
  Comedo, 589
  Corn, 663
  Cornu cutaneum, 663
  Culex, 733
  Cysticercus cellulosæ, 732
  Delhi boil, 606
  Demodex folliculorum, 732
  Dermatalgia, 711
  Dermatitis, 600
    calorica, 601
    exfoliativa, 623
    gangrænosa, 604
    herpetiformis, 611
    medicamentosa, 601
    traumatica, 600
    venenata, 600
  Dermatolysis, 675
  Dermato-syphilis, 699
  Dracunculus, 732
  Ecthyma, 653
  Eczema, 625
    erythematosum, 626
    papulosum, 627
    pustulosum, 627
    vesiculosum, 627
  Elephantiasis, 674
  Epithelioma, 707
  Erythema, 593
    intertrigo, 594
    multiforme, 595
    nodosum, 596
    simplex, 593
  Exanthematous syphilide, 700
  Favus, 715
  Fibroma, 686
  Filaria medinensis, 732
  Flea, 733
  Furunculus, 604
  Gad-fly, 732
  Gnat, 733
  Guinea-worm, 732
  Herpes, 607
    facialis, 608
    iris, 609
    simplex, 607
    zoster, 610
  Hyperidrosis, 583
  Hypertrichosis, 669
  Ichthyosis, 666
  Impetigo, 651
    contagiosa, 652
  Itch, 726
  Ixodes, 733
  Jigger, 732
  Keloid, 685
  Keratosis pilaris, 660
  Lentigo, 658
  Leptus, 731
  Lichen ruber, 623
    scrofulosus, 624
  Lousiness, 728
  Lupus erythematosus, 689
    vulgaris, 693
  Lymphangioma, 689
  Macular syphiloderm, 700
  Miliaria, 654
  Milium, 592
  Mole, 666
  Molluscum epitheliale, 661
    fibrosum, 686
  Morphoea, 672
  Mosquito, 733
  Myoma, 687
  Nævus pigmentosus, 666
  Neuroma, 686
  Oestrus, 732
  Onychauxis, 669
  Pediculosis, 728
    capitis, 729
    corporis, 730
    pubis, 731
  Pemphigus, 656
  Phosphoridrosis, 585
  Phtheiriasis, 728
  Pityriasis rosea, 621
    rubra, 622
  Pompholyx, 655
  Prurigo, 639
  Pruritus, 711
    hiemalis, 714
  Psoriasis, 614
  Pulex penetrans, 732
    irritans, 733
  Rhinocoprion penetrans, 732
  Roseola syphilitica, 700
  Sarcoma, 710
  Scabies, 726
  Sclerema neonatorum, 671
  Scrofuloderma, 671
  Seborrhoea, 586
    congestiva, 689
  Senile atrophy, 684
  Steatoma, 592
  Sudamen, 586
  Sycosis, 649
  Syphilis cutanea, 699
  Syphiloderma bullosum, 705
    erythematosum, 700
    gummatosum, 705
    papulosum, 701
    pigmentosum, 701
    pustulosum, 703
    tuberculosum, 704
  Ticks, 733
  Tinea circinata, 717
    favosa, 715
    sycosis, 723
    tonsurans, 720
    tricophytina, 717
    versicolor, 724
  Uridrosis, 585
  Urticaria, 597
    pigmentosa, 599
  Verruca, 664
  Vitiligo, 677
  Vitiligoidea, 687
  Wart, 664
  Wood-ticks, 733
  Xanthelasma, 687
  Xanthoma, 687

Smallpox as a cause of inflammation of middle ear, 819
  in pregnancy, 425

Soft cancer of the uterus, 274

Sound, use of, in uterine explorations, 152

Sounds in treatment of inflammation of bladder, 125

Special sense, disorders of, in pregnancy, 423

Specula, use of, in uterine explorations, 153

Spermorrhagia in seminal incontinence, 138

Spina bifida in the diagnosis of cystic tumors of ovary, 307

Spinal cord, relation of, to diseases of the eye, 792

Stages of chronic metritis, 452

Statistics of ovariotomy, 314

Steatoma as a disease of the skin, 592

Sterility as a symptom of acquired anteflexion of uterus, 178

Stramonium as a cause of dermatitis medicamentosa, 604

Stricture at junction of urethra and bladder in women, 365
  of urethra in women, 363

Strychnia as a cause of dermatitis medicamentosa, 604
  in treatment of atony of bladder, 134
    of paralysis of the bladder in women, 351

Subacute urethritis in women, 355

Subinvolution as a cause of chronic metritis, 450

Sudamen, as a disorder of secretion in diseases of skin, 586

Sufficient food in polyuria, 33
  liquid in polyuria, 33

Sulphate of zinc in the treatment of acute urethritis in women, 353

Supernumerary kidney, 21

Supports of uterus, normal, 150

Surgical treatment of fibrous tumors of the uterus, 266

Sweating in the treatment of acute parenchymatous nephritis, 80

Sycosis, 644

Symptomatology and course of prolapsus vaginæ, 377
  of dilatation of the urethra in women, 358
  of dislocations of the urethra in women, 361
  of floating kidney, 23
  of myalgia, 531
  of parametritis, 213
  of phlegmonous inflammation of the labia, 391
  of stricture of the urethra in women, 363
  of vaginismus, 384
  of vulvitis, 389

Symptoms of abortion, 500
    preliminary, 499
  of acute catarrh of middle ear, 821
    cystitis, 126
    diffuse nephritis, 82
    metritis, 448
    parenchymatous nephritis, 79
    purulent inflammation of middle ear, 826
  of alopecia areata, 680
  of amenorrhoea, 187
  of anteflexion of uterus (acquired), 178
  of anteversion of uterus (pathological), 174
  of atrophy of the bladder in women, 348
  of brain abscess following chronic inflammation of middle ear, 832
  of calculous pyelitis, 51
  of callositas, 662
  of carcinoma of uterus, 276
  of chorea in pregnancy, 422
  of chronic cystitis, 129
    diffuse nephritis, 88
    metritis, 453
    ovaritis, 285
    parenchymatous nephritis, 81
    purulent inflammation of middle ear, 828
  of chyluria, 119
  of congestion of kidney, 70
  of cystic tumors of the ovary, 303
  of cystitis in women, 343
  of cysto-vaginal hernia, 377
  of cysts of kidney, 63
  of dermatitis herpetiformis, 612
  of dermoid cysts of the ovary, 300
  of diseases of kidneys in pregnancy, 418
  of displacements of uterus, 151
  of eczema, 625
    erythematosum, 626
    pustulosum, 627
    vesiculosum, 627
  of foreign bodies in the external ear, 816
  of furuncle of the external auditory canal, 814
  of furunculus, 605
  of hæmatoma, 401
  of hemianopia, 778
  of hemorrhage from the bladder in women, 340
  of herpes zoster, 610
      ophthalmicus, 785
  of hyperæmia of bladder in women, 339
  of hypertrophy of bladder in women, 348
  of ichthyosis, 667
  of impacted cerumen in external auditory canal, 812
  of imperforate hymen, 374
  of impetigo contagiosa, 652
  of inflammation of bladder, 124
  of lupus erythematosus, 689
    vulgaris, 693
  of malignant growths of kidney, 61
  of mastoid disease, 834
  of nephritis in scarlatina, 84
  of neuro-paralytic ophthalmia, 787
  of nystagmus, 783
  of onychauxis, 669
  of pediculosis capitis, 729
  of pelvic hæmatocele, 242
  of perimetritis, 230
  of perinephritis, 102
  of phlebitis with thrombosis following chronic inflammation of middle
        ear, 833
  of pityriasis rubra, 622
  of polyuria, 27
  of progressive muscular atrophy, 547
  of prolapse of ovary, 287
    uterus, 158
  of prurigo, 640
  of pruritus vulvæ, 393
  of pseudo-hypertrophic paralysis, 558
        in the trunk, 565
  of psoriasis, 614
  of pudendal hernia, 398
  of purulent meningitis as a sequel of chronic inflammation of middle
        ear, 831
  of pyelo-nephritis, 99
  of renal colic, 43
  of retroflexion of uterus, 167
  of retroversion of uterus, 165
  of sarcoma of skin, 710
  of scabies, 726
  of scrofuloderma, 698
  of simple icterus in pregnancy, 415
  of syphiloderma erythematosum, 700
  of tinea favosa, 715
  of urethral caruncle, 403
  of vegetable parasites in the external ear, 815

Synonyms and classification of prolapsus vaginæ, 376
  of abortion, 467
  of callositas, 667
  of carbunculus, 606
  of chronic congestion of kidney, 69
    metritis, 450
  of elephantiasis, 674
  of furunculus, 604
  of hypertrichosis, 669
  of ichthyosis, 666
  of molluscum epitheliale, 661
  of myalgia, 529
  of onychauxis, 669
  of parametritis, 209
  of pediculosis, 728
  of perimetritis, 227
  of progressive muscular atrophy, 540
  of pseudo-hypertrophic paralysis, 557
  of scleroderma, 671
  of sycosis, 649
  of syphiloderma vesiculosum, 702
  of vaginitis, 368
  of vitiligo, 677

Syphilis as a cause of inflammation of middle ear, 819
  cutanea, 699
  in abortion, 491
  in pregnancy, 428
  in relation to diseases of the eye, 800

Syphiloderma bullosum, 705
  erythematosum, 700
  gummatosum, 705
  papulosum, 701
  pigmentosum, 701
  pustulosum, 703
  tuberculosum, 704
  vesiculosum, 702

Systemic diseases in relation to diseases of the eye, 800
  treatment of vaginismus, 386


T.

Tabes dorsalis in relation to diseases of the eye, 793

Tampons in treatment of carcinoma of the uterus, 278
    of fibrous tumors of the uterus, 258

Tannic acid in treatment of dilatation of urethra in women, 359
    of hemorrhage from bladder, 135

Tapping in treatment of ovarian cysts, 308

Termination of abortion, 504
  of functional disorders in connection with the menopause, 432
  of myalgia, 533
  of pelvic hæmatocele, 243
  of perimetritis, 229
  of polyuria, 30
  of vaginismus, 384

Terminations of chronic metritis, 456

Tests for albuminuria, 35

Tetanus in pregnancy, 421

Third pair of cranial nerves, affections of, 780

Thompson's method in diagnosis of calculous pyelitis, 49

Tinea circinata, 717
  favosa, 715
  sycosis, 723
  tonsurans, 720
  tricophytina, 717
  versicolor, 724

Tinnitus aurium as a symptom of acute catarrh of middle ear, 821
    in diseases of internal ear, 836

Tobacco as a cause of toxic amblyopia, 803

Tonics in treatment of lichen ruber, 624

Toothache in pregnancy, 413

Torticollis as a symptom of myalgia, 332

Toxic amblyopia, 803
    in medical ophthalmology, 803

Treatment of abortion, 509
  of acne, 642
    rosacea, 648
  of acute catarrh of middle ear, 822
    cystitis, 127
    endometritis, 461
    lobar pneumonia in pregnancy, 431
    metritis, 449
    parenchymatous nephritis, 80
    purulent inflammation oi' middle ear, 826
    urethritis in women, 353
  of albuminuria, 42
  of alopecia areata, 681
  of amenorrhoea, 189
  of angioma of the skin, 688
  of anteversion of uterus (acquired), 179
        (pathological), 175
  of atony of bladder, 134
  of atrophy of bladder in women, 349
  of bromidrosis as a disease of the skin, 585
  of calculous pyelitis, 51
  of callositas, 662
  of cancer of the vagina, 383
  of carbunculus, 607
  of carcinoma of the uterus, 277
  of chlorosis and hydræmia as a disorder of pregnancy, 406
  of chorea in pregnancy, 423
  of chronic catarrh of middle ear, 825
    congestion of kidney, 72
    cystitis, 131
    diffuse nephritis, 95
    endometritis, 464
    metritis, 457
    ovaritis, 285
    perimetritis, 233
    purulent inflammation of middle ear, 829
  of chyluria, 120
  of circulatory disturbances in pregnancy, 408
  of clavus, 663
  of comedo, 591
  of cornu cutaneum, 664
  of cystitis in wound, 345
  of cysts of canal of Nuck, 397
  of cysts of parovarium, 295
  of deaf-mutism, 840
  of dermatitis calorica, 601
    herpetiformis, 613
    venenata, 601
  of dermoid cysts of the ovary, 300
  of diabetes mellitus in pregnancy, 416
  of dilatation of urethra in women, 359
  of diseases of kidneys in pregnancy, 418
  of dislocations of the urethra in women, 362
  of dysmenorrhoea, 198
  of ecthyma, 654
  of eczema, 632
    of the auricle, 811
  of elephantiasis, 675
    of the vulva, 460
  of entero-vaginal hernia, 379
  of epithelioma, 709
    of the uterus, 280
  of erythema intertrigo, 594
    multiforme, 596
    nodosum, 597
    simplex, 594
  of fibrous tumors of the uterus, 257
  of floating kidney, 25
  of foreign bodies in the external ear, 816
  of furuncle of the external auditory canal, 814
  of furuncles of labia, 392
  of hæmatoma, 401
  of hæmophilia as a disorder of pregnancy, 407
  of hemorrhage from bladder, 135
        in women, 340
  of hernia of the ovary, 290
  of herpes iris, 609
    simplex, 609
    zoster, 611
  of hyperæmia of bladder in women, 339
  of hyperidrosis as a disease of the skin, 583
  of hypertrichosis, 670
  of hypertrophy of the bladder in women, 348
    of the vulva, 399
  of ichthyosis, 668
  of impacted cerumen in the external auditory canal, 813
  of imperforate hymen, 375
  of impetigo contagiosa, 653
  of inflammation of bladder, 125
  of inversion of urethral mucous membrane in women, 362
  of keloid, 685
  of keratosis pilaris, 661
  of lichen ruber, 624
  of lupus erythematosus, 691
    vulgaris, 695
  of malformations of ovaries and oviducts, 283
  of malignant growths of kidney, 62
    tumors of the ovary, 299
  of mastoid disease, 834
  of Menière's disease, 840
  of menorrhagia, 203
  of miliaria, 655
  of milium, 592
  of morphoea, 674
  of myalgia, 538
  of nævus pigmentosus, 666
  of nephritis, 83
  of neurosis of bladder, 133
  of onychauxis, 669
  of ovarian cysts, 308
  of paralysis of the bladder in women, 351
  of parametritis, 219
  of parasites of kidney, 66
  of pedicle after ovariotomy, 375
  of pediculosis capitis, 729
  of pelvic abscess, 222
    hæmatocele, 243
  of pemphigus, 657
  of perimetritis, 232
  of perinephritis, 108
  of pernicious progressive anæmia of pregnancy, 406
  of phlegmonous inflammation of the labia majora, 391
  of pityriasis rubra, 622
  of plethora as a disorder of pregnancy, 407
  of polyuria, 33
  of progressive muscular atrophy, 554
  of prolapse of ovary, 288
    of uterus, 159
  of pruritus, 712
    hiemalis, 714
    vulvæ, 393
  of pseudo-hypertrophic paralysis, 579
  of psoriasis, 617
  of pudendal hernia, 398
  of pyelitis, 55
  of pyelo-nephritis, 101
  of renal colic, 45
  of retroflexion of uterus, 168
  of retroversion of uterus, 166, 168
  of sarcomatous tumors of the uterus, 273
        vagina, 382
  of scabies, 728
  of scleroderma, 672
  of scrofuloderma, 699
  of seborrhoea, 588
  of seminal incontinence, 143
  of stricture of the urethra in women, 364
  of sudamen, 586
  of sycosis, 650
  of syphilis in pregnancy, 429
  of syphiloderma bullosum, 705
  of tinea circinata, 719
    favosa, 716
    sycosis, 724
    tonsurans, 722
    versicolor, 726
  of urethral caruncle, 403
  of urticaria, 599
  of vaginismus, 385
  of vaginitis, 371
  of vegetable parasites in the external ear, 815
  of verruca, 665
  of vitiligo, 677
  of the vomiting of pregnancy, 410
  of vulvitis, 390

Tuberculosis as a cause of inflammation of middle ear, 819
  in pregnancy, 431
  in relation to diseases of the eye, 802
  of kidney, 64

Tumors, uterine, 245
  Carcinomatous, 274
    Medullary, or soft, 274
      Clinical history of, 275
      Diagnosis, 276
      Etiology of, 274
      General symptoms, 276
      Prognosis, 277
      Treatment, 277
        Operative, 278
        Tampons in, 278
    Epitheliomatous, 278
      Clinical history, 279
      Diagnosis, 279
      Prognosis, 280
      Treatment, 280
        Operative, 280
    Fibroid, 245
      Clinical history, 250
      Development, mode of, 246
      Diagnosis, 252
      Effects of, 248
      Etiology of, 250
      Locations of, 248
      Prognosis, 254
      Relations and structure, 245
      Treatment of, curative, 259
        Ammonium chloride, 259
        Ergot, 259
        Iodide of potash, 259
        Palliative, 257
          Tampons, 258
          Tents, 258
        Surgical, 266
          Laparotomy, 269
          Laparo-hysterectomy, 269
  Sarcomatous, 271
    Clinical history of, 271
    Diagnosis, 272
    Prognosis, 272
    Treatment, 273

Tuning-fork in examination of the ear, 807

Turpentine as a cause of dermatitis medicamentosa, 604

Typhoid fever as a cause of inflammation of middle ear, 820
        of ophthalmitis, 767
    in pregnancy, 426

Typhus fever in pregnancy, 427


U.

Umbilical cord, the, as a local cause of abortion, 491

Unnatural hardness in congestion of kidney, 69

Ureters, diseases of, 67

Urethral caruncle, 403

Urethritis, acute, in women, 353

Uridrosis, 585

URINARY ORGANS, DISEASES OF THE--
  Bladder, diseases of, 123
    Acute cystitis, 126
    Atony and paralysis, 133
    Catarrh, 128
    Chronic cystitis, 128
    Hemorrhage from, 134
    Inflammation, 123
    Neuroses of, 132
    New growths, 136
    Paralysis and atony, 133
  Chyluria, 114
  Hæmaturia and hæmoglobinuria, 103
    Malarial, 107
      Malignant, 112
  Kidneys, 19
    Albuminuria, 34
    Bright's disease, 72
    Calculous pyelitis, 47
    Chyluria, 114
    Congestion, chronic, 69
    Cysts, 63
    Floating, 21
    Malignant growths, 60
    Nephritis, 82
      Acute diffuse, 82
        of scarlatina, 84
        parenchymatous, 78
      Chronic diffuse, 84
        parenchymatous, 80
    Parasites, 65
    Perinephritis, 102
    Polyuria, 27
    Pyelitis, 53
    Pyelo-nephritis, 99
    Tuberculosis, 64

URINARY ORGANS IN WOMEN, DISEASES OF, 339
  _Functional Diseases_, 349
    Acute urethritis, 353
      Diagnosis, 353
      Treatment, 353
        Nitrate of silver in, 353
        Sulphate of zinc in, 353
      Varieties of, 353
    Circumscribed urethritis, 355
    Dilatation of the urethra, 355
      Description, 355
      Diagnosis, 358
      Etiology of, 357
      Prognosis, 359
      Symptomatology, 358
      Treatment, 359
        Alum in, 359
        Excision in, 359
        Tannic acid, 359
    Dislocations of the urethra, 360
      Description of, 360
      Diagnosis of, 361
      Etiology of, 361
      Prognosis of, 361
      Symptomatology, 361
      Treatment of, 362
    Inflammation of the urethral glands, 354
      Description of, 354
    Inversion of urethral mucous membrane, 362
      Causes, 362
      Prognosis, 362
      Treatment, 362
    Paralysis, 350
      Invasion of, 351
      Prognosis of, 351
      Treatment of, 351
        Electricity, 351
        Strychnia, 351
    Prolapsus of urethral mucous membrane, 362
    Stricture at junction of urethra and bladder, 365
      Description, 365
      Morbid anatomy of, 365
      Symptoms, 365
      Treatment, 365
    Stricture of the urethra, 363
      Diagnosis, 364
      Pathology, 363
      Prognosis, 364
      Symptomatology, 363
      Treatment, 364
        Incision in, 364
        Use of dilators, 364
          of urethrotome, 364
    Subacute urethritis, 355
  _Organic Diseases_, 339
    Atrophy, 348
      Symptoms and diagnosis, 348
      Treatment of, 349
    Cystitis, 341
      Diagnosis, 344
      Etiology, 341
      Pathology, 341
      Symptoms of, 343
        Albuminuria in urine, 343
        Nervous, 344
        Pain, 343
        Specific gravity of urine in, 343
        Tenesmus, 343
        Toxic, 344
      Treatment, 345
        Antiseptics in, 347
        Borax and water in, 346
        Diet, 345
        Dover's powder in, 346
        Milk diet in, 345
        Morphia suppositories in, 346
        Nitrate of silver in, 347
    Hemorrhage, 340
      Causes of, 340
      Symptoms of, 340
      Treatment of, 340
        Hæmostatics in, 340
    Hyperæmia, 339
      Diagnosis of, 339
      Etiology of, 339
      Morbid anatomy of, 339
      Symptoms of, 339
      Treatment of, 339
    Hypertrophy, 348
      Diagnosis, 348
      Etiology, 348
      Symptoms, 348
      Treatment, 348

Urticaria, 597
  pigmentosa, 599

Use of trocar in treatment of ovarian cysts, 308
  voice in examination of the ear, 807
  watch in examinations of the ear, 807

Uterine axis, 148

Uterine fibroids in the diagnosis of cystic tumors of ovary, 306
  mucosa as a local cause of abortion, 488
    in early pregnancy, 476

Uterus, anteflexion of, 176
    Definition of, 176
    Diagnosis of, 178
    Etiology of, 177
    Pathology of, 177
    Symptoms of, 178
      Dysmenorrhoea as a, 178
      Sterility as a, 178
      Vesical, 178
    Treatment of, 179
      By rapid dilatation of cervix, 179
      Sims's method of, 179
  Ante-locations of, 153
  Anteversion of, 174
    Diagnosis of, 175
    Etiology of, 174
    Prognosis in, 175
    Symptoms of, 175
      Dragging sensation in, 175
    Treatment of, 175
      Medicated cotton pledgets in, 176
      Pessaries in, 176
  Ascent of, 153
  Axis of, 148
  Carcinoma of, 274
  Descent of, 154

Uterus, diseases of--endometritis, acute, 460
    Diagnosis, 461
    Etiology of, 460
    Pathological anatomy, 461
    Prognosis, 461
    Treatment, 461
  Endometritis, chronic, 462
    Chronic catarrh, 462
    Diagnosis, 464
    Dysmenorrhoea membranacea, 463
    Etiology, 462
    Pathological anatomy, 462
    Prognosis, 464
    Treatment, 464
      Curative, 465
      Local, 465
      Prophylactic, 464
  Metritis, acute, 447
    Diagnosis, 449
    Etiology, 447
    Pathological anatomy, 448
    Prognosis, 449
    Symptoms, 448
    Treatment, 449
  Metritis, chronic, 450
    Definition of, 450
    Diagnosis, 456
    Etiology, 450
      Hyperæmia, 451
      Lacerated cervix in the, 451
      Subinvolution in the, 450
    Pathological anatomy of, 452
      Stages in the, 452
    Physical signs, 454
    Prognosis, 456
    Symptoms, 453
    Synonyms for, 450
    Treatment, 457
      General, 459
        Ergot in the, 460
      Local, 457
        Alterations, 459
        Castration, 459
        Depletion, local, 458
        Glycerin tampons, 458
        Hot-water douche, 457
        Operative, 459
    Terminations, 456
  Disorders of functions of, 182
    Amenorrhoea, 183
      Cause of, 184
        Atrophy as a, 186
        Chlorosis as a, 185
        Exposure as a, 187
        Psychical, 187
        Pulmonary tuberculosis, 186
      Diagnosis of, 186
      Pathological conditions in, 185
      Symptoms of, 187
        Constipation as a, 189
      Treatment of, 189
        By apiol, 190
        By electricity, 191
        By permanganate of potash, 191
        By rue and saffron, 190
        By savin, 190
    Dysmenorrhoea, 192
      Diagnosis of, 194, 195
      Prognosis, 197
      Treatment of, 198
    Menorrhagia, 200
      Causes of, 201
      Treatment of, 203
  Displacement of, as a cause of disturbed vision, 757
      Definition of, 150
      Diagnosis of, 151
      Nomenclature of, 150
      Symptoms of, 151
  Epithelioma of, 278
  Examinations of, 151
    Digital, 152
      Left hand in, 152
  Explorations of, 152
    Specula in, 153
    Use of sound in, 152
  Fibrous tumors of, 245
  Lateral flexions of, 174
    Locations of, 153
    Versions of, 174
  Normal location of, 147
    Movements of, 149
    Supports of, 150
  Prolapse, 154
    Course of, 158
    Degrees of, 154
    Diagnosis of, 159
    Etiology of, 154
    Pathological anatomy of, 157
    Prophylaxis of, 159
    Symptoms of, 158
      Acute vaginitis, 158
      Bearing-down feeling, 158
      Catarrh of bladder, 157
      Cystocele, 158
      Enlargement of cervix, 157
      Erosion of cervix, 157
      Pelvic peritonitis, 158
      Rectocele, 158
      Vesical irritation, 156
    Treatment of, 161
      Anterior elytrorrhaphy, 161
        After-treatment in, 163
        Performance of, 162
      Methods of, 159
      Perineorrhaphy, 163
        Performance of, 164
      Pessaries in, 160
        Functions of, 160
  Retroflexion, 166
    Diagnosis of, 168
    Etiology of, 166
    Pathology, 166
    Symptoms of, 167
    Treatment of, 168
      Bimanual replacement in, 170
      Digital touch in, 168
      Dry cupping in, 168
      Pessaries in, 171
        Danger in use of, 173
      Reposition in, 171
      Vaginal touch in, 168
  Retro-locations, 153
  Retroversion, 165
    Course of, 166
    Diagnosis of, 166
    Etiology of, 166
    History of, 166
    Prognosis of, 166
    Symptoms of, 167
      Bearing-down feeling in, 166
      Constipation in, 166
    Treatment of, 166, 168
      Bimanual replacement, 170
  Sarcomatous tumors of, 271
  Tumors of, see _Tumors_.


V.

Vagina, anatomy of, 367
  Atresia of, 373, 376
    Definition, 373
    Hymenalis, 374
  Cancer of, 382
    Diagnosis of, 383
    Treatment of, 383
  Cicatrices, 380
  Cystic tumors of, 381
  Cystocele vaginalis, 377
  Cysto-vaginal hernia, 377
    Symptoms, 377
  Diseases of, 367
  Double, 380
  Enterocele vaginalis, 378
  Entero-vaginal hernia, 378
    Treatment, 379
  Fibrous tumors of, 381
  Growths in, 381
  Imperforate hymen, 374
    Diagnosis, 374
    Prognosis, 375
    Symptoms, 374
    Treatment, 375
  Prolapsus of, 376
    Definition, 376
    Etiology, 377
    Pathology, 377
    Symptomatology and course, 377
    Synonyms and classification, 376
  Recto-vaginal hernia, 378
  Retrocele vaginalis, 378
  Sarcomatous tumors of, 381
    Diagnosis, 382
    Treatment of, 382

Vaginal douche in retroflexion of uterus, 168

Vaginismus, 383
  Complications, 384
  Course, 384
  Diagnosis, 385
  Duration, 384
  Etiology, 384
  Pathology, 385
  Prognosis, 385
  Symptomatology, 384
  Termination, 384
  Treatment of, 385
    dilators in the, 386
    systemic, 386

Vaginitis, 366
  Acute, in prolapse of uterus, 158
  Complications, 369
  Course, 369
  Decubitus in, 371
  Definition of, 368
  Diagnosis, 371
  Duration, 369
  Etiology of, 368
  Pathology, 369
  Prognosis, 371
  Symptomatology, 369
  Synonyms of, 368
  Terminations, 369
  Treatment, 371
    Chloral in the, 372
    Infections in the, 372
    Irrigation in the, 372
  Varieties of, 368

Varieties of acne, 641
  of acute urethritis in women, 353
  of atrophia cutis, 684
  of calculous pyelitis, 47
  of cysts of kidney, 63
  of dermatitis herpetiformis, 612
  of epithelioma, 707
  of foreign bodies in the external ear, 816
  of herpes simplex, 608
  of ichthyosis, 666
  of inflammation of bladder, 123
  of leptus, 731
  of lichen ruber, 623
  of pessaries, 160
  of psoriasis, 615
  of pyelo-nephritis, 99
  of oöphorectomy, 291
  of parasites of kidney, 65
  of pediculosis, 728
  of pelvic hæmatocele, 241
  of sarcomatous tumors of the uterus, 272
  of scrofuloderma, 699
  of seborrhoea, 587
  of syphiloderma papulosum, 701
    pustulosum, 703
    vesiculosum, 702
  of urticaria, 598
  of vaginitis, 368
  of verruca, 665
  of vulvitis, 391

Variola as a cause of ophthalmitis, 761

Vegetable parasites in the external ear, 815

Verruca, 665

Versions of uterus, 165, 174

Vertigo as a symptom of diseases of kidneys in pregnancy, 418

Vesical irritation caused by prolapse of uterus, 156
  symptoms of acquired anteflexion of uterus, 178

Vision, disturbed, caused by disease of the sexual organs, 755

Vitiligo, 677

Vomiting in pregnancy, 408

Vulva, anatomy of, 388
  Diseases of, 388
    Atresia of, 373
    Cancer of, 402
      Treatment, 402
    Cysts of the canal of Nuck, 397
      Definition, 397
      Treatment, 398
    Elephantiasis, 399
      Definition, 399
      Etiology, 399
      Pathology, 399
      Treatment, 400
    Furuncles of the labia, 392
      Definition, 392
      Treatment of, 392
        Nitrate of silver in, 392
    Hæmatoma, 401
      Definition of, 401
      Diagnosis, 401
      Etiology, 401
      Symptoms, 401
      Treatment, 401
    Hydrocele in women, 397
    Hypertrophy, 398
      Treatment, 399
    Phlegmonous inflammation of the labia majora, 391
      Definition, 391
      Diagnosis, 391
      Symptomatology, 391
      Treatment, 391
    Pruritus vulvæ, 392
      Course, 393
      Definition, 392
      Etiology, 392
      Symptoms, 393
      Treatment, 393
    Pudendal hernia, 398
      Definition, 398
      Etiology, 398
      Symptoms, 398
      Treatment, 398
    Urethral caruncle, 403
      Definition of, 403
      Diagnosis, 403
      Etiology, 403
      Pathology, 403
      Symptoms, 403
      Treatment, 403
    Vulvitis, 389
      Course, 389
      Definition, 389
      Duration, 389
      Etiology, 389
      Symptomatology, 389
      Treatment of, 390
        Lotions in the, 390
      Varieties of, 391


W.

Washes in the treatment of pruritus, 713

Washing out of bladder in the treatment of pyelitis, 55

Water, hot, in the treatment of parametritis, 220

Whooping cough as a cause of inflammation of middle ear, 820


X.

Xanthoma, 681


Y.

Yellow fever as a cause of ophthalmitis, 767




END OF VOLUME IV.