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.

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.

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.