A SYSTEM OF TREATMENT IN FOUR VOLUMES Volume I. General Medicine and Surgery Volume II. General Medicine and Surgery Volume III. Special Subjects Volume IV. Obstetrics and Gynaecology A SYSTEM OF TREATMENT BY MANY WRITERS EDITED BY ARTHUR LATHAM M.A., M.D. Oxon.; F.R.C.P. Lond. PHYSICIAN AND LECTURER ON MEDICINE, ST. GEORGE'S HOSPITAL AND T. CRISP ENGLISH M.B., B.S. Lond.; F.R.C.S. Eng. SENIOR ASSISTANT SURGEON AND LECTURER ON PRACTICAL SURGERY, ST. GEORGE'S HOSPITAL VOLUME II. GENERAL MEDICINE AND SURGERY New York THE MACMILL AN COMPANY 1914 All rights reserved 35 -?-s Printed in Gt-ent Britain. PREFACE. DURING the last ten years our knowledge of the measures available for the treatment of disease and the relief of symptoms has become more scientific and therefore more definite in its application. Not only have many of our ideas undergone profound modification, but new fields of work, some of great promise, have been discovered. Of these we may instance Vaccine Therapy, X-ray Therapy, Radium Therapy, Ionic Medication and measures dependent on improved methods of observation and diagnosis such as Broncho- scopy. The subject of the treatment of disease consequently has become more specialised and makes greater demands upon all branches of the medical profession than formerly. The aim of these volumes is to provide the General Practitioner with a series of practical articles, in as concise a form as possible, describing the modern methods of dealing with all diseases and written by those who have had special experience in the subjects with which they deal. There are many difficulties in preparing such a work as this. Our knowledge is not yet sufficiently exact to permit dogmatic expression in all instances, or to enable us to differentiate sharply between the various forms of disease. It is therefore inevitable that certain articles should overlap, and that there should be legitimate differences of opinion not only in the subject-matter itself but also with regard to the classification adopted. The Editors have always been guided in their final decision by considerations of convenience rather than of strict symmetry. They recognise that their decisions are therefore open to criticism and will gladly welcome suggestions, either for alterations or additions, to be incorporated in future issues. This "System of Treatment" was commenced rather less than two years ago, and it is hoped that no material addition to our knowledge made during that period has been omitted. The attempt to keep thoroughly abreast of these additions has been rendered rather more difficult than usual by the decision to issue all four volumes simultaneously, and to provide each with an index which is complete for the whole work. The Editors wish to express their gratitude to a large number vi Preface. of their colleagues who have in one way or another generously come to their assistance. Sir Patrick Manson, Sir Havelock Charles, Dr. St. Clair Thompson, Dr. Eisien Eussell, Dr. Gordon Holmes, Mr. Richard Lake and Mr. Victor Bonney have advised them with regard to those departments of Medicine and Surgery with which their names are associated. Dr. Nachbar has kindly given his advice and has also revised a number of the manuscripts. Dr. Torrens and Mr. Frankau, respectively Medical and Surgical Registrar at St. George's Hospital, have acted as sub-editors, reading all the manuscripts and assisting in the passage of proofs through the Press. The Editors are also indebted to Mr. Charles Hewitt for the preparation of the complete index attached to each volume, to Mr. A. L. Clarke for the correction of the references, and to Mr. J. D. Marshall, of Messrs. Bell and Croyden, who is responsible for the correctness of the various prescriptions. In addition to the many original illustrations a number of others have been kindly lent by different authors and publishers. These are duly acknowledged in the text. TABLE OF CONTENTS. DISEASES OF THE BLOOD AND BLOOD FORMING ORGANS. ADDISOX'S (PERNICIOUS) AX.KMIA AN JO MI A DUE TO SOME DEFINITE MALADY, BUT NOT DUE TO OB- VIOUS BLOOD Loss . AN.EMIA DUE TO ACTUAL Loss OF BLOOD .... CHLOROSIS HJ-IMOPHILIA . APLASTIC A. N.K.MIA LEUKAEMIA . PSKI'DO-LEUK/EMIA . PUBPURA , Dr. Herbert Fn-nrli. Dr. Herbert Frenrlt . />/. J/trbrrf Frem-h . lir. Herbert French . Dr. Herbert French . Dr. Herbert French . Professor George R. Murraij Dr. James Torrens . . Professor George A'. Murray I'ACK 1 13 18 20 4','> DISEASES OF THE ADRENAL GLANDS. ADDISON'S DISEASE . Dr. Otto Grunbaum 4G DISEASES OF THE THYROID GLAND. THE ADMINISTRATION OF THY- ROID EXTRACT CONGESTION AND INFLAMMATION OF THE THYROID GLAND . Sr i;< ; ICAL TREATMENT OF L\ FLAM- MATORY AFFECTIONS OF THE THYROID GLAND . EXOPHTHALMIC GOITRE THE SURGICAL TREATMENT OF EXOPHTHALMIC GOITRE . GOITRE INFANTILISM .... MYXCEDEMA AND CRETINISM MALIGNANT DISEASE OF THE THYROID GLAND . NOCTURNAL ENURES is THYROID INADEQUACY Dr. Leonard Williams Dr. Leonard Williams Mr. T. P. Legg . Dr. W. Hale While Mr. T. P. Mr. T. P. Legg . Dr. Leonard William* I tf. Leonard Williams Mr. T. l\ Legg . Dr. Leonard Williams Dr. Leonard William* 49 51 54 5$ 62 71 72 73 75 78 VI 11 Table of Contents. INJURIES AND DISEASES OF INJURIES OF THE SPLEEN . SURGICAL TREATMENT OF DIS- EASES OF THE SPLEEN . SPLENOMEGALY . CHRONIC POLYCYTH.-EMIA WITH CYANOSIS AND ENLARGED SPLEEN AFFECTIONS OF THE LIPS. HARELIP OTHER AFFECTIONS OF THE LIPS DISEASES AND AFFECTIONS FRACTURES OF THE JAWS . INJURIES AND DISEASES OF THE TEMPORO-MAXILLARY JOINT . INFLAMMATORY DISEASES OF THE JAWS BENIGN GROWTHS OF THE JAWS MALIGNANT DISEASE OF THE JAWS AFFECTIONS THE SPLEEN. PACK Mr. Arthur Connell . . 79 Mr. Arthur Connell . . 81 Professor George R. Murray . 82 Professor George E. Murray . 84 Mr. James Berry . Mr. James Berry . OF THE JAWS. Mr. Ernest W. Hey Groves JA/-. Ernest W. Hey Groves Mr. Ernest W. Hey Groves Mr. Ernest W. Hey Groves Mr. Ernest W. Hey Groves OF THE MOUTH AND DISEASES AND TONGUE. STOMATITIS .... OTHER AFFECTIONS OF THE MOUTH DISEASES AND AFFECTIONS OF THE TONGUE DISEASES AND AFFECTIONS CLEFT PALATE . OTHER AFFECTIONS OF THE PALATE Mr. t '. H. S. FranJcau . DISEASES AND AFFECTIONS OF THE SALIVARY GLANDS. INFLAMMATION OF THE SALIVARY GLANDS Mr. T. P. Legg OTHER DISEASES AND AFFEC- TIONS OF THE SALIVARY GLANDS Mr. T. P. Legg DISEASES AND AFFECTIONS OF THE NECK. Dr. Arthur J. Hall Dr. Arthur J. Halt Mr. Jonathan Hutchimon OF THE PALATE. Mr. James Berry . CUT THROAT FISTUL2E .... CYSTS .... DISEASES AND AFFECTIONS STRICTURE OF THE CEsopHAcrs IN.IUKIKS AND MALFORMATIONS OF THE (ESOPHAGI'S Mr. T. P. Legg . Mr. T. P. Legg . Mr. T. P. Legg . OF THE OESOPHAGUS. Mr. T. P. Legg . . Mr. T. P. Legy . 85 96 99 104 107 109 112 120 126 182 147 156 157 159 164 166 167 171 184 Table of Contents. IX GENERAL ARTICLES IN CONNECTION WITH THE ALI MENTARY TRACT AND ABDOMEN. DIETETICS THE PRINCIPLES OF INFANT FEEDING FOOD FEVER . ABDOMINAL INJURIES THE PREPARATION OF PATIENTS FOR ABDOMINAL OPERATIONS . THE TREATMENT OF PATIENTS AFTER ABDOMINAL OPERATIONS AFFECTIONS OF THE UMBILICUS. Dr. E. I. Spriggs . l)r. E. I. Sjn-iggs . Dr. Eustace Smith . Mr. Edred M. Corner Mr. T. Crisp English Mr. T. Crisp English Mr. Ernest W. Hey Groves PAUK 190 214 233 242 262 277 DISEASES AND AFFECTIONS OF THE STOMACH AND DUODENUM. INJURIES OF THE STOMACH ATONY OF THE STOMACH . ATROPHY OF THE STOMACH CANCER OF THE STOMACH THE SURGICAL TREATMENT OF CANCER OF THE STOMACH ACUTE DILATATION OF THE STOMACH .... ACUTE POST-OPERATIVE DILATA- TION OF THE STOMACH . ! CHRONIC DILATATION OF THE STOMACH (PYLORIC STENOSIS) SURGICAL TREATMENT OF PYLO- RIC STENOSIS AND OBSTRUCTIVE DILATATION .... DISPLACEMENTS OF THK STOMACH SURGICAL TREATMENT OF GAS- TROPTOSIS .... HEMORRHAGE FROM Til E STOMACH SritGicAL TREATMENT OF H.EMA- TKMES1S HOUR-GLASS STOMACH PERIGASTRITIS .... HYPERTROPHIC STENOSIS OF THE PYLORUS .... SURGICAL TREATMENT OF HYPER- TROPHIC PYLORIC STENOSIS . INFLAMMATIONS OF THE STOMACH XF.UVOTS IMSFASES OF THE STOMACH Mr. A. W. Mayo-Robson . 282 Dr. W. Soltau Fenwk-k . .286 Dr. W. Soltau Fenwick . . 293 Dr. W. Soltau Fenwick . . 296 Mr. A. W. Mayo-Robson . 302 Dr. W. Soltau Fenwick . .310 Mr.A.W.Mayo-Rooson . 311 Dr. W. Soltau Fenwick . 311 Mr. A. W. Mayo-Robson . 316 Dr. W. Soltau Femvick . .318 Mr. A. IV. Mayo-Robson . 323 Dr. W. Soltau Fenwick . . 325 Mr. A. W. Mayo-Robson . 331 Mr. A. W. Mayo-Robson . 334 Mr. A. W. Mayo-Robson . 336 Dr. Edmund Cautley . . 337 Mr. A. W. Mayo-Robson . 342 Dr. W. Soltau Fenwick . . 345 Dr. W. Soltau Feme id . . 354 Table of Contents. DISEASES AND AFFECTIONS OF THE STOMACH AND DUODENUM conti >i tied. PARASITES AND CONCRETIONS OF Dr. W. Sollau Fen/rick . STOMACH .... SECRETORY DISORDERS OF THE STOMACH .... SYMPTOMATIC TREATMENT OF DISORDERED DIGESTION IN THE STOMACH .... ULCER OF THE STOMACH AND DUODENUM .... THE SURGICAL TREATMENT OF ULCER OF THE STOMACH . . Mr. A. W. Mayo-Robson PERFORATING ULCER OF THE STOMACH .... Mr. A. W. Mayo-Robson SURGICAL TREATMENT OF ULCER OF THE DUODENUM . . Mr. A. W. Mayo-Robson PERFORATING ULCER OF THE DUODENUM . SEA-SICKNESS TETANY OF THE STOMACH . BENIGN TUMOURS OF THE STOMACH Mr. A. W. Mayo-Robson VOLVULUS OF THE STOMACH . Mr. A. W. Mayo-Robson Dr. W. Sollau Fentcirh . I>r. IT. Soltau fen wick . Dr. W. Soltau Femrirlc . Mr. A. W. Mayo-Robson Dr. W. Sollau Fenwick . Mr. A. W. Mayo-Robson DISEASES AND AFFECTIONS OF THE INTESTINES. APPENDICITIS .... Co: MAC DISEASE COLIC IN CHILDREN . CONSTIPATION IN CHILDREN ADULTS . THE OPERATIVE TREATMENT OF CHRONIC CONSTIPATION DUE TO DISEASE OR ABNORMALITIES OF THE COLON .... DlARRHCEAL DISEASES IN CHILDREN . ENTERITIS (ACUTE AND CHRONIC) IN ADULTS . FISTULA OF THE INTESTINES . FOREIGN BODIES IN THE IN- TKS'HNES HERNIA INTESTINAL OBSTRUCTION . INTCSSUSCBPTION PERFORATION OF THE INTESTINE Mr. T. Crisp English Dr. James Torrens Dr. G. A. Sutherland Dr. G. A. Sutherland Dr. Arthur F. Hertz Mr. P. Lockhart Mummery Dr. G. A. Sutherland . Dr. Robert Saundby Mr. Ernest W. Heij Groves Mr. Ernest W. Hey droves Mr ckhhart Mummery . 588 .)//. P. Lock/tar I Mummer// . 589 Mr. /'. Ltickhart Mummer// . .">!)( i Mr. P. Lockhurt Mummer// . 51)1 DISEASES AND AFFECTIONS OF THE RECTUM AND ANUS. DISEASES OF THE ANO-RECTAL AREA MALFORMATIONS OF THE RECTUM RECTAL NEUROSES AND OBSCURE RECTAL PAIN HAEMORRHOIDS .... PROLAPSE AND PROCIDENTIA OF THE RECTUM . ... Si MPLE TUMOURS OF THE RECTUM MALIGNANT GROWTHS OF THE RECTUM . /S'/V l-'reilericl; \Vallis Sir /'/>/. .\rtlnir Latham 62C 6.52 648 645 DISEASES AND AFFECTIONS OF THE LIVER. ABSCESS OF THE LIVER (THE SURGICAL TREATMENT OF) ACUTE YELLOW ATROPHY . ANOMALIES IN FORM AND POSI- TION OF THE LIVEII CIRRHOSIS OF THE LIVER. DISEASES OF THE BLOOD VESSELS OF THE LIVER Mr. James Cant/if . . . 648 In: //. I). RoUeston . . 6:>7 In: II. I). RoUeston . . 6:)!) Dr. //. D. Uullrstnn . . 660 In : //. D. RoUeston . 666 XI 1 Table of Contents. DISEASES AND AFFECTIONS OF THE UVER continued. DEGENERATIONS OF THE LIVER . HYDATID CYSTS OF THE LIVER JAUNDICE LARDACEOUS OR AMYLOID DIS- EASE OF THE LlVEE TROPICAL LIVER TUMOURS OF THE LIVER . Dr. H. D. Rolleston Mr. T. Crisp Eni/lixh Dr. H. D. Rolleston Dr. H. D. Rolleston Dr. G. O. Low Dr. H. D. Rolleston 668 061) 670 675 676 C7< DISEASES AND AFFECTIONS OF THE GALL-BLADDER AND BILE DUCTS. INJURIES OF THE BILE PASSAGES CHOLELITHIASIS. THE SURGICAL TREATMENT OF CHOLELITHIASIS FISTULA OF THE GALL-BLADDER AND BILE DUCTS . INFLAMMATORY AFFECTIONS OF THE GALL-BLADDER AND BILE DTCTS TUMOURS OF THE GALL-BLADDER TUMOURS OF THE BILE DUCTS . Mr. A. W. Mayo-Robson . 680 Dr. H. D. Rolleston . ,.682 Mr. A. W. Mayo-Robson . 686 Mr. A. W. Mayo-Rubxon . 698 Mr. A. W. Mayo-Robson . 700 Mr. A. W. Mayo-Robson . 710 Mr. A. W. Mayo-Robson . 713 DISEASES AND AFFECTIONS OF THE PANCREAS. INJURIES OF THE PANCREAS ACUTE PANCREATITIS SUBACUTE PANCREATITIS . CHRONIC PANCREATITIS PANCREATIC CALCULI PANCREATIC CYSTS . CANCER OF THE PANCREAS Mr. A. W. Mayo-Robson . 716 Mr. A. W. Mayo-Robson . 718 Mr. A. W. Mayo-Robson . 720 Mr. A. W. Mayo-Robson . 723 Mr. A. W. Mayo-Robson . 724 Mr. A. W. Mayo-Robson . 726 Mr. A. W. Mayo-Robson . 72!) DISEASES AND AFFECTIONS OF THE KIDNEY. URINARY DISORDERS. BACILLURIA , ANEURYSM OF THE RENAL ARTERY RENAL CALCULUS RENAL AND PERI-RENAL FISTULA HYDRONEPHROSIS INJURIKS OK THK KIDNEY. MOVABLE KIDNEY Dr. A. E. Garrod . . 730 Dr. Arthur Latliam . .751 Mr. J. W. Thomson Walker . 752 Mr. J. W. Thomson Walker . 753 Mr. J. W. Thomson Walker . 767 Mr. J. W. Thomson Walker . 770 Mr. J. W. Thomson Walker . 780 Mr. J. W. Thomson Walker 7l . 864 Mr. Sydney (!. MacDonald . 866 Mr. Sydney G. Murlxmuhl . ^68 Mr. Sydney <,'. McDonald . 870 XIV Table of Contents. DISEASES AND AFFECTIONS OF THE PENIS. BALANITIS AND POSTHITIS . Mr. Ivor Back CAVERNOSITIS .... Mr. Ivor Back CONGENITAL MALFORMATIONS OF THE PENIS .... Mr. Ivor Back INJURIES OF THE PENIS . . Mr. Ivor Back MALIGNANT DISEASE OF THE PENIS ..... Mr. Ivor Back PAPILLOMATA OF THE PENIS . Mr. Ivor Back PARAPHIMOSIS .... Mr. Ivor Back PHIMOSIS . . Mr. Ivor Back PACiK 874 874 875 876 877 879 879 880 DISEASES AND AFFECTIONS OF THE URETHRA. INJURIES OF THE URETHRA STRICTURE EXTRAVASATION OF URINE FISTULA OF THE URETHRA PERI-URETHRAL ABSCESS . Mr. Ivor Back Mr. Ivor Hack Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back CHRONIC URETHRITIS (GLEET) . Mr. C. H. 8. Frankau 882 886 893 894 895 897 DISEASES AND AFFECTIONS OF THE SCROTUM . . . Mr. Ivor Back 900 DISEASES AND AFFECTIONS OF THE TESTICLE. HERNIA TESTIS. IMPERFECT DESCENT OF THE TESTIS INFLAMMATION OF THE TESTIS . INJURIES OF THE TESTIS . SYPHILITIC DISEASES OF THE TESTIS TORSION OF THE TESTIS . TUBERCULOUS DISEASES OF THE TESTIS TUMOURS OF THE TESTIS . IMPOTENCE Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. Ivor Back Mr. J. Ernest Lane 901 902 906 907 907 907 908 910 911 DISEASES AND AFFECTIONS OF THE TUNICA VAGINALIS. H^EMATOCELE HYDROCELE Mr. Ivor Back Mr. Ivor Back 913 914 Table of Contents. DISEASES AND AFFECTIONS OF THE SPERMATIC CORD. HJEMATOMA .... Mr. Ivor Back HYDROCELE .... Mr. Ivor Batk VABICOCELE. (/r AFFKCTIONS OF VEINS, VOL. L, p. 1323) XV PACK 917 917 DISEASES AND AFFECTIONS OF THE PROSTATE GLAND. CALCULI OF THE PROSTATE INJURIES or THE PROSTATE ACUTE PROSTATITIS . CHRONIC PROSTATITIS GOUTY PROSTATITIS . ONANITIC PROSTATITIS SYPHILIS OF THE PROSTATE TUBERCULOUS PROSTATITIS TUMOURS OF THE PROSTATE FIBROUS ENLARGEMENT OF THE PROSTATE Mr. John Mr. John Mr. John Mr. John Mr. John Mr. John Mr. John Mr. John Mr. John Pardoe Pardoe Pardoe Pardoe Pardoe Pardoe Pardoe Pardoe Pardoe Mr. John Pardoe 918 919 920 924 926 927 927 928 930 950 DISEASES AND AFFECTIONS OF THE BREAST. CYSTS DUCT PAPILLOMA F i BRO- ADENOMATA OF THE BREASTS HYPERTROPHY OF THE BREASTS INFLAMMATORY AFFECTIONS OF THE BREAST .... MALIGNANT DISEASE OF THE BREAST NEURALGIA OF THE BREAST AFFECTIONS OF THE NIPPLES . OPERATIVE DIAGNOSIS OF DOUBT- FUL TUMOURS OF THE BREAST TUBERCULOSIS OF THE BREAST . Mr. T. Crisp English Mr. T. Crisp English Mr. T. Crisp English Mr. T. Crisp English Mr. T. ( 'risp English Mr. T. Crisp Mr. T. Crisp English Mr. T. Crisp English Mr. T. Crisp English Mr. T. Crisp English 952 954 955 957 958 963 976 977 979 981 CERTAIN DISEASES AND AFFECTIONS OF THE NERVOUS SYSTEM OF OBSCURE ORIGIN. COMA. INFANTILE CONVULSIONS . EPILEPSY .... THE SURGICAL TREATMENT EPILEPSY HYSTERIA . . Dr. T. Grainger Stewart. . Dr. Alfred M. Gossage . Dr. William Aldren Turner OF Mr. C. H. S. Frankau . Dr. H. Campbell Thomson 982 986 990 1007 1008 XVI Table of Contents. CERTAIN DISEASES AND AFFECTIONS OF THE NERVOUS SYSTEM OF OBSCURE ORIGIN-twrfiK7. INSOMNIA LUMBAR PUNCTURE . MIGRAINE AND OTHER FORMS OF PERIODIC HEADACHE NIGHT TERRORS NEURASTHENIA .... PSYCH ASTHENIA .... Tics AND SPASMS TORTICOLLIS Dr. Maarici' Craij and Dr. E. D. Macnamara . .1014 Dr. Purees Stewart . . 1025 Dr. James Collwr . . Dr. Edmund Can fie// . Dr. James Taylor . . Dr. James Taylor . . Dr. Wilfred Harris . .1047 Dr. S. A. Kinnier Wilson . 1050 GENERAL DISEASES OF THE NERVOUS SYSTEM. AMYOTROPHIC LATERAL SCLERO- SIS ACUTE ANTERIOR POLIOMYELITIS INFANTILE PARALYSIS, XERVE ANASTOMOSIS IN BULBAR PALSY .... CEREBRO- SPINAL SYPHILIS. DISSEMINATED SCLEROSIS . GENERAL PARALYSIS OF THE INSANE LANDRY'S PARALYSIS PROGRESSIVE MUSCULAR ATROPHY .... SUB - ACUTE COMBINED DE- GENERATION OF THE SPINAL CORD TABES DORSALIS Dr. S. A. Kinnier Wilson . ]u.V! Dr. Judson S. Bury . r>55 Mr. James Sherren. . . ID.")!) Dr. S. A. Kinnier Witwn . luOl Dr. E. Farquhar Buzzard . 1063 Dr. J. S. Risien Russell . . lo7<> Dr. E. Farquhar Buzzard . in? 7 Dr. S. A. Kinnier Wilson . 1080 Dr. S. A. Kinnier Wilson .1081 Dr. Gordon Holmes. . .1083 Dr. J. S. Risien. Russell . . 1085 DISEASES AND AFFECTIONS OF THE NERVES. FACIAL PARALYSIS . HERPES ZOSTER INJURIES OF NERVES TRAUMATIC NEURITIS INJURIES OF SPECIAL NERVES . NEURALGIA . 'I'm; SURGICAL TREATMENT OF NEURALGIA .... NEURITIS DIVISION OF POSTERIOR ROOTS . Dr. Judson S. Bury . . 1003 Dr. S. A. Kinnier Wilson . 1096 J/r. James Sherren . . . 1098 Mr. James Sherren. . . 1106 .)//-. James Sherren. . . 1108 Dr. Wilfred Harris . .1114 Mr* James Sherren . .1127 Dr. T. Grainger Stewart . . 1130 J/r. James Sherren . . 1133 Table of Contents. xvii DISEASES AND AFFECTIONS OF THE NERVES --cvntinwl. MULTIPLE XEURITIS . XYSTAGMUS - . TUMOURS OF NERVES Dr. T. Grainger Stewart Dr. Wilfred Harris Mr. PACE 1134 1140 1142 DISEASES AND AFFECTIONS OF THE BRAIN. APHASIA AND OTHER SPEECH DEFECTS OF CEREBRAL ORI- GIN APRAXIA THE CEREBRAL PALSIES OF IN- FANCY THE SURGICAL TREATMENT OF CEREBRAL PALSIES OF IN- FANCY CEREBELLAR CONDITIONS IN CHILDREN .... CEREBRAL EMBOLISM . CEREBRAL HEMORRHAGE . CEREBRAL THROMBOSIS HEMIPLEGIA .... HERNIA CEREBRI HYDROCEPHALUS SURGICAL TREATMENT OF HYURO- CEPHALUS .... MENINGOCELE . . . PARAPLEGIA .... THE MEDICAL TREATMENT OF TUMOURS OF THE BRAIN SURGICAL TREATMENT OF TUMOURS OF THE BRAIN Dr. James Collier . . .1148 Dr. -lames Collier . . .1150 Dr. Gordon Holmes. . . 1153 Mr. Holier! June* (tnd Mr. D. McCrae Ailken . . .1157 Dr. Alfred M. Gossage . .1165 Dr. T. Grainger Stewart . . 1167 Dr. T. Grainger Stewart . 1 His Dr. T. Grainger Stewart . 1177 Dr. E. Farquhar Buzzard . 1181 Mr. C. H. S. FranTcaii . .1190 Dr. S. A. Kinnier Wilson . 1191 Mr. H. S. Pendlelniry . .1193 Mr. ('. H. S. Frtinltau . .11 !4 Dr. S. A. Kinnier Wilson . 1 1'.'"> Dr. T. (Ira inner ^ten-art . 1200 Mr. Donald Armour . I2ol DISEASES AND AFFECTIONS OF THE SPINAL CORD. CAISSON DISEASE IL-EMATOMYELIA MYELITIS SYRINGOMYELIA .... TUMOURS OF THE SPINAL CORD Dr. A'. Faniuliar Blizzard . 1208 Dr. E. Farquhar Buzzard .1210 Dr. h'. Farquhar Huzza rd . 1212 Dr. Gordon Holmes . .1219 Mr. Donald Armour . 1221 VASOMOTOR AND TROPHIC DISEASES. ACROMEGALY .... Dr. Alfred M. ACHRONDROPLASIA . . . Dr. A/fret/ M. S.T. VOL. II. . 1226 . 1227 XV111 Table of Contents. VASOMOTOR AND TROPHIC DISEASES-"'/// ; ANGIONEUROTIC (EDEMA . ERYTHROMELALGIA . FACIAL HEMIATROPHY HYPERTROPHIC PULMONARY OSTEO-ARTHROPATHY INTERMITTENT CLAUDICATION ; INTERMITTENT LIMP LEONTIASIS OSSEA . OSTEITIS DEFORMANS (PAGET'S DISEASE) .... OSTEOGENESIS IMPERFECTA. RAYNAUD'S DISEASE . VASOMOTOR NEUROSES FAMILIAL DISEASES. AMAUROTIC FAMILY IDIOCY AMYOTONIA CONGENITA CHRONIC DISORDERS WITH CERE- BELLAR SYMPTOMS . THE FAMILY FORM OF MUSCULAR ATROPHY ix CHILDREN . FAMILY PERIODIC PARALYSIS . FRIEDRICH'S DISEASE HEREDITARY SPASTIC PARA- PLEGIA HIXTINGDON'S CHOREA MUSCULAR DYSTROPHIES . MYOTONIA ATROPHICA .. CONGENITA PERONEAL MUSCULAR ATROPHY Dr. Alfred J/. Gossage . .1228 Dr. Alfred II. Go*sa;ie . .1230 Dr. S. A. Ki'inier Wil*on . 1232 Dr. Alfred J/. Gossage . . 12 :'.:'. Dr. S. A. Kinnier Wilson . 1284 Dr. Alfred M. Gossage . .1236 "Dr. Alfred J/. Gossage . .1237 Dr. Alfred I'M. Gossage . . 1237 Dr. Alfred M. Gossage . .1238 Dr. S. A. Kin trier Wilson . 1242 Dr. Gordon Holmes . .1244 Dr. Gordon Holmes . . 124.~> Dr. Gordon Holmes . . 1240 Dr. Gordon Holmes . .1247 Dr. Gordon Holmes . .1247 Dr. Gordon Holmes . .1248 Dr. Gordon Holmes . .1249 Dr. Gordon Holmes . .1241* Dr. Gordon Holme* . . 12.~u Dr. Goi-don Holmes . / 1852 Dr. Gordon Holmes . . 1252 Dr. Gordon Holmes . 12."i.", DISEASES CHARACTERISED BY DISORDERS OF MUSCULAR FUNCTION. MYASTHENIA GRAVIS PARAMYOCLONUS MULTIPLEX Dr. James Torrens Dr. S. A. Kinnier Wilson \ 2:. I DISEASES OF OBSCURE ORIGIN CHARACTERISED CHIEFLY BY DISORDERS OF MOTION. CHOREA OCCUPATION NEUROSES CRAFT PALSIES PARALYSIS AGITANS . TETANY JN CHILDREN Dr. Herbert French AND Dr. Wilfred Dr. Pur res Stewart Dr. Wilfred Harris Dr. Edmund Cautley 1257 1264 126!> 1271 1272 Table of Contents. xix MENTAL DISEASES. PAOK GENERAL CONSIDERATIONS. . Dr. Maurice Craig antl Dr. E. D. Macnamara . . 1274 MANIA Dr. Maurice Craig and Dr. E. D. Macnamara . . 1284 MELANCHOLIA .... Dr. Maurice Craig and Dr. E. D. Macnamara . .1290 EXHAUSTION PSYCHOSES . . Dr. Maurice Craig and Dr. E. D. Marnamara . . 1299 PSYCHOSKS ASSOCIATED WITH CIIANCKS i.\ THE THYROID />/. Maurice Crai// and Dr. ft LAN i> E. D. Macnamara . . 1301 Toxic PSYCHOSES . . . Dr. Mauris Craig and Dr. /,'. D. Marnamara . . 1303 DKMKNTIA PR^ECOX . . . Dr. Maurice Craig and Dr. E. D. Marnamara . . 1305 THE MENTAL ASPECTS OF Dr. Maurice Craig and Dr. HYSTERIA . . . . E. D. Macnamara . . 130G PARANOIA Dr. Maurice Craig and Dr. E. D. Macnamara . . 1309 THE MENTAL ASPECTS OF Dr. Maurice Craig and Dr. EPILEPSY .... H. D. Macnamara . . 1310 OBSESSIVE AND IMPERATIVE Dr. Maurice Craig and Dr. IDEAS E. D. Macnamara . . 1313 PERVERSIONS .... Dr. Maurice Craig and Dr. E. D. Macnamara . .1315 MASTURBATION .... Dr. Maurice Craig and Dr. E. D. Macnamara . . 131 G IDIOCY AND FEEBLE-MINDEDNESS Dr. Maurice Craig and Dr. E. D. Macnamara . .1318 DISEASES AND A'FFECTIONS OF MUSCLES AND FASCLE. INJURIES OF MUSCLES . . Mr. C. H. A'. Prankau . . 1321 INFLAMMATORY AFFECTIONS OF MTSCLK Mr. C. H. 8. Frankau . . 1324 Ni:w GROWTHS OF MUSCLE . Mr. <'. H. S. Frankau . . 1325 DISEASES AND AFFECTIONS OF TENDONS AND THEIR SHEATHS. INJURIES OF TENDONS . . Mr. C. H. 8. Frankau . . 1326 AFFKITIONS OF THE TENDON SHEATHS Mr. C. H. S. Frankau . .1330 DISEASES AND AFFECTIONS OF BURS/E Mr. C. H. S. Franlcan . . 1 3:34 b 2 XXI List of Contributors Adamson, Horatio G., M.D., M.R.C.P., Physician in charge of Skin Dept., St. Bartholomew's Hospital. Aitken, D. McCrae, M.B., Ch.B., F.R.C.S., Assistant Surgeon, St. Vincent's Surgical Home for Cripples; Demon- strator of Anatomy, Middlesex Hospital. Anderson, Miss McCall, Matron, St. George's Hospital. Andrews, H. Russell, M.D., M.R.C.P., Obstetric Physician, London Hospital; Lecturer on Midwifery and Diseases of Women, London Hospital Medical College. Armour, Donald, F.R.C.S., Surgeon, National Hospital for Paralysed and Epileptic ; Surgeon, Belgrave Hospital for Children ; Senior Assistant Surgeon, West London Hospital. Back, Ivor, M.B., F.R.C.S., Assistant Surgeon, St. George's Hospital ; Lecturer on Operative Surgery, St. George's Hospital. Bagshawe, Arthur W. G., M.B., B.C., D.P.H., Director of the Sleeping Sickness Bureau, Royal Society. Ballantyne, John Wm., M.D., F.R.C.P. Edin., Physician, Royal Maternity Hospital, Edinburgh ; Lecturer on Midwifery and Gynaecology, Surgeons' Hall and Edinburgh School of Medicine for Women. Barwell, Harold S., M.B., F.R.C.S., Surgeon for Diseases of Throat, St. George's Hospital ; Surgeon in charge, Ear and Throat Dept., Hampstead General Hospital. Bayly, H. Wansey, M.R.C.S., L.R.C.P., Assistant in Bacteriological Dept., St. George's Hospital ; Pathologist, London Lock Hospital. xxii System of Treatment. Bell, W. Blair, M.D., B.S., Assistant Gynaecological Surgeon, Royal Infirmary, Liverpool. Bennett, Norman G., M.B., B.C. Cantab., L.D.S. Eng., Dental Surgeon, Royal Dental Hospital, London, and St. George's Hospital. Bennett, Sir William, K.C.V.O., F.R.C.S., Senior Surgeon, Seamen's Hospital; Consulting Surgeon, St. George's Hospital. Berkeley, Comyns, M.D., B.C. Camb., F.R.C.P., Obstetric and Gynaecological Surgeon, Middlesex Hospital ; Surgeon, Chelsea Hospital for Women. Berry, James, B.S. Lond., F.R.C.S., Senior Surgeon, Royal Free Hospital; Surgeon, Alexandra Hospital for Hip Disease. Blacker, George, M.D., F.R.C.S., F.R.C.P., Obstetric Physician, University College Hospital ; Teacher of Practical Midwifery, University College Hospital Medical School. Bland-Sutton, John, F.R.C.S., Surgeon, Middlesex Hospital Member of Cancer Investigation Committee. Blumfeld, Joseph, M.D., B.C. Camb., Senior Anaesthetist, St. George's Hospital ; Honorary Anaesthetist, St. Mary's Hospital. Bonney, Victor, M.D., M.S., F.R.C.S., M.R.C.P., Assistant Obstetric and Gynaecological Surgeon, Middlesex Hospital; Surgeon, Chelsea Hospital for Women. Brewis, N. T., M.B., F.R.C.P., F.R.C.S. Edin., Gynaecologist, Edinburgh Royal Infirmary. Briscoe, J. Charlton, M.D., F.R.C.P., Assistant Physician, King's College Hospital ; Senior Physician, Evelina Hospital for Sick Children. Brown, W. Carnegie, M.D., M.R.C.P., Joint Secretary, Society of Tropical Medicine and Hygiene. Bruce, J. Mitchell, M.D., F.R.C.P., LL.D., Consulting Physician to King Edward VII. Sanatorium, Charing Cross Hospital and Brompton Hospital for Consumption. List of Contributors. xxiii Bruce, W. Ironside, M.D., Physician in charge, X-ray and Electrical Depts., Charing Cross Hospital ; Honorary Radiographer, Hospital for Sick Children, Great Ormond Street. Buckley, Charles W., M.D., Late House Physician, St. Mary's Hospital. Bury, Judson S., M.D., F.R.C.P., Physician, Manchester Royal Infirmary. Buzzard, E. Farquhar, M.D., F.R.C.P., Physician to Out-patients, St. Thomas's Hospital and National Hospital for Paralysed and Epileptic. Caiger, F. Foord, M.D., D.P.H., F.R.C.P., Medical Superintendent and Lecturer on Infectious Diseases, South Western Fever Hospital. Cameron, Samuel J., M.B., Ch.B., Assistant to Regius Professor of Midwifery, University of Glasgow ; Gynaecologist to Out-patients, Western Infirmary, Glasgow. Cantlie, James, M.B., F.R.C.S., D.P.H., Surgeon, Seamen's Hospital ; Lecturer on Surgery, London School of Tropical Medicine. Carr, J. Walter, M.D., F.R.C.P., F.R.C.S., Senior Physician, Victoria Hospital for Children, Chelsea; Physician, Royal Free Hospital. Cathcart, George C., M.D., Surgeon, London Throat Hospital ; late Lecturer on Voice Production to School Board for London. Cautley, Edmund, M.D..F.R.C.P., Senior Physician, Belgrave Hospital for Children ; Physician Metropolitan Hospital. Charles, Sir R. Havelock, G.C.V.O., M.Ch., F.R.C.S.I., Sergeant Surgeon to H.M. the King; Member of the Medical Board, India Office. Cheatle, G. Lenthal, C.B., F.R.C.S., Surgeon, King's College Hospital. xxiv System of Treatment. Clarke, Ernest, M.D., F.R.C.S., Senior Surgeon, Central London Ophthalmic Hospital ; Consulting Ophthalmic Surgeon, Miller Hospital. Collier, James, M.D., F.R.C.P., Physician, St. George's Hospital ; Physician in charge of Out-patients, National Hospital for the Paralysed and Epileptic, Queen Square; Physician, Royal Eye Hospital. Connell, Arthur, F.R.C.S. Edin., Honorary Surgeon, Sheffield Royal Infirmary ; Lecturer on Surgery, Sheffield University. Corner, Edred M., M.C., F.R.C.S., Surgeon in charge, Out-patients, and Lecturer on Practical Surgery, St. Thomas's Hospital ; Surgeon, Hospital for Sick Children, Great Ormond Street. Craig, Maurice, M.D.. F.R.C.P., Physician for Mental Diseases and Lecturer in Mental Diseases, Guy's Hospital. Cuff, Herbert E., M.D., F.R.C.S., Medical Officer for General Purposes, Metropolitan Asylums Board ; late Medical Superintendent, North Eastern Fever Hospital. Cunningham, Herbert H. B., M.D., F.R.C.S.I., External Examiner in Ophthalmology and Otology, National University of Ireland; Examiner in Ophthalmology and Otology, Royal College of Surgeons, Ireland; Ophthalmic Surgeon, Ulster Hospital for Women and Children. Dakin, W. R., M.D., F.R.C.P., Obstetric Physician and Lecturer on Midwifery, St. George's Hospital ; Physician, General Lying-in Hospital. Daniels, C. W., M.B., M.R.C.P., Lecturer on Tropical Medicine, formerly Director, at London School of Tropical Medicine ; Lecturer on Tropical Diseases, London Hospital. Dent, Clinton T., M.C., F.R.C.S., Surgeon, St. George's Hospital ; Lecturer on Surgery, St. George's Hospital Medical School. Des Vceux, Harold A., M.D., M.R.C.S. List of Contributors. xxv Dobbie, Mina L., M.D., B.Ch. Dominici, H., In charge of Pathological and Physical Depts., Radium Laboratory, Paris. Doyne, Robert W., F.R.C.S., Reader in Ophthalmology, Oxford University. English, T. Crisp, F.R.C.S., Senior Assistant Surgeon, and Lecturer on Practical Surgery, St. George's Hospital; Assistant Surgeon, Grosvenor Hospital for Women. Fenwick, W. Soltau, M.D., M.R.C.P.; Senior Physician, London Temperance Hospital. ' Fothergill, William E., M.D., C.M., Honorary Assistant Gynecological Surgeon, Manchester Royal Infirmary ; Lecturer on Obstetrics and Gynaecology, Victoria University, Manchester. Fox, R. Fortescue, M.D., M.R.C.P., Late President, British Balneological and Climatological Society ; Con- sulting Physician, Mineral Water Hospital, Strathpefier Spa. Fox, Wilfrid, M.D., M.R.C.P., Physician for Diseases of the Skin, St. George's Hospital ; Assistant Physician for Diseases of the Skin, Seamen's Hospital, Greenwich. Frankau, Claude H. S., M.B., B.S., F.R.C.S., Surgical Registrar, St. George's Hospital. Fraser, J. S., M.B., Ch.B., F.R.C.S. Edin., Assistant Surgeon, Ear and Throat Dept., Royal Infirmary, Edinburgh ; Lecturer on Diseases of Throat, Nose and Ear, School of Medicine of Royal Colleges, Edinburgh. Freeland, James R., M.D., Late Assistant Master, Rotunda Hospital, Dublin. French, Herbert, M.D., F.R.C.P., Assistant Physician, Pathologist and Lecturer on Forensic Medicine at Guy's Hospital. xxvi System of Treatment. Gardiner, Frederick, M.D., F.R.C.S. Edin., Assistant Physician, Skin Dept., Royal Infirmary, Edinburgh ; Lecturer on Dermatology, School of Medicine for Women, Edinburgh. Garrod, Archibald E., M.D., F.R.C.P., F.R.S., Physician with charge of Out-patients and Lecturer on Chemical Pathology, St. Bartholomew's Hospital ; Physician, Hospital for Sick Children, Great Ormond Street. Gibbons, Robert A., M.D., M.R.C.P., Physician Accoucheur to H.R.H. Princess Alexander of Teck ; Physician, Grosvenor Hospital for Women. Goodall, E. Wilberforce, M.D., B.S., Medical Superintendent, Eastern Hospital; late Teacher of Infectious "Diseases in Royal Army Medical College. Gossage, Alfred Milne, M.D., F.R.C.P., Physician to Out-patients, Westminster Hospital and East London Hospital for Children ; Joint Lecturer on Medicine, Westminster Hospital Medical School. Grimsdale, Harold, M.B., B.C., F.R.C.S., Ophthalmic Surgeon and Lecturer on Ophthalmic Surgery, St. George's Hospital; Surgeon, Royal Westminster Ophthalmic Hospital. Groves, Ernest W. Hey, M.D., M.S., F.R.C.S., Assistant Surgeon, Bristol General Hospital ; Senior Demonstrator in Anatomy, Bristol University. Griinbaum, Otto F. F. M.D., F.R.C.P., Assistant Physician, London Hospital; late Physician to Out-patients, City of London Hospital for Diseases of the Chest. Guthrie, Thomas, M.B., B.C., F.R.C.S. Honorary Anrist and Laryngologist, Victoria Central Hospital, Liscard. Hall, Arthur J., M.D., F.R.C.P., Lecturer on Practical Medicine, University of Sheffield; Physician Sheffield Royal Hospital. Hamel, Gust., M.V.O., M.D. Harris, Wilfred, M.D., F.R.C.P., Physician to, and Lecturer on Neurology at, St. Mary's Hospital; Physician, Hospital for Epilepsy and Paralysis, Maida Vale. List of Contributors. xxvii Haward, Warrington, F.R.C.S., Consulting Surgeon, St. George's Hospital. Hay, John, M.D., M.R.C.P., Senior Assistant Physician, Royal Infirmary, Liverpool. Hellier, John B., M.D., Professor of Obstetrics, University of Leeds ; Obstetric Physician, Leeds General Infirmary. Herringham, Wilmot P., M.D., F.R.C.P., Physician, St. Bartholomew's Hospital ; Consulting Physician, Paddington Green Children's Hospital. Hertz, Arthur F., M.D., F.R.C.P., Assistant Physician, Guy's Hospital. Hett, G. Seccombe, M.B., F.R.C.S., Surgeon Laryngologist, Mount Vernon Hospital for Consumption ; Assistant in Ear and Throat Dept., University College Hospital. Holland, Eardley L., M.D., F.R.C.S., M.R.C.P., Physician, City of London Lying-in Hospital ; Examiner, Central Midwives' Board. Holmes, Gordon, M.D., M.R.C.P., Assistant Physician, National Hospital for the Paralysed and Epileptic, Queen Square ; Assistant Physician, Seamen's Hospital, Greenwich. Horder, Thomas J., M.D., F.R.C.P., Physician, Great Northern Central Hospital ; Physician, Cancer Hospital. Huggard, 'William R., M.D., LL.D., F.R.C.P., Visiting Physician, Queen Alexandra Sanatorium, Davos. Hutchinson, Jonathan, F.R.C.S., Surgeon, London Hospital ; Lecturer on Surgery, London Hospital Medical College. Inman, A. Conyers, M.A., M.B., Superintendent of Pathological Laboratory, Brompton Consumption Hospital. xxviii System of Treatment. Jackson, Chevalier, M.D., Professor of Laryngology, University of Pittsburg; Laryngologist to Eye and Ear Hospital, Pittsburg. Jaffrey, Francis, F.R.C.S., Surgeon, St. George's Hospital; Surgeon, Belgrave Hospital for Children. Jones, Henry Lewis, M.D., F.R.C.P., Medical Officer in charge of Electrical Dept., St. Bartholomew's Hospital. Jones, Robert, Ch.M., F.R.C.S. Edin., Lecturer on Orthopaedic Surgery University of Liverpool ; Honorary Surgeon, Royal Southern Hospital, Liverpool; Surgeon, Royal Liverpool Country Hospital for Children. Keith, Arthur, M.D., LL.D., F.R.C.S., Hunterian Professor and Conservator of Museum, Royal College of Surgeons. Kelly, Brown, M.D., C.M., Surgeon for Diseases of the Throat and Nose, Victoria Infirmary, Glasgow. Kerr, J. M. Munro, M.D., C.M., Muir'aead Professor of Midwifery and Gynaecology, Glasgow University ; Obstetric Physician, Glasgow Maternity Hospital. Lack, H. Lambert, M.D., F.R.C.S., Surgeon, Throat Dept., and Lecturer on Diseases of the Throat, London Hospital. Lake, Richard, F.R.C.S., Lecturer on Otology, London School of Clinical Medicine ; Aural Surgeon, Seamen's Hospital; Surgeon, Royal Ear Hospital. Lane, J. Ernest, F.R.C.S., Senior Surgeon and Lecturer on Clinical Surgery, St. 'Mary's Hospital; Senior Surgeon, London Lock Hospital. Lane, W. Arbuthnot, M.S., F.R.C.S., Surgeon, Guy's Hospital ; Senior Surgeon, Hospital for Sick Children, Great Ormond Street. Latham, Arthur, M.D., F.R.C.P., Physician, and Lecturer on Medicine, St. George's Hospital ; Physician, Mount Yernon Hospital for Consumption and Diseases of the Chest ; Advisory Physician, Hospital for Diseases of the Throat, Golden Square^ and General Lying-in Hospital. List of Contributors. xxix Latham, P. W., M.D., F.R.C.P., Late Downing Professor of Medicine, University of Cambridge ; Consulting Physician, Addenbrooke's Hospital, Cambridge. Lawson, Arnold, F.R.C.S., Surgeon, Royal London Ophthalmic Hospital ; Assistant Ophthalmic Surgeon, Middlesex Hospital. Lawson, David, M.D., F.R.S.E., Senior Physician, Nordrach-on-Dee Sanatorium. Legg, T. Percy, M.S., F.R.C.S., Surgeon, Royal Free Hospital; Assistant Surgeon, King's College Hospital. Lillingston, Claude, B.A., B.C. Llewellyn, R. Llewelyn Jones, M.B., Late Medical Officer, Royal Mineral Water Hospital, Bath. Lockyer, Cuthbert, M.D., F.R.C.S., M.R.C.P., Lecturer on Practical Obstetrics, Charing Cross Hospital' Medical School ; Senior Physician to Out-Patients, Samaritan Hospital and British Lying-in Hospital. Love, James Kerr, M.D., Aural Surgeon, Royal Infirmary, Glasgow ; Aurist, Glasgow Institution for the Education of the Deaf and Dumb. Low, George C., M.A., M.D., Lecturer on Tropical Diseases, Post-Graduate College, West London Hospital ; Lecturer in Parasitology and Medical Entomology, King's College. Luff, Arthur P., M.D., F.R.C.P., Physician, St. Mary's Hospital. MacDonald, Sydney G., M.B., F.R.C.S., Clinical Assistant, St. Peter's Hospital for Urinary Diseases. Mackenzie, Hector, M.D., F.R.C.P., Physician and Lecturer on Medicine, St. Thomas' Hospital ; Physician, Brompton Hospital for Consumption. Mackenzie, James, M.D., LL.D., M.R.C.P., Physician, Mount Vernon Hospital. xxx System of Treatment. MacLeod, J. M. H., M.D., M.R.C.P., Physician for Diseases of the Skin, Charing Cross Hospital and Victoria Hospital for Children ; Lecturer on Dermatology, London School of Tropical Medicine. Macnamara, E. D., M.D., F.R.C.P., Physician, West End Hospital for Nervous Diseases ; Assistant Physician, and Lecturer on Medicine, Westminster Hospital. Maddox, Ernest E., M.D., F.R.C.S. Edin. Ophthalmic Surgeon, Royal Victoria and West Hants. Hospital, Bourne- mouth. Milligan, William, M.D., C.M., Aurist and Laryngologist, Manchester Royal Infirmary ; Lecturer on Diseases of the Ear, University of Manchester. Monsarrat, Keith W., M.B., CM., F.R.C.S. Edin. Surgeon, Northern Hospital, Liverpool ; Lecturer on Clinical and Operative Surgery, University of Liverpool. Mummery, P. Lockhart, M.B., B.C., F.R.C.S., Senior Assistant Surgeon, St. Mark's Hospital for Diseases of the Rectum ; Senior Surgeon, Queen's Hospital for Children. Murray, George, M.D., D.C.L., F.R.C.P., Professor of Systematic Medicine, Victoria University of Manchester ; Physician, Royal Infirmary, Manchester. Ogle, Cyril, M.D., F.R.C.P., Physician, Lecturer on Therapeutics and Joint Lecturer on Medicine, St. George's Hospital. Oliver, Sir Thomas, M.D., LL.D., F.R.C.P., Joint Professor of Principles and Practice of Medicine, College of Medicine, Newcastle-on-Tyne; Physician, Royal Victoria Infirmary, Newcastle-on-Tyne. Pardoe, John, M.B., F.R.C.S., Senior Assistant Surgeon, St. Peter's Hospital; Assistant Surgeon, West London Hospital. Paterson, Donald Rose, M.D., M.R.C.P., Surgeon, Ear, Nose and Throat Dept., Cardiff Infirmary; Consulting Surgeon, Diseases of the Ear, Nose and Throat, Royal Seamen's Hospital, Cardiff. List of Contributors. xxxi Paterson, Marcus S., M.B., L.R.C.P., Medical Director, King Edward VII. Memorial in Wales. Pearson, S. Vere, M.B., M.K.C.P., Physician, Mundesley Sanatorium. Pendlebury, Herbert S., M.B., B.C., F.R.C.S., Surgeon, and Lecturer on Surgery, St. George's Hospital ; Surgeon, Royal Waterloo Hospital for Children and Women. Perkins, J. John, M.B., F.R.C.P., Physician, Brompton Consumption Hospital; Physician, St. Thomas' Hospital. Powell, Llewelyn, M.B., B.C., Anaesthetist, St. George's Hospital, and National Hospital for Paralysed and Epileptic, Queen Square. Price, Frederick W., M.D., M.R.C.P., Physician, Great Northern Central Hospital ; Physician and Honorary Pathologist, Mount Vernon Hospital for Consumption. Purslow, C. E., M.D., M.R.C.P., Honorary Obstetric Officer, Queen's Hospital, Birmingham ; Consulting Surgeon, Birmingham Maternity Hospital. Ricketts, Thomas F., M.D., M.R.C.P., Medical Superintendent, Small-pox Hospital (Metropolitan Asylums Board). Roberts, C. Hubert, M.D., F.R.C.S., F.R.C.P., Senior Physician, Samaritan Hospital for Women; Physician, In- patients, Queen Charlotte's Lying-in Hospital. Roberts, J. Reid, C.I.E., Lt.-Col. I. M.S., M.B., M.S., F.R.C.S. Robson, A. W. Mayo-, C.V.O., D.Sc., F.R.C.S., Emeritus Professor of Surgery, University of Leeds ; Consulting Surgeon, Leeds General Infirmary. Rolleston, Humphry Davy, M.D., F.R.C.P., Senior Physician, St. George's Hospital ; Physician, Victoria Hospital for Children. xxxii System of Treatment. Romer, Frank, M.R.C.S., Consulting Surgeon, London Guarantee and Accident Co. ; Honorary Surgeon, Royal Academy of Music. Rowntree, Cecil, M.B., B.S., F.R.C.S., Surgical Registrar, Middlesex Hospital ; Assistant Surgeon, Cancer Hospital. Russell, J. S. Risien, M.D., F.R.C.P., Professor of Clinical Medicine, University College ; Physician, University College Hospital; Physician, National Hospital for Paralysed and Epileptic, Queen Square. Sandwith, F. M., M.D., F.R.C.P., Gresham Professor of Physic; Consulting Physician, Kasr el Ainy Hospital, Cairo ; Lecturer, London School of Tropical Medicine and St. Thomas' Hospital. Saundby, Robert, M.D., F.R.C.P., LL.D., Professor of Medicine, University of. Birmingham ; Senior Physician, Birmingham General Hospital. Sherren, James, F.R.C.S., Surgeon, London Hospital ; Surgeon, Poplar Hospital for Accidents ; Examiner in Anatomy for Primary F.R.C.S. Shrubsall, Frank C., M.D., M.R.C.P., D.P.H. Simpson, W. J. R., C.M.G., M.D., F.R.C.P., Professor of Hygiene, King's College, London ; Lecturer on Tropical Hygiene, London School of Tropical Medicine. Smith, A. Lionel, M.B., M.R.C.P., Late Physician to Out-patients, General Lying-in Hospital, Lambeth ; late Obstetric Physician, St. Marylebone General Dispensary. Smith, Eustace, M.D., F.R.C.P., Senior Physician, East London Hospital for Children; Consulting Physician, City of London Hospital for Diseases of the Chest. Smith, G. Bellingham, M.B., B.S., F.R.C.S., Obstetric Surgeon, Guy's Hospital. List of Contributors. xxxiii Smith, G. F. Darwall, M.B., B.Ch., F.R.C.S., Senior Surgeon to Out-patients, Samaritan Free Hospital ; Physician, General Lying-in Hospital ; Obstetric Tutor, St. George's Hospital. Smith, S. Maynard, M.B., B.S., F.R.C.S., Surgeon to Out-patients, St. Mary's Hospital ; Senior Assistant Surgeon, Victoria Hospital for Children ; Surgeon, London Fever Hospital. Spencer, C. G., Major R.A.M.C., M.B., F.R.C.S., Late Professor of Military Surgery. Royal Army Medical College. Spitta, Harold R. D., M.D., D.P.H., Bacteriologist to Household of H.M. the King; Assistant Bacteriologis and Lecturer on Public Health and Hygiene, St. George's Hospital. Spriggs, Edmund Ivens, M.D., F.R.C.P., Senior Assistant Physician, St. George's Hospital ; Physician, Victoria Hospital for Children. Stevens, Thomas G., M.D., F.R.C.S., M.R.C.P., Physician to Out-patients, Queen Charlotte's Hospital ; Physician, Hospital for Women, Soho Square. Stewart, Purves, M.D., F.R.C.P., Physician to Out-patients, Westminster Hospital ; Physician, West End Hospital for Nervous Diseases. Stewart, T. Grainger, M.B., M.R.C.P., Assistant Physician, National Hospital for Paralysed and Epiteptic ; Assistant Physician, West London Hospital. Stiles, Harold J., M.B., F.R.C.S. Edin., Surgeon, Chalmers' Hospital, Edinburgh ; Surgeon, Royal Edinburgh Hospital for Sick Children. Sunderland, Septimus, M.D., M.R.C.P., Obstetric Physician, French Hospital; Physician, Royal Waterloo .Hospital for Children and Women. Sutherland, G. A., M.D., F.R.C.P., Physician, Paddington Green Children's Hospital and Hampstead General Hospital. S.T. -VOL. II . C xxxiv System of Treatment. Swayne, Walter Carless, M.D., Ch.B., Professor of Obstetrics, University of Bristol; Obstetric Physician, Bristol Royal Infirmary. Taylor, Edward H., M.D., B.Ch., F.R.C.S.I., University Professor in Surgery, Trinity College, Dublin ; Surgeon, Sir P. Dun's Hospital. Taylor, Gordon, M.S., F.R.C.S., Assistant Surgeon, Middlesex Hospital. Taylor, James, M.D., F.R.C.P., Physician, National Hospital for Paralysed and Epileptic, Queen Square ; Physician, Royal London Ophthalmic Hospital. Telling, W. H. Maxwell, M.D., M.R.C.P., Senior Assistant Physician, Leeds General Infirmary; Physician, Hospital for Women and Children, Leeds; Lecturer on Clinical Medicine, University of Leeds. Thomson, H. Campbell, M.D., F.R.C.P., Physician to Out-patients, Middlesex Hospital; Physician, Hospital for Epilepsy and Paralysis, Maida Vale. Thomson, J. C., M.D., D.P.H., Medical Officer of Health, County of Dumfries ; late Medical Officer in charge of Hong Kong Plague Hospital. Thorburn, William, M.D., B.S., F.R.C.S., Professor of Clinical Surgery, University of Manchester; Surgeon, Manchester Royal Infirmary. Tod, HuViter F., M.D., F.R.C.S., Aural Surgeon, London Hospital; Lecturer in Aural Surgery, London Hospital Medical College. Torrens, J. A., M.B., B.S., M.R.C.P., Medical Registrar, St. George's Hospital ; Physician to Out-patients, Paddington Green Children's Hospital. Turner, G. R., F.R.C.S., Surgeon, St. George's Hospital, List of Contributors. xxxv Turner, Philip, M.S., F.R.C.S., Assistant Surgeon, Guy's Hospital. Turner, W. Aldren, M.D., F.R.C.P., Physician and Lecturer on Neurology, King's College Hospital; Physician to Out-patients, National Hospital for Paralysed and Epileptic, Queen Square. Tweedy, E. Hastings, F.R. C.P.I., Obstetric Physician and Gynaecologist, Dr. Steevens' Hospital, Dublin late Master, Rotunda Hospital, Dublin. Von Eicken, Carl, M.D., Professor of Oto-Laryngo-Rhinology, University of Giessen. Waggett, E. B., M.B., B.C., Surgeon, Throat Dept., Charing Cross Hospital. Walker, J. W. Thomson, M.B., C.M., F.R.C.S., Assistant Surgeon, St. Peter's Hospital for Stone ; Surgeon to Out- patients, North West London and Hampstead General Hospital. Wallis, Sir Frederick C., M.B., B.C., F.R.C.S., Surgeon, Charing Cross Hospital ; Surgeon, St. Mark's Hospital ; Surgeon, Grosvenor Hospital for Women. Waterhouse, Herbert F., M.D., F.R.C.S., Surgeon and Lecturer on Surgery, Charing Cross Hospital; Senior Surgeon, Victoria Hospital for Children. Watson, C. Gordon, F.R.C.S., Assistant Surgeon, St. Bartholomew's Hospital; Surgeon, Metropolitan Hospital; Assistant Surgeon, St. Mark's Hospital for Fistula. Watson-Williams, P., M.D., Lecturer on Laryngology and Rhinology, University of Bristol ; Surgeon Ear, Nose and Throat Dept., Bristol Royal Infirmary. xxxvi System of Treatment. Wells, A. Primrose, M.A., L.R.C.S., L.R.C.P., Late Electrical and Light Physician, St. Luke's Hostel. West, C. Ernest, F.R.C.S., Aural Surgeon, St. Bartholomew's Hospital. Westmacott, Frederic H., F.R.C.S., Surgeon, Throat and Ear Dept., Manchester Children's Hospital ; Aural Surgeon, St. John's Hospital for Ear and Eye, Manchester. Wethered, Frank J., M.D., F.R.C.P., Physician, Brompton Consumption Hospital ; Physician in charge of Out-patients, Middlesex Hospital. White, W. Hale, M.D., F.R.C.P., Senior Physician, Guy's Hospital ; Lecturer on Medicine, Guy's Hospital. Whitehead, Arthur L., M.B., B.S., Ophthalmic and Aural Surgeon, General Infirmary, Leeds ; Lecturer on Clinical Ophthalmology and Otology, University of Leeds. Wilkinson, George, M.B., B.C., F.R.C.S., Surgeon, Ear and Throat Dept., Sheffield Royal Hospital. Willcoxy William H., M.D., F.R.C.P., Physician to Out-patients, St. Mary's Hospital; Medical Tutor and Lecturer on Public Health, Pathological Chemistry and Forensic Medicine, St. Mary's Hospital. Williams, Leonard, M.D., M.R.C.P., Physician, French Hospital; Physician, Miller Hospital; Assistant Physician, Metropolitan Hospital. Wilson, S. A. Kinnier, M.D., M.R.C.P., Registrar, National Hospital for Paralysed and Epileptic, Queen Square. Wilson, Thomas, M.D., F.R.C.S., Lecturer on Midwifery and Gynaecology, University of Birmingham ; Obstetric Officer, General Hospital, Birmingham ; Senior Physician to In-patients, Maternity Hospital, Birmingham. List of Contributors. xxxvii Woods, John Francis, M.D., M.R.C.S., Late Medical Superintendent, Hoxton House Asylum. Young, Robert Arthur, M.D., F.R.C.P., Assistant Physician, Brompton Consumption Hospital ; Physician to Out-patients, Middlesex Hospital ; Lecturer on Pharmacology and Therapeutics, Middlesex Hospital Medical School. A SYSTEM OF TREATMENT. DISEASES OF THE BLOOD AND BLOOD FORMING ORGANS. ADDISON'S (PERNICIOUS) ANAEMIA. THE gist of the treatment of pernicious anaemia is : Best to the extent of confinement in bed during the severe stages ; the adminis- tration of arsenic in one form or another if it can be borne ; as liberal a diet as the patient can take and retain ; and attention to the gastro-intestinal tract, especially the relief and cure of any oral sepsis that may be present. The all-important point is to diagnose the condition as early as possible and to stave off the later stages by the early adoption of arsenical treatment. Even when a severe stage of anaemia has been reached the tendency is for temporary recovery to come about even if no particular treatment is adopted ; relapse is sure to take place in spite of treatment, but the rallies may be two, three, four, five or six, or more before the fatal ending ensues ; some cases die in a month, more survive for a year, and some for ten years or more. General Treatment. Pernicious anaemia causes so marked a loss of strength, at any rate by the time it is recognisable by present tests, that when it has been diagnosed the patient is already so weak that he generally takes to his bed willingly, at any rate for the time being. He need not be kept there permanently, for within a few weeks it is probable that the blood condition, even though it has not got back to normal, will have so much improved that the patient's strength will permit of his wearing his clothes again and very likely of his going for a change of air or even returning to business, even if only for a few months. If any severe degree of the malady has been reached, however, rest in bed, preferably in an airy room into which the sun enters freely, is to be advocated strongly. The patient's temperature, pulse rate and respiration S.T. VOL. n. 1 2 Addison's (Pernicious) Anaemia. should be charted carefully, for there is nearly always a certain amount of pyrexia at this stage, indicative perhaps of the toxic origin of the complaint. There is no reason why he should not get out of bed to use the commode should he prefer that to the bed-pan ; but otherwise than this he should remain at complete rest. He will thereby minimise the danger there is of his heart becoming dilated to a sufficient degree to cause reflex or so-called " anaemic " vomiting. Much of the nausea and vomiting of per- nicious anaemia is due to the patient being up and about in spite of the severity of his anaemia, though an additional factor undoubtedly is the arsenic that is prescribed. It is important to minimise the tendency to vomiting in every possible way, and one such way is to avoid physical exertion. Diet. There is no particular foodstuff of the ordinary whole- some kind which is contra-indicated in pernicious anaemia ; indeed, the more the patient can eat and the more varied the dietary the better. Partly on account of the cardiac dilatation, however, partly on account of the tendency to deficiency in the hydrochloric acid in the gastric juice, partly owing to the administration of arsenic by the mouth, and partly, perhaps, owing to lesions in the gastric mucosa, it is sometimes exceedingly difficult to enable these patients to eat even the simplest foods without nausea or actual vomiting. No detailed diet sheets can be made out, therefore, for whereas one patient can take tea, toast and butter and an egg for breakfast ; boiled fish, potatoes and a milk pudding at mid-day ; a cup of tea and bread and butter at 4 p.m., and some vegetables or a plain pudding or stewed fruit and custard in the evening, the next patient may be unable to take anything more than plain milk or perhaps milk thickened with Benger's food or the like, and even then cannot do so without being sick sometimes. The only rules that can be laid down are, that each case must be treated on its own merits ; that the patients' own wishes as regards dietary should be strictly consulted, for they can very often suggest something which, because they have fancied it, they can keep down, when anything suggested by others would be brought up ; that all articles of diet should be transmitted to the patient in as tasteful and tempting a way as possible as regards the cooking, the amount put upon the plate at one time, the flavouring, the warmth and all the other little things which make for success in invalid cooking in general ; and that the patient should be allowed as liberal a diet as may be found possible in an individual case. The question of alcohol will arise ; the same applies to beverages as to foods, the patient's own wishes as regards champagne, light wine, whisky Addison's (Pernicious) Anaemia. 3 and soda, plain water, soda water, aerated water, tea, cocoa, coffee, milk, being used as a guide, though naturally the amount of alcohol consumed should be kept within moderate limits. Arsenic is the drug par excellence for the relief of pernicious anaemia. It is generally prescribed in the form of liquor arsenicalis [U.S. P. liquor potassii arsenitis] in a simple mixture to be taken well diluted with water and after food. The dose is generally 5 min. three times a day to begin with, increasing by 1 min. in each dose every five or six days until the patient may be taking 10 min., 12 min., or even more, three, or even four, times a day. Some patients bear even large doses such as these perfectly well without either nausea, vomiting, or diarrhoea, and in these cases relief to the anremia is much more easy to obtain than it is in other patients in whom the giving of arsenic has to be counter- manded on account of the distressing gastro-intestinal symptoms that it produces. Some cases suffer more from diarrhoea, others more from nausea and vomiting ; in either case it will be necessary as a rule to desist from giving arsenic altogether for the time being and to employ gastro-intestinal remedies until the untoward symptoms abate, and then to start with quite small doses of liquor arsenicalis again, increasing them with great caution and minimis- ing the tendency to gastro-intestinal derangement by giving remedies, such as bismuth and morphia, or astringents, such as hfernatoxylum, to 2 oz. of the decoction ; krameria, pulvis catechu compositus (B.P.), 10 to 40 gr. ; kino, pulvis kino compositus (B.P.), 5 to 20 gr. ; tannic acid, 2 to 5 gr. ; gallic acid, 5 to 15 gr. ; copper sulphate, T ^ to J gr. ; tannigen, 10 gr. ; laudanum, 5 to 15 min. [U.S.P. 8 to 9 min.]; pulvis opii compositus (B.P.), 2 to 10 gr. ; pulvis cretae aromaticus (B.P.), 10 to 60 gr. [U.S.P. pulvis aromaticus, gr. 1 to 6, pulvis cretse compositus, gr. 10 to 60] ; pulvis crette aromaticus cum opio (B.P), 10 to 40 gr. [U.S.P. pulvis aromaticus, gr. 1 to 4, pulvis cretse compositus, gr. 10 to 40, pulvis opii, gr. to 1]. It is impossible to give all the prescriptions that may be found useful in different cases ; one can but indicate the drugs that might be employed, but if the chief tendency is to nausea and vomiting with epigastric pain the following prescription may be found useful : ty . Bismuthi Oxycarbonatis, gr. 10 ; Sodii Bicarbonatis, gr. 10; Liquoris Morphinae Hydrochloridi, mi 10; Pulveris Tragacanthse Compositi, gr. 10 ; Aquam, ad j [U.S.P. I. Bismuthi Subcarbonatis, gr. 10 ; Sodii Bicarbonatis, gr. 10 ; Morphinfe Hydrochloridi, gr. -j^; Pulveris Tragacanthse, gr. 2; Pulveris Acacia?, gr. 2 ; Pulveris Amyli, gr. 2 ; Sacchari, gr. 6 ; Aquam, ad 5]] . Dose, two tablespoonfuls thrice daily or oftener, 12 4 Addison's (Pernicious) Anaemia. If diarrhoea is so troublesome as to interfere with the use of the arsenic, one might employ either the following mixture : 1^ . Cretae Preparatae, gr. 15 ; Pulveris Tragacanthae, gr. 2 ; Sacchari Puri- ficati, 5ss; Tincturae Opii, m.10; Vini Ipecacuanhas, iitlO ; Decoctum Haematoxyli, ad jj [U.S.P. 1^. Cretae Preparatae, gr. 15; Pulveris TragacahthaB, gr. 2; Sacchari, 533; Tincturae Opii, m& ; Vini Ipecacuanhas, ii|6 ; Decoctum Haematoxyli, ad jj]; dose, two table- spoonfuls thrice daily or oftener; or in very severe cases a pill containing sulphate of copper, as in the following prescription: R. Cupri Sulphatis, gr. | ; Opii, gr. ; Pulveris Glycyrrhizae, gr. 2 ; Glucosi liquidi, q.s. Mix for one pill. Dose, one or two pills as often as may be directed. If arsenic can be taken in the form of the liquor when pre- cautions such as the above are taken, well and good ; otherwise it may be necessary to give it in some other form. When Fowler's solution cannot be retained it sometimes happens that liquor arsenii hydrochloricus [U.S.P. liquor acidi arseniosi] can be given in doses similar to those of Fowler's solution, but in an acid instead of a neutral or alkaline mixture, along with dilute hydro- chloric or dilute sulphuric acid, in 10 to 15 min. doses. Other preparations of arsenic may be tried in pill form, such as acid urn arseniosum, ^ to i gr. ; sodii arsenas, ^ to -^ gr. ; arsenii iodidum, ^ to i gr. ; ferri arsenas, ^ to J gr. The sodium arsenate may be given alternatively, not as a pill, but in the form of liquor sodii arsenatis, which contains about half the percentage of metallic arsenic that liquor arsenicalis does, and is sometimes well borne in doses of from 2 min. upwards when Fowler's solution is not tolerated. Donovan's solution (liquor arsenii et hydrargyri iodidi) is not so often employed in cases of pernicious anaemia as it is in the anaemia of tertiary syphilis, but in some cases it might be used when other varieties of arsenic fail, in 5 to 20 min. doses, in the form of a simple mixture. When all efforts at giving arsenic by the mouth prove unsuc- cessful it is probable that attempts will be made to give it hypodermically, in which case the cacodylate of sodium (sodium dimethyl-arsenate) may be employed to the extent of J to of a grain daily, or every other day. Much has been written lately about certain organic compounds of arsenic, especially atoxyl (sodium anil-arsenate), soamin, which is closely related to atoxyl, and other similar compounds, of which the most recent has been termed by Professor Erhlich " No. 606," and it was thought at one time that these, though very much richer in arsenic than the inorganic compounds, were free from any toxic effects; they Addison's (Pernicious) Anaemia. 5 were given hypodermically in doses of from 1 to 3 gr., but the use of all but " 606 " is now much less fashionable than it was, because many patients have developed acute optic atrophy and other lesions as the direct result of using these drugs, whilst there are as yet no reports as to the value of " 606 " in pernicious anaemia. Arsenical waters are sometimes serviceable, especially when other means of giving arsenic fail. The patient may either take them at home in bottle, or better still, if it is possible for him to travel, he may go to the spa and drink the natural waters upon the spot. Amongst the best known arsenical waters are those at Levico, in the Austrian Tyrol (1,760 feet), the water of the strong spring containing 4*6 parts per 1,000 of sulphate of iron, and arsenic equivalent to 0*006 parts per 1,000 of arsenious acid. The quantity of Levico water to be taken daily is about \ oz. to start with, diluted with plain water and drunk after food, the dose being increased until the patient is taking as much as 3 oz. a day. Other arsenical springs are those of La Bourboule, in Auvergne (2,770 feet), the Source Perriere containing the equivalent of 0*028 parts per 1,000 of sodium ar senate, the dose of the water being from \ to \ pint, hot, three times daily after meals. At Royat, also in the Auvergne (1,460 feet), the St. Victor Spring contains 0*004 parts per 1,000 of sodium arsenate, the dose being 1 to 3 pints daily. The Celestines Spring at Vichy (850 feet) con- tains the equivalent of 0*002 parts per 1,000 of sodium arsenate, 1 to 3 pints being taken daily. One of the strongest of the arsenical waters is that of Roncegno, in the Tyrol, which, in addition to 3'0 parts per 1,000 of iron sulphate, contains the equivalent of 0*15 parts per 1,000 of arsenious acid ; the dose usually being a table- spoonful at a time, gradually increased to two tablespoonfuls well diluted with plain water, and taken only when the stomach contains food. There is no particular benefit to be obtained by special baths or other varieties of spa treatment, the chief value of the spas mentioned above being due to the arsenic in the waters themselves. Iron. It is a remarkable thing that iron, which is of such immense benefit in cases of chlorosis, is of relatively little value in pernicious anreniia, at any rate when it is given by itself. Never- theless, just as small doses of arsenic may be of material assistance along with iron in the cure of chlorosis, so may iron be of undoubted benefit in assisting the cure or at least the temporary relief of pernicious anaemia with arsenic. Dr. Byroin Bramwell 1 who was the first to insist upon the value of arsenic in these cases, has recently 6 Addison's (Pernicious) Anaemia. pointed out the value of iron as an accessory in this way. When the red corpuscles have risen perhaps from 545,000 to 1,600,000 per cubic millimetre under arsenic, the disease may seem to resist and not improve further ; on then prescribing some form of iron such as those recommended in the treatment of chlorosis for instance, two Blaud's pills three times a day a further considerable improvement may often be produced readily, especially if the arsenic is continued at the same time. It is always difficult to be certain in cases of this kind whether any given treatment is really beneficial, seeing that with rest in bed and suitable care the patients tend to improve up to a certain point by themselves ; but one has a very distinct impression that organic forms of iron are even more beneficial than inorganic in thus assisting the effects of arsenic in pernicious anaemia, and amongst such organic preparations one would like to mention in particular some that are directly prepared from animal haemoglobin. Nauseous though these are at first, it is remarkable how the patients shortly begin to realise that the remedy is doing them good, so that they become unwilling to omit it notwithstanding the nauseous taste. Oral and gastro-intestinal antiseptics. Although it is gene- rally held nowadays that the septic anaemia which results from long-standing caries of the teeth and pyorrhoea alveolaris is not the same as pernicious anemia, and although it is open to considerable doubt whether it even predisposes to or develops into pernicious anaemia, there can be little doubt that pernicious anaemia patients suffering from oral sepsis should have their mouths carefully attended to. It is, however, unwise to be too energetic in the matter of eradicating carious teeth ; more harm than good has sometimes been done by extracting too large a number of septic stumps at a time. The tearing of the tissues and the opening up of capillary vessels in the immediate neighbourhood of the sepsis has led to a dangerous degree of acute septic absorption or even fatal septicaemia which could have been avoided if the steps taken in regard to the mouth had been more deliberate and if a smaller amount of work had been done at a time. With this caution the treatment required for the mouth will generally be obvious, consisting mainly of stopping, disinfection and extraction. The following is a useful antiseptic mouth wash: 1^. Salol, gr. 12; Thymol, gr. 1J; Olei Anisi, rrij ; Olei Menthae Piperitse, in.2 ; Elixir Glusidi, in.12 ; Spiritus rectificati, jj. A few drops of this should be added to a wineglassful of water and used for rinsing out the mouth. Another useful preparation is ordinary hydrogen peroxide solution, of which as many drops as may Addison's (Pernicious) Anaemia. 7 seem good to the patient may be added to a small tumbler of water. A good firm tooth brush should be used at least three times a day, together with an antiseptic tooth powder of which the following is an example : R . Potassii Chloratis, gr. 40 ; Pulveris Saponis Duri, gr. 80; Acidi Carbolic! Purissimi, gr. 7 ; Olei Cinnamomi, in. 10; Calcii Carbonatis Praecipitati, 3]. If there is any generalised stomatitis this needs treatment by antiseptic measures, the acuter the stomatitis the milder the remedies that should be employed. Ordinary glycerine and borax may be sufficient in many cases, provided it is efficiently used, being applied best upon lint by means of the nurse's finger, whilst in less acute cases an active antiseptic, such as chinosol solution 1 in 500, or the sulol and thymol mouth wash prescribed above may be employed. Not a few proprietary mouth washes upon the market are both pleasant and efficient, but it is difficult to mention any of them by name here. Vaccine treatment has been extensively resorted to of recent years, especially in those cases in which pyorrhoaa alveolaris has been a prominent feature. It may be pointed out that a certain proportion of cases of pernicious anaemia have absolutely perfect teeth and no stomatitis at all, so that oral treatment is not invari- ably required ; but when sepsis is present it may be very difficult to overcome, and to assist in relieving the mouth vaccines prepared from cultures made from the patient's own teeth and gums have been used. There can be no doubt that the tendency to vaccine treatment is immensely overdone, but at the same time in suitably selected cases, undoubted benefits are obtainable, and if the dosage and the intervals between the doses are suitably supervised by those who are familiar with their use vaccine treatment is to be recom- mended in a certain number of cases of pernicious anaemia. It is impossible to lay down any definite rules to be followed, because each case needs treating upon its merits in this respect, and whereas the dose would be 5,000,000 bacteria repeated once a week in one case it may need to be 5,000,000 repeated once in three weeks in another case, or 100,000,000 repeated every four or five days in a third, and so on. My own opinion is that vaccine treatment should never be lightly entered into, that the dosage should be quite small to begin with, that the best guide as to whether it should be repeated or as to whether the dose should be increased is the general condition of the patient, which is of more value than is any estimation of the opsouic index. I should add that I am not at all convinced but that if a series of cases were treated without vaccines and compared with another series of cases that were treated with 8 Addison's (Pernicious) Anaemia. vaccines there would probably not be a great deal of difference between the two. Anti- streptococcus serum was advocated some years ago by those who regarded streptococci as the most important pathogenic organisms in the pus obtained from pyorrhoea alveolaris. When pernicious anaemia was regarded as an exjtreme degree of the toxaemia due to the oral sepsis it was thought that the adminis- tration of an ti- streptococcus serum would be of material benefit in the cure of the disease. It is very difficult to be sure whether it does any good or not, but certainly the benefits that result from its use have not come up to expectations, and seeing that its hypo- dermic administration is painful and that it cannot be repeated indefinitely on account of the phenomena of anaphylaxis and the symptoms of so-called serum disease, it has lately gone out of fashion in the cure of pernicious anaemia. Horse serum has been employed less with a view to any antiseptic action it may have than as a means of promoting nutrition generally in the same way that it does in some severe cases of marasmic children. Upon the whole, however, pernicious anaemia cases do not become marasmic, but rather remain of good bulk, and in these cases there is little indica- tion for the use of horse serum as a remedy. It might be employed, however, in those rarer cases in which marked wasting is a feature. Intestinal antiseptics have been very generally employed, especially by those who hold the view that whatever the toxin may be that leads to pernicious anaemia it is probably produced by or absorbed from the gastro-intestinal tract. There is no actual proof that the alimentary canal is the site of absorption of the supposed bacteria or hypothetical toxins of pernicious anaemia, but there is undoubtedly a great tendency for diarrhoea to occur even before arsenic is given in the treatment of the disease, so that the adminis- tration of intestinal antiseptics would seem to be indicated even if there is no proof that intestinal putrefaction is the cause of the disease. Amongst the different remedies that may be used for the purpose may be mentioned in particular glycerine of carbolic acid, 5 min. ; boric acid, 5 to 15 gr. ; thymol, to 2 gr. as a pill ; creosote, 1 to 5 min. suspended in mucilage or in capsules, diluted with three times the quantity of almond oil, these capsules being coated with keratin if it is desired that they shall not be dissolved until they have passed on from the stomach into the intestine ; naphthol, 10 gr. ; bismuth salicylate, 5 to 20 gr. ; sodium sulpho- carbolate, 5 to 15 gr. ; salol, 5 to 15 gr. in cachets or suspended ; sulphurous acid, to 1 drachm ; precipitated sulphur in doses of 10 gr. up to 1 drachm or more. Lactic-acid-producing bacilli and Addison's (Pernicious) Anaemia. 9 their products, such as lacto-bacilline, have been recommended recently with the idea of replacing inimical bacteria in the bowel by those which are more useful; thus Dill 2 found much benefit from lacto-bacilline in a case of pernicious anaemia in which the stools contained enormous numbers of Streptococci faecalis and Bacilli enteritidis of Gartner. It is very difficult to say whether benefits which may seem to be due to this treatment are really due to it or not, but judiciously prescribed and carefully watched there would seem to be no reason why this line of treatment might not do good, particularly in those cases in which gastro-intestinal symptoms are prominent. Grawitz' method of treating pernicious anaemia is to resort to lavage of the stomach ; the diet consisting strictly of milk and vegetables, enemata being administered daily, arsenic and hydro- chloric acid being given by the mouth. The stomach is washed out through a tube and funnel every other day. When vomiting is itself a troublesome symptom there is something to be said in favour of this treatment, but when the stomach seems to be per- forming its functions well lavage would seem to be an unnecessarily uncomfortable prescription. Both infusion and transfusion have been recommended by some authorities, actual blood having been transfused in earlier cases, though infusion of normal saline at body temperature into the subcutaneous tissues of the axillae is more frequently recommended than actual blood transfusion nowadays. The most recent form of infusion is by the use of deep-sea water, collected specially on shipboard, sterilised and diluted so as to be isotonic with the blood, subcutaneous injections of 1 to 3 oz. being given each day, if need be for some weeks. The inventors of this line of treatment have said a great deal in its favour in the treatment of many forms of malnutrition, but pernicious anaemia cases are as a rule not emaciated or ill-nourished in the ordinary sense, so that infusion and transfusion do not generally seem to be indicated. Bone marrow, both in the fresh and in the lightly cooked state in the form of thin sandwiches, or as specially prepared extract of bone marrow, has been advocated with a view particularly to stimu- lating still further the blood-forming activities of the bones in pernicious anaemia ; theoretically this treatment should be admir- able, but in practice it has not yielded any very definite results. Oxygen inhalations undoubtedly do good in those cases of pernicious anaemia in which the haemoglobin is immensely reduced, down perhaps to 20 or even 15 per cent, of normal ; the extremely low oxygen tension of the blood in these cases would seem to be io Addison's (Pernicious) Anasmia. responsible for certain of the secondary symptoms and effects of pernicious anaemia, particularly the changes in the spinal cord and peripheral nerves, which may cause extensive degeneration of the long tracts, producing symptoms like those of locomotor ataxy or spastic paraplegia or more scattered lesions of the peripheral nerves, with symptoms of acro-paraesthesia, needles-and-pins and so forth in the extremities. As the blood condition improves there is less need for oxygen, but during the severe stages it is well to give it by means of a properly fitting mask and valves, the administration being continued for five minutes at a time every half hour whilst the patient is awake. It is as well that the oxygen should be warmed before it is taken into the lungs. As ordinarily adminis- tered by means of a rubber tube and funnel oxygen is for the most part wasted, but a suitable yet simple apparatus, such as that devised by Professor Leonard Hill, makes oxygen of real therapeutic value in cases of this kind. TREATMENT OF COMPLICATIONS. Most patients suffering from pernicious anaemia, when they are going downhill in their final relapse, simply grow weaker and weaker until they finally cease to live. There are not, as a rule, many complications that need active treatment. There is a tendency to oedema of the legs when the patient, having been kept at rest in bed, begins to get about again during convalescence; massage of the feet, ankles and legs, especially simple rubbing in an upward direction without too much force goes far to minimise this tendency, and even when oedema occurs it is not as a rule painful. Crepe velpeau bandages as a local support to the feet, ankles and legs are very grateful in many cases. Nervous symptoms are common, especially subjective sensations of numbness in the hands, tingling or peculiar feelings of cold or heat ; actual pain in various parts due, doubtless, to ill-defined lesions in the peripheral nerves, or even the effects of actual lesions in the spinal cord, may all need treatment. Bromides may be required if the patient suffers at the same time from much giddiness and difficulty in getting to sleep, whilst locally gentle massage with or without use of faradic electricity may often give relief. Haemorrhages are not uncommon, but they are very seldom in themselves severe. They do not often need active treatment, and when they do the case is generally a very severe one and almost beyond the reach of treatment, though the haematemesis, haemoptysis, epistaxis, metrorrhagia, loss of blood from the bowels, and so forth, Addison's (Pernicious) Anaemia. T i will each be treated in the same way as if these were due to other causes, whilst calcium salts, either the chloride or the lactate or the iodide in doses of from 2 to 60 gr. will be resorted to in the vain hope that thereby the coagulability of the blood may be increased and the haemorrhage stopped. The best remedy when visceral haemorrhage is severe is opium in one or other of its forms. Cerebral haemorrhage may occur spontaneously in pernicious ammuia, but little can be done to prevent its ending fatally. Intercurrent maladies may develop but they are rare ; when they do arise they need treatment on the same lines as in other cases; one would mention in particular lobar pneumonia and inflammation of the serous membranes pleurisy or pericarditis, with effusion, or ascites ; when fluid accumulates in a serous cavity to such an amount as to cause actual distress it may need to be removed by paracentesis. CONVALESCENCE. The probability is that the patient whose pernicious anaemia has been recognised early, and who has at once been treated by rest, arsenic, generous diet and fresh air, will rally within a month or six weeks, and in not a few cases the haemoglobin and the red corpuscles both become normal or nearly normal for the time being. The difficulty is that, do what one will, the patient is almost certain to relapse, sometimes within a few months, some- times in a few weeks, occasionally not for a year or more. Seeing, therefore, that the patient is never really cured, one may speak of the whole period of temporary recovery as one of convalescence. During this time there is no reason why the patient should not return to his work, provided it is not a laborious occupation and provided it is carried out under healthy surroundings. This return to work does not hasten relapses, and it takes away the sense of invalidism and incurability which is so apt to depress patients when they are prevented from carrying on any occupation. Even though the recovery be but partial it is wise to allow the patient to do some work in the interval if he can. The diet should be as generous as possible though the appetite is not as a rule good, and it is often useful to prescribe an acid mixture such as : 1^ . Extract! Nucis Vomicae Liquidi, iril; AcidiSulphuriciDiluti, 111 15 ; Tincturse Gentianae Compositse, 5^ ; Aquam Chloroformi, ad j|. [U.S. P. 1^. Fluid extracti Nucis Vomicae, nil ; Acidi Sulphurici Diluti, ni.15 ; Tincturae Gentianae Composite, 5|; Aquae Chloroformi, 5ij ; Aquam, ad 5!]. Dose, one tablespoonful in a little water thrice daily between meals. 12 Addison's (Pernicious) Anaemia. It is also wise to prescribe arsenic, not continuously, but with short intervals of a few days or a week or two during which none is given. Five minims of liquor arsenii hydrochloricus [U.S.P. liquor acidi arseniosi] may be added to the above mixture, in which case it should be taken immediately after food instead of between meals ; or the patient may take Levico or Koncegno water after meals in doses of 1 to 2 tablespoonfuls diluted with plain water. Relapse is sure to occur within a longer or shorter time, in which case it is wise not to wait too long before the patient is advised to rest upon a couch or in bed again, and carry out the same treat- ment as in the first attack. It is most important, however, not to tell the patient beforehand that speedy relapses are likely to occur, and as far as possible the dangers of the disease should be entirely hidden from him. If he should be alarmed by accidentally hearing the unfortunate adjective " pernicious," he can be honestly assured that taken in time it is by no means so dire a malady as to have merited the term. If only on account of the ill-effect upon the patient the too-well-established name of the disease should if possible be changed, and as an alternative it might well be spoken of as Addison's anemia. HERBERT FRENCH. KEFERENCES. 1 Bramwell, B., "Note on the Treatment of Pernicious Anoemia," Brit. Med. Journ., 1909, I., p. 209. 2 Lancet, 1908, II., p. 1600. ANEMIA DUE TO SOME DEFINITE MALADY BUT NOT DUE TO OBVIOUS BLOOD LOSS. THE term " secondary anaemia " has been used in so loose a way in clinical medicine that it is now best not used at all. It is on this account that so long a heading is employed above to denote one group of conditions in which anaemia is secondary, another group consisting of conditions in which anaemia is the result of actual blood loss, acute and abundant or recurrent. There are many different maladies that may be associated with pronounced anaemia, and one may say of all of them that the principles of treatment are : To relieve or cure the primary condition whenever possible ; to encourage as liberal a diet as circumstances will allow ; to advise living in as bright and airy surroundings as may be, out of doors when possible or in a large room with open windows and a southern aspect when the primary malady necessi- tates confinement to the house or to bed ; and to treat the anaemia itself upon the same lines as those described for chlorosis (p. 20). Iron, arsenic and quinine are the main remedies to rely upon, particularly iron, adopting that variety which is found not to upset the gastro-intestinal functions. If these general principles are borne in mind, there is little more to be said about the treatment of the anaemia itself, seeing that the therapeutics of each individual primary malady are discussed elsewhere in this work. One may enumerate the commoner conditions, however, as follows : Anaemia caused by pulmonary tuberculosis : The best cure for the anaemia of pulmonary tuberculosis is sunshine ; iron needs to be used with considerable caution, because the appetite is already apt to be capricious and the patient cannot afford to run the risk of having it made worse. Seaside air is to be preferred whenever possible, particularly if the patient is a good sailor and is not too ill to spend most of the day actually on the sea in a small sailing boat. Some patients do better in the country, however. Fresh air, sunshine, no work if there is pyrexia, but graduated exercise if there is none, are the essentials, and it is much better for the patient to be any- where than amongst other patients of the same kind, as at a sanatorium, provided he has learned what living the fresh-air life means. Small doses of arsenic are most serviceable in these cases, and sleep should be encouraged by using even opiates if they are, needed to' quieten a troublesome night cough. 14 Symptomatic Anaemia. Anaemia in ailing children : Children often suffer from pallor when they are not well, and the two best remedies for the anaemia itself are cod-liver oil and extract of malt and iron. The beneficial effects of the latter are often wonderful, especially in children who live in towns. One of the best preparations is the following : Take of pyrophosphate of iron, 2 parts ; water, 3 parts ; dissolve and add extract of malt, 95 parts. Children generally take this with avidity in doses of from one to four teaspoonf uls three or four times a day, though older patients tend to find it nauseating. It is essential to treat whatever cause for ill-health may be detected in any particular case. Errors of diet, particularly the consumption of sweets between meals, should be corrected. If there are enlarged glands in the neck, or other evidence of possible tuberculosis, the milk supply should be carefully investigated, and, if possible, only milk from tuberculin-tested cows allowed. The amount of surgical tuberculosis attributable to cow's milk both in towns and in the country is incredible. Mouth breathing should be steadily discouraged until a child who has acquired that habit is gradually broken of it. Adenoids or enlarged tonsils may need removal, but it is important to realise that the object of the opera- tion is merely to restore the nasal airway and that the adenoids will recur unless nose-breathing is inculcated and re-established. Coli-bacilluria is not an uncommon cause of ill-health in children, and it may remain undetected unless specimens of urine are examined for pus cells microscropically ; mild cases may be cured by giving urotropine in 5 or 10 gr. doses, but severer cases may require confinement to bed, potassium citrate in 5 or 10 gr. doses, and urotropine or helmitol in 10 gr. doses ; whilst some observers believe that coli-vaccine treatment is also beneficial. Rickets is often associated with anaemia ; attention to the diet, administration of malt and iron, and greater care in keeping the child out of doors and as much as possible in sunshine, should cure both the rickets and the anaemia. Pediculosis capitis is a common cause for serious ill- health and anaemia amongst the poorer classes, especially in girls ; there may be obvious nits with or without sore places on the back of the neck and enlarged occipital and mastoid glands. Weak lysol compresses to the head, combing with sassafras oil, or the applica- tion of methylated spirits, should rapidly expel the pediculi ; sassafras oil is preferable to methylated spirits if there are actual sores, because the spirits cause the latter to smart intensely ; otherwise there is no better eradicant of pediculi than methylated spirits. For Pseudo-leuktemia infantum (von Jaksch's disease) see p. 42. Symptomatic Anaemia. 15 Acute rheumatism is very apt to cause pronounced anaemia, especially when it recurs at short intervals and necessitates the use of sodium salicylate or aceto-salicylic acid in large doses over long periods. It is possible that the remedy itself is responsible for part of this anaemia ; to obviate this it is usual to add some preparation of iron to the sodium salicylate mixture after the first week or ten days, as in the following prescription : 1^ . Ferri et Ammonii Citratis, gr. 5 ; Sodii Salicylatis, gr. 15 ; Glycerini, 5ss ; Aquam, ad 3]. Dose, two tablespoonfuls thrice daily or oftener. Heart disease sometimes causes plethora rather than anaemia, especially in mitral cases. Two forms of heart disease in par- ticular, however, tend to cause serious anaemia syphilitic aortic regurgitation, and fungating endocarditis. Iron remedies are indicated in both cases, together with arsenic and anti- syphilitic remedies in the former and suitable serum or vaccine treatment in the latter. Intestinal parasites, particularly Ankylostomum duodenale and Bothriocephahu latiis, and to a less extent Tcenia soliuin and Tcenia victUocaiK'Uata, may lead to profound anaemia. Early diagnosis and eradication of the worms afford the best means of curing the anaemia, though severe cases may be a long while in recovery, even when iron remedies are employed as in chlorosis. Cases of this kind often do better at a spa than at home, one of the best watering-places for the purpose in the late spring, summer and early autumn being Schwalbach (1,042 feet), or if a higher altitude can be borne, Tarasp (3,996 feet). Tropical anaemia, especially that which has resulted from repeated attacks of tertian, quartan, or sestivo-autumnal malaria, blackwater fever, dysentery, or some of the many less well-defined febrile maladies of the tropics, may be very difficult to cure. Milder cases recover completely within a few months of returning to England, even when no particular treatment is adopted. Severer cases require active treatment with iron, quinine and arsenic, upon lines similar to those advised for chlorosis, except that it is only in exceptional cases that confinement to bed is necessary. Residence in a warm sunny atmosphere is to be recommended, so that winters may be spent at Mentone or elsewhere in the Riviera, rather than in England ; the seaside is generally better than the country, especially if the patient can spend much of his time sailing in a small boat, though much benefit is also obtainable, especially by women, from residence at a chalybeate spa. Convalescence from many maladies, especially those that have entailed long confinement to bed, such as typhoid fever, is associated 1 6 Symptomatic Anaemia. with anaemia. Iron, arsenic and quinine are usually prescribed, but change of air and scene, especially when the change is to open- air and sunshine afford the best remedy. Septic states are nearly always associated with more or less anaemia. Iron, quinine and arsenic, will assist in relieving the latter, but the best treatment is to remove the septic cause when- ever possible. The therapeutics of the various septic conditions will be found elsewhere : Oral sepsis ; leucorrhoea ; enclometritis ; constipation and intestinal putrefaction ; acute, chronic, mucous, muco-membranous colitis ; totid bronchitis ; bronchiectasis ; phthisis, with pyogenic infection of the lung cavities ; ulcerative colitis ; cystitis ; pyelonephritis ; acute and chronic rheumatoid arthritis, infective synovitis or arthritis, as distinct from osteo- arthritis ; infective endocarditis ; long continuing sinuses associated with bone necrosis ; psoas abscess, hip-joint disease, empyema, mastoid abscess, pyosalpinx ; chronic appendicitis ; ischio-rectal abscess; permeal fistulae*; recurrent pyodermia, and so on. Surgical and vaccine treatments may suggest themselves in many such cases in addition to the symptomatic treatment of the anaemia. Cancer, especially when it involves vital organs such as the oesophagus or stomach, or leads to foetid ulceration, or to sleepless- ness from pain, may cause progressive and severe anaemia. It is seldom possible to relieve this, because the end is not far off, but sunshine, iron, morphia, and as generous a diet as possible, especially as regards meat, will be the best measures for relieving the anaemia. Plumbism generally causes pronounced anaemia, and so may the chronic effects of other chemical substances such as naphtha vapour, carbon bisulphide, petrol, and many other substances used in different commercial processes. The best treatment is prophylactic ; the source of chronic poisoning having been discovered, steps should be taken to obviate it for the future. Sometimes the source of lead poisoning is clear enough, being indicated by the patient's employ- ment as a plumber, painter, pottery glazer or the like ; often, however, it is most difficult to trace the mischief to its source, for instance, in the case of hairwashes, water supply, foods or hobbies. The anaemia itself is best treated with iron and iodides, the syrupus ferri iodidi (B.P.) being particularly good in doses of from to 1 fluid drachm. The bowels should be kept well open with magnesium sulphate, and the patient should drink lemonade made artificially with 20 min. of dilute sulphuric acid to each ounce, and syrup of lemon [U.S.P. syrup of citric acid] to taste. Symptomatic Anaemia. 17 Syphilis is sometimes responsible for considerable or even severe anaemia, both in the secondary and in the tertiary stages. Iron may benefit the anaemia, but small doses of arsenic are even more beneficial ; it may be combined with mercury and iodide in the form of Donovan's solution liquor arsenii et hydragyri iodidi (B.P.) of which 5 to 20 min. or more may be prescribed in a simple mixture to be taken twice or thrice daily after food. The more efficient the anti-syphilitic treatment, the less the liability to tertiary anaemia, and mercurial inunctions will generally be found better than giving mercury by the mouth. Hypodermic injections of mercury are not unaccompanied by disadvantages, but they may be required in a few cases. A course of treatment at Aix-la- Chapelle is to be recommended in many instances. Bright' s disease, particularly the chronic tubal variety, is apt to cause pronounced anaemia the large white person with the large white kidney. It is important to minimise the anaemia in these cases. If it is associated with marked oedema, restriction of salt in the dietary may be advocated, though this has proved less beneficial than was at first expected. Iron preparations may be ordered as in chlorosis, but the most important point of all is to allow a generous diet, including meat. Notwithstanding the presence of abundant albumin in the urine in these cases, it is important to realise that this is a permanent condition ; the patients should be encouraged to live as nearly a normal life as possible, and, provided that ordinary moderation is observed, the dietary should be precisely the same as that of a healthy individual. The anaemia will often disappear when meat is allowed in this way, and the patient will live longer rather than less long upon the more generous dietary. HERBERT FRENCH. ANAEMIA DUE TO ACTUAL LOSS OF BLOOD. ANEMIA and blood loss may both be the effects of some common cause, as in certain cases of severe purpura (q.v.) ; or the anaemia may be directly due to blood loss, either a single copious bleeding, such as post-partum haemorrhage, haematemesis, or haemoptysis, or recurrent bleedings, as in some cases of uterine fibromyomata or rectal polypi. In all such cases it is important, whenever possible, to stop the bleeding either by means of absolute rest, morphia injections, styptics, or by means of ligatures, excision of the bleeding focus, or other surgical measures. Details of the treatment to be adopted for the various forms of bleeding will be found elsewhere in this work. It remains to cure the anaemia itself. After an acute bleeding, when the latter has been checked, the first thing is to save the patient from dying of the extreme anaemia that has suddenly developed. He should be kept absolutely still in a darkened well-ventilated room, the air of which is about 70 F., with warm blankets next the skin, and hot bottles to the feet and flanks ; the foot of the bed should be raised by means of bricks, books or otherwise, so that the patient's feet are slightly higher than his head ; the legs and arms should be gently but firmly bandaged over cotton-wool from their distal ends up to the trunk, partly to keep them warm, and partly to drive as much blood as may be in towards the heart for use in the brain and more vital organs. The abdomen may be bandaged in a similar way if the bleeding has not been intra-abdominal. These bandages may be left on for an hour or longer until the patient complains of their being irksome ; mean- while the necessary apparatus and solutions for saline infusion are got ready as quickly as possible ; two pints or more may be given rapidly by the intravenous method or into the subcutaneous tissues of the axillae, after which it is better to rely rather upon the continuous rectal method. The use of pituitary extract is much advocated nowadays as a very successful way of overcoming shock. The more the blood pressure has fallen the more good is the pituitary extract likely to do. It is issued in small glass phials containing 1 c.c. of 20 per cent, sterile extract, equivalent to 0'2 gramme of fresh posterior lobe of the pituitary body. This may be given by intramuscular or intravenous injection, or it may be added to the saline fluid used Anaemia due to Actual Loss of Blood. 19 for infusion. Its effect comes on in less than half an hour and continues for twelve hours or more, by which time the dose may be repeated if need be. If the acute bleeding has not been from the stomach, hot brandy and water, hot coffee, or similar warming and stimulating drinks, may be allowed ; thirst will presently be extreme, notwithstanding infusion ; bland fluids, especially water, may be allowed ad libitum, preferably in small quantities at a time, but administered frequently. The feeling of impending suffocation is best alleviated by the use of oxygen inhalations, especially when the latter are given through properly fitting apparatus with a mask and valves. Strychnine injections are less used than formerly, but they might be employed if no pituitary extract is available. Sleep should be encouraged, but it is too risky to give any powerful hypnotic such as morphia. When the immediate danger of death has passed the ansemia itself will need careful treatment upon the same lines as those described for chlorosis (p. 20). There is a strong tendency towards spontaneous and rapid recovery, so that in six weeks or two months time the blood has often become normal again. This tendency should be borne in mind and drug treatment should not be too active. Small doses of iron and still smaller doses of arsenic are likely to do more good than larger ones in cases of sudden acute anaemia, though this is less true of patients in whom the bleeding, without being at any one time extreme, has been recurrent over a long period. If after recovery up to a certain point there are signs of the cure lagging, a change of air and scene, particularly to some part where the sun shines, will often prove very beneficial, to Worthing, Eastbourne, Cornwall, or the Channel Islands, if it is thought wiser not to go abroad. HERBERT FRENCH. 22 20 CHLOROSIS. THEKE are a very large number of different conditions that may produce ansemia of the chlorotic type, the essential features of the blood changes being great diminution in the percentage of haemo- globin, a less reduction in the percentage of red corpuscles, so that the colour index is less, and often much less, than 1, whilst at the same time the leucocytes exhibit no particular change either in total numbers or in the differential leucocyte count. Chlorosis itself, however, is a distinct malady easily recognisable in most cases, confined to the female sex, seldom if ever developing before puberty, though common after it and during the succeeding years ; it becomes progressively less common with each year after twenty, and it is most common and most severe between seventeen and twenty. Typical chlorosis, with the greenish yellow hue that gave the name to the complaint, is not so frequent as are minor degrees of the malady, which may show any stage from slight paleness to typical and unmistakable chlorosis. The essential points in the treatment of a severe case are four, namely : Complete rest in bed for the time being ; sunshine and fresh air, even though the patient is in bed ; the administration of iron ; and precautions to ensure that constipation does not persist. The omission of strict attention to any one of the above principles is liable to be followed by failure in the cure of the patient ; if, however, one were asked to say which of the four principles enumerated above should be most insisted upon it would be the necessity for complete rest in bed in severe cases. Rest, Sunshine, Air. The patient is very often a servant girl, who, working indoors most of the week, has developed so marked a degree of chlorosis that she now suffers from shortness of breath on going upstairs, from more or less swelling of the feet when she has been on them any length of time, from inability to take food properly because ordinary diet causes severe pain in the upper part of the abdomen and necessitates vomiting in order to relieve this, from irregularity of the monthly periods or complete amenorrhoea for months at a time with more or less constipation ; such a patient put to bed in a sunny room, attended by a careful nurse and supplied with an abundance of good plain food of every kind, including meat at least once a day, Chlorosis. 21 will very often become perfectly well in six to eight weeks, even though no iron and no laxatives are administered. The most that such a patient should be allowed to do in the way of physical exercise should be to get out of bed to use the commode, though even this might be interdicted for the first week or ten days. The sunny bright aspect of the room in which the treatment is carried out is an important factor in tlie cure, and it is even probable that servant girls and others would not become chlorotic at all if from the beginning they had beeli in the habit of living in sunny rooms with open windows and had had some pleasurable outdoor exercise every day instead of, as so often happens, spending many days or even weeks at a time within doors, perhaps in sunless rooms, often with closed windows, and frequently without outdoor exercise except in the evening, when it is already dark. It is true that chlorosis occurs in country places as well as in towns, but errors in the general mode of living will almost always be found to account for it in country cases, for life in a cottage may be as much indoor and sunless as life in a town house. The rest in bed should be absolute for four weeks at least, unless both haemoglobin and red corpuscles have risen to normal within this time, which is unlikely. It is sometimes advisable to continue treatment in bed for as long as six or even eight weeks, though if by this time the haemoglobin has not yet risen to normal it will be wise to let the patient begin to sit up and then gradually to use her feet a little until she has recovered sufficient ambulatory power to be able to go away for a change of scene, either to the country or to the seaside, as her own inclinations and the circumstances of the case most indicate. It is often wise to go from one place to another during convalescence, ending at a higher altitude than that at which the treatment was begun. Physical exertion should be resumed only with considerable care and with careful attention to the amount of increase allowed each day, for a relapse may readily be brought about by too quick a return to daily avocations. The severest case of chlorosis, however, is generally curable com- pletely within twelve weeks if circumstances allow of full attention to details in the treatment. Preparations of Iron. The administration of iron is beyond doubt the most important medicinal factor in the cure of chlorosis. We need not enter here into a discussion of the way in which the iron does good ; indeed, nobody really knows how it does so. The fact remains, however, that chlorosis is more rapidly curable with iron than without it, though iron by itself without the patient being put to bed in a sunny room and fed 22 Chlorosis. well is very apt to fail in the good effects that may have been expected of it. A very large number of different iron prepara- tions have been recommended by different observers and at different times, each in turn having been vaunted as immensely better than the others ; this multiplicity of preparations almost certainly indicates that no one variety of iron is essentially better than another, and the best line of treatment to adopt is to prescribe in the first instance one of the common inorganic forms, especially the sulphate, the carbonate or the perchloride ; and to continue to use this if the patient can take it without developing gastric or other ill-effects ; but to change it for one of the many other iron remedies if the stronger types cannot be tolerated. The chief ill-effects of iron to be on the watch for are marked blacken- ing of the tongue and possibly of the teeth, unless the medicine is taken through a straw, is given in pill or other solid form, or unless a mouth wash and tooth brush are employed after each dose ; con- stipation, owing to the astringent action of the drug, which usually necessitates the use with it either of a saline laxative or else of some such drags as aloes and nux vomica ; dyspeptic symptoms, followed by nausea and a disinclination for food, which are very much less common in patients confined to bed than in those who are up and about, but which if they should arise in a patient who is not in bed are very difficult to relieve except by changing the iron prepara- tion that is being administered ; and a continuous dull but severe pain either in the back about the region of the tenth dorsal vertebra or beneath one or other shoulder-blade, particularly the right near its inferior angle ; this pain in the back due to iron may come on when there is neither constipation nor obvious gastric derangement or loss of appetite, and it is difficult to remedy except by either leaving off the iron altogether or at least changing the iron preparation that is being employed for some other. Probably one of the best remedies for all-round use is Griffith's mixture, mistura ferri composita (B.P.), the active ingredient of which is ferrous carbonate formed by the interaction of ferrous sulphate and ferrous carbonate. The difficulty is that the prepara- tion will not keep, changing colour by oxidising more or less within a few days, and therefore requiring to be made up fresh at short intervals. The patient should be able to take a fluid ounce three or even four times daily. The perchloride of iron is generally too astringent to be continued with for long periods at a stretch, but as an alternative to other iron preparations, or for use in a case in which improvement has taken place up to a certain point, but in which it is desired to hasten Chlorosis. 23 the cure as much as possible, ferric chloride may often be used with advantage, the solution being preferable to the tincture, and a suit- able mixture being : R. Liquoris Ferri Perchloridi, in.15 ; Glycerini, 5J ; Magnesii Sulphatis, q.s., e.g., 5^ ; Acidi Sulphurici Diluti, HI 10 ; Aquam Chloroformi, ad jj [U.S.P. 1^. Liquoris Ferri Chloridi, ill 4 ; Glycerini, 5] ; Magnesii Sulphatis, q.s., e.g., 5! ; Acidi Sul- phurici Diluti, 111 10; Aquae Chloroformi, 3^; Aquam, ad ^j] . Dose, 1 oz. three or four times daily. The chloride may also be prescribed with ammonia in a mixture which is nearly neutral and almost free from astringent taste, as in mistura ferri ammoniata (B.P.C.), which is as follows: 1^. Liquoris Ferri Perchloridi, iilO; Spiritus Ammonias Arornatici, ill 10; Syrupi Simplicis, lit 40; Aquam, ad j [U.S.P. ty. Liquoris Ferri Chloridi, ir|,3; Spiritus Ammonias Aromatici, iij.10; Syrupi, ii[40 ; Aquam, ad gj] . Dose, 1 oz. three or four times a day. Ferrous sulphate may also be prescribed in a mixture form as in the following prescription : 1^ . Ferri Sulphatis, gr. 4 ; Magnesii Sulphatis, q.s., e.g., gr. 40; Acidi Sulphurici Diluti, rn.10; Aquam Chloroformi, ad jj [U.S.P. 1^. Ferri Sulphatis, gr. 4; Magnesii Su-lphatis, q.s., e.g., gr. 40; Acidi Sulphurici Diluti, ntlO; Aquae Chloroformi, |; Aquam, ad ^j] . Dose, 1 oz. three or four times a day. More often, however, the sulphate is prescribed in pill form along with a carbonate, so that when the pill dissolves within the stomach or intestines fresh carbonate of iron is formed, as in the case of the well-known Blaud's pill (pilula ferri (B.P.) ) [U.S.P. Massa Ferri Carbonatis] , of which the dose is 5 to 15 gr. three times a day, each 5-gr. pill containing 1 gr. of ferrous carbonate. When cos- tiveness is a troublesome symptom, and Blaud's pill is being used, one may add aloes or nux vomica or both, as in the following pre- scription : R. Extracti Nucis Vomicae, gr. J; Ferri Sulphatis Exsiccati, gr. 1 ; Extracti Aloes Barbadensis, gr. 1 ; Extracti Glycyrrhizje, gr. 1; Glucosi Liquidi, gr. J ; Misce, fiat pilula. Dose, one or two such pills twice or three times a day as directed. Carbonate of soda may be incorporated in the above pill if required. If there is much tendency to gastric disturbances in spite of rest in bed it may be wise to add some carminative to the medicine so that the prescription might read as follows : R . Tincturse Ferri Perchloridi, ttil2 ; Glycerini, 5 ; Tincturaa Cardamomi Cornpositae, 5^; Aquam, ad 5] [U.S.P. 1^. Tincturae Ferri Chloridi, nt9; 24 Chlorosis. Glycerin!, 5^ ; Tincturae Cardamomi Composite, 5^; Aquam, ad 53] . Dose, one to two tablespoonfuls thrice or four times daily ; or, R. Ferri Sulphatis, gr. 4 ; Sodii Bicarbonatis, gr. 15 ; Tincturae Zingiberis, rn,20 ; Magnesii Sulphatis, 53 ; Syrupi, 5j ; Aquam Chloroformi, ad jj [U.S.P. 1^. Ferri Sulphatis, gr. 4; Sodii Bicarbonatis, gr, 15 ; Tincturae Zingiberis, 111 10 ; Magnesii Sul- phatis, 5j ; Syrupi, 5J ; Aquae Chloroformi, ; Aquam, ad 5]] . Dose, two tablespoonfuls two or three times daily. The amount of saline laxative will naturally be varied according to circumstances, and it is wise to reduce it to a minimum. Keduced iron (ferrum redactum), of which the dose is from 1 to 15 gr., needs to be freshly prepared, because it readily oxidises, particularly in the presence of any damp ; it is held by some, how- ever, that it is more efficacious than are the more saturated salts of iron, partly, perhaps, because it contains a large percentage of iron in small bulk. It is tasteless, and it is generally prescribed in the form of lozenges containing 1 gr. of reduced iron in each with a simple basis. Scale Preparations. To write all the various prescriptions that have yielded good results in the treatment of chlorosis will be to overfill the space allotted to this article. In actual practice it will be found that, provided the patient is kept in bed, one or other of the above prescriptions will be suitable in a large propor- tion of cases. Should none of them be found tolerable, however, the next step would probably be to employ a milder form of iron, particularly one of the scale preparations (ferrum tartaratum, ferri et ammonii citras, and ferri et quinines citras), the dose of all of which is from 5 to 10 gr. Unfortunately, although these are much better borne than the stronger preparations already mentioned, they are generally much less effective in the cure of the disease. It may be necessary to resort to them, however, when the patient is first put to bed until as time goes on it is found that the scale preparations can be changed in a week or ten days for the carbo- nate, the sulphate or the perchloride. It is not at all unusual to prescribe small doses of arsenic at the same time, as in the follow- ing prescription : 1^. Liquoris Arsenicalis, ir|,2; Ferri et Ammonii Citratis, gr. 10 ; Syrupi, 5^ ; Aquam Anethi, ad |. Dose, one tablespoonful thrice daily after food. Organic Iron Compounds. There are a very large number of organic iron compounds upon the market, many of which are decidedly beneficial, though seldom more so than are the ordinary iron compounds when the latter can be borne. It is not possible, for obvious reasons, to give the names of the various proprietary Chlorosis. 25 compounds of iron that may be found of use in certain cases when any particular circumstances render the inorganic salts ineligible. Preparations from eggs, from haemoglobin, compounds of iron with albumin, with meat extract, with peptone, with somatose, with glidine, are widely advertised ; one can only say that the form of iron employed in any given case is of much less importance than that some form should be given. One might mention, in particular, however, that "there are various compounds termed "alginates," derived directly or indirectly from seaweed, and that the iron salt, alginate of iron, which may be prescribed as such, but which is also obtainable in a proprietary form, seem to have certain advantages, of which the chief are that it is a tasteless powder, that it is not soluble in acids and therefore does not have any action on the stomach, being only dissolved when it reaches the small intestine, that it does not cause constipation, and that it can be taken when dyspeptic symptoms are already present in the case without increasing that dyspepsia. The dose is from 5 to 10 gr., and it is prescribed preferably in cachets. Iron Wines. Two other and entirely different ways in which iron may be utilised in chlorosis are first in the form of wine, whether natural or artificial, and secondly, as a mineral water, either in bottle or at a spa. There are two wines containing iron in the British Pharmacopoeia, namely, steel wine, or vinum ferri, which is a solution of iron wire in sherry, the strength being 1 part in 20, and the dose 1 to 4 fluid drachms ; the other is vinum ferri citratis, 1 gr. of iron and ammonium citrate being dissolved in each fluid drachm of orange wine, the dose being from 1 to 4 drachms. It will depend to a considerable extent upon the general views both of the patient, of her parents and friends, and of the medical atten- dant himself, upon the whole question of alcohol whether any wine of this kind should be used or not ; upon the whole, however, the tendency nowadays is not to prescribe alcoholic preparations when others will do as well and steel wine is g9ing out of fashion ; if any wine were ordered at all it would more likely take the form of a product of grapes that have been grown upon ferruginous soil, particularly certain forms of Chianti or else a Burgundy from certain Australian vineyards. There are not a few proprietary remedies of repute in which iron wine is combined with various meat extracts or other products. Chalybeate "Waters and Spas. As regards chalybeate waters there are large numbers obtainable in bottle, but there is no particular advantage in any of them over the making of iron water for oneself ; a series of clear glass wine bottles filled with 26 Chlorosis. water, and a rusty nail dropped into each, will make an iron mineral water at home which is quite as beneficial as any water bottled at a spa. There are many natural waters that contain iron either in solution or in suspension, and in many parts of the British Islands the rusty deposits upon the stones near little springs that have no name indicate the ferruginous strata from which they come ; any of these are beneficial in chlorotic cases if uncontaminated in other respects. The three best known chalybeate watering-places in Great Britain are Harrogate, Tunbridge Wells and Woodhall Spa, whilst of those upon the Continent the most familiar are perhaps St. Moritz and Tarasp, in Switzerland, Spa, in Belgium, Homburg and Schwalbach, in Germany, Marienbad, in Bohemia, and Levico, in Austria. The richest of all these in iron is that at Levico, whilst the water there has the additional advantage of containing small quantities of arsenic as well. As a general rule it is unusual to take a patient suffering from severe chlorosis to a spa, because a cure is so readily obtainable without this if only the patient is put to bed ; it is more common to adopt spa treatment for anaemia due to other causes, such for instance as prolonged and delayed convalescence after some serious illness, blood loss, and so forth. The choice of a spa will depend largely upon the circumstances of each individual case ; it is unwise to take anaemic patients suddenly to any high altitude, so that whereas St. Moritz (5,820 feet) and Tarasp (3,996 feet) are very beneficial as places for the completion of a cure, Schwalbach (1,042 feet) is much better to begin with. No spa treatment is really advisable in these cases in the cold months of the autumn, winter or early spring. Baths. Those who are strong advocates of water cures advise carbonic acid baths, sweat baths, wet and dry rubbings and all the various douches which are so much in vogue, but none of these are essential to the successful cure of chlorosis, and it is very probable that they might do harm in the treatment of the earlier stages of a severe case when rest is so essential. Later, the change of surroundings, the open-air and sunshine are probably much more curative than are the baths themselves. Drugs other than Iron. Arsenic is so valuable in many cases of severe anaemia, especially pernicious anaemia, that it is surprising that it is of such relatively little value in chlorosis ; administered without iron it does little good, but many observers hold that small doses of the liquor arsenicalis are beneficial when given along with iron, as in the prescription on p. 24. Quinine is favoured by some authorities. It may be given Chlorosis. 27 combined with iron in the scale preparation (iron and quinine citrate) or it may be prescribed in small doses of the tincture along with whatever liquid form of iron is being used. During late convalescence it may be prescribed simply as a tonic. Sulphur is administered most conveniently in cachets, and although it is not easy to be sure how it acts there can be little doubt that it is beneficial in many cases. Sublimed sulphur may be given in 5 to 10 gr. doses twice or three times daily, or what is perhaps a commoner way of prescribing the remedy, a teaspoonful or more may be ordered once or twice a week either in cachets or stirred up with some soft foodstuff with which it can be readily swallowed. Sulphur seems to do most good in cases in which there is a marked tendency to constipation, though by itself it seldom if ever cures that tendency. Manganese, or combinations of manganese and iron with peptone or other albuminoid bases, has been advocated by some authorities, but in practice there is little advantage in this treatment over that more generally followed. The same applies to other remedies which have been advocated from time to time, such for instance as periodic inhalation of oxygen ; oral administration of chloride of gold and sodium (auri et sodii chloridi, U.S.P.), in doses of about ^ gr. ; small venesections ; and compressed air baths. The patient may become completely well when any or all of these are being adopted, but there is really little to indicate that they accelerate the cure. Digitalis is recommended by some authorities when there is considerable shortness of breath on exertion or when the tendency to O3clema of the legs is considerable. It seldom happens, however, that the cardiac symptoms are not immediately relieved by rest in bed, and the use of digitalis as a means of stimulating the heart to more work in order to obviate the necessity for the patient going to bed is erroneous treatment for the chlorosis itself. Theocin-sodium acetate has been recommended recently in a similar way, with the idea of expelling the surplus of water from the blood ; water is removed by the bowel at the same time by giving suitable doses of magnesium and sodium sulphate. Theocin- sodium acetate is prescribed in 5 gr. doses four times a day, together with 5 min. of tincture of digitalis in each dose. Patients undoubtedly recover under this treatment, but it is questionable whether they would not do so just as w r ell with simple rest in bed, good diet and sunny surroundings. Emetics, such as zinc sulphate or large doses of ferrous sulphate, have been highly recommended by some, emesis being produced 28 Chlorosis. once a day or every other day, generally in the morning ; there are some instances in which chlorosis, having obstinately refused to improve upon other lines of treatment, has readily got better when the dose of iron sulphate reached the vomiting point, so that little if any of it passed on into the intestines. Restriction of common salt is a line of treatment that has been adopted by those who regard fluid retention and hydrsemia as an important part of the pathology of chlorosis and think that such retention may be due to difficulty in the elimination of sodium chloride, as it is in some cases of nephritis. Observers who hold this view restrict the amount of common salt used both in cooking and upon the patient's plate as much as possible. There is little, however, to show that this is necessary. Intestinal antiseptics, such as glycerine of carbolic acid in 5 min. doses, beta-naphthol in 10 gr. doses, creosote in 1 min. doses in keratin-coated capsules to ensure it not being liberated until it has passed on into the intestines, sodium sulpho-carbolate in 10 to 20 gr. doses, and various brands of lactic acid producing bacilli or their products, have been prescribed from time to time in cases of chlorosis by those who consider constipation and hypothetical decomposition in the bowel to be an essential part in the pathology of the complaint. Some patients have received actual harm from advertised bacillary- products, but upon the whole, when suitable care is adopted in prescribing these or the intestinal antiseptics, a certain amount of benefit has accrued in many cases. Bismuth salts; bicarbonate of soda; carminatives, such as ginger, peppermint, dill ; bitters, such as gentian ; acids, such as dilute hydrochloric, nitro-hydrochloric, or sulphuric, with small doses of nux vomica, pepsin or extract of malt ; and perhaps in severe cases of gastric disturbance liquor morphinse hydrochloridi along with bismuth, to alleviate the epigastric pain, nausea or vomiting, have all been used when it has been necessary for monetary or other reasons for the patient to remain at her work instead of going to bed ; but by far the best remedy for the gastric symptoms is absolute rest in bed. Diet. Many patients suffering from chlorosis complain of inability to take ordinary diet. Often indeed, for fear of getting fat, the anfemic but relatively plump chlorotic girl has purposely been refraining from food as far as possible, and has even tried the raw rice and lemon juice treatment which is popular from the point of view of weight reduction. Sooner or later a stage is reached at which if work still has to be done, nausea and not infrequently actual vomiting of food supervenes, and not a few cases ,of chlorosis Chlorosis. 29 suffer from severe pains in the upper part of the abdomen, inability to keep anything down, and even haematemesis, so that a diagnosis of gastric ulcer may be suggested when really no actual macro- scopic ulcer is present. The reason for the gastric symptoms in these cases would seem to be cardiac dilatation, for within twenty- four or thirty-six hours' of putting such a case to bed and allowing the heart to recover its tone, the diet can nearly always be increased readily until within a day or two ordinary food is being taken. It is important that full diet should be resumed as soon as it is possible, the patient having the ordinary three main meals a day, and meat with at least one of them. Considerable stress has been laid by some observers upon the particular need of giving such foodstuffs as are relatively rich in iron, but the best results are obtained not by being guided by the chemical analyses of the foods but by the inclinations of the patient, provided they are limited to the ordinary plain foodstuffs. Bread, toast, butter, jam, marma- lade, eggs, milk, tea, coffee, cocoa, fish, whether boiled or fried, potatoes, peas, beans, cabbage, cauliflower, spinach, butcher's meat, puddings made witli rice, tapioca, cornflour, wheatflour, stewed fruits or fresh fruits of all kinds all these may be allowed. Some observers would limit the liquids taken whilst others would rather increase them with a view to diminishing the tendency to constipa- tion. The best line of treatment to aim at as regards diet would be that though resting in bed the chlorotic girl should eat the same kind of foods and in nearly the same quantities as would a healthy girl who is up and about. It may be necessary to assist the digestion in the earlier stages of chlorosis by giving extract of malt and iron, or dilute hydrochloric acid and pepsin, but in the great majority of cases it is surprising how little carminative medicines and still less bismuth or morphia are required even in severe chlorosis, provided the patient is strictly confined to bed. Directly such patients get up, however, unless the blood condition has returned to normal, as will seldom be the case in less than four to six weeks, there will be immediate recurrence of the epigastric pain, the nausea and the vomiting, when physical exertion is resorted to and the heart again becomes dilated. The best treatment for the gastric symptoms of chlorosis is to minimise the work of the heart. Constipation. Most cases of chlorosis are very constipated. This constipation is very difficult to relieve, particularly during the time the patient is of necessity confined to bed whilst the blood condition is being restored to normal. The remedy employed must be chosen upon the merits of each individual case. It is very 30 Chlorosis. important indeed, however, to avoid over-stimulating the bowel, for it is to so doing at the age when chlorosis is common that much of the severe constipation of later years is due. The commonest cause of constipation in middle life is the abuse of purgatives when younger. Bearing this fact in mind, the careful physician will rather allow his patient to be constipated when in bed than adopt drastic measures for the opening of the bowels. It is most unwise to prescribe calomel, or repeated doses of castor oil or increasing quantities of cascara sagrada. It may be necessary to order minimum doses of nux vomica and aloes, as in the pill prescribed on p. 23 ; magnesium or sodium sulphate may be incorporated in minimum quantities in the iron mixture that is ordered ; but wiser than either of these is the exhibition of suitable quantities of fresh or uncooked fruits, no limitation to the amount of simple fluids taken, an avoidance of undue anxiety when the bowels have not been opened by themselves for a day or two, and if the constipation is persistent the use of a simple soap enema every third day instead of the prescription of purgatives by the mouth. When in six or eight weeks time the chlorosis itself has been cured and the patient is again up and about the most important point in the treatment of the tendency to constipation is that the patient should each day try hard at the water-closet to have the bowels moved at a fixed time, until with the constant repetition of the effort daily regularity of the colon is restored within a few months and constipation ceases to exist. Every time an active purgative is prescribed in such a case the re-education of the colon is delayed. General Hygiene. There may be many small points about the patient which may not be normal and which may require treatment simultaneously with the cure of the chlorosis. Carious teeth, for example, should be stopped or removed ; the mouth should be kept clean with a tooth brush and suitable tooth powder or mouth wash. For the prevention of a recurrence of chlorosis after a cure it is most important that the patient should spend as much of each day in the fresh air and sunshine as possible, and that at night she should sleep in a room with the windows open wide and with as much fresh air entering the room as may be. It is often advisable to prescribe a morning bath, hot or cold as the case may be, something stimulating, perhaps, being added to the water, such as an ammonia preparation or the like. Over-fatigue is to be avoided and ample time should be allowed for meals, and upon the least indication of a return of the chlorosis iron in some form or other should be prescribed, and the patient should have a daily rest in addition to that which she has in bed at night. Iron Chlorosis. 31 given continuously loses its effect, but given intermittently it will often prevent a relapse. (Edema of the legs may show a tendency to persist even when the chlorosis itself is better ; in such cases much benefit is to be expected from upward rubbing from the feet towards the knees, preferably by somebody who understands massage. It may also be a comfort in such cases to have a woollen woven elastic bandage that can be wound smoothly on to the foot and leg in the morning as a support. Marriage. The question of whether or not a chlorotic girl should marry often arises. It would always be wiser for the patient to undergo a course of treatment in order if possible to cure the chlorosis before marriage took place ; nevertheless it is worthy of note that severe chlorosis is quite uncommon after marriage, and indeed many girls and young women who have been more or less chlorotic from the age of seventeen upwards, lose their anaemia altogether when they marry. Marriage indeed, though it is not to be advocated in a severe case of chlorosis until the latter has been relieved as far as possible first, is in itself a cure for chlorotic anaemia. HERBERT FRENCH. HEMOPHILIA. HEMOPHILIA itself is a congenital condition which we do not know how to cure. Nevertheless a haemophilic patient often needs medical assistance, especially for the stopping of continuous bleeding from trivial wounds. Treatment of such a case resolves itself into three parts, namely, prophylactic, that is to say, the prevention of scratches and cuts; the checking of active bleeding, external, internal, or both ; and the relief of the profound anaemia that may result if blood loss continues in spite of efforts to check it. Prophylactic measures are obvious ; no pins, buckles, or similar sharp or angular bodies should be permitted in the clothing ; no pocket knife should be allowed ; teeth should not be extracted, the milk teeth being allowed to come out by themselves, whilst the permanent teeth should be inspected regularly, and if need be stopped sufficiently early to obviate any need for extraction ; the household furniture should be kept free from projecting nail ends, tin-tacks, splinters, and so on. The lad is almost certain to scratch, cut or lacerate himself sooner or later by some accident, but the kind of precautions that can be taken to minimise the risk are obvious. Should some scratch or cut occur in spite of precautions to prevent it, the patient has sometimes bled to death in spite of every effort to stop the steady oozing. The chief lines of treatment that may be adopted are as follows : The Encouragement of Coagulation locally. The best way of accomplishing this in some cases is to tease out sterile cotton-wool into the finest possible fluff and to apply this lightly over the bleeding surface, renewing the fluff as fast as it is saturated with blood, but not displacing any clot that may become attached to the skin. The object of the cotton-wool fluff is the same as that of the bundle of twigs used to whip blood in making fibrin, the greater the number of foreign particles in contact with shed blood the greater is its tendency to clot. Cobwebs act in the same way, but there is the risk of their being dangerously septic. Matico leaves (B.P., 1885) used to be employed for the same purpose, on account of the numerous hairs on their under-surfaces. Styptics may also be applied, especially per-salts of iron, of which the perchloride is perhaps the best. The liquor perchloridi (B.P.) Haemophilia. 33 may suffice, but more often the liquor ferri perchloridi fortis (B.P.) [U.S. P. liquor ferri chloridi] is employed either as it is or diluted with a little plain water. The liquor ferri persulphatis (B.P.) [U.S. P. liquor ferri tersulphatis] is also very astringent. Lead salts are less often used because there is some danger of undue absorption ; the liquor plurnbi subacetatis fortis (B.P.) [U.S. P. liquor plumbi subacetatis] is a very astringent preparation, but it is strong enough to irritate the skin at the same time. Copper sulphate is another styptic ; it may be applied directly as powdered crystals, or in solution, but it is not often employed. Hama- melis and tannic acid are the best known vegetable styptics : 1 part of either the tinctura or the liquor hamamelidis may be diluted with anything up to 20 parts of water, or tannic acid powder may be applied as such. Local vaso-constriction may be used as a means of lessening the bleeding, the most powerful vase-constrictor being adrenalin chloride, which may be applied in a sterile solution of a strength of 1 in 1,000, either by means of a brush or on lint or cotton-wool. Its effect does not last long, but the immediate blanching of the bleeding part generally checks the oozing for the time being ; the application has to be repeated at short intervals. The simultaneous use of adrenalin chloride and of strong solution of perchloride of iron may effectually stop the bleeding. Ergot as a local application, or liquid extract of ergot by the mouth; or injectio ergotse hypodermica (B.P.), or subcutaneous administration of ergotine or ergotinine, are all useless in haemophilia. Extreme cold applied locally by means of ice, or ethyl-chloride spray, may assist materially in checking bleeding from a superficial cut, but it is difficult to continue the cold application long enough to prevent recurrence of the oozing when the part is allowed to get warm again. Local pressure naturally suggests itself as another line of treatment ; the trouble is that it is very difficult to apply sufficient pressure continuously to the skin in one spot without causing the patient unbearable discomfort, and possibly risking local gangrene. When it is a tooth socket that is bleeding the gum may be blanched with adrenalin chloride solution, 1 in 1,000, and then the cavity can sometimes be packed with wool rapidly but firmly, and the latter covered over with a rubber dressing that may serve to prevent further bleeding ; but it is astoundingly difficult sometimes to check the oozing even in this way. Other surgical measures have often proved successful. Notwithstanding the risk of further bleeding, the S.T. VOL. n. 3 34 Haemophilia. superficial vessels above and below the bleeding point have sometimes teen underrun with needles and the oozing checked by silk liga- tures passing figure-of-eight- wise over the skin between the pro- jecting ends of the needles; in desperate cases use has been made of the curious fact that whereas small cuts in haemophilics often ooze excessively, deep incisions sometimes bleed but little more than they do in healthy persons ; a scalpel has been used to convert a scratch or superficial cut into a decided incision that can then be either packed and firmly bandaged, or even in some cases successfully stitched up. The actual cautery has been resorted to sometimes, and occasionally with success. Internal remedies for the relief of the bleeding will certainly be tried, but none of them has any proven value. Calcium chloride will probably be given in doses varying from 5 to 60 gr. twice, thrice or four times daily. This salt has a very nauseous taste, but it cannot be given in cachet because it is so deliquescent. It may be made up in gelatin-coated capsules, or it may be prescribed with syrup of lemon, as in the following mixture : 1^ . Calcii Chloridi, gr.10; Syrupi Limonis, 5Jss ; Mucilaginis Simplicis, 5ij ; Aquam Chloroformi, ad. jj [U.S.P. 1^. Calcii Chloridi, gr. 10; Syrupi Acidi Citrici, 5jss : Mucilaginis Acaciae, 51] ; Aquae Chloroformi, ss ; Aquam, ad ^j] . Dose, two tablespoonfuls two-hourly. It is given with the object of increasing the coagulability of the blood, but it is very doubtful whether it really does any good. .Calcium lactate is an alternative which may be given in simple suspension or in cachets in doses of 10 to 60 gr. several times a day. Calcium iodide is preferred by some ; it is deliquescent and has a bitter taste, but it can be taken in doses of from 1 to 5 gr. in the form of a mixture containing simple syrup and water : 1^, Calcii lodidi, gr. 5; Syrupi Simplicis, 5ij ; Aquam Chloroformi, ad ;y. [U.S.P. 1^. Calcii lodidi, gr. 5 ; Syrupi, 5ij ; Aquae Chloro- formi, 388 ; Aquam, ad gjj . Dose, two tablespoonfuls as often as directed. Oil of turpentine has been used for internal administration in some cases, but there would seem to be some danger in this because haematuria may occur spontaneously in haemophilics, and there- fore turpentine would perhaps be unduly prone to affect the kidneys. Gelatine injected subcutaneously has been used to increase the coagulability of the blood in other maladies, notably in cases of aortic aneurysm ; but it is scarcely admissible in a haemophilic on account of the extreme probability that the injection itself would Haemophilia. 35 cause extensive local bleeding. The administration of gelatine by the mouth does not answer the same purpose. Some observers have advocated injecting serum from animals, such as the horse, or even fresh human serum, intravenously, with the idea of supplying some factor which is deficient in the patient's blood ; but there is a risk of persistent bleeding at the site of the injections themselves, and there is little evidence to show they are beneficial. When spontaneous haemorrhages occur they may take place from mucous membranes epistaxis, bleeding from the mouth, haematuria, haemorrhage per rectum, less often haematemesis and seldom haemoptysis ; or they may take the form of subcutaneous haemato- mata, haemarthrosis, and sub-periosteal haemorrhages. Treatment in such cases is very difficult indeed ; calcium salts will be adminis- tered by the mouth ; mucous membranes that can be reached will be irrigated with adrenalin solution or treated with styptics ; opium or morphia by the mouth, not hypodermically, may be required, partly to check internal haemorrhage, partly to relieve the acute pain associated with recent haemorrhage into a joint or beneath a periosteum. Local applications of cold would be better than heat on theoretical grounds, but for the relief of pain hot fomentations, or opium stupes, may be necessitated ; or belladonna liniment may be applied under lint, cotton-wool, and bandage. If any haematoma should suppurate, as it may do, it should be fomented until it is on the verge of pointing before it is incised, for the risk of further haemorrhage is thereby rendered far less than it would be if it were opened earlier through thicker intervening tissues. Careful nursing is essential, not only on account of the acuteness of the pains at the sites of recent internal haemorrhages, but also in order to prevent the further bleeding that may result from the slightest injury or after any but gentle handling. Bedsores may readily form unless the patient is kept clean and carefully attended to. Whilst taking care not to injure any part, it is at the same time important to see that the limbs do not lie in any one position so long that contractures or other deformities unexpectedly arise. The mouth should be carefully rinsed out with a simple antiseptic mouth wash several times a day, particularly if blood clot forms in it. Diet. The diet should be as generous as may be compatible with the circumstances of any particular case. Haernatemesis is fortunately rare, though when it does occur feeding by the mouth may need to be changed for a time to nutrient enemata. The mouth may some- times bleed so easily or become so sore that no solid food can be 32 36 Haemophilia. swallowed. Otherwise nearly all plain foods are permissible, includ- ing cooked butcher's meats. If anything is to be avoided, it would be such foods as contain substances that might drain the body of calcium, especially things containing citric acid, such as lemons. The grounds for omitting these are purely theoretical, however ; in practice all simple foodstuffs are good if the patient can digest them. Iron. So anaemic may a ha3mophilic patient become that active treatment similar to that described for acute haemorrhage (p. 18) may be required, with the exception that infusion should seldom if ever be intravenous or subcutaneous, but should rather be given by the continuous rectal method from the start. Similarly, pituitary extract should be added to the fluid that is given per rectum instead of being injected hypodermically ; 8 c.c. of 20 per cent, solution being employed instead of the 1 c.c. that would be given with syringe and needle. If the patient survives the acute bleeding, he will need treatment for his anaemia. Best in bed, sunshine, air, good food, and the absence of further bleedings, rapidly lead to restoration of the patient's colour. A month or six weeks may suffice to restore the red corpuscles and haemoglobin to normal, particularly if small doses of iron are given as described under chlorosis (p. 21). Change of air and scene will complete the cure of the anaemia if only another haemorrhage does not supervene ; the difficulty is that bleedings are very liable to recur, especially when the patient is subject to those of the spontaneous type ; with each successive drain of strength it becomes more difficult to cure the resultant anaemia with iron and the other remedies at our disposal. -HERBERT FRENCH. 37 APLASTIC ANAEMIA. BESIDES the so-called blood diseases that have distinctive blood changes, spleno-medullary and lymphatic leukaemia and pernicious anaemia and those which have more or less definite clinical signs although they have no pathognomonic blood counts, Hodgkin's disease, lyniphademona, lymphoma, pseudo-leukaemia infantum, chloroma, there are a number of severe anaemias which are as yet difficult to classify ; of these some are associated with decided enlargement of the spleen and are therefore styled splenic anaemia though this group probably includes more conditions than one, and many such cases prove ultimately to have been early stages of cirrhosis of the liver (Banti's disease) ; another group is more closely allied to pernicious anaemia, but differs from the latter in that there is little megalocytic and no megaloblastic reaction in the blood, whilst post-mortem examination reveals pallor of the marrow of the long bones instead of the redness that is found in pernicious anaemia. Such cases are now differentiated under the title of aplastic anemia. It is difficult, however, to advise any different treatment for this malady to that already described for pernicious anaemia rest, fresh air, sunshine, arsenic, oxygen and as generous a diet as the patient can take. The difficulty is that no details are known of the pathology of the affection, and hitherto it has always proved fatal in a comparatively small number of months. HERBERT FRENCH. LEUKAEMIA. IN describing the treatment of leukaemia it will be most convenient to deal with the two chief varieties, viz. : spleno-medullary leukaemia (or myelaemia) and lymphatic leukaemia separately. SPLENO-MEDULLARY LEUKAEMIA. This form of leukaemia is characterised by great and uniform enlargement of the spleen and by a high degree of leukaemia in which the number of the granular leucocytes may be increased to 300,000 or more in the cubic millimetre of blood. The character and proportion of the different varieties of leucocytes is also altered ; the polymorphonuclear cells constitute about one half the total number and myelocytes about one third, while the eosinophils may be increased up to 5 or 10 per cent. Our knowledge of the causation and of the pathology of the disease is still very limited, and consequently treatment is largely empirical and based on the results of clinical experience. The beneficial effect of X-rays appears to be due to their power of breaking up the superabundant leucocytes, and possibly also of diminishing the rapidity of their formation and discharge into the blood- stream. This result is due to the development of leucolytic substances in the body under the influence of the rays. Both the serum of an animal which has been treated by X-rays and the extract of a spleen which has been exposed to them before removal when injected into another animal cause a reduction in the number of leucocytes. Similar leucolytic substances have been found to be present in the blood of patients suffering from leukaemia who were improving under X - ray treatment. General Treatment. In the more acute forms of the disease rest in bed is required as long as there is any fever. If the temperature is normal the patient may be allowed to go about, but it is not advisable for him to do any work which can be avoided. He is unfit for any laborious occupation, and he should not be exposed to the risk of any injury to the abdomen in the region of the enlarged spleen, as any severe blow may cause rupture of its capsule and fatal intra-peritoneal haemorrhage. Rest in the open air, or in an open shelter, is useful, and the general level of health must be well maintained by an ample but easily digested diet, any excess being carefully avoided. Leukaemia. 39 Medicinal Treatment. Arsenic is by far the most useful drug in the treatment of leukaemia. Five minims of liquor arsenicalis [U.S. P. liquor potassii arsenitis] may be given three times a day after meals. This dose should be gradually increased by the addition of 1 min. of the liquor arsenicalis every other day until the limit of toleration is reached. In some cases any increase in the dose beyond 7 or 8 min. induces pain in the stomach or diarrhoea; in others large doses are tolerated, and in a few cases the dose can be increased up to as much as 25 min. four times a day. Arsenic and atoxyl have been injected beneath the skin and even directly into the spleen, but no special advantage is gained by this method of administration. Under the influence of arsenic the spleen decreases in size and the number of leucocytes in the blood is materially diminished. Quinine and phosphorus have also been used with benefit in some cases. Dr. J. H. Drysdale obtained remarkably good results in one case by the administration of 8 gr. of naphthalene tetrachloride every three and later every two hours. X-ray Treatment. Undoubtedly the regular application of X-rays is (at the present time) the most valuable means we possess for treating myeloid leukaemia. In early cases the action in reducing the size of the spleen is very marked. It becomes softer and more movable and may return almost if not quite to its normal dimensions, so that it is no longer palpable below the left costal margin. The leucocytes are broken up, as is shown by their rapid reduction in number and by the increase in the amount of uric acid in the urine. It is chiefly the granular cells which are destroyed, the lymphocytes being unaffected. It is probable that the excessive formation of leucocytes is also held in check by the X-rays, for experiments in animals have shown that this function of the bone marrow may be arrested altogether. The effects of the treatment generally appear within a week or two, and after a course of two or three months' treatment they are well marked. The myelocytes, eosinophiles and mast cells become reduced in numbers, while the polynuclear neutrophiles are at first relatively increased in number. In some cases the blood -count may become quite normal. I am indebted to Dr. A. E. Barclay for the following technical details of the treatment as it is applied in the electrical department of the Manchester Royal Infirmary. The current is obtained from a coil. At each sitting one Sabouraud dose(= 5 Holzknecht units) is given through a filter composed of four layers of boiler felt. Bather a high vacuum, about fi on the Benoist scale, is used. A Leukaemia. current of 1 milliampere is passed through the tube. Each application lasts about ten minutes. The rays are applied over the spleen ; if the skin becomes red they are applied over the ends of the long bones instead until the redness disappears. By this means dermatitis is avoided. The treatment is generally given twice a week, the effects upon the blood being watched by weekly blood counts. If the number of leucocytes diminishes too rapidly the treatment is given only once a week or even once in a fortnight. It is advisable to regulate the treatment so as gradually to reduce the number of leucocytes to 20,000 per cubic millimetre of the blood, and then to give one dose of the X-rays each fortnight. The urine must also be tested for albumin between each dose of the rays. If any albumin is found it is an indication of too rapid a destruction of leucocytes, and the dose must be diminished at once. The results of the treatment are illustrated by the case of a man aged thirty-eight, who was under my care at the Manchester Royal Infirmary for three months. During this time X-ray treatment was applied by Dr. Barclay and arsenic was given as well nearly all the time. Examination of the blood by Dr. Loveday on admission showed per cubic millimetre 1,853,000 red corpuscles and 96,600 leucocytes, 58 per cent, of which were polymorphonuclear cells and 25 per cent, myelocytes. The spleen was greatly enlarged, extending below the level of the umbilicus and across the middle line. After two months' treatment the red corpuscles were found by Dr. Leech to be 4,856,000 and the leucocytes 2,000, of which 43 per cent, were polymorplioneucleas and 1 per cent, myelocytes. The spleen was much diminished in size, but was still easily to be felt, extending well below the left costal margin. In the case of a woman who was also under my care at the Man- chester Royal Infirmary the changes in the blood were as follows, the first examination being made before the treatment by X-rays : Leucocytes per c.mm. Erythrocytes per c.mm. Haemoglobin. May 30th . 212,000 5,056,000 66 per cent. June 18th 68,000 2,992,000 56 July 4th ... 34,000 2,080,000 48 Jul/ 28th . 5,000 4,320,000 60 The rapid fall in the number of leucocytes is clearly shown. The decrease in the number of the red blood corpuscles and in the percentage of haemoglobin in the earlier stages of the treatment and their final increase is also noteworthy. Leukaemia. 41 After two or three months treatment the number of applications may be reduced to one or two in a month. In some cases the improved condition persists for several weeks or even months after the X-ray treatment has ceased. Dr. Cabot mentions that he only knows of one case in which the patient remained healthy for more than a year. It is advisable, therefore, to continue the treatment or else a relapse will occur sooner or later. There is as yet no definite evidence that a permanent cure can be established, but the disease can be held in check and the patient may enjoy a very fail- measure of health for several years, if the treatment is continued at intervals. Partly owing to the haemorrhagic tendency in this disease removal of the spleen has proved to be a very dangerous operation, and even when the immediate effects of the operation have been survived no appreciable benefit to the patient has accrued. Excision of the spleen is therefore useless and should not be attempted. LYMPHATIC LEUKAEMIA. In this form of leukaemia, which may be either acute or chronic, there is an enlargement of one or more groups of lymphatic glands, the spleen is increased in size and there is an absolute and relative increase in the number of the lymphocytes. The total number of leucocytes may be from 100,000 to 200,000 per cubic millimetre of the blood. Acute lymphatic leukaemia generally runs a rapid course and ends fatally in a few weeks. Little can be done beyond treating symptoms as they arise. Thus haemorrhages from mucous surfaces can be treated by the local application of 1 in 1,000 solution of adrenalin chloride. No drug appears to exercise any influence upon the progress of the disease. The application of X-rays is not only useless, but in some cases has appeared to be harmful. Chronic lymphatic leukaemia runs a more prolonged course and considerable benefit may be derived from the administration of arsenic in increasing doses in the same manner as already described above, though it does not prevent the ultimate fatal ter- mination. The application of X-rays to the spleen and to the enlarged lymphatic glands produces very little effect upon the condition of the blood in this form of leukaemia, as the rays do not affect the lymphocytes. The enlarged lymphatic glands may be reduced in size and so may become discrete and more movable. Occasionally an enlarged gland may disappear. On the whole, however, the results of the X-ray treatment are very much less 42 Pseudo-Leukaemia. marked than in myelaemia. The application of an ice-bag over the spleen may cause some reduction in its size. Inhalations of oxygen have been found beneficial by some. GEORGE R. MURRAY. KEFERENCES. Muir, E., Allbutt and Kolleston's "System of Medicine," 2nd edit., 1909, Vol. V., p. 825. Gulland, G. L., Hutchinson and Collier, " Index of Treatment,'' 6th edit., 1911, p. 543. Lazarus. A., "NothnageTs Encyclopaedia of Practical Medicine " (Diseases of the Blood), 1905, pp. 613 and 675. Cabot, B. C., Osier and Macrae's " System of Medicine," 1908, Vol. IV., p. 672. Harris, H. (Abstract) Med. Chron., Manchester, 1909, XLIV., p. 274. PSEUDO-LEUKAEMIA. THERE is not sufficient unanimity of opinion as to what disease or symptom complex is meant when the term " pseudo-leukaemia " is used. In England, for the most part, the term is now used to denote the infantile form of splenic anaemia or the anaemia pseudo- leukaemica infantum of von Jaksch. Paltauf and others have described under this heading the condition which is more generally known as lymphadenoma ; while Bamberger and other German writers have described as pseudo-leukaemia a condition of lymphatic leukaemia without the characteristic blood picture, a state which may be considered as analogous to the aplastic form of pernicious anaemia. In view of this uncertainty the inevitable conclusion is that it would be better if the term "pseudo-leukaemia" were either no longer employed or strictly limited in application to cases of von Jaksch's disease. From the point of view of treatment it is important sharply to differentiate between the adult type of splenic anaemia occurring in children and von Jaksch's disease. This may readily be done by a blood examination. In the former case there is a leucopenia ivith a relative lyinphocytosis, while in the latter there is a marked leucocytosis (often up to 50,000) and usually many myelocytes and erythroblasts. In both conditions there is a secondary anaemia. For most cases of splenic anaemia splenectomy is probably the best treatment (sea pp. 81 83 of this volume). For von Jaksch's disease the spleen should never be excised : the treatment should be dietetic, hygienic and tonic, being directed at the underlying defect in metabolism which is often of a rachitic nature. Great benefit will often result from the exhibition of meat juice, malt and cod-liver oil, combined with such drugs as iron, arsenic, and the glycerophosphates. JAMES TORRENS. 43 PURPURA. ALL varieties of purpura are characterised by the occurrence of haemorrhages in the skin, mucous membranes and viscera. In some forms there may be external bleeding from mucous mem- branes as well. As the causes of the disease are still obscure, treatment is directed to the care of the patient, so as to avoid the ill-effects of the disease and to the prevention or arrest of haemorrhages by the best means we have as yet at our disposal. General Treatment. In all forms of purpura any movement or exposure of the surface of the body to changes of temperature favours the recurrence of haemorrhage. It is therefore essential that the patient should be confined to bed as long as fresh haemorrhages occur and it is advisable to prolong the rest in bed for at least a week after the last crop of purpuric spots has appeared. Fresh air is beneficial and, weather permitting, the bed may be placed near an open window or even out of doors, during the daytime, provided the patient is kept warm so as to avoid any risk of chill to the surface of the skin. The surroundings should be bright and cheerful and freedom from worry and anxiety should as far as possible be ensured. Careful nursing is important, as the patient requires very gentle handling, and in moving him as little pressure as possible should be exerted at any one point as fresh ecchymoses are easily produced by any rough handling or pressure. The bed should be comfort- able and the under-sheet smooth and free from creases. While the hemorrhages are recurring the diet should chiefly consist of milk and foods prepared with milk. Fresh fruit and vegetables may also be given. When the attack is over food which contains iron, such as fresh beef or mutton, eggs, spinach and asparagus, is to be recommended during convalescence. If there is constipation, fruit, honey or marmalade ma} 7 be taken with advantage. As long as fresh haemorrhages occur baths are not advisable and no friction must be applied to the skin as long as any rash is visible. When the haemorrhages have ceased to appear warm baths may be employed. Dr. Pratt advises a daily bath at 95 F. for ten minutes at first, the temperature of the water being one degree lower each day until 87 or 85 is reached. Sulphur baths are employed in some of the hospitals in Paris. Fitten recommends 44 Purpura. the use of warm carbon dioxide baths or warm salt water baths while arsenic is taken internally. Medicinal Treatment. As long as the haemorrhages continue calcium salts should be given. Of these calcium lactate is the most suitable and may be given in the following form : fy . Calcii Lactatis, gr. 10 to 15; Aq. Chloroformi, 5] [U.S.P. 1^. Calcii Lactatis, gr. 10 to 15 ; Aquae Chloroformi, jss ; Aquam, ad 3J] ; three times a day, or every three or four hours in severe forms. It is advisable to continue the administration of this drug for a week or ten days after the occurrence of the last petechial eruption. Oil of turpentine is a valuable remedy in many cases, so much so that it was regarded by Sir S. Mackenzie as a specific in many cases of so-called purpura rheumatica. It may be given in doses of 10 to 20 min. three or four times in the twenty-four hours. It is most conveniently administered either in capsules, in suspension with mucilage, or in the following combination as recommended by Mackenzie: 1^. 01. Terebinth, irj,10; Tinct. Quillaiae Sapon., ir^lO ; Aq. Cassiae, ad 5]. Much larger doses than these have been recommended by Dr. Eustace Smith in the case of well-nourished children. He gives 2 drachms of turpentine with an equal quantity of castor oil to a child six years of age and even larger doses to older children. The aperient action of the castor oil probably prevents the absorption of any large proportion of the turpentine. In purpura haemorrhagica bleeding from the mucous membranes should be treated by the local application of 1 in 1,000 solution of adrenalin chloride. The mouth or nose may be irrigated with the solution. If this proves insufficient a small pad of absorbent wool or lint saturated with the solution should be held in contact with the bleeding point, whenever this is accessible, for several minutes. If there is epistaxis the nasal cavity may be packed with gauze or lint soaked in the adrenalin solution, which is left in situ for twenty- four hours. As an alternative, the application of a 2 per cent, solu- tion of gelatine to the bleeding surface is useful in some cases. Where there is haemorrhage from the oesophagus, stomach or other part of the alimentary canal, the adrenalin chloride solution may be given by the mouth in doses of 10 to 30 min. at intervals of three or four hours. Henoch recommended, in the form of purpura which was first described by him, the application of an ice-bag to the abdomen and feeding with iced milk. Ergot and hamamelis have been employed, but are less reliable than the remedies already mentioned. During convalescence and especially in the more chronic forms of Purpura. 45 purpura, arsenic and iron rna} 7 be given on account of the secondary anaemia produced by the attack. A course of arsenic in small doses, such as from 3 to 5 min. of Fowler's solution, may be given two or three times a day for several weeks, as it appears to diminish the liability to recurrence. Change of climate is also advisable at this stage, country or mountain air at a moderate elevation being the most suitable. GEORGE R. MURRAY. REFERENCES. Pratt, J. II., Osier and Macrae's " System of Medicine," 1908, Vol. IV., p. 715. Mackenzie, Sir S., Allbutt arid Rolleston's " System of Medicine," 1909, Vol. V., p. 8(54. Ilenoch, E., " Vorlesungen iiber Kinderkrankheiten," Berlin, 1899, 4te, Aufi., p. 803. 4 6 DISEASES OF THE DUCTLESS GLANDS. DISEASES OF THE ADRENAL GLANDS (ADDISON'S DISEASE). UNTIL recently the treatment of Addison's disease has been considered hopeless. Without being unduly optimistic, we may believe that shortly we shall be able to do much to ameliorate the condition of sufferers from this disease. There is no doubt that when the suprarenal glands, together with all the cells of a similar character in other parts of the abdomen, have been destroyed, life becomes impossible. In spite of the great advance in arterial surgery there is but little prospect in the near future of successful transplantation. It must be remembered that in addition to disease of the suprarenal glands some pathological conditions of the sympathetic system may give- rise to symptoms indistinguishable from Addison's disease ; in all probability this is not due to destruction of the chromaffin cells lying in its neighbourhood but to alteration in the nervous mechanism. The progress of diagnostic methods will lead to the recognition of suprarenal disease at an earlier date, a date sufficiently early to permit in a certain number of cases of means being adopted to prevent the total destruction of the glands. This will be feasible in a few morbid conditions, but since the greater number of cases of Addison's disease are due to tuberculous infection of the suprarenal glands, any treatment which is successful when applied to local tuberculosis will arrest this complaint. Treatment therefore at the present day may be divided under three headings : (1) Curative ; (2) Palliative ; (3) Symptomatic. Curative Treatment. In order to establish the curative treat- ment we must determine whether the adrenal glands are being destroyed by an infection with the tubercle bacillus, the spirochaete of syphilis, by a new growth, or by an increase of fibrous tissue. Occasionally differential diagnosis is far from easy. Since the tubercle bacillus is the commonest cause we must determine first whether the patient is infected with this. The manifold tests, such as that ascribed to Koch, to Pirquet and to Calmette, along with the variability of the tuberculo-opsonic index, permit us to decide whether there is any tuberculosis in the body of the patient, but Addison's Disease. 47 none of these tests assist in localising the site of the infection. The Wassermann reaction will determine the presence or absence of the spirochaste infection. Repeated careful examination of the abdomen may permit us to decide upon the presence of a suprarenal tumour, but since a small tumour may be very destructive and placed in an inaccessible position, it is only in -a low percentage of cases that palpation will give a hint of its presence. The diagnosis of fibrosis of the suprarenal can be arrived at only by a method of elimination, there being no definite signs of the condition. Having come to the conclusion that the disease is due to a tubercu- lous infection of the suprarenal the question of treatment arises. In the main it should be the same as that of any other tuberculous infection, namely, fresh air and appropriate food. In addition to this, minute doses of tuberculin should be given, controlled by their effect upon the opsonic index. The initial doses of tuberculin should be even less than that usually given to patients suffering from localised tuberculosis, because a marked reaction of the suprarenal glands would prove fatal immediately, therefore the amount chosen must be such as to make this impossible. It is true that Lenhartz has reported a successful result, or at any rate improvement lasting over many months, by injecting large quantities of the original Koch's tuberculin, but we must not place too much reliance upon a single observation. If the Wassermann reaction is positive, a course of anti-syphilitic treatment is indicated or an injection of an appropriate dose of Ehrlich's 606 preparation. If there is any suggestion of a tumour, laparotomy should be performed in case the new growth is removable. Palliative Treatment. Palliative treatment consists in supply- ing suprarenal secretion. The substance manufactured by the suprarenal glands stimulates the sympathetic system, and by this means maintains the tone of the blood-vessels. Usually the blood pressure falls below 100 mm. Hg. in cases of suprarenal disease, and this is an indication for the administration of suprarenal extract. The dose should be large, 3 or 4 grammes of the dried gland may be given with advantage ; occasionally vomiting coincides with the administration of the preparation, but conclusive evidence should be obtained that it is propter and not post before orders are given to cease the treatment. If the blood pressure does not rise after the administration of the drug for several days, it is useless to continue it, because either the patient is not suffering from supra- renal inadequacy, or, if he is, the sympathetic system, too, is diseased, 48 Addison's Disease. and there is no advantage in supplying the hormone when the tissue upon which it should act cannot respond. Treatment of Symptoms. Symptoms are manifold, but possibly the most distressing is vomiting, whilst constipation and diarrhoea may be of long standing and extremely difficult to treat with drugs. Vomiting frequently persists in spite of the administration of alkalies, bismuth, oxalate of cerium and drugs of that type, and it is wiser to use some sedative to the gastric mucous membrane and to the nervous system, such as chloretone or cocaine, in small but frequent doses. Constipation is due to want of tone of the plain muscle of the intestine, and there is very great difficulty in exciting peristaltic action in this, whilst if once excited uncontrollable diarrhoea may set in; therefore we should adopt some means to prevent the contents of the intestine becoming dry and hard. Two methods are at our disposal, either the administration of some oil which will not be absorbed by the intestine, or the administration of some colloid which will refuse to part with water after having once absorbed some in the upper part of the intestine. Therefore we may prescribe either 5 grammes of liquid paraffin three or four times a day this can with advantage be made into an emul- sion with a little syrup of ginger or we may give 3 or 4 grammes of powdered agar two or three times a day along with food. Either of these methods will prevent the faeces becoming hard. An attempt to stimulate the peristalsis may be made by giving a combination of cascara, aloes and nux vomica, in minute doses, but it is wiser to have recourse to enemata. Occasionally diarrhoea is persistent. Bismuth in large doses may be administered, but it must be remembered that the bowel is asthenic, and that bismuth may conglomerate and lead to obstruction, and therefore it should be used with caution. Another symptom which may give rise to much annoyance is want of muscular power, but as a rule it is sustained effort which fails rather than single movements, and therefore if the patient be kept in bed this myasthenia does not become a serious symptom. Loss of appetite may be treated with bitter stomachics and by general massage. OTTO GRUNBAUM. 49 DISEASES OF THE THYROID GLAND. THE ADMINISTRATION OF THYROID EXTRACT THE dosage of thyroid extract as advertised in books of phar- macology stands in urgent need of revision. The dos9 originally decided upon, namely, 5 gr. three times daily, was based upon experiences gained from cases of myxoBdema which had previously been treated by subcutaneous injection. In the light of the know- ledge which has since been accumulated on the subject it is quite evident that 15 gr. a day is an enormous dose, which, if it be given at all, should be gradually arrived at from very small beginnings. One of the most remarkable things in connection with thyroid extract is the fact that the patients who stand most in need of it are precisely those who most readily show signs of intolerance. It is to be supposed that the tissues of people suffering from high degrees of thyroid insufficiency are loaded with mucin, and that if this is set free too rapidly for efficient excretion symptoms of intolerance will ensue. The dose with which to begin treatment by thyroid extract should therefore never exceed \ gr. twice daily. This may be rapidly increased after the first week of treatment, more especially if it has produced a definite increase in the urinary output. The first subjective sign of intolerance is the consciousness, the obtrusive consciousness, of the heart's action. This will frequently appear long before any heart hurry has been produced. One patient, a comparatively spare man, complained of it while his pulse rate was still below 70 per minute. Another early symptom is a coryza of much the same type as that produced by iodide of potassium. Tachycardia, high temperature, diarrhoea, or rapid emaciation, should never be allowed to occur. They indicate a high degree of excess, and patients under treatment with thyroid extract ought to be kept under careful observation. Some drugs seem to enhance the action of thyroid extract, and it is often possible to attain the desired end with very small doses of the extract by associating with it two or three drops of Fowler's solution, and 2 or 3 gr. of calcium iodide, in ^ oz. water. One of the difficulties in connection with prescribing thyroid extract is that the public seem to know more about it than they do about most drugs. Many people, in the days of heroic dosage, had some very unpleasant experiences with it, and S.T. VOL. n. 4 50 The Administration of Thyroid Extract. many women have taken it sub rosa with a view of improving their complexion, their figure or their hair, usually in large doses, with disastrous results. For this reason it is desirable to be able to prescribe the extract in some form which is not easily recognisable to the eye of the layman. Messrs. Squire & Co., of Oxford Street, have arranged that the name " elixir colloid " (Squire) shall be synonymous among chemists with "elixir thyroid" (Squire), and under circumstances such as the above I always prescribe this preparation, which I have found quite reliable. It has the further advantage that it can be given in very small doses. The only other preparation which I have used is that of Messrs. Burroughs Wellcome & Co., in tabloid form, which I have also found to be entirely trustworthy. LEONARD WILLIAMS. CONGESTION AND INFLAMMATION OF THE THYROID GLAND. THE thyroid gland is liable to become congested under certain temporary physiological circumstances, such as puberty, menstrua- tion, pregnancy and sexual excitement. The gland enlarges and occasionally becomes tender, as though increased demands were being made upon its activities. The condition generally subsides when the cause which provoked it is over. It may, however, persist and prove to be the commencement of a goitre. The enlargement thus caused is usually described as "hypertrophy," a term which is incorrect and misleading. In the case of pregnancy this condition should be treated, because the congestion almost certainly means that the amount of available colloid is insufficient for the mother 1)1 us the embryo, so that if allowed to continue the health of one or both may be jeopardised, the mother by having her thyroid activities exhausted and thus requiring a prolonged convalescence ; the child by being inadequately supplied with a material which is essential to its normal development. The treatment consists of the exhibition of small doses of thyroid extract, if necessary, during the whole period of pregnancy. Where the condition is due to any of the other causes referred to above no treatment is necessary in the vast majority of cases ; but if there should be any persistence of the enlargement, thyroid extract should be prescribed. It is to be supposed that among the many functions of the thyroid secretion there is one which protects the organism against certain forms of infective invasion ; that the gland, in short, con- tributes something to the natural defences of the body. It is only on this supposition that it is possible to explain the fact that the thyroid becomes enlarged, tender, congested, and even inflamed in the course of certain acute specific fevers. This is liable to occur in all the exanthemata ; it is common in typhoid fever, and has been observed in malaria and cholera. It is, however, in con- ditions of true rheumatism, whether it be in the form of rheumatic fever, erythema nodosum, or tonsilitis, that congestion and inflam- mation most readily appear. When slight the local discomfort is seldom complained of, but it may become so severe as to cause great pain in swallowing, considerable dyspnoea and pressure effects in varying degree upon the cervical and brachial nerves. When 42 52 Congestion and Inflammation of Thyroid Gland. the inflammation is severe the danger of its extension to the trachea and glottis should not be overlooked. Except as the result of typhoid fever (metastatic abscesses) and pyaemia, the inflammatory condition seldom proceeds to the stage of suppuration. Should it do so, no time must be lost in invoking the aid of the surgeon, because the pus readily escapes from the capsule of the gland to find its way into the tissues of the neck, a complication which may easily prove fatal. The kind of treatment to be adopted in the presence of a congestive or inflammatory state of the thyroid must be dictated by circumstances. In mild cases nothing more than hot fomentations are required. In those which threaten to cause symptoms such as dysphagia or dyspnoea, more especially if an inflammation which is acute is tending to spread so as to cause oedema of the glottis, recourse should be had to the local abstraction of blood by means of leeches. As many as three or four leeches should be placed over the inflamed area, preferably along its lower border, so that later on the clothes may the more easily conceal the rather unsightly scars. If these means fail in affording the necessary relief to urgent symptoms it will be necessary to ask the surgeon to undertake the anxious task of removing as much of the inflamed gland as will ensure the preservation of life. LEONARD WILLIAMS. 53 SURGICAL TREATMENT OF INFLAMMATORY AFFECTIONS OF THE THYROID GLAND. Acute Inflammation may occur in a normal thyroid or in one which is the seat of a goitre. It is not a common condition. As an idiopathic affection it occurs in pyaemia, or in the course of one of the specific fevers, such as typhoid fever, and then generally in the later stages of the diseases. Traumatic inflammation is rarely seen in a healthy thyroid ; it is not uncommon after tapping and injection of a goitre. Suppuration frequently occurs as a result of acute inflammation ; the pus is very likely to penetrate the capsule of the gland, burrowing into the cellular tissue of the neck or bursting into the trachea or pharynx. In the early stages, before the formation of pus, hot fomenta- tions should be applied locally and other means used to alleviate the pain. As soon as it is evident that suppuration is present, the pus should be evacuated by incision and drainage if the gland is otherwise healthy or is the seat of a parenchymatous goitre. If, however, the pus is within an encapsuled tumour, it may be possible to enucleate the tumour ; but when the tumour is firmly adherent to surrounding parts it is better not to attempt enucleation but to incise and drain the abscess cavity. A large tube should be employed and healing must be encouraged to take place from the bottom of the cavity, so that a fistula is not left. Other Inflammatory Affections. Tuberculosis usually occurs in the form of miliary tubercle and as a part of general tuberculosis. Syphilis in the early secondary stages of the disease may cause a general enlargement of the gland and, in the late stages, gumruata may form. When gummata occur, the pressure on the trachea may cause so much dyspnoea as to necessitate tracheotomy. A very rare piimari/ chronic inflammation of the gland occurs and is characterised by the formation of a tumour of great density which becomes adherent to and even infiltrates the surrounding tissues and structures. It thus simulates malignant disease. If the disease is seen before it has penetrated the capsule, extirpation of the affected lobe is the proper treatment. In advanced cases tracheotomy may be required. T. P. LEGG. 54 EXOPHTHALMIC GOlTRE. A FEW cases of exophthalmic goitre recover without any treatment, for I have written to patients who have left the hospital without deriving any benefit from their stay in it, and have heard from some of them that they slowly mended without treatment, became well and able to follow their employment, and that their health was still good when they received my letter, many years after they regained their health. We have no means of telling in any particular case whether the patient will recover without treatment, and the number who so recover is few ; therefore we ought always to try to persuade the patient to undergo treatment. Rest. By far the most important part of treatment, and must be complete. The patient must go to bed, usually for many weeks, often for several months. Even those who are very slightly ill will get well quicker if they, to begin with, go to bed for a few weeks. The air of the room should be fresh and the surroundings cheerful. Best of all, a bedroom in the country, with windows almost always open and so arranged that the patient can see out of them ; during fine weather the bed may if possible be wheeled into the garden or the patient may live on a balcony. Should she not object, a bedpan and bed-urinal should be used, so that the rest in bed will be complete ; but often she finds a difficulty in using a bed- pan ; then she may be allowed to get out of bed to empty the bowels, but she should use a bed-urinal to relieve the bladder. The length of stay in bed will depend upon the progress made, but as just mentioned the least will generally be many weeks. The best guide is the pulse, when that has been regular and of normal, or very nearly normal, rate for three or four weeks, then the patient may lie on a sofa for an hour or two every day. After a few days more she may sit in an arm-chair for an hour a day, and so gradually do a very little more each day. The secret of success is only to allow a very little latitude each time any alteration is made. If the case has been severe the patient ought not to be allowed out of her room until three or four weeks after she has got up, and especially any progress with walking, particularly up and down stairs, must be very slow. Exophthalmic goitre is often partly due to nervous shock, and sufferers from it usually have tremor, which is worse when they Exophthalmic Goitre. 55 are excited, and they are very excitable; therefore they must lead quiet, peaceable lives while they lie in bed. The mistress of the house and children must resign her duties of management and must be spared all domestic and other worries. The most that may be allowed is a little very light reading that requires no mental effort and does not excite. Usually it is well not even to allow this. Diet. It is quite exceptional to see a sufferer from exophthalmic goitre who is fat, indeed most of them are very thin ; therefore, as they lie in bed they should be carefully fed so that they may gain weight. Ordinary plain simple food, such as they are accustomed to take, is best, with the addition of milk and egg. A good plan is to beat up one egg in J pint of milk and let the patient drink a little every two hours, so that she gets through a pint of this mixture in the day. If the taste of it is disagreeable a little vanilla or coffee may be added. Should the patient not gain weight more may be taken or she may have Benger's or some similar food. Inasmuch as the milk and blood serum of thyroidectomised goats is by some thought to be beneficial, Dr. Hector Mackenzie has suggested that sufferers from exophthalmic goitre should take very little milk and meat. I have not been in the habit of restricting them in these articles of food, but if such restriction is made other food must be given instead, e.g., carbohydrates and fat, for whatever diet is given it must be abundant, so that the patient may gain in weight. Some advise that the patients should drink large quan- tities of water to wash out the poison that must be circulating in them. This seems reasonable. Drugs have very little effect on the disease itself. Belladonna is often prescribed, but as the patients are usually put to bed it is impossible to tell whether it does any good. There is no evidence that it does, and as it increases the rapidity of the pulse and produces nervous excitement it hardly appears to be a suitable drug. Digitalis is almost equally popular, and if the pulse is very rapid it may be given, say ten drops of the tincture or 1 gr. of the powdered leaves as a pill, or 1 fluid drachm of the infusion in some simple mixture three or four times a day. But in many cases the patient feels sick or is sick, or the digitalis obviously interferes with digestion ; then it certainly should not be given. When nervous symptoms are very evident, it is wise to order 15 to 20 gr. of bromide of potassium three times a day. This is best taken directly after meals in plenty of water. If, as is sometimes the case, the patient has diarrhoea, she should be put to bed at once and allowed to take only small quantities of milk every hour until 56 Exophthalmic Goitre. the diarrhoea stops, and if necessary chlorodyne should be given, for this seems to be the best drug to correct the diarrhoea. Aperients are rarely needed and must be given with great caution, lest they start an intractable diarrhoea. Arsenic has been used, but it is not to be recommended, for it may cause diarrhoea and other gastro- intestinal symptoms that are difficult to check. Some apply Leiter's coils to the thyroid, others give thymus gland, others iodine, but without benefit. Thyroid gland tablets have often been given. It is difficult to see how they can be of help ; indeed, one would have thought that they would do harm ; but several cases, especially of the chronic variety, appear to be a little better for taking thyroid. The anaemia will improve as the patient improves, and no drugs are needed for it. Moebius's antithyroid serum is the blood serum of rams upon whom thyroidectomy has been performed six weeks previously. It has often of late years been given for exophthalmic goitre. Whether it does good is doubtful. My impression gained as a result of often ordering it is that it certainly does no harm, and in some cases probably slightly aids the other means towards recovery used in any particular case. Usually 5 min. dropped into a little milk are given three times a day after meals. The dose is quickly increased until the patient is taking 20 or 30 min. for a dose. It is an expensive drug. Rodagen is a white powder consisting of the dried milk of goats whose thyroid has been removed. Milk sugar is added as a preservative ; it, too, has been much given lately to those suffering from this disease, but no demonstrable benefit to the cardial symptoms has followed its use ; nevertheless some patients seem better for it ; they say they feel better and they are quieter. The usual dose is 60 gr. three times a day, but some authors consider that two or three times this amount should be given. It is very expensive. Various electrical treatments have been employed without benefit ; nor, as far as my experience goes, has success followed the application of the X-rays. Climate. Circumstances are sometimes such that the patient cannot lie up, or in a few instances the disease is so very slight that it is thought to be unnecessary that she should. In such cases we must consider where to send her, and the same considera- tions guide us in selecting a place to which to send a patient who has benefited after a long rest in bed. The place chosen must be quiet; there must be none of the distractions of a fashionable health resort. The country, where it is easy to get constant fresh air, is very desirable; a quiet country house with a large garden is Exophthalmic Goitre. 57 best. The patient should be out of doors all day but never get tired from exercise, so she must lie down and sit a good deal. No mental worries should be allowed to bother her. Often stopping in one place too long bores her. Then she is much improved by moving to some other quiet place. Few patients are more benefited by change of scene than sufferers from exophthalmic goitre. There is no special advantage in the seaside, but high altitudes often do harm. The details of treatment by surgery, e.g., excision of half the gland, ligature of some of the thyroid arteries, do not fall within the scope of this article, but when considering the desirability of operating we must remember that very severe cases are unsuitable for operation, as they often die after it. Mild cases will often get well without any operation. Many patients have died as a direct result of the operation, and very quickly after it, some even under the anaesthetic, and even including mild cases it is the experience of many that the mortality after operation is severe. There is no doubt that an operation, which is very rarely desirable, should not be undertaken without very careful consideration, and only when prolonged medical treatment has had a fair trial and has failed. W. HALE WHITE. THE SURGICAL TREATMENT OF EXOPHTHALMIC GOfTRE. DURING recent years exophthalmic goitre has been treated by operative measures, and though different surgeons have published large numbers of cases which have been designated as genuine examples of this affection, it is by no means certain that all of them should have been classified as such. And thus it becomes very difficult to estimate how much benefit may be expected to follow an operation for this disease. Exophthalmic goitre may be primary, in which the classical signs and symptoms are present from the onset; it maybe secondary to a pre-c.i'istin) in- flammatory diseases, such as cancrum oris, tuberculosis, syphilis, etc., which have led to actual destruction of the tissues of the lips. Lacerated and incised wounds which have been allowed to heal with faulty approximation of the surfaces are best treated by reopening freely along the line of scar, cutting away if necessary redundant scar tissue, replacing the parts in correct position, and accurately uniting the freshly made raw surfaces. The same principles that guide us in the treatment of harelip apply here also, care being taken to undercut if necessary the parts that are attached to the bone so as to allow of accurate suturing without undue tension. As in harelip, the line of junction between skin and mucous membrane should be restored as accurately as possible if a good result from an artistic point of view is to be obtained. If actual loss of substance has occurred, very free undercutting will be required, and it will often be necessary to carry incisions far beyond the originally wounded area, so as to obtain one or more flaps of tissue with which to fill up the gap in the lip. For an extensive reconstruction of the lower lip it will be neces- sary to carry curved incisions below the chin on one or both sides, and to dissect up freely on either side of the chin. Deformities due to loss of substance from infective diseases (tubercle, syphilis, etc.) should not be treated by operation until the primary disease has been thoroughly cured and the parts are in a healthy condition. They may then be dealt with on* the principles already described. (2) Inflammatory Affections of the lips do not differ in their treatment from similar affections elsewhere and do not require special mention here. The treatment of tuberculous, syphilitic and other innocent forms of ulceration is the treatment (local and general) of the primary disease (see under Tubercle, Syphilis, etc.). Affections of the Lips. 97 (3) New Growths. Imior,'nt tumours such as adenomata, papillomata and mucous cysts, rarely attain a large size and may be treated easily by free excision. Care should be taken that in the healing of the wounds so made contraction and deformity do not occur. In the case of tumours, such as adenomata and cysts, which project on the mucous surface of the lips, as much as possible of the mucous membrane should be preserved to form a covering for the raw surface produced by the operation. Large nsevi (including the so-called aneurysm by anastomosis) not uncommonly affect the lips and often require formidable operations for their removal. If not suitable for electrolysis, which is the best treatment in most cases, they must be excised. Haemorrhage is the main danger of such operations, and is especially to be feared if the tumour extends, as it so often does into the neighbouring parts of the face. Whenever possible, flaps of mucous membrane should be turned back from the surface of the tumour. One or more incisions may have to be made in the skin to obtain free access to the growth, and the surgeon should aim as far as possible at cutting through the healthy tissue in the neighbourhood of the tumour rather than through the very vascular tumour itself. Ligature of masses of nrevoid tissue that cannot be removed with the knife may have to be combined with excision of the more accessible portions. Maliijnant tumours that are especially prone to affect the lips are rodent ulcer and carcinoma (epithelioma). Rodent ulcer is generally best treated nowadays by X-rays or radium, but if these forms of treatment are not available, free excision is required. It is important to bear in mind that rodent carcinoma spreads beneath the skin for some little distance beyond the visible area of ulcerating disease. The lines of incision for its removal should, therefore, always be at least inch away from the apparent margin of the disease. It is essentially a local disease, capable of complete eradication by a sufficiently thorough operation. Recurrence after removal would not be nearly as common as it is were the surgeon to pay more attention in the first instance to the complete removal of the disease and less to the deformity he is causing by his operation. The deformity can subsequently be remedied if necessary by a plastic operation. Incomplete removal leads to further operations which often, in the end, lead to far more deformity than would originally have been produced by a really thorough operation. S.T. VOL. n. 7 98 Affections of the Lips. In the treatment of epithelioma of the lips similar principles apply. The disease is essentially a local one, and in its early stages at least it is readily curable, and completely curable, if only it is thoroughly removed with a sufficiency of surrounding parts, together with the neighbouring lymphatic glands. When the disease is confined to the free margins of the lip it can readily be removed, although some undercutting of the soft parts from the neighbouring bone will often be necessary to minimise the resulting deformity. When the disease is close to, or is involving, the jaw a much more extensive operation is required, and it may even in some cases be necessary to leave a large open wound to be closed subsequently by a secondary plastic operation. In the planning of an operation for the removal of a carcinoma of the lip the path of infection pursued by the disease should not be forgotten, and the excision of neighbouring tissues should be much more free in this direction than in any other. In order to fill up the gap left after an extensive excision it is often necessary to carry curved incisions well below the chin and to dissect up extensive flaps of soft tissues, in order to effect a good restoration of the lip. Thorough removal of the neighbouring lymphatic glands should always be performed either at the time of the primary operation or a few weeks later. JAMES BERRY. 99 DISEASES AND AFFECTIONS OF THE JAWS. FRACTURES OF THE JAWS. The Upper Jaw. The upper jaw is comparatively rarely the seat of fracture and then usually as the result of direct violence by some smashing or crushing blow. The fracture may merely implicate one of the processes of the maxilla, the nasal or alveolar processes or the orbital plate being the most likely to suffer in this way ; or the whole body of the bone may be smashed in towards the antrum, and in this case the fracture will probably extend to the ethmoid and sphenoid bones and thus involve the base of the skull. Certain complications may attend these fractures owing to the anatomical relations of the maxilla to blood-vessels, air spaces and nerves. These are: (1) Epiphora from injury of the nasal duct ; (2) surgical emphysema from a communication of the cavity of the antrum with the subcutaneous tissues ; (3) severe haemorrhage from branches of the internal maxillary artery ; this may occur into the nose or pharynx, or more commonly as a large subcutaneous hfematoma ; (4) anaesthesia of the cheek, teeth and lips from sever- ance of the infra-orbital nerve. Owing to the abundant blood supply, suppuration or necrosis is very rare, whilst union is firm and rapid. The chief indications for treatment are : (1) The prevention of facial deformity ; (2) correction of dental displacement ; and (3) cure of epiphora. (1) The Prevention of Facial Deformity. If the injury has been the result of a penetrating wound, e.g., that of a bullet or a spike, it is best to deal with the resulting deformity by enlargement of the external wound and a replacement or removal of displaced bony splinters. If the malar process has been violently impacted into the antrum, it will be necessary to turn up the upper lip, incise the mucous membrane at the junction of the cheek and gums and by careful leverage attempt to prise out the impacted fragments. A gauze drain is left in the antrum and brought into the mouth. (2) Correction of Dental Displacement. If the alveolar border is broken off from the body of the jaw the utmost care will be necessary to prevent the loss of the teeth or their displacement. The deformity should be corrected by digital pressure under an anaesthetic and when the teeth of the two jaws have been brought 72 ioo Fractures of the Jaws. into correct apposition, a firm jaw bandage is applied and kept in position for a week or ten days, the patient being fed by a tube placed between tbe cheek and the teeth. (3) Cure of Epiphora. Epiphora which results from an injury of the nasal duct usually subsides spontaneously within a few days, being due then merely to laceration and congestion of the mucous membrane lining its interior. If, however, it persists the lachrymal sac must be opened and metal sounds passed down into the nose in order to re-establish its patency. The other complications of fractured upper jaw, e.g., ecchymosis, anaesthesia and emphysema, do not, as a rule, require any special treatment. Separation of the Upper Jaws from the Skull. This rare accident, which results from severe crushing injuries, is known as Guerin's fracture. Both superior maxillae, together with the palate bones, are displaced from their attachments to the cranium. This involves fracturing of the pterygoid plates of the sphenoid and of the malar bones. The treatment consists in an attempt at reduction of the deformity under an anaesthetic. If this can be successfully accomplished there is not much liability to recurrence provided that the jaws are kept at rest by firm bandaging. Fracture of the Lower Jaw. This fracture is comparatively common and the innumerable devices which have been and still are suggested for its treatment show how difficult it has been for successful cure. It is necessary to classify the cases according to the locality and nature of the fracture as follows : (1) Fractures of the body, i.e., the tooth-bearing region of the jaw : these are always compound : (a) Unilateral : the bone is usually broken in front of the mental foramen in the socket of the canine tooth. (b) Bilateral : the symphysis and anterior part of the jaw are separated from the remaining portions and are displaced downwards by the attachment of the geniohyoid and geniohyoglossi muscles. (c) Median : this is the rarest of the varieties because the sym- physis is the strongest part of the jaw. It results from indirect violence, as, for example, when the head is run over and the two sides of the jaw are forcibly compressed. (2) Fractures of the ramus and its condylar or coronoid pro- cesses : these may be simple or compound, the latter usually resulting from gunshot injuries. From the point of view of treatment, however, all cases may be divided into : (1) Those without displacement ; (2) those with dis- placement ; (3) those involving the neighbourhood of the joint. Fractures of the Jaws. 101 Fractures of the Lower Jaw without Displacement. These are decidedly uncommon or else they are overlooked. Painful mastication, local tenderness on pressure over the fractured spot and blood-stained discharge from the mouth are the chief indica- tions. The treatment is simple and consists in the application of an ordinary jaw bandage in the first instance and then of a well- moulded leather or gutta-percha splint provided with straps to go over the upper part of the head. This should be worn continuously for six days, feeding being by a tube between the teeth and gums. Then, for a further period of about a fortnight, the splint may be removed during meals, the patient being fed with soft spoon food. Fractures of the Lower Jaw with Displacement. This con- stitutes the really important and disputable part of the subject. The jaw is broken through a tooth socket on one or both sides, the mucous membrane is torn so that the injured bone is in communica- tion with the septic cavity of the mouth, and the anterior fragment is displaced downwards so that it puts a number of teeth out of action with their opponents. Usually there is no difficulty in reducing the displacement, but it recurs almost immediately. In many cases the alveolar border of the jaw necroses and sinuses may remain for many months opening into the mouth. For all these reasons this type of fracture is rightly regarded as one which requires great care in its treatment. But inasmuch as many of the splints and contrivances designed for this object were invented in the old days when pugilism and sepsis were both much commoner than they are at present, the majority of them may be regarded as having only a historical interest. There are three forms of treatment which may be applied to these cases, viz. : (1) Simple bandages and splints ; (2) complicated splints ; (3) direct fixation of the bone. SIMPLE BANDAGES AND SPLINTS. In those cases in which the displacement is slight and easily kept in a rectified position, the method described for cases without displacement may be adopted. But in this case it is wise to allow a fortnight to elapse before removing the splint even temporarily. The disadvantage of the method, besides the deprival of solid food for so long a time, is that it is difficult to keep the mouth clean, but a tooth brush and mouth washes, if used before and after each feeding, may remedy this. When the anterior fragment is much displaced it may be easier to adapt the fragments when the jaw is open. Under these cir- cumstances an internal gutta-percha splint (Gunning's) may be applied if the patient will not consent to direct suture of the bones. An anaesthetic is administered, the mouth opened, and the IO2 Fractures of the Jaws. fragments replaced in good position. A mass of soft gutta-percha is then moulded so as to fit inside both jaws and embrace the crowns of all the teeth. A hole is made in this splint between the incisor teeth for feeding and cleansing the mouth. The jaws are then firmly bandaged together, and the apparatus retained without moving the splint for three weeks. This method will only succeed if the reposition of the fragments is very accurately carried out, and the splint well made by a dental surgeon (see Dental Surgery, Vol. III.). COMPLICATED SPLINTS. There are many of these, but it is high time they were relegated to oblivion. Some, the wire dental splints, act by encircling the crowns of all the lower teeth by stout wire, with fine wire between the teeth. Others form more or less complicated moulds of the dental margin of the jaw, which are fastened by steel bands, bars or screws to other splints on the outer surface of the mandible. There are many reasons why all such contrivances should be abandoned. They are difficult of manufacture, uncertain in action, uncomfortable to the patient, and make efficient cleansing of the mouth impossible. The wire inter- dental varieties tend to loosen the teeth whose function it is their main object to preserve, and they render the septic state of the jaw much worse by the inevitable retention of food debris. DIRECT UNION OF THE BONE. This undoubtedly should be the method of choice in all fractures of the lower jaw with much displacement. In carrying it out the following principles should be observed : To remove any carious teeth or tooth fragments from the proximity of the fracture ; to perform the bone fixation through a clean incision made externally below the body of the jaw, wiring or screwing the dense bone along its lower margin, and avoiding the fragmented and friable alveolar margin. An incision, 3 centimetres long, is made well within the line of the edge of the mandible. This leaves a very inconspicuous scar, and does not divide the facial nerve filaments to the angle of the mouth. The periosteum is divided along the margin of the bone and a suitable metal plate placed over the fractured area, and the drill holes marked when the bone is being held in accurate position by an assistant. Any adult jaw will readily take screws 1 centimetre long and 3 millimetres in diameter. The holes for the screws ought to be drilled by a dental engine, or, if this is not available, by an Archimedean screw. When the plate is in position the periosteum is sewn over it and skin united by fine sutures or clips. If the fracture is double the same procedure is adopted on the other side. The direction of the screw holes should be upwards and inwards, as this gives the longest Fractures of the Jaws. 103 thickness of dense bone, without risk of perforating the canal of the dental nerve or the tooth sockets. There ought to be no difficulty in getting the metal plate, screws and drills even in the most remote places, and it is well worth waiting for two or three days to obtain them. Wiring is not nearly so easy or satisfactory, because the holes must be made right through the bone, and it is rather troublesome to get the wire from the deep surface through the second hole. After direct union of fracture of the jaw, bandages are only necessary for one week or ten days, and they FIG. 1. Union of a fracture of the mandible through an external incision, by means of a steel plate and screws. should be removed frequently during this time for spoon feeding and for cleansing the mouth. Fnn-tures of the Ram us an<\ its Processes. No general rule can be laid down for these cases, but usually no special apparatus or operation is necessary for their treatment. In gunshot injuries with comminution of the condyle and coronoid process the wound should be enlarged and cleansed, loose fragments of bone removed, and movements of the jaw carefully begun within one week of the accident. Ankylosis of the joint is the danger to be guarded against in these cases, rather than want of union or displacement. io4 Dislocation of the Jaw. INJURIES AND DISEASES OF THE TEMPORO- MAXILLARY JOINT. Dislocation of the Jaw. Between the condyle of the jaw and the glenoid fossa on each side there are two joints within a single capsule, separated from one another by a disc of nbro-cartilage. The lower joint between the jaw and the disc is a hinge, whilst that between the disc and the skull is a gliding joint. In dislo- cation of the jaw the condyle, with the disc, slips forward over the eminentia articularis. In the majority of cases it is only a sub- luxation, being wholly within the capsule of the joint. Reduction is rendered difficult by the facts that the condyle lies in front of the line of action of the masseter and internal pterygoid muscles, the spasm of which tends further to push it forwards, and that there is no muscle to oppose the forward drag of the external pterygoid. In some cases, too, the coronoid process becomes hitched in front of the malar bone. It is, therefore, clear that the main factor in the reduction of the deformity must be the abolition of muscular spasm. The dislocation, which is usually the result of extreme yawning or of the injudicious use of the gag in mouth operations, is almost always bilateral, but occasionally is one-sided. It is much commoner in women than in men. Treatment of Recent Cases. The patient is seated in a high- backed chair or one provided with a firm head rest. The operator wraps his thumbs with thick gauze and places them over the last lower molar teeth, the fingers lying underneath the chin. The thumbs are pressed firmly downwards and the jaw opened more widely than ever. This serves to overcome the muscular spasm ; the coronoid process is unhooked, and then, whilst firm pressure is maintained downwards on the molar teeth, the chin is raised and pushed backwards. In some cases, especially when the accident has happened more than once, this manoeuvre may succeed, even without an anaesthetic, but in the majority of cases an anaesthetic will be necessary. The method of placing a wooden cylinder between the back molars on both sides, and using this as a fulcrum, whilst upward leverage is made on the chin, is much inferior to that already described, because there is great difficulty in keeping the wood in position unless it is hitched behind the teeth, in which case it prevents the backward movement of the ramus of the jaw. No special after-treatment, except ordinary caution in yawning, is required. Treatment of Old Unreduced Cases. It is very rare to meet with these nowadays, but at all costs and after any lapse of time, such Ankylosis of the Jaw. 105 a case should be submitted to treatment, because the condition so seriously interferes with both feeding and speaking. Up to a period of six weeks from the accident simple manipulation under an anaesthetic may still be successful, but in any case it is wise to be prepared before the anaesthetic is administered to go on to operative measures. Before resorting to the final expedient of excision of the condyle, it is worth while to try to lever down the neck of the jaw through a small incision below the zygoma on both sides. Through this incision a blunt-pointed periosteal elevator is pushed until it engages in the sigmoid notch. When this has been done on both sides a simultaneous raising of the elevators will serve to disengage the condyle from the temporal fossa and the coronoid process from the malar. If this fails, then the neck of the jaw must be sawn through and the condyle removed on both sides. Inflammatory Diseases of the Temporo-maxillary Joint, Considering the proximity of the jaw joint to that common seat of suppuration, the ear, it is somewhat remarkable how seldom it becomes affected by acute arthritis. This immunity is probably due to the interposition of a lobe of the parotid gland between the tympanic plate and the capsule of the joint ; but acute septic arthritis of this joint does rarely occur in connection with wounds, suppurative parotitis and otitis, or in infancy probably under con- ditions similar to those causing the acute arthritis of infancy in other joints. In all these conditions the diagnosis is liable to be confused with that of inflammatory disease of the parotid gland, which causes similar pain and difficulty in mastication, and the need for special treatment may only be recognised at a late date when ankylosis has resulted. Subacute or chronic inflammatory disease may result from rheumatism, osteo-arthritis or gonorrhoea, but in such cases there is seldom any special indication for treatment beyond that appro- priate for the causative disease. In osteo-artliritis a painful grating and clicking of the joint may be caused by the fibrillation and degeneration of the inter-articular fibro-cartilage. Usually this is not so severe as to call for surgical intervention, and the pain can be temporarily relieved by counter-irritation by iodine or blisters applied over the joint. In the more inveterate cases in which mastication is seriously interfered with, however, the joint should be opened through a horizontal incision below the zygoma and the degenerated remains of the cartilage removed. Ankylosis of the Jaw. Fixation of the jaw may result from a true intra-articular bony or fibrous union resulting from any of io6 Ankylosis of the Ja\v. FIG. 2. Boxwood wedge for the treatment of fibrous ankylosis of the jaw. the above inflammatory diseases, or from a false or extra-articular fibrosis resulting from scars or septic processes in the neighbour- hood. Temporary inability to open the mouth is often caused by inflammatory diseases of the tonsils, pharynx, or molar teeth, but the nature and treatment of this are usually so obvious as to need no separate description. The Treatment of True Bony Ankylosis. If it is quite clear that the jaw fixation is due to bony union of the joint surfaces the best treatment is excision of the condvle. An inci- sion about 4 centimetres long is made along the lower border of the zygoma, beginning just in front of the ear, down to the deep fascia covering the parotid. This is cautiously divided by blunt dissection so as to avoid branches of the facial nerve. The parotid gland is retracted downwards and backwards, and the origin of the masseter muscle divided in the posterior part of the wound. The neck of the jaw is now exposed, and it is divided by a sharp chisel and bone forceps (there is not room for the employ- ment of a rigid saw, and if Gigli's wire saw is used it is liable to break owing to the sharp flexion necessary). The capsule of the joint is opened and the condyle removed after chiselling through the adhesions to the temporal bone. The cut neck of the jaw is rounded off and the cut fibres of the masseter muscle united to the internal pterygoid so as to interpose a barrier of soft parts between the bone surfaces. Usually only one side requires operation. The Treatment of Fibrous Ankylosis. When the fixation of the jaw is not absolute, but permits of slight movement, the first method to be adopted is that by wedges and gags. In the first instance, these should be employed under full anesthesia so as to abolish muscular spasm and allow of a forcible stretching of fibrous adhesions. A sharp wooden wedge (Fig. 2) is first used to lever open the front teeth, then a powerful screw wedge (Fig. 4) is inserted and opened as far as possible without injury to the teeth. Subsequently the patient is instructed to apply some form of wedge gag daily, the boxwood screw (Fig. 3) probably being the most convenient. This FIG. 3. Boxwood screw wedges. The patient places the small end between his incisor teeth, and rotates it as far as possible. This proceeding is repeated daily. Inflammatory Diseases of the Jaws. 107 after-treatment must be continued for many months if any per- manent results are to be obtained. Treatment of Severe Grades of Extra-articular Adhesions. In those cases where the last-mentioned treatment has failed, a new joint must be made on both sides of the jaw in the region of the angle. A curved incision is made outside the margin of the angle, beginning below the lower margin of the lobule of the ear and ending in front of the insertion of the masseter. The soft parts are all turned upwards, the facial vessels being retracted in front. The masseter is separated from its attachment to the outer surface of the jaw, the periosteum being raised with the muscle, and a V-shaped piece of the bone at the junction of the ramus and body sawn through. Smart haemorrhage will result from the division of the FIG. 4. Powerful screw gag. It can only be used if the front teeth are firm and strong, and the tips should be protected by rubber tubing to prevent chipping the enamel. inferior dental artery in the substance of the bone, and this must be stopped by plugging with aseptic wax or a wooden splinter which has been boiled. In the bed from which the bone has been removed lies the deep surface of the internal pterygoid muscle. The masseter and pterygoid muscles should be sewn together over as wide an area as possible so as to prevent union of the adjacent bony sur- faces. The same procedure must be adopted on the opposite side. It is not to be expected that any powerful mastication will be possible after this operation. Its main object will be to enable the mouth to be opened so that soft food can be taken. INFLAMMATORY DISEASES OF THE JAWS. The inflammatory conditions of the jaws may be classified as follows : (1) Acute pyogenic infection, (a) localised, from teeth io8 Necrosis of the Jaw. or antrum ; (i) diffuse osteomyelitis ; (2) chronic pyogenic infec- tion, pyorrho?a alveolaris, phosphorous necrosis ; (3) chronic specific disease, syphilis, tubercle, actinomycosis. Diseases associated with the teeth and the antrum and pyorrhoea are dealt with elsewhere (see Dental Surgery, and Diseases of the Antrum, Vol. III.). Necrosis of the Jaw. In its simple form associated with dental periostitis and in its acute infective form the treatment of necrosis of the jaws does not require any special discussion ; but the chronic diffuse inflammation which leads to very extensive necrosis in phos- phorus workers is peculiar, and its treatment requires careful consideration. Prophylactic Treatment is, of course, of the first importance. Working with yellow phosphorus should be restricted as far as possible, as the red phosphorus, from which safety matches are made, appears to be harmless. All the teeth should be period- ically inspected and carious teeth removed or efficiently stopped, because the disease always begins as an osteitis round a carious tooth. The hands should be thoroughly washed between work and meals, as it is probable that food contamination is even more deleterious than inhalation of fumes ; and, lastly, cleanliness, sunlight and ventilation should be secured in the factories and the home life of the workers. Curative Treatment. On the first appearance of the disease the gum becomes retracted from the teeth and pus exudes from its margin. The tissues over the jaw swell and break in various positions, both internal and external, and through these openings a quantity of foul pus is constantly discharged. The originally sound teeth become loosened and fall out and mastication is rendered impossible. In the bone itself, especially along the dental margin, large areas become soft and carious, new spongy bone forms a periosteal involucrum, and the dense parts of the body and rarnus undergo necrosis. The whole process is very slow and many months elapse before separation of sequestra take place. It is very impor- tant, therefore, to recognise and treat the condition in its earliest stages. The teeth in the affected area should be removed and the whole of the alveolar border freely chiselled and scraped away, the patient being, of course, absolutely removed from contact with phosphorus or its fumes. In the advanced condition it is far better boldly to attack the disease through an external incision than to wait in the hope of being able to remove sequestra through the mouth. The jaw is quite useless for mastication and forms a serious menace to life. In extreme cases the greater part of the Benign Growths of the Jaw. 109 mandible may require to be removed, but it is usually possible to preserve the rami, and by connecting these at the time by one of the varieties of artificial jaw (see section on Tumours of the Jaw), the facial appearance may be preserved and a useful member eventually obtained. The Specific Infective Diseases of the jaws must be treated on similar lines to those of such affections of other bones. Tuber- culous disease may affect the orbital margin, the angle of the mandible or the malar process, and it will necessitate local incision and scraping. Actinomycotu is particularly liable to affect the angle or any part of the body of the lower jaw, when it may readily be mistaken for a recurrent dental abscess. Free erasion of the disease with administration of large doses of iodides is the treat- ment required, and it should be energetically carried out before extension to the lungs or digestive organs has occurred (see Actinomycosis, Vol. I). BENIGN GROWTHS OF THE JAW. Simple tumours of the jaw are usually cysts connected with the teeth, but the ordinary varieties of benign bony outgrowths, osteoma, fibroma, also occur with some rarety. Osteoma usually grow with extreme slowness from the angle of the mandible, and are of the dense ivory variety. They may cause some distortion of the face, for which their removal will be necessary. This is best effected with the aid of a surgical motor or, if the growth is pedunculated, by a Gigli's saw. The bone is so dense that an attempt to remove it by the chisel and mallet may result in fracture of the jaw. Fibromata. These vary much in appearance and clinical course. In the simplest form it grows from the margins of the dental sockets as a fibrous cpulis which is comparatively soft and covered by vascular mucous membrane. Such a growth should be freely removed with the margin of alveolus that it grows from directly it is observed. There is no reliable means of determining whether a given epulis is fibrous or myeloid, except microscopical examination, and it is almost as easy to remove the growth thoroughly as to take a part of it for section. Other varieties of fibromata are much rarer. In physical signs and locality of occurrence they exactly resemble the sarcomata, but the rate of their growth is very slow. Clinically it is certain, and pathologically it is probable, that there is no sharp differentiation between the benign fibroma and the malignant sarcoma. It is therefore necessary to remove these tumours as soon as they are recognised. If they occur as well-defined periosteal growths the local complete removal will present no iio Benign Growths of the Jaw. difficulty. If they involve the upper jaw, then it would be wise first to remove a portion for microscopical examination before deciding between a local tumour removal or an extensive resection of the jaw. It is probable that the few cases of so-called sarcoma of the jaw who have survived for long periods after excision are in reality instances of fibroma. Solid tumours of the jaw may arise from the tooth roots. These are termed Radicular Odontomes and are in reality merely ivory exostoses of dental origin. They are only likely to simulate jaw tumours when occurring in the teeth of the upper set, the canine and premolars being those most often affected. The tumour may practically fill the maxillary antrum and bulge forward upon the cheek. The clue to diagnosis is given by the shape of one of the teeth whose root is larger than the crown. These dental growths must be removed by cutting through the mucous membrane and thin bony shell which overlies them, and then pulling the mass outwards by the crown of the tooth. Simple Cysts of the Jaw. Cysts of the jaws are of common occurrence, and it is probable that they are chiefly of dental origin, though in the upper jaw the mucocele of the antrum arises from the mucous membrane lining that cavity. Some grow at the root of a mature tooth, others (follicular odontomes) consist of the tooth follicle itself with the unerupted crown in its cavity. All these simple cysts are of slow growth and are not associated with much pain. They expand the overlying bone so that at length it can be indented like the shell of a ping-pong ball. Their treatment is simple and satisfactory and consists in the removal of as much of the outer bony wall as possible after incision of the mucous membrane. The cavity is then laid freely open and its lining, together with any dental rudiments, thoroughly removed by scraping. It is packed tightly to stop the oozing, and when the packing is removed on the second day it is syringed out with a solution of Condy's fluid or of glycothymoline after every meal. Myeloid Growths of the Jaw. These used to be termed " mye- loid sarcomata" and "malignant epulis" but it is better to place them in a class by themselves and call them " myelomata," because whilst locally malignant in the sense of destroying and replacing all the tissues with which they come in contact, they cause no metastases and do not affect the lymph glands. Myeloid Epulis occurs as a fungating polypoid mass from the gums round the socket of a tooth. It bleeds freely and it slowly invades the adjacent part of the alveolus. Its substance is replete with large multi-nucleated cells which makes its Benign Growths of the Jaw. 1 1 1 microscopical diagnosis easy. The treatment consists in removal by the chisel and sharp spoon of the alveolar border of the jaw from which it is growing. Central Myelomata. These occur chiefly in the lower jaw as medullary tumours, which, growing slowly and causing an absorp- tion of the overlying bone, closely resemble cysts ; in fact, their FIG. 5. An operation for the removal of a tumour of the lower jaw without destroying the continuity of the latter. M, masseter muscle turned up ; F, facial artery tied and cut. vascular stroma does often become the seat of spurious blood cysts, which makes this resemblance closer. The treatment is a matter which, in principle, is the same as that of the epulis, but com- plicated in practice by the desirability of preserving the continuity of the lower jaw. In the old days when the limited malignancy of a myeloma was not recognised the affected half of the jaw would be resected, but this is quite unjustifiable in the light of our present knowledge. Two operations are necessary. At the first the growth ii2 Malignant Disease of the Jaws. is merely explored. If it proves to be a simple cyst the treatment can then and there be completed. But if it is a solid haemorrhagic mass, then a part of this must be microscoped before deciding upon the ultimate operative scope. The microscopical diagnosis of a myeloma is so easy that a section taken immediately, whilst the patient is under the anaesthetic, may be relied upon. If the growth has converted the whole of the jaw into a friable, egg- shell-like mass, it may be inevitable to remove a part of the jaw in its whole thickness, but nowadays this is rarely necessary, and it is possible to preserve a bridge of the dense bone along the lower margin of the body. In the case of a small growth about the size of a plum the operation can be conducted inside the mouth by means of a chisel and sharp spoon. After drying out the cavity left by scraping, a solution of zinc chloride (40 gr. to the ounce) is thoroughly rubbed in and the cavity is then packed with iodoform gauze. If the tumour is too large to attack from the mouth, the cheek is turned up by an incision round the angle of the jaw the facial vessels being tied and cut. Then with a fine keyhole saw the whole tumour may be cut away without opening it, the lower margin of bone being preserved. It is necessary to protect the tongue from the point of the saw by gauze pads. Epithelial Odontomes ; Fibrocystic Disease. This is a very rare disease and so far has only been observed in the lower jaw. It consists in an irregular epithelial proliferation from the embryonic tooth germs. It grows comparatively slowly, and the epithelial tubules become dilated to form numerous small cysts separated by dense fibrous tissue. It is quite uncertain at what period in its history it becomes truly malignant, but in those cases treated by conservative methods of chiselling and scraping, recurrence with epitheliornatous disease of the glands has usually taken place. When, therefore, the diagnosis has been established a free primary resection of the jaw should be carried out, the bone being divided well beyond the disease on either side. It will in this way usually be possible to retain enough of the ascending ramus to afford attachment to an artificial jaw in the manner described below. MALIGNANT DISEASE OF THE JAWS* Sarcoma is unfortunately by no means a rare disease of the jaws, occurring at any age and usually developing with great rapidity. Carcinoma occurs in the upper jaw of elderly people, starting no doubt in the mucous membrane of the antrum. In the early Malignant Disease of the Jaws. 113 stages malignant disease may readily be mistaken for some inflammatory affection, this being especially tbe case with the superior maxilla, where antral suppuration produces an exactly similar appearance to that of a rapidly growing sarcoma. The fact that in its early stages malignant disease is painless should be the safeguard against this error, which often costs the patient his life. In the case of the Lower Jaw the limitations and connection |'K;. 6. Showing the best method of division and union ot the jaw by a V-shaped saw cut. This prevents all tendency of the two halves of the jaw moving upon one another. of the new growth can usually be explored without difficulty, and provided that the diagnosis has been made certain, the treat- ment admits of no doubt. In cases where the disease is clearly unilateral, the half jaw should be removed, with its adjacent muscles and periosteum. The genial tubercles may be spared on the side of the excision, as they afford such important attachments to the tongue and larynx. But the masseter on the outside, and the pterygoid, mylohyoid and buccinator muscles on the inner side should be freely removed. As a preliminary to this extensive S.T. VOL. u. 8 ii4 Malignant Disease of the Jaws. resection the glands in the submaxillary triangle, including the salivary, should be removed and the external carotid artery tied. If the growth encroaches upon the region of the symphysis menti the greater part of the body of the jaw should be removed, leaving the rami if possible for the attachment of an artificial jaw. The Restoration of Continuity of the Lower Jaw. In some operations, e.g., Symes' method of tongue excision, the symphysis menti is cut through, and unless special means are taken to prevent it, the two halves of the jaw remain ununited and the patient's troubles, which are great enough already, increased by a disability to masticate. The ordinary wiring of the fragments is not enough, because the region of the sym- physis, being very hard and avascular, is slow to unite, and the part is usually in a septic condition. There are two methods by which this can be prevented. The best is to make the saw cut through the sym- physis angular instead of linear, using a fine keyhole saw. The muscles attached to the genial tubercles must be separated first and held out of the way. The lines of saw cut should be planned and holes drilled for wire, screws or pegs before the bone is divided. When a part of the jaw has been removed for malignant disease it is a matter of great importance to provide a temporary sub- stitute for the part removed at the time of the operation. This acts as a splint, and if it is not used the two halves of the jaw become pulled inwards by muscular action and mastication is rendered impossible. It is, moreover, very difficult to fit a dental plate for such a patient later on, because fibrous contraction has distorted the mandible beyond rectification. Various splints have been devised, e.g., Martin's, which consists of gutta-percha with metal attachments to the jaw stumps; Partsch's, which is a simple metal band, and Stoppany's, which is a moulded and perforated aluminium plate shaped like the chin. FIG. 7. Showing an aluminium plate formed into an artificial jaw and fixed in place by steel screws. Malignant Disease of the Jaws. 115 These no doubt are all excellent, but they have this great draw- back, that they have to be made before the operation, and it is usually impossible to accurately foresee how much of the jaw is going to be removed. Under these circumstances it is best to be provided with a suitable metal splint considerably larger than will be required and be prepared to cut it to the necessary length after the excision is completed. It is then attached by screws to the ends of the jaw and the soft parts sewn over it. In some cases it will remain permanently in position, becoming embedded in the soft tissues. In others it will have to be removed at the end of about a month or six weeks, by which time a permanent dental plate will have been prepared. The condition may also be treated by bone grafting, a piece of the patient's own rib being the most convenient material to employ. The rib is removed with its periosteum and fastened in position by wiring. It is seldom that this method can be employed at the time of resection of the jaw, because the patient's condition will not allow of the further operation and because the bone will have to be transplanted into a septic cavity (the mouth). But it has been successfully employed after the mouth has healed, by making a bed for the new bone through an external incision. In the case of the Upper Jaw the matter is much more difficult, because it is impossible to ascertain what are the limits of the growth before operation. The ethmoidal and sphenoidal air cells or the interior of the nose, or the pterygoid fossa, may be invaded by malignant growth at a time when, from the outward appearance, the disease is early. However, as in general terms it may be definitely stated that malignant disease of the upper jaw must be treated by excision, it may make for simplicity if we begin with the proposition and proceed to discuss certain limitations and conditions which affect it. (1) Diagnostic Operations. In every case in which a swelling of the upper jaw occurs and is not speedily relieved by the removal of a tooth or evacuation of the antrum, no time should be lost in exploring this swelling and freely removing a portion for micro- scopical diagnosis. It is the utmost folly in such cases to wait for further signs to develop, and if the condition is benign or inflam- matory this early operation will bring about its cure, whereas if it is malignant, it w T ill be dealt with at the only stage at which any radical cure can be expected. (2) Limitations. Extensive fungation into the nasal cavities, displacement of the eyeball, swelling at the back of the pharynx or 82 u6 Malignant Disease of the Jaws. in the temporal fossa, are signs which indicate that the disease has already spread beyond the limits of the maxilla and make any radical removal impossible. Involvement of the skin either by actual fungation or by adherence to the growth will be a contra- indication when it is associated with evidence of a large and extensive growth. In children, when the growth has rapidly assumed a large size, it is useless to operate, as such patients usually die after the operation or suffer a speedy recurrence. (3) Partial or Modified Operations. If the lower border of the jaw is the seat of the growth it is wise to preserve the orbital plate of the maxilla in order to maintain the position and functions of the eye. If the disease is early and situated on the upper part of the jaw the muco-periosteum of the hard palate may be preserved and stitched to the cheek so as to shut off the cavity of the mouth from that left by the removal of the growth. If the growth extends back into the orbit it is better to remove the eyeball at the time and clear out the bony socket, scraping and treating with zinc chloride the ethmoid and sphenoid cells. If the skin is adherent to or involved by the growth it must be freely removed and the defect remedied by a plastic operation. (4) The Removal of Lymph Glands. If the submaxillary and cervical lymph glands are affected their removal will naturally be undertaken either before or after the jaw is removed. But it is wise to make a routine procedure of clearing out all the lymph gland tissue in every case, and if this is done at the first stage of the operation (through a curved incision running from the angle of the jaw to the hyoid bone and thence up to the symphysis) the external carotid can be ligatured at the same time. (5) Control of Hemorrhage. As ordinarily practised, the excision of the maxilla is an avulsion in which many branches of the internal maxillary artery are torn, and this tearing, together with hot water and gauze pressure, is the only means relied upon for the arrest of haemorrhage. For this reason the operation is one with a very high mortality. In any case the nerve shock is extreme and if there are added to this great loss of blood and the liability for the blood to be inspired into the air passages, the danger is greatly increased ; we hold, therefore, that some preliminary method of haemostasia ought always to be undertaken. The easiest is by ligature of the external carotid artery above the superior thyroid. This may be combined with the removal of the lymph glands. The temporary clamping of the common carotid has also been adopted, but it involves the risk of severe Malignant Disease of the Jaws. 117 bleeding after the removal of the clamp, because the torn vessels cannot be individually ligatured. (6) The Method of Ancesthesia. There is always a great liability for blood to collect in the pharynx and run into the air passages. This may be minimised by ligature of the carotid and by placing the patient in a head-down position. But though the latter pre- vents blood trickling down into the trachea, it greatly increases the venous oozing. On the Continent a method has been adopted by choice which is often enforced by necessity, viz., the cessation of the anaesthesia after the blood begins to collect in the throat. As the result, the larynx regains its reflex sensibility and blood is coughed up. Kronlein practises what is termed " suggestive anaesthesia " by morphia ( gr.) before the operation, and " a few whiffs " of ether at the time. To us this appears to be sheer barbarism under a euphemistic title. A preliminary laryngotomy prevents all this trouble and danger. It is performed in about two minutes and the pharynx can then be firmly packed, and the anaesthetist has his own field to himself, whilst the patient is afforded complete oblivion to what is one of the most terrible operations in surgical practice. When this is done the patient can be elevated so that the body is at an angle of 45 degrees with the horizon, and the venous oozing will then be reduced to a minimum. (7) Results of the Operation. According to most authors and as a matter of common experience, the operation is one with a very high death rate and very poor ultimate results. Professor Schlatter quotes the following figures to show the influence of anaesthesia in causing the mortality : Xo. of Case. Period. Mortality, percent. Rahe, 606 . . 1827 to 1873, pre-ansesthetic period . . 18'4 Kronlein, 158 . 1870 to 1897 21'5 Konig 30-0 Kronlein . . By method of " suggestive anaesthesia " . 2*8 Sir H. T. Butlin considers that 30 per cent, represents the opera- tive mortality, but, in marked contrast to every other writer, Cheyne and Burghard, without giving details, say they have had no mortality. If the above described methods are adopted as a routine, i.e., ligation of the carotid and preliminary laryngotomy, there seems no reason why the mortality should be any greater than 5 per cent. As regards permanent results, the question turns chiefly on the pathological nature of the growth and the period at which it is attacked. The soft round-celled sarcoma which has already filled the whole jaw at the time of operation is probably absolutely hope- n8 Malignant Disease of the Jaws. less. The hard fibro-sarcoma limited to the anterior face of the bone gives a good prospect of cure. Unfortunately such cases are the exception. Schlatter has collected 133 cases of this operation with only 19 three-year survivals. Butlin reports only 4 out of 64. There does not seem to be any definite difference either in prognosis or treatment between sarcoma and carcinoma of the maxilla. Konig has recently recorded 8 cases (out of 48) of carcinoma of the upper maxilla which survived operation for periods varying between ten and twenty-six years. These results are attributed by the author to the method of removing the jaw with a very wide margin of surrounding tissues. 1 (8) The Routine Operation. Incisions are made in the soft parts from a point just below the inner canthus of the eye outwards to the external angular process of the frontal and downwards in the margin between the nose and cheek, round the ala and through the mid-line of the lip. The skin flap thus marked out is turned outwards, the muscles and fat being left on the bone. The orbital periosteum is separated from the maxilla. The muco-periosteum of the hard palate is incised in the mid-line after extraction of the central incisor tooth, the junction of hard and soft palates is cut through by curved scissors. The malar bone is cut through to the spheno-maxillary fissure by a Gigli's saw ; in the same manner the nasal process of the maxilla is cut between the lachrymal groove and the anterior nares, after separating the cartilage from the latter. The hard palate is divided by a keyhole saw in the mid-line. The bone is then wrenched out by lion forceps. The part is thoroughly irrigated with water at 110 F. and packed with iodoform gauze. The skin flap is accurately sutured in position. The gauze is removed on the second day and the cavity irrigated with glycothymoline or Condy's fluid and repacked. About a month after the operation a false jaw should be made by a dentist, to preserve the outline of the cheek and to shut off as far as possible the cavity from the mouth. (9) Treatment other than Operative. Apart from operation, the injection of Coley's fluid is the only method at present which is available for trial ; and that it has only a remote chance of success is shown by the fact that Dr. Coley himself, out of a total of 500 cases of malignant disease of all kinds, chiefly sarcoma, has only had success in 52, and only one of these was a sarcoma of the upper jaw. 2 The first dose is min. of the mixed toxins of bacillus prodigiosus and erysipelas. This is repeated daily, increasing by \ min. each day, until a reaction occurs, and then repeated only Malignant Disease of the Jaws. 119 after the temperature has been normal for three days. The one successful case had 103 injections in all, lasting from August, 1901, to January, 1902. ERNEST W. HEY GROVES. REFERENCES. 1 " Archiv f. klinchir Berlin," 1910, XCIL, p. 918. 2 Wiiiberg, O. K., Med. Record, New York, 1902, LXL, p. 681, andProc. Roy, Soc. Med., 1910, III. (Surg. Sect.), p. 32. 120 DISEASES AND AFFECTIONS OF THE MOUTH. STOMATITIS. CATARRHAL STOMATITIS. THIS, the most simple form of stomatitis, may occur at any age ; either in infancy, associated with dentition or gastro-intestinal dis- orders, or at other times, as the result of irritation or indigestion. It does not produce constitutional disturbance. Treatment consists in the local application of glycerine of borax and the administration of bland non-irritating foods. Any gastro-intestinal disorder will require appropriate treatment. APHTHOUS STOMATITIS. This usually occurs during the first four years of life, though it may occasionally be seen in rather older children. Constitutional symptoms are well marked and sometimes precede the local by a day or two. It usually lasts from seven to ten days in spite of vigorous local and general treatment. Prophylaxis. This consists in scrupulous cleanliness on the part of the mother, or nurse, as regards everything that comes in contact witti the child's mouth. The food itself, together with all utensils for preparing the food or conveying it to the mouth, must receive careful attention. The use of dirty " soothers " should be avoided. Prophylaxis, indeed, means constant care as to the general hygiene of the child. As the disease sometimes attacks more than one member of a household, it is well to isolate a suffer- ing child from its companions as regards spoons, cups, kissing, etc. Local Treatment. In most cases this should be simple but thorough. Cleansing the mouth with lint or absorbent wool soaked in boiled water, or in a saturated solution of boric acid, is both preventive and curative. Kerley gives the following directions for washing a baby's mouth : " The child is placed on its side or stomach, the index finger of the mother, or nurse, being thoroughly wrapped in absorbent cotton. The finger is then dipped into the solu- tion and, without expressing the fluid, is placed in the child's mouth. By gentle pressure upon the gums and cheeks a sufficient amount of the fluid will be expressed to run out of the mouth and effectually cleanse it. The washing is assisted by the opposition offered by the child to the manipulation of the tongue, cheeks and jaw." Stomatitis. 121 The use of stronger astringents is unnecessary except in severe cases. Of these may be mentioned : Alum, either as powder with equal parts of bismuth, or as solution (10 gr. to the fluid ounce) applied on a swab or brush ; or silver nitrate, applied to individual aphthae in solid stick form, or in solution (10 gr. to the fluid ounce) on a fine brush point once or twice daily. General Treatment. As a rule this is unnecessary and has no direct effect on the stomatitis. Some writers recommend the administration of chlorate of potassium internally. Attention must be paid to the condition of the bowels, and any tendency to consti- pation or diarrhoea must be suitably dealt with. Mercury, in the form of grey powder or calomel, is recommended by some, whilst others consider that in any form its use is contra-indicated in stomatitis of all sorts. Food. So long as the mouth is sore the administration of food will be more or less interfered with, and it may be necessary to feed, for a time, with the spoon. It should be given cool. Ice to suck will be grateful and comforting. If breast-fed, the milk should be withdrawn by a breast pump for this purpose. ULCERATIVE STOMATITIS. This condition is essentially associated with fully-developed teeth, and usually occurs from the age of four to twelve years. It is more common in the lower classes, probably due to dirt and bad nutrition. It not uncommonly follows various specific fevers, particularly measles and typhoid fever, or some other general disease producing a cachectic state. It may occur in adults, par- ticularly in crowded institutions of an insanitary character. Prophylaxis. This includes general hygiene, cleanliness of the mouth and teeth, especially during any specific fever, proper atten- tion to dental caries, suitable and varied food, and fresh air. Chlorate of potash, given internally, is, practically, a specific ; it is important that a sufficient quantity of the drug be given. Two grains every three or four hours, making not more than a total of 15 gr. in the twenty -four hours, may be given to a child of three years old. In adults 20 gr. may be given thrice daily. The possible dangers from the use of chlorate of potash in this condition seem to be almost nil and are quite outweighed by its advantages. Local Treatment. Hydrogen peroxide (2 to 10 per cent.) solu- tion in water is a useful mouth wash. It should be used several times daily and the mouth then frequently rinsed with water. Potassium permanganate in a fairly strong solution may be used 122 Stomatitis. for sponging or flushing the gums. In severe or obstinate cases Pfaundler and Schlossmann recommend the direct application of iodoform gauze soaked with aluminium acetate or pencilling the gums -with zinc chloride (5 per cent.) twice daily. The latter has the advantage of not attacking the healthy mucosa. Powdered alum, chloride of lime, or iodoform, applied dry, have also been found useful. Diet and General Hygiene. Attention to these is of the highest importance in promoting recovery. A plentiful supply of fresh air will often act in a surprisingly beneficial manner. If possible, the child should be out of doors altogether. If this is not possible, the window should be kept wide open and the child close to it. Exceptional cleanliness is called for to counteract the fcetor of the mouth. Food must be sufficient in amount and varied in kind. The difficulty of mastication will necessitate liquid food only, and the natural tendency to resist taking even liquids, owing to the discomfort caused, must be firmly overcome. If necessary, forcible feeding must be resorted to. In addition to milk, beef-tea, eggs, etc., fruit juices and fresh vegetable purges, etc., may be given with advantage. Stimulants may also be required both during the disease and in convalescence. When the mouth condition is im- proving, astringent tonics, iron, cinchona, etc., are useful. If the teeth become loosened it is desirable, if possible, to leave them alone in the hope that, with recovery, they may become firm again. If, however, necrosis sets in, it will be necessary to extract the affected teeth. RECURRENT STOMATITIS. In this condition there are frequent outbreaks of small painful ulcers about the tongue and lips. Treatment consists of the use of soothing and antiseptic mouth washes, touching the ulcers with chromic acid solution or silver nitrate, and the avoidance of irritating foods or tobacco. The disease, however, runs its course in spite of treatment, and recurrences take place without any apparent cause. PARASITIC STOMATITIS (THRUSH). Prophylaxis. Except when the condition occurs as a compli- cation in the course of wasting diseases or inflammation in the alimentary canal, it is practically limited to the first month of life, and owing to the ease and certainty with which it may be pre- vented every expectant mother and monthly nurse should be fully Stomatitis. 123 instructed. The infant's mouth should be carefully wiped out with a small clean piece of linen, moistened in water, after each feed. Neglect of this simple precaution sometimes leads to a train of gastro-intestinal symptoms which may seriously prejudice its future health. Local Treatment. In the uncomplicated cases the disease is usually soon got rid of by the frequent application of borax in glycerine, and strict cleanliness, though the question of diet should be carefully inquired into and controlled. Escherich's boric acid teat is sometimes used. It consists of a compress of sterilised cotton dipped in finely-powdered boric acid and wrapped in gauze to form a small ball, from a strawberry to a hazel nut in size. It may be dipped in a weak saccharine solution to make it palatable. It is important that it should be the proper size and shape ; it should be kept free from contamination. In severe cases a more radical local treatment may be necessary, such as pencilling the affected areas with 1 per cent, formalin solution or the addition of sulphate of zinc (10 gr. to the ounce) to the mouth wash, and in still more severe cases the application of papain (3 or 4 gr. with glycerine, and painted over with a thick brush) in order to soften and remove the fungus, has been recom- mended. General Treatment. All cases of thrush, however mild, require, in addition to local measures, careful attention to the general health and to details of personal hygiene ; fresh air, cleanliness, a diet carefully regulated both as to quantity and quality, and the correction of any gastro-intestinal errors. The more severe the case the more does this general treatment increase in relative importance. The very presence of a severe or intractable thrush connotes an ill child. Under such circumstances it may require the utmost skill and care in dieting and treatment to effect an improvement ; for with increased severity of the mouth condition comes corresponding difficulty in taking food, and consequently a distaste for food. Spoon or even nasal feeding may be necessary. The exact arrangement of the diet will vary with each individual case, but it must be remembered that the condition is an asthenic one, and stimulants, such as white wine whey, etc., are often of great benefit. In certain cases the elimination of starchy food is efficacious. Internal Treatment must depend upon the individual conditions found ; gastro-intestinal derangements, such as constipation, diarrhoea, etc., or general nutritional diseases, such as anaemia, rickets, etc., will each require appropriate treatment. 124 Stomatitis. When thrush occurs as a sequela of exhausting diseases the treat- ment is mainly that of the original disease, but local treatment is still important. Chlorate of potassium given internally is sometimes of service in these cases. Thrush in adults is usually limited to persons suffering from the more advanced stages of tuberculosis, typhoid and other specific fevers or various cachectic states. Local treatment must be on similar lines to that recommended for the same condition in childhood. General treatment must be directed to the primary disease. GANGRENOUS STOMATITIS (CANCRUM ORIS; NOMA). The very high mortality of this specific bacterial infection (80 to 90 per cent.) makes its preventive treatment of the greatest im- portance. In general this consists of hygienic measures, particularly as regards the supply of sufficient nutritious food and fresh air. As, however, the disease is particularly liable to occur in children debilitated by one of the specific fevers, special attention should be given to the thorough cleansing of the mouth throughout such an illness. When the process has once begun heroic methods are imperative. The organism in the whole of the infected area (if possible) must be absolutely destroyed. The most simple and effective method is free excision. This must be done under anaesthesia. The apparently healthy tissues, for a considerable margin beyond the visible disease, must be removed, and the cut surface cauterised by Paquelin's cautery. Some prefer free destruction by Paquelin's cautery alone, without excision, or by pure nitric acid, acid nitrate of mercury, sulphuric acid, etc. Whichever of these methods is used it must be done thoroughly and effectually ; there must be no half measures. In addition to our attempts to destroy the parasite it is im- portant: (1) To isolate the patient ; (2) to destroy everything that has been in contact with the mouth ; (3) to keep the parts as sweet as possible by means of free irrigation, with hydrogen peroxide lotion, carbolic acid (1 per cent.) or other antiseptic solution; (4) to keep the window wide open, or better still, keep the child out of doors altogether ; (5) to give plenty of stimulating food. Alcohol is well tolerated and may be given freely. If recovery takes place at all, convalescence will be tedious, and will require the usual tonic treatment. No plastic operation should Stomatitis. 125 be attempted until some time after complete recovery has taken place. The disease is one in which vaccine treatment (see Vaccine Therapy, Vol. III.) seems to hold out a promise of success. If this hope is realised the older heroic methods may become unnecessary. MERCURIAL STOMATITIS. Prophylaxis. As this condition is solely due to the absorption of mercury by the system, it is desirable that in all cases where persons are exposed to the action of this metal, either in the course of their work, or as a drug, whether internal or external, they should be clearly warned of the possibility of its occurrence and informed as to its earliest symptoms. This is specially important because of the marked susceptibility of some persons to even small doses of the drug. Before beginning a course of mercury it is advisable that special attention be given to the state of the mouth. Carious teeth should be filled or removed, deposits of tartar scraped away, and daily brushing of the teeth insisted upon. Frequent rinsing of the month with an antiseptic solution is most important. A solution of hydrogen peroxide in water (2 to 10 per cent.) is useful. Kraus recommends sublimate solution (1 in 4,000 to 1 in 2,000), which, although it contains mercury, is found in practice to prevent stomatitis. Local Treatment. Antiseptic and deodorant mouth washes must be used frequently. Those mentioned under Prophylaxis will be found useful. Potassium permanganate in fairly strong solution may be used as a deodorant. If ulcers are present they should be painted with chromic acid (10 gr. to the fluid ounce) or silver nitrate (solid). If very painful a previous application of cocaine solution may be necessary. General Treatment. Internally, especially in cases of syphilis, the following mixture may be given : 1^ . Potassii Chloratis, gr. 10 ; Dec. Sarsas Co., sij, t.d.s. Bland liquid foods without seasoning will alone be tolerated. There are certain somewhat rare cases of mercurial stomatitis, not usually referred to in the text-books, in which, in addition to great swelling of the tongue, gums and fauces, with more or less hypersecretion of saliva, practically the whole of the buccal and pharyngeal mucosa is covered with a thick yellowish membrane, simulating diphtheria. Such cases are more likely to occur where there is defective elimination owing to kidney disease, and unless recognised early may prove disastrous. 126 Leukoplakia Buccalis. LEUKOPLAKIA BUCCALIS. The treatment in all stages of severity of this condition consists in the prohibition of what has been the original cause. In most cases this is tobacco, either smoked or chewed. This should be given up entirely. If the condition, however, is only slight it may be sufficient to diminish the quantity of tobacco daily or to vary the manner of smoking, by changing the position of the pipe or changing from one kind of " smoke " to another. In a certain number of cases this is all that will be tolerated, but seeing that the condition is one which tends to advance, and that the restricted smoker is always tending to exceed his irksome limit, it is more satisfactory to get him to break the habit entirely. The chewing of tobacco should, in all cases, be absolutely forbidden. The diet should be plain and simple, avoiding all things which give dis- comfort to the tongue, particularly hot or highly seasoned articles, acids or salted foods. Alcohol should be limited in quantity and spirits avoided. Local Treatment. In mild cases the occasional painting with solution of chromic acid (5 to 10 gr. to the ounce (Butlin)) or tannic acid solution, mel-boracis or alum is sufficient. Chlorate of potash lozenges may also be sucked frequently. In severer cases frequent applications will be required. In such cases Butlin and Spencer recommend preparations with a greasy basis. Their basis may be either of ordinary cold cream or of lanoline (6 parts) and vaseline (2 parts) ; to this may be added such active drugs as the prescriber desires, which should be rather sedatives than irritants. All irritation is harmful and any form of caustic must be avoided. The applications should be repeated frequently during the day, for it must be remembered that, just as in diseases of the skin, the applications quickly become absorbed by the clothes or rubbed off, so the movements of the tongue and the flooding of the mouth with saliva tend quickly to remove any application. General Treatment must be directed to any known defect, such as gout, constipation, syphilis, etc., details of which will be found under corresponding articles. In certain cases leukoplakia-like conditions of the mouth are associated with, and form part of, certain skin diseases, lichen planus, psoriasis, syphilis, etc. Treat- ment of these is merely that of the skin disease of which they form a part. Oral Sepsis. 127 FCETOR ORIS. The causes of offensive breath are numerous and varied. In each case it is imperative to ascertain the cause, and to direct treatment to that. Thus acute or chronic diseases of the nose, naso-pharynx, mouth, teeth, gums, jaws, resophagus, stomach, intestines, or air passages may each be the starting point. Chronic fcetor of the breath is commonly due to carious teeth or ozcena, and in spite of careful treatment may be difficult to remove. It must not be forgotten that, in some cases, the condition is a sub- jective one ; the patient complains of the breath being offensive when to the observer it is not so. Such cases belong to the category of imaginary affections, and treatment must be directed to the general mental condition rather than the mouth. In all such cases a very thorough examination of the mouth and nose should be made, not merely to confirm the diagnosis, but also to satisfy the patient's anxieties. ORAL SEPSIS. This term should be limited to the more severe septic conditions, such as pyorrhoaa alveolar is, or to an indurated septic inflammation of the gums with septic discharge from chronic sinuses, associated with necrosis of the teeth. Treatment, whether preventive or therapeutic, lies rather with the dental surgeon than with the physician. But it is the physician to whom the patient first appeals, and he must be the adviser on many points of difficulty that may arise in treatment. Thus, in a severe case of pernicious anaemia associated with oral sepsis, the question of how far the patient is in a fit condition to undergo radical treatment at the hands of the dental surgeon will be one for the medical man to answer, and may prove a delicate and difficult one. Prophylaxis. It is desirable that proper attention should be given to cleansing the mouth and teeth from early childhood. The regular daily use of a toothbrush, especially before going to rest, with soap and water, either as a simple curd soap, or in the form of a reliable prepared tooth soap, is essential ; the child should be taught to do this thoroughly, not perfunctorily, and clean teeth should be insisted upon. The toothbrush alone, however, does not effectively cleanse those places where caries-producing organisms are chiefly located, namely, in the clefts between adjoining teeth. These places 128 Oral Sepsis. may be best kept clean by the regular " silking of the teeth " ; for this purpose a prepared silk, thin rubber tissue, or even the edge of a handkerchief, should be passed between adjacent teeth once or twice a week, or even daily at bedtime. The value of such a pro- cedure in preventing caries is very great 1 (Fig. 1). When caries first appears, it should be dealt with at once by the dental surgeon, and, seeing that the earlier stages are easily over- looked, it is well that regular routine visits should be made to him every three months, even where, apparently, there is nothing wrong. To wait until pain announces the caries is to wait much too long. After brushing, the mouth should be thoroughly rinsed with clean water or a suitable mouth wash. The fol- lowing is a useful for- mula, which has the advantage of being pleasant to use, slightly astringent, and leaving an agreeable odour be- hind : Borax, 5j ; Eau- de - Cologne, jj ; Kose If such simple daily hygiene of the mouth is all caries, whenever it occurs, promptly FIG 1. Rubber tooth cleaner (Harrison's Reg. No. 569,430). The instrument consists of a simple holding device (A.), between the jaws of which (D. and B.) a strip of rubber (C.), for cleaning between the teeth, can be kept stretched. Nos. 1,2,3 show the method of fixing the rubber strip in position. Water, ad jviij. persevered in and dealt with, oral sepsis except as an accidental infection will be very rare. If, however, sepsis has occurred, it will require prompt and radical treatment at the dentist's hands ; stumps must be extracted, 1 A simple and effective instrument for this purpose has recently been devised by Mr. Frank Harrison, L.D.S., and is shown in the figure. Ptyalisrn. 129 cavities cleansed and filled, accumulations of tartar removed and antiseptic mouth washes, or antiseptic ointments freely applied. The patient should use the mouth wash every two, three or four hours ; each mouthful should be retained for half a minute; this should be repeated ten times at each sitting. It is surprising how willingly most patients will follow out such definite instructions, and how much better are the results so obtained than when vague indefinite directions are alone given. Where artificial tooth-plates are worn they should be kept scrupulously clean. When possible, they should be removed and rinsed, or brushed, after each meal ; they should always be removed on going to bed, brushed with soap and water, and placed in a tumbler of water or some simple deodorant antiseptic solution. It is important that no roots of teeth should be retained under or covered by a denture. In all febrile cases particular attention should be given to the mouth ; if artificial teeth are worn they should be removed entirely or only put in during meals, or occasionally. Mouth washes such as the formula given above should be freely used for rinsing or wiping out the mouth after every meal. Brushing of the teeth with some antiseptic tooth soap of known value should be performed even more frequently than in health, and the tongue carefully scraped and wiped regularly. If a radical operation in the form of an extraction of many teeth is performed great care must be taken at the operation to prevent the aspiration of stumps into the air passages ; whilst for many days afterwards the mouth should be thoroughly and frequently washed out with antiseptics to prevent general infection. To what extent vaccine therapy may in the near future be utilised in the early treatment of caries or septic conditions of the gums is at present hardly ripe for dogmatic statement, but its importance cannot be overlooked in considering the question of oral sepsis. (See Vaccine Therapy and Pyorrhoaa Alveolaris.) SUPERSECRETION (INCREASED SALIVATION, PTYALISM). The commonest causes of supersecretion are : (1) The presence of some disease of the mouth ; (2) mercurialism. For their suit- able treatment see the preceding paragraphs of this article. Other occasional causes to which treatment must be directed are : Reflex irritations from affections of distal organs, e.g., the pancreas, stomach, and uterus (including gestation) ; toxins of certain specific fevers, variola, typhus, etc. ; various drugs, gold, S.T. VOL. n. y 130 Xerostomia. copper, iodides, tobacco, jaborandi, musCarin, rabies; certain mental diseases. Occasionally the condition seems to be idiopathic ; in such cases extr. belladonna ( to gr.) may be given as a pill, three times daily, or atropine sulphate (^ gr.). These cases usually occur in neurotic subjects, and it is important to attend carefully to the general hygiene, change of scene, removal from all sources of worry, bracing climate, regular hours, plenty of good plain food. Arsenic and preparations of iron are useful. XEROSTOMIA (DRY MOUTH). This disease is fortunately very rare as, when present, it is a source of much discomfort. The extreme dryness of the buccal mucous membrane, owing to the absence of saliva, interferes greatly with the mastication of food. It occurs most commonly in females of middle or old age, and is often associated with some nervous disorder or follows some nervous shock. A sudden and acute form occurs in fright. It is occasionally produced by a rapid progressive atrophy of the salivary glands. As a secondary affection it may be an acute symptom accompanying or preceding secondary parotitis and consequently may be of service in the differential diagnosis between this affection and mumps. Carious teeth and other forms of irritation should receive attention. Jaborandi or -pilocarpine have been given on physio- logical grounds, and are said to have been beneficial in some cases ; in others, however, they have proved useless. These drugs are given, as a rule, hypodermically, but Fraser recommends that 5 minims of a 2 per cent, solution of pilocarpine should be given to the patient to hold in his mouth for a few minutes from time to time, or that a gr. tabloid of this drug should be allowed to dissolve on the tongue. Osier mentions a case in which improve- ment followed the local use of a galvanic current for three months, in a young man aged thirty-two. General treatment consists in the careful selection of such bland foods as are found to be most easily taken. In this respect the patient's own feelings will be our best guide. As a rule, salt or seasoned foods cause discomfort ; solids cannot be properly made into a bolus owing to the absence of saliva, and reliance must be placed on thick broths or soups, milk preparations, jellies, beaten up eggs, etc. Xerostomia. 131 Directly before each meal the mouth should be thoroughly moistened with glycerine of borax. If artificial teeth are worn, they should be thoroughly cleansed after meals, and, perhaps, only worn during meals. Glycerine of borax is useful as an occasional lubricant for the mouth. ARTHUR J. HALL. 92 132 DISEASES AND AFFECTIONS OF THE TONGUE. Wounds of the Tongue. These are frequently produced by the patient's teeth and are rarely of sufficient extent or depth to require surgical interference. A weak carbolic mouth wash may sometimes be indicated. It should be remembered that now and then a sharp piece of tooth or a broken clay pipe-stem has been driven into the tongue and become imbedded there ; when covered over by the healed mucous membrane an indurated lump remains which may cause us to suspect a tumour. Incised wounds of the tongue, if fairly deep, may cause obstinate haemorrhage. If this is of the nature of persistent oozing the best treatment will be to cleanse the wound and insert two or more deep sutures of fine silkworm-gut by means of a curved needle. These will hold the edges together and control the bleeding. After two or three days they require removal. But if the haemorrhage is plainly arterial it is better to tie the bleeding vessel with Japanese silk. In order to effect this, especially if the wound is placed far back in the tongue, it may be necessary to give an anaesthetic, to have the mouth well opened by a gag, and perhaps to enlarge the wound. Unless the latter is very jagged or already septic, sutures should be employed to bring the surfaces together. An antiseptic mouth wash must be frequently used for a few days. Ice is of course useful in checking bleeding from a small wound of the tongue. It is a remarkable fact that a few cases have been recorded in which " the whole tongue " has been torn out of the mouth and yet the patient has recovered. Perhaps the most troublesome form of arterial haemorrhage after wounds of the tongue is secondary haemorrhage, coming on several days after an accident or an operation when the mouth has become septic. This was a fairly frequent complication of removal of the tongue by the ecrasenr, especially the galvanic one. In its treat- ment no time should be lost in tying one or both lingual arteries in the neck. Tongue Tie. Abnormal shortness of the fraenum linguae rarely requires surgical interference, as the frsenum tends to lengthen with the growth of the child. If, however, there is difficulty with suckling Tuberculous Disease of the Tongue. 133 or the child is backward in talking or lisps, the fnenum may be divided with advantage. The framum is put on the stretch by the forefinger and thumb of the left hand and the free edge is then cautiously divided with a pair of blunt-pointed scissors ; as soon as the mucous membrane is divided no further cutting should be done, but the cut mucous membrane is separated upwards by the finger nail or a blunt dissector. No stitches are required. It is not necessary in the majority of cases to employ general anaesthesia ; the local application of a 2 per cent, solution of eucaine will usually be found to be sufficient. Acute Parenchymatous Glossitis. This condition may result from a direct infection, as from a wound or during the course of an infectious fever, or as the result of mercurial treatment, in which case immediate cessation of such treatment is necessary. In the first instance a brisk purge should be given and an antiseptic mouth wash (such as Condy's fluid 1 part, water 4 parts) should be ordered to be used frequently. If resolution does not commence under this treatment scarification of the tongue with a guarded scalpel is often useful ; this should be preceded by the application of 2 per cent, eucaine as an anaesthetic. As soon as there is evidence of abscess formation a free incision should be made into the suspected focus. It sometimes happens that there is some respiratory embarrassment owing to commencing oedema of the glottis ; in such cases early and free longitudinal incisions should be made along the dorsum of the tongue and every preparation should be made to perform tracheotomy if necessary. Sublingual Abscess. Suppuration beneath the tongue should be treated by immediate incision into the most prominent part of the swelling, taking care not to injure the ranine veins. In some cases the suppurative process may also involve the submental region ; if this is so, an external counter-opening is also indicated. The after-treatment consists in hot fomentations externally with the free use of antiseptic mouth washes. Naevi. Naevi may be capillary, cavernous, or lymphatic. Small capillary naevi rarely require treatment unless they are exposed to injury from the teeth, in which case they should be excised, the resulting wound being sutured with catgut. Small cavernous naevi may be treated in the same way ; if, however, they are large and involve the tongue extensively they are very difficult to treat ; the best results are probably to be obtained by electrolysis. Lymphatic naevi, which if diffuse may produce a condition of macroglossia, are best treated by electrolysis or electrolysis combined with excision of a wedge of the affected area. 134 Syphilis of the Tongue. Tuberculous Disease of the Tongue is met with occasionally as a solitary nodule or ulcer, having no distinctive features, and therefore readily mistaken for a syphilitic lesion or an epithelioma. Its treatment is excision of the ulcer with a sufficient margin of healthy tissue around. Another form involves the tongue in several places and is a complication usually of advanced phthisis, tuberculous disease of the larynx, etc. No local treatment beyond palliative measures (mild antiseptic washes, eucaine solution, etc.) can be of use in these grave cases. A dental ulcer requires attention to, and possibly removal of, the sharp tootli which has caused the lesion, with the application of the electric cautery or pure carbolic acid to the ulcer itself. Great care should be exercised not to mistake an epitheliomatous for a dental ulcer, and resort should be had to microscopic examina- tion in any doubtful case. SYPHILITIC AFFECTIONS OF THE TONGUE. Chancre of the Tongue. It will be understood that infecting or syphilitic chancres are alone referred to ; so far as is known the " soft chancre " is never met with in this region. It may be said that the only difficulty in the treatment lies in the correct diagnosis which, partly owing to the rarity of lingual chancres, is often delayed or mistaken. The sore may have been treated as a dental or tuberculous ulcer, and we have known cases in which a portion has been excised in order to test the diagnosis made of epithelioma. Stress is to be laid on the bubo nearly always present in the submaxillary region or over the carotid vessels. The spirochaeta pallida should be sought for in doubtful cases, but the constant occurrence of similar spiral micro-organisms in the secretions of the mouth must be borne in mind. But little local treatment is required for chancres of the tongue. Their excision is rarely if ever indicated, as by the time the correct diagnosis is made the poison is already widespread. Lotio nigra (B.P.) may be used frequently to wash the sore with, and the patient must be brought speedily under the influence of mercury. Whether this is given by inunction, intramuscular injections, or by the mouth, must depend upon the surgeon's views. For our part we prefer the steady administration of pulv. hydrargyri c creta and pulv. ipecac, co. [U.S.P. pulv. ipecac, et opii] in pills or tabloids containing 1 gr. of each. Four of these should be taken at regular intervals during the day, to be diminished to three if the gums become touched. The patient must abstain from alcohol during the mercurial course. Syphilis of the Tongue 135 Secondary Syphilitic Lesions of the Tongue. The treatment of these must vary with their nature and duration. Their variety is remarkable ; the chief forms are the following : (1) Mucous patches, raised white ones similar to those often met with on the lips, palate, tonsils or pharynx. (2) Superficial ulcers. (3) Bald patches or areas of denudation of papillae to be compared with the patchy alopecia of the scalp due to syphilis. (4) Warty or papillomatous growths, chiefly met with far back on the dorsum of the tongue. (5) Persistent white patches or leucomata, which must be dis- tinguished from true leukoplakia due to excessive smoking. Several of these lesions may be met with on the same tongue. For some, especially the mucous patches, a prolonged course of mercury taken internally is the best treatment, and this applies to the other forms if the patient is really in the secondary stage. But a superficial glossitis, taking the form of recurrent ulcers or white patches, occurring in a patient whose syphilis dates back several years, is often better treated by careful local measures and the removal of all irritants than by pushing specific remedies. In such cases mercury, however administered, may effect little or nothing, whilst iodides may only depress the patient. In all these cases the question of local irritation, especially from smoking and the use of spirits, must be enquired into. ' The use of both cigars and cigarettes is to be wholly forbidden, and in some cases even the occasional pipe must be included in the ban. Any sharp teeth must be attended to by the dentist. The warty growth seen in the secondary stage may be so persistent that vigorous treatment with caustics, such as a solution of nitrate of silver (20 to 40 gr. to the ounce) or the acid nitrate of mercury, may be indicated. We have, however, found that pushing the internal administration of mercury, with or without iodides, usually effects a cure. Ulcers in the early secondary stage are well treated by the occasional application of nitrate of silver or chromic acid in solution, the exact strength of which must vary. We have found the former the more useful of the two. A solution of bicyanide of mercury (1 to 5 gr. to the ounce of water) has a long-standing reputation as an application to syphilitic sores ; it is very poisonous and must be used with caution ; we have not found that it possesses any advantage to counterbalance this drawback. Lotia nigra is a safe mercurial wash, though not a pleasant one in appearance. The use of a mouth wash of bichloride of mercury is attended with some risk of salivation and of damage to the teeth ; if it is used we 136 Syphilis of the Tongue. advise that the surgeon alone should apply it. With this provision a strong solution may he painted on any obstinate syphilitic lesion, e.g., bichloride of mercury, 1 part ; glycerine, 10 parts ; absolute alcohol to 100 parts. Chinosol occasionally answers well when all mercurial applications have failed, and in obstinate cases we strongly advise that it should be given a trial. One is apt to order chinosol, which has an undoubted effect 011 syphilitic ulcers of all kinds, in too strong proportions ; on such a sensitive part as the inflamed lingual surface it must be used exceedingly weak. A mouth wash of chinosol 1 part, water 500 to 1,000 parts, or an application of 1 in 100 parts is strong enough. Sir H. T. Butlin and Sir Henry Morris have recommended the use of the blue ointment (the ung. hydrargyri, B.P.) for syphilitic sores of the tongue, but the difficulty of using it will be obvious. To sum up, the early syphilitic lesions of the tongue, whatever their nature, should be treated mainly by the careful administration of mercury, by removing all sources of irritation, and by the judicious use of local applications, of which the best are nitrate of silver, chinosol, chromic acid and certain mercurial lotions. Much patience may be required, as it is easy to obtain healing, but relapse is very frequent. Perseverance is, however, well rewarded if the condition is prevented from drifting on into an inveterate chronic glossitis, which is one of the most troublesome and dangerous of all the remote results that may follow in the syphilitic train. In this form ulcers, white patches, sclerosis, bald areas and papillomatous projections may all be met with. In addition, gummatous lumps or diffuse deep infiltration are some- times seen. It is for the latter conditions that iodides are so valuable. Iodide of sodium, iodide of potassium, iodide of ammonium (of each 3 to 5 gr.), syrup of orange (1 drachm), may be given freely diluted, and the dose increased every few days. Or, if preferred, one of the many new preparations of iodine may be tried instead of the iodides, and this is, perhaps, best worth doing if the latter depress or produce catarrh. lodipin (or iodinol) seems to be the most generally used, and the best of these new compounds ; it is merely iodine and oil of sesame in the proportion of 10 per cent, and 25 per cent, of iodine. One drachm of the 25 per cent, iodipin may be given as a dose either hypodermically or in capsules, each dose being then equivalent to about 5 gr. of iodide of potassium. As to their relative value in causing absorption of gummatous material in the tongue or elsewhere, Leucomata of the Tongue. 137 we have no hesitation in saying that the iodides are superior, and should be employed whenever possible in preference to iodipin and its congeners. A point of importance has now to be noted. A considerable pro- portion of the cases of cancer of the tongue develop in men who have had syphilis, and the transition from chronic tertiary glossitis to epithelioma is an easy one and apt to be overlooked. Even a gummatous ulcer of the tongue may closely simulate a sloughing epithelioma, and rice rerun. In any doubtful case the "therapeutic test," i.e., the administration of increasing doses of iodides, should not be persisted in for long without resorting to excision of part of the suspicious edge and careful microscopic examination. It may be noted that iodides occasionally fail or are very slow to cure true gummatous ulcer, and that, on the other hand, their administration usually makes a cancerous sore of the mouth improve in appearance, " clean up," for some days. In the treatment of obstinate lesions of the tongue in the intermediate or tertiary stage of syphilis (apart from gummatous infiltration, which has just been described) the following points should be noted : (1) The measures advocated already for the secondary lesions are likely to be of use, and in addition the occasional use by the surgeon of the acid nitrate of mercury to any superficial ulcer is to be recommended. This should be applied with a glass brush, care being taken to limit the action of the caustic by the use of blotting paper. (2) The avoidance of local irritants must be insisted on. The syphilitic poison undoubtedly leaves the mucous membrane of the tongue and mouth unduly susceptible to such irritants for many years in some patients. In these it may be necessary to avoid both alcohol and tobacco as well as all condiments, such as mustard, pepper, etc. (3) Specific remedies are liable to be overdone and may even cause harm. For example, one patient with relapsing glossitis took considerable doses of iodides for ten years and underwent a course of mercurial injections without any advantage ; another patient went through nine courses of mercurial inunctions at Aix ; his tongue being worse at the end of them than at the beginning. It may, however, be admitted that now and then a course of injections or inunction is useful, and certainly iodides are worthy of trial if the history shows that specific remedies have never been persevered with. Salvarsan may also be tried. Leucomata of the Tongue and Leukoplakia. It is almost 138 Epithelioma of the Tongue. unnecessary to point out that scars left by syphilitic ulcers need no treatment, local or general. Apart from these there is an uncommon condition of thin white patches (leucomata) especially met with along the sides of the tongue, which simulate syphilitic lesions. Usually their subject has some form of chronic skin trouble, such as a dry eczema or lichen psoriasis ; but the mucous membranes may be alone involved. Together with the local use of some soothing application, such as the glycerinum boracis, it is worth while to try the effect of a course of arsenic for this condition. This remedy is also useful in relapsing herpetic conditions of the tongue and mouth, especially combined with small doses of opium (in the form of liq. arsenicalis and liq. opii sedativus). We have now to refer to the well-known leukoplakia of the tongue, where dense white patches of thickened epithelium are found on the dorsum or lateral aspects, a disease which is of remarkable per- sistence and whose tendency to pass into epithelioma has been thoroughly established. That leukoplakia may occur in those who have had syphilis is true, but anti-syphilitic treatment has no effect upon it whatever. True leukoplakia is solely due to excessive smoking, aided sometimes by spirit drinking. The knowledge of this fact will point to the appropriate treatment, but, unfortunately, when once started, the removal of the cause does not lead to a cure. In fact, there is no known remedy that is really effective short of excision of the dense white patches, and this involves such scarring of the tongue that it cannot be recommended for most cases. It has been claimed that the X-rays or radium have now and then led to cure ; this may be true, but the cases in which we have tried them have been wholly disappointing. A patient with leuko- plakia must give up smoking entirely, must avoid spirits, and should be seen from time to time in order that the first indication of epitheliomatous change should be met by surgical measures. The danger of epithelioma, however, need not be exaggerated ; leukoplakia may exist ten or twenty years without going on to cancer. The occurrence of an ulcer or of a papillomatous growth in the centre of the white patch is almost certain evidence that this change has occurred, and no time should then be lost in resorting to excision. EPITHELIOMA OF THE TONGUE. There is but little variety in the forms of malignant disease of the tongue. Sarcoma is exceedingly rare, scirrhous or atrophic cancer still more so; practically all the cases are examples of squamous epithelioma. In few, if any, parts of the body is the effect Epithelioma of the Tongue. 139 of chronic irritation and inflammation in directly producing cancer more marked. It may be said that in a large proportion of cases there is a pre-cancerous stage of cancer of the tongue, one in which careful treatment and absolute avoidance of all irritants may succeed for long in warding off the evil day. Cancer of the tongue, being a squamous epithelioma, is but little amenable to the influence either of the X-rays or of radium ; rodent ulcer (which is often cured by either) is not a squamous epithelioma, but has a very different histology. Again, the chief danger of cancer of the tongue lies in early infection of lymphatic glands, secondary deposits in the viscera being of extraordinary rarity ; in this it conforms to the rule as to squamous epithelioma ; but the rapidity with which the cervical glands are infected by lymphatic emboli from a cancer of the tongue has no equal in examples of squamous epithelioma elsewhere in the body. These considerations help to form the basis for our treatment of lingual cancer. (1) No trust should be placed in X-rays or radium ; valuable time will be lost by so doing, and a case possibly curable by excision may be converted into a hopeless one. (2) A thorough operation must include removal of those lymphatic glands which are likely to be infected as well as a sufficiently free excision of the primary growth. This holds true although no enlargement of the lymphatic glands can be felt before the operation. The two points mentioned are conceded by nearly all surgeons at the present time, but there is great variety in the method of carrying out the " radical operation," if indeed, it deserve to be so called ; for even the most elaborate operations for cancer of the tongue are too often followed by recurrence within a few years. In some, fortunately, the term " cure" is warranted. It must also be pointed out that a few of the most successful cases have been those in which the tongue alone was operated on, but without doubt the prognosis is considerably improved by the simultaneous removal of lymphatic glands. We may note here that the chance of survival for more than three or four years after a thorough operation for cancer of the tongue appears to be about 1 in 4 or 1 in 5. But very much depends on the earliest possible recognition of the cancerous change. All are agreed that excision of the tongue is best performed with curved scissors (as introduced by Whitehead), and that ccrascnrs of every kind should be regarded as obsolete. It is also agreed that to perform the early method of Kocher, excision of the tongue 140 Epithelioma of the Tongue. through a lateral wound in the neck, is to run needless danger, and that this operation should be reserved for exceptional cases of involvement of the floor of the mouth. But the number of questions still unsettled is large. They include the following : Should the lower jaw be divided in order to obtain more free access to the tongue ? Should the operation be done in two stages, separated by a fortnight or more, or in only one ? If done in two stages, should the tongue or the cervical glands be first removed? Is laryngotomy useful as a preliminary measure in the tongue operation, and has it any effect in warding off the risk of pneumonia? Should the lingual arteries be secured in the mouth, or should they be tied with the facial vessels in the neck, or should the external carotid be tied? Exceptional cases require special measures ; now and then, for example, division of the lower jaw may be required, though quite unnecessary in most cases. If the complete operation on tongue and glands can be carried out in one stage there are obvious advantages in so doing. There are few, if any, operations which are faced by the patient with so much dread and fear as removal of the tongue. In fact, the most " heroic " of these operations, where all the tongue down to the hyoid bone is removed, involves so much after-misery and discomfort that several of its victims have resorted to suicide. In any case where excision of part of the tongue has been advised the patient knows that a certain amount of mutilation, and of impairment of speech will be involved. It is difficult enough to persuade him to submit ; it will be a much greater ordeal to go through two major operations, including two anaesthetics, and doubling the patient's expense or stay in hospital. It is admitted by Mr. Butlin, who is the chief advocate of the two-stage operation, that in about 40 per cent, of his cases the patient could not be induced to submit to the second part (the removal of the lymphatic glands). This is an important consideration. Another advantage of the one-stage operation is that by preliminary ligature of both linguals in the neck after the removal of the lymphatic glands excision of the tongue itself is almost a bloodless procedure. Epithelioma of the tongue is most commonly found on one lateral border, and the danger as regards lymphatic infection then lies mainly on the same side of the neck. Secondary deposits occur in the glands outside the submaxillary triangle at the junction of the facial and jugular veins, in those about the Epithelioma of the Tongue. 141 carotid bifurcation, over and behind the internal jugular vein, along its course down the neck. All these glands lie beneath the deep cervical fascia. In addition to these, there are a few lymphatic glands in the submaxillary triangle, embedded in the salivary gland itself, which are rarely infected in cancer of the tongue, though frequently in cancer of the lower lip and floor of the mouth. It is usually advisable to remove the whole submaxillary gland and to ligature both facial and lingual artery on the affected side. If the epithelioma of the tongue infiltrates deeply, or is situated near the middle line, it is essential to remove the lymphatic glands mentioned above on both sides of the neck. The following is a sketch of the operation advised in an ordinary case : (1) A curved incision is made from the angle of the jaw down to the hyoid bone and up to near the symphysis of the jaw. From a point behind the centre of this incision a second cut is made for several inches down the anterior border of the sterno-mastoid, which is thoroughly exposed. The flaps of skin, platysma and fascia, are reflected and held aside by suture retractors. (2) The submaxillary gland is dissected out, the facial artery and vein being tied in two places, and a ligature placed round the divided end of Wharton's duct. (3) The lymphatic glands over the carotid bifurcation, beneath the angle of the jaw and along the jugular vein, are carefully dissected out so that the main vessels are bared. It often happens that a small portion of the parotid gland is removed at the same time ; this is of no importance. The jugular vein should be cleared of its glands as low as possible. If necessary, the sterno- mastoid muscle may be divided to assist the dissection, but this is not required in most cases. (4) The lingual artery is easily found through a small incision in the hyoglossus muscle, and is tied. (5) The wound is sewn up, and a drainage tube is sutured in its lower end. A pad of gauze is applied, the neck turned over, and the surgeon repeats the procedure on the opposite side, or if the cancer is wholly unilateral he limits his interference to ligature of the opposite lingual through the ordinary incision. After suture of this wound a light dressing is bandaged round the neck. The operation so far has been a tedious one, lasting at least an hour, but the anaesthetist will not have been interfered with in any way, and after this but little more anaesthetic will be required. The mouth is held open by a gag, the cheek retracted (in 142 Epithelioma of the Tongue. exceptional cases it may be divided on the side affected), the tongue secured bv volsellum forceps or a deep suture and drawn well out of the mouth. ' This step is made easy by free division of the fraenum and underlying muscle. The excision of the tongue is done with curved scissors, and it must be made wide of the epitheliomatous area. As a rule, a large wedge-shaped piece should be taken, sometimes one half only suffices, but whenever possible, a healthy portion of tongue should be left to help in articulation and deglutition. This is of great importance as regards the future comfort of the patient. As a rule, sutures are not to be recommended in the stump of the tongue, nor is the use of any antiseptic varnish (such as Whitehead's, containing benzoin and iodoform) satisfactory. Sedulous care in nursing will be required to keep the mouth sweet ; antiseptic sprays should not be used, but either of the following, employed with small sponges, are excellent : pure carbolic acid, ^ to 1 drachm, rectified spirit, to 2 oz., water, to 8 oz. ; or thymoglycine applied in full strength. Sanitas or peroxide of hydrogen are also useful. Similar preparations diluted should be used to syringe or wash out the mouth frequently. It is surprising how soon the patient can sit up and perform these measures for cleansing the mouth and how well he manages fluid food given through a feeder with long nozzle or rubber tube attached. Nasal feeding is very rarely required. The details of after-treatment in these cases of extensive operations on the tongue deserve special attention. In over seventy such cases treated by the writer there have been only three deaths connected with the operation. In one of these death occurred during the administration of the anaesthetic, laryngotomy had been done, and, owing to the extent of the disease, excision ought not to have been attempted. Even counting this case, the direct mortality has only been about 5 per cent., without it only 3 per cent. This satisfactory result could not have been obtained but for the great care in the after-treatment taken by the nurses, and the following sketch of what is generally done will be found helpful : On,' hour Ix'fore the operation an enema containing strong coffee (4 to 6 oz.) and brandy (2 oz.) is given. Immediately nfti-r the operation and before the patient comes round, an enema containing a pint of warm saline solution and 2 oz. of brandy is given. Strychnine and caffeine injections of the usual strength are given hypodermically every three hours if necessary, but the amount of shock is not great as a rule. Epithelioma of the Tongue. 143 As soon us possible after the patient has come round from the anaesthetic he sits up and the nurse gently syringes or swabs the mouth out with one of the solutions given already. This is con- tinued through the first night every quarter of an hour unless the patient is asleep. Hot water is allowed in small quantities through a rubber tube or a feeding cup ; but if oozing is troublesome iced water should be used. Nutrient enemata are given every eight hours for the first two days, after which the bowel is cleared out by a soap and water enema, and sufficient food is then taken by mouth to render the other method of feeding unnecessary. During the day after operation the mouth is carefully cleansed every half hour ; 2 oz. of milk and 1 oz. of water are given every hour. On th<; second day cleansing the mouth is done less frequently, but this will entirely depend on the state of the raw surface, the absence of any foetor, etc. The patient may have milk and egg, or beef-tea. Feeding must be continued through the night at regular intervals. On or after the third day custards and jellies can probably be taken, and on the sixth day probably pounded fish or mince. At this time, also, the patient may attend to the mouth if carefully watched and instructed. After every feed the washing-out should be done. It is a mistake to keep the patient long in bed ; he is often better out of it on the second day or third day. Care must of course be taken to prevent contamination of the neck dressings, but if the latter are attended to daily and kept covered with mackintosh (pink jaconet) trouble in this direction ought hardly ever to arise. There is no part of the body in which extensive wounds heal more kindly than the neck, and the scars from this operation become quite inconspicuous. No mention has been made of laryngotomy, as, in our opinion, it is an unnecessary complication ; in fact, if the gland dissection is done at the same time as the tongue excision a laryngotomy would be very much in the way. As already noted, Sir H. T. Butlin and some other surgeons recommend that the first operation should be limited to removal of the submaxillary gland and lymphatic glands in the anterior triangle, and that from two to three weeks later the tongue should be partly or completely excised with a preliminary laryngotomy and ligature of the lingual arteries in the mouth. When an epithelioma of the tongue invades the floor of the mouth the prognosis of operation becomes very grave, and perhaps the worst cases of all are those in which it starts far back and invades the pillars of the fauces and the tonsillar region. It is not 144 Sarcoma of the Tongue. possible here to define which cases should be submitted to operation, which are unsuitable for it, and, further, what exact form the operation should take. Each case must be judged on its merits ; not infrequently the patient's general state of health will have some influence on the surgeon's mind in coming to a decision, as well as the extent of the local disease. The most important factor of all is the condition of the lymphatic glands of the neck. If these are neither much enlarged, adherent nor softening, the primary growth in the mouth, however extensive, may, as a rule, be attacked at the same time that the glands are removed and the external carotid artery tied. Even if the neck wound has to communicate with the mouth for a time, the risk of cellulitis is worth running for the chance of considerable prolongation of life. But if large secondary glands have become firmly adherent to the deep muscles, the jugular vein or the carotid artery, the attempt at excision is bound to fail and should not be made. What can be done for these inoperable and for hopeless recurrent cases of lingual cancer ? Kadium or the X-rays will almost surely be resorted to, and of the two we recommend the X-rays, applied in very powerful dosage for ten to twenty minutes at a time, at intervals of a few days. The pain, at least, will be diminished by this means, though the rate of growth may not be checked. Opium, best given in the form of nepenthe, will be required sooner or later. On no account should Coley's streptococcic fluid be injected ; its absolute failure to do good has been demonstrated again and again. On the other hand, it is apt to make the patient feverish and ill, and in nearly all cases adds to the discomfort and pain of his last days. (See also Tumours, Vol. I.) SARCOMA OF THE TONGUE. The only treatment for this rare condition that can be of the least avail is excision. The growth may be either a round-celled or in large part a spindle-celled sarcoma. The former is closely allied to lympho-sarcoma and has the terribly malignant character of the latter form of growth. At the same time there is perhaps not much to choose between the two varieties from this point of view. Excision undoubtedly prolongs life, but those cases which have been well recorded and followed up prove that of every five patients with sarcoma of the tongue that are operated on only one will be found alive after two or three years have elapsed. The tongue in cases of sarcoma may become greatly enlarged, and as it is not a question of dissecting out lymphatic glands Cysts of the Tongue. 145 laryngotomy may be advised as a preliminary measure. Otherwise there may be difficulty and danger in giving the anaesthetic. With laryngotomy performed and a sponge kept in the pharynx to prevent blood running backwards, the operation is made easier. The mucous membrane is freely divided from the frsenum back- wards on either side, keeping the scissors well down in the floor of the mouth ; this enables the tongue to be drawn well forwards and both lingual vessels to be secured with ligatures before division. Sarcoma of the tongue appears sometimes to be well limited all round as though encapsulated, and hence its excision may seem easy and very promising ; but as already noted the prognosis is most grave, death occurring from secondary deposits in the lunge and the other viscera, occasionally even in the cervical lymphatic glands. CYSTS OF THE TONGUE AND FLOOR OF THE MOUTH. The chief cysts of the tongue and floor of the mouth are mucous retention cysts (of which the well-known ranula is the chief example) and dermoid cysts. The former are by far the most frequent. The only treatment for dermoid cysts is excision, which should be carried out through an incision in the middle line in the neck, between the chin and the hyoid bone. The cyst usually bulges towards the skin in this region, and no great thickness of muscle will have, therefore, to be cut through. It will shell out without much difficulty. A fine drain should be inserted in the wound for a day or two. A Ranula is, on the other hand, very difficult or impossible to dissect 'out whole; moreover, it should, with rare exceptions, be attacked through the mouth. So apt is it to recur, that we advise that a general anaesthetic should be given in .order that the surgeon may have the best chance in his dissection. The mucous membrane is incised carefully parallel with Wharton's duct, which it is important not to injure. By means of the " dissector," the cyst may be isolated to a considerable extent before it ruptures or is opened. The glairy fluid that escapes is thoroughly mopped up. The edges of the cyst wall are seized with fine serrated forceps ; the cyst is then opened from end to end, and as much as possible of its wall is dissected out. If the surgeon is compelled to leave a good deal of the wall behind he should apply to this a probe dipped in pure carbolic acid, or a brush dipped in strong nitrate of silver solution. Some recommend pure chromic acid, but we have known this produce excessive inflammatory reaction. The operation is not infrequently performed under the local S.T. VOL. n. 10 146 Cysts of the Tongue. application of cocaine or eucaine, but this makes a thorough removal of the cyst wall difficult, except in the most simple cases of ranula. JONATHAN HUTCHINSON. EEFERENCES. Poirier, Professor Paul, "Traitement du Cancer de la Langue," Bull, et Mem. Soc. de Chir. de Paris, 1905, N.S., Vol. XXXI., pp. 743753. Butlin, Sir H. T., " Cancer of the Tongue," Brit. Med. Journ., 1905, I., pp. 285289 ; ibid., 1909, L, pp. 310. Butlin, Sir H. T., " On Radium in the Treatment of Cancer, etc.," Lancet, 1909, I., pp. 14111414. Treves, Sir F., and Hutchinson, J., " Manual of Operative Surgery," 1903, II., pp. 241258. 147 DISEASES AND AFFECTIONS OF THE PALATE. CLEFT PALATE. IN the great majority of cases of cleft palate the only treatment that is advisable is closure by operation. In a small minority, chiefly those seen for the first time in adult life, mechanical treatment by some form of obturator is preferable. In children even the widest clefts can almost invariably be closed by a suitable operation. Treatment by obturators will be discussed later. The operative treatment, the more important branch of the subject, will be taken first. Operative Treatment. In dealing with the operative treatment of cleft palate the first point to be considered is the age at ivliich the operation should be undertaken in order that the best result may be obtained. Theoretically, the sooner the cleft in the palate is closed the better. If the palate can be restored to the normal or nearly so, before the child has learnt to speak, articulation is subsequently less likely to be imperfect. In a certain number of cases, chiefly of narrow clefts and of clefts limited to the soft palate, it is wise to do the operation quite early, within the first few months of life, and nothing is gained by delay. In most cases, however, it is far better, in the interests of the child, not to perform a very early operation but to wait a year or two, and to operate upon the palate towards the end of the second year, or even in some cases a little later still. The harelip should certainly be closed quite early, within a few weeks or even days of birth. If this is done and the surgeon and parents are con- tent to wait a year or two, it will be found that the cleft in the palate becomes relatively much narrower, and the operation proportionately easy and satisfactory. It is quite common, for example, in a new born child with complete harelip and cleft palate, to see a wide space between maxilla and premaxilla. After closure of the cleft in the lip this space gradually diminishes and after a year or two has either wholly disappeared or is reduced to a narrow chink. It is, as a rule, better not to wait much longer than the period above named, because a defective articulation once thoroughly established is difficult to correct. A cleft which shows much less tendency to spontaneous closure 102 148 Cleft Palate. than does the ordinary variety of the complete cleft, is that which involves all the palate except the alveolar arch and which is not associated with harelip. Sometimes these clefts are extremely wide and have a broad rounded anterior end. Such clefts are difficult to close at any age, but are best treated, in my opinion, towards the end of the second year. A few of the very worst are best treated at a still later age. I have not yet met with a case of this kind which I have not succeeded in closing, but I have never attempted to close this variety during the first year of life. It is sometimes urged, and the argument at first sight seems a plausible one, that it is best to attempt closure of the palate before the lip is operated upon. The sole advantage of this is that the palatine cleft is a little more accessible to view. But this slight advantage is far more than compensated for by the greater relative width of the cleft. The real difficulty of a cleft palate operation to ' any one who is reasonably skilful with his fingers, lies not in the inaccessibility of the cleft, but in obtaining sufficient tissue for its closure. This brings me to the kind of operation which should be employed. There are two chief methods in vogue at the present day. One is that which has long been associated with the names of Langenbeck, Fergusson, Thomas Smith and others, and in the opinion of the writer, and he thinks, of most surgeons who have had much practical experience of cleft palate operations, it is much the best. It consists briefly in dissecting up the soft tissues of the hard palate from the underlying bone, in separating the soft palate from the posterior margin of the hard palate, and suturing the pared edges of these soft tissues after they have been shifted towards the middle line. The operation is, however, by no means an easy one, and the operator should be thoroughly familiar with all its details before he undertakes to perform it. The chief objection that has been raised to this operation is that in most cases it is necessary to make a lateral incision through the palatine soft tissues on one or both sides, to enable the parts to be approximated without undue tension. These incisions are really in most cases little more than a tenotomy of the tensor palati muscles. The other method, which certainly has the merit of simplicity, consists in cutting a large flap of tissue from one side of the palate, taking up if necessary the tissues of the gum, turning this over like the leaf of a book and inserting its edge under the tissues of the opposite side. The soft palate is dealt with in a somewhat similar way by splitting. One advantage of this operation is that it avoids the lateral incisions above mentioned. The principal objection to it, besides its severity, is the tendency to sloughing or to subsequent Cleft Palate. 149 atrophy of the flap thus fashioned, and the imperfect nature of the soft palate that is thus formed. The muscular flap formed by splitting and turning back the soft palate necessarily undergoes atrophy. It is not an operation that can be recommended, as the after-results in most cases seem to be poor, especially as regards the soft palate. Another operation which, like the last, has become fashionable of late years is that commonly known as Brophy's operation. The theory of it is good, for in a cleft palate there is no actual loss of tissue. The two halves of the palate have simply failed to coalesce. Brophy forces them violently together and unites them by means of a stout silver wire passed transversely through the upper jaws. This wire is kept in place for several weeks, and the subse- quent closure of the cleft is greatly facilitated. The operation, at any rate as performed in this country, is undoubtedly a severe one, and to my certain knowledge has been followed by death in many cases. Worse still, the child may develop necrosis of the jaw and live. The disastrous effect of an extensive necrosis upon the subsequent development of an infant's jaw and teeth is well known. I have never myself performed this operation. The operation can only be performed in the first few months of life while the bones are still soft and pliable. It may be added that in the illustration which Brophy gives of the anatomy of the jaw, a large area of cancellous bone is shown between the teeth and the orbit, and it is in this bone that the wire is supposed to lie. Eeference to the actual skull of an infant will show that no such area exists, the permanent (unerupted) teeth being separated from the floor of the orbit merely by a very thin plate of bone (see the dissections of skulls in the odontological collection at the Royal College of Surgeons). It is difficult to understand how a wire can be passed through the upper jaw of a young infant without, on the one hand, trans- fixing the orbit, on the other hand inflicting damage upon the germs of the permanent teeth. The operation cannot be recom- mended until more details are forthcoming as to the ultimate results of the operation. The few surgeons who still recommend the operation have not as yet, so far as I am aware, published any detailed series of cases either with or without after-results. THE OPERATION FOR CLEFT PALATE. Anaesthetic. Chloroform is best for this operation. It should be administered through a Junker's tube. The anaesthesia should not be deep. Cleft Palate. Haemorrhage must be controlled by sponge pressure and by frequent swabbing out of the pharynx. If the head is well extended the blood will tend to run into the naso-pharynx rather than towards the larynx. Gag. No gag has yet been invented for this operation which can compare with Smith's, fulfilling as it does the three-fold function of keeping the mouth widely open, of depressing the tongue, and of reflecting light towards the palate. It is, however, not an easy gag to hold correctly, and the proper use of it has to be learnt. It is worth while for the operator to take the trouble to ex- plain to the nurse or other assistant in charge of it the exact way in which it is to be held. Common mistakes in the use of this gag are pushing the tongue backwards over the larynx, de- pressing the lower jaw unduly and com- G. 'k.r-The operation for cleft palate. A puncture has been made through the soft tissues of the hard palate, and a raspatory inserted between the perios- teum and the bone. This and the next five figures are from drawings of ati 'actual case in which the cleft was completely closed by the writer. A cast of the palate was taken before the operation Was begun. pressing the sides of the pharynx with the fingers. All these errors can easily be avoided with a little care. The essential steps of the operation are : (1) liaising the soft tissues of the hard palate from the under- lying bone. This may be done by raspatories and an aneurysm needle, either from the inner edge or through a small puncture at the back and outer part of the hard palate. (2) Detachment of the soft palate from the posterior edge of the hard palate. This is effected by means of sharply curved, blunt- pointed scissors, one blade of which is inserted between the hard palate and the newly raised muco-periosteal tissues. The other blade is in the naso-pharynx. The cut is then made from within outwards. It is the omission or incomplete performance of this step that is often responsible for the unsuccessful result of operation. Cleft Palate. (3) Paring the margins of the cleft, and then careful suture with moderately fine fishing gut. The sutures should be passed by means of slender rectangular needles mounted on long handles. They should be inserted about J to J inch apart. The edges of the wound should be carefully everted before the sutures are tied, so as to bring broad surfaces of the wound into apposition. The sutures should not be tied very tightly, or strangulation and sloughing of the edges may occur. It is best to suture the soft palate first. After, or in bad cases before, the sutures have been tied, a lateral incision to re- lieve tension is made on one or both sides of the palate through the whole thickness of the soft tissues. The exact position and length of these incisions must depend on the degree of tension. As a rule an incision beginning just inside and a little in front of the posterior palatine foramen and extending backwards and outwards for to f inch will suffice. After-treatment. The child should be kept as quiet as possible. A small dose of Tr. opii given at the time of the operation is useful. For the first week or ten days the child should be fed with milk only, and not very frequently. It is a good plan to give the child a drink of warm water to which a little chlorate of potash has been added (10 gr. to the ounce) immediately after each feed. Spraying the mouth or frequent washing out is to be avoided, unless the wound has become definitely septic. In the latter case foetor of the breath will be noticed. The stitches should be left in situ for at least ten days or a fortnight. Some operators prefer to leave them until they drop off spontaneously. If, at the end of a fortnight or so, it is found that a considerable part of the wound has broken down, but the edges are granulating and clean, it may be advisable to put the child again under chloroform, and to insert a few more FIG. 2. Showing the mode in which an aneurysm needle or a curved raspatory is used in the separation of the muco- periosteum, working from the margii. of the cleft. 152 Cleft Palate. stitches to bring the edges into approximation. But this should not be done too early for fear of breaking down the parts which have already united. Fresh paring of the edges is not advisable. If the operation has been a complete failure, it is best to wait several weeks and then, when the parts are thoroughly clean, to do the operation over again. After every operation for cleft palate great care should be taken to train the child to speak slowly and correctly. The ultimate result as regards speech will depend largely upon the attention which the mother or nurse pays to this point in the first year or two after the operation. In all cases of complete cleft palate associated with harelip there will be more or less irregu- larity of the teeth, especially the 'ront teeth. This irregularity is partly responsible for the defective speech which may exist after the performance of an otherwise successful cleft palate operation. It is impor- tant, therefore, that the services of a dentist should be obtained for the regulation of the teeth during childhood before the deformity has become per- manent. Missing teeth should be replaced by means of a suit- able plate. The latter will have to be renewed once or twice a year in the case of a growing child. It is a mistake, however, to think that treatment by means of a denture should be postponed until the child is grown up. Much harm to the articulation is often caused by such delay. Treatment by Obturators. If any special reason exists why the patient should not be treated by operation, then an obturator should be fitted to the cleft palate. Its use should be restricted to the following cases : (1) Most adult cleft palate patients. In these patients, although the closure of the cleft by operation is usually quite easy, yet the probable benefit to articulation is scarcely sufficient to justify it. It should be remembered also that a cleft palate FIG. 3. Mode in which temporary pres- sure can be applied by sponge and thumb, if hasmorrhage is at all troublesome during the separation of the soft tissues from the bone. Cleft Palate. 153 operation on an adult may easily render the speech worse than it was before. (2) Children who have undergone an unsuccessful operation which has heen followed by extensive sloughing, so that insufficient tissue is left for the closure of the cleft by any subsequent plastic operation. (3) Cases in which the soft palate has been successfully closed by operation, but in which a large hole in the hard palate remains which cannot be closed by operation. In many cases of this kind in young subjects, even the temporary wearing of a plate does much good, and may lead in time to complete spontaneous closure of the hole. It may be stated as a general rule that obturators are very satisfactory in the treatment of aper- tures in the rigid hard palate, while in the case of the soft palate nothing has yet been invented which gives really satisfactory results. For the hard palate all that is wanted is a thin plate of gold or vulcanite that will cover the opening. Such a plate is easily fitted to the teeth, and as many cleft palate patients have some irregu- larity in the dental arch, the plate may also serve a useful purpose in correcting this. It is important that the plate be laid over the cleft and not inserted into it. If the latter mistake is made the cleft will tend to become wider instead of narrower as age advances. Any attempt to replace by mechanical apparatus a muscular structure such as the soft palate, capable of delicate voluntary movements, must necessarily be very imperfect. It is for this reason that a well-executed operation which restores the soft palate FIG. 4. -The very important step of freeiug the soft palate froifl the posterior edge of the bony palate. One blade of the scissors lies in the nose, the other between the bone and muco-periosteum of the palate. Note that the axis of the scissors has been rotated after insertion of the blades. 154 Cleft Palate. FIG. 5. The separation of the soft tissues having been effected and the edges of the cleft pared, the first suture is about to be passed at the anterior part of the soft palate. Note the direction in which the point of the rectangular needle is being inserted. FIG. 6. The soft palate having been sutured, is drawn forward by a pair of clip forceps attached to the uncut sutures, while sutures are being passed transversely through the uvula. Cleft Palate. while preserving its movements is greatly to be preferred to an obturator as far as the soft palate is concerned. Obturators for the soft palate fall into two classes, those in which the extension backwards from the hard palate is rigid and those in which some degree of mobility is aimed at. B FIG. 7. Showing the manner in which sutures often have to be passed at the anterior end of the cleft, when the rectangular needle cannot con- veniently carry the same suture through both sides of the cleft. A. The needle has been passed through one edge of the cleft and then with- drawn, leaving a loop of suture projecting into the cleft. B. A second suture has been passed through the other edge of the cleft and then through the loop of the first suture. C. By pulling simultaneously upon both ends of the first suture, the second suture is carried completely across the cleft and is ready for tying. In the first class the best form is that in which a conical mass of vulcanite or some similar material is firmly fixed to the posterior edge of the plate that covers the hard palate. This mass should very nearly, l>ut not quit?, fill up the space between nose and pharynx. Air is thus enabled to pass freely through the naso- pharynx when the muscles of the latter are at rest. But when it is desired to close this passage completely, in deglutition or 156 Affections of the Palate. phouation, a very slight contraction of the muscles is sufficient to do this. In the second form of obturator the posterior part may be an elastic flap which lies against the under-surface of the soft palate, following it in its movements. Such an apparatus is not easily tolerated and does not effect a really efficient closure of the cleft. A much better form is that in which an oval, more or less rigid, mass with concave sides is united by a metallic spring and swivel to the more rigid part of the obturator. The posterior part which lies in the cleft of the soft palate is grasped by the latter when in action and follows its movements. Such an obturator, if really well made, is a very great help to articulation. It is, however, very difficult to make. It should be borne in mind that any soft palate obturator is at first exceedingly irksome and irritating to the wearer. Much patience must be exercised before the pharynx becomes sufficiently tolerant to bear it without great discomfort. In no case should an obturator be fitted to any child before the age of six years. Between this age and that of puberty an obturator may often be applied with advantage if its object is to facilitate the closure of a hole left in the hard palate after a partially successful operation; or it may be worn with advantage to correct irregularities in the dental arch and so to improve articulation. An obturator applied to a growing jaw will of course require frequent renewal. It is seldom, if ever, desirable to place a soft palate obturator in the mouth of a child. JAMES BERRY. The illustration in this article are taken from Berru and Lfqq's "Hare-Lip and Cleft-Palate:' OTHER AFFECTIONS OF THE PALATE. Acquired Perforations of the Palate. These lesions are almost always the result of tertiary syphilis. In the majority of cases they should be treated by the use of obturators; plastic operations for their closure are rarely satisfactory, but may be attempted when the perforation is small and the other conditions are favourable. Tumours of the Palate. Innocent tumours are easily removed. Sarcoma and squamous-celled carcinoma, when removable, require partial excision of the upper jaw. C. H. S. FRANKAU. DISEASES AND INJURIES OF THE SALIVARY GLANDS. INFLAMMATION OF THE SALIVARY GLANDS. Primary Parotitis. (1) Mumps. (See Special Article, Vol. I., p. 256.) (2) Simple Parotitis is occasionally due to exposure to cold. It also results from the administration of mercury, the impaction of a calculus in the duct or to inflammation extending along the duct from the mouth. The inflammation following an impacted calculus is of a chronic character leading to an increase in size and hardness of the gland from the formation of fibrous tissue, or it may be acute and cause suppuration. When the inflammation is due to infection spreading along the duct, suppuration may occur and pus may be seen entering the mouth from the duct or it may be made to exude by pressure along the course of the duct. When the inflammation is due to mercury the administration of the drug should be at once discontinued. Hot fomentations should be applied over the gland ; chlorate of potash in doses of 10 gr. should be given every four hours, and astringent mouth washes containing chlorate of potash (10 gr.) and alum (5 gr.) should be used frequently. As this form of parotitis is more likely to occur in patients with septic mouths, all decayed teeth and stumps should be removed or " stopped " before the administration of mercury is begun ; any pyorrhoea alveolaris should also be treated. If an impacted calculus is the cause of the affection it should be removed. When the infection spreads along the duct from the mouth, the state of the latter should be rendered as aseptic as possible by the removal of decayed teeth and stumps, the regular use of antiseptic and astringent gargles, such as sanitas (1 drachm to a pint of water) or chlorate of potash and alum, or weak carbolic (1 in 80 to 100) lotion. The duct may be slit up from inside the mouth so as to provide a freer exit for the pus. If the pus has involved a large portion of the gland it must be evacuated through an external incision over the most oedematous 158 Inflammation of the Salivary Glands. area. This operation should not be delayed too long, if slitting up the duct is insufficient, as there is a tendency for the pus to burrow into the surrounding parts. The incision must be placed so as not to injure the facial nerve, and a medium-sized drainage tube will be required. Secondary or Symptomatic Parotitis occurs in the course of an acute infective disease, such as typhoid fever, pneumonia, pyaemia ; during the puerperium and after lesions or operations on the abdominal and pelvic viscera. Two views are held as to the origin of this affection : (1) That it is due to infection ascending the duct from a septic mouth ; (2) that the infection is by the blood stream and pyaemic in origin. In the great majority of cases the former method of origin is the correct one, and hence the necessity of keeping the mouth clean in all cases of disease and especially after abdominal lesions and operations. The parotitis may be simple, but very often it is suppurative. Owing to the density of the parotid fascia the pus is liable to burrow deeply rather than come to the surface ; thus it may pass into the neck or towards the base of the skull, or burst into the mouth or into the external auditory meatus ; hence, as soon as it is evident from the oadema of the skin that suppuration is present, the abscess should be opened by Hilton's method. A horizontal incision sufficiently large to provide a free exit and drainage for the pus should be made, and it must be placed so as not to damage the facial nerve. A tube is better than a gauze drain. In the earlier stages of the affection hot fomentations must be applied over the gland, and the mouth kept as aseptic as possible by the frequent use of antiseptic mouth washes, the use of a tooth brush, and the removal of all debris and purulent material from the teeth and from the spaces between the gums and cheeks, by means of cotton-wool swabs held in forceps or fastened to a stick, the swabs being soaked in an antiseptic, such as 1 in 80 carbolic or sanitas and water. The tongue should be kept as clean as possible, and moist thick fur may be scraped off with a spoon or spatula. Bicarbonate of soda (gr. 10 ad j water) is very useful for detaching adherent crusts or mucus ; the swabs should be dipped in the solution and then rubbed firmly over the surface. If possible, decayed teeth and stumps should be removed, especially if they are loose. The Submaxillary and Sublingual Glands are not so fre- quently affected by inflammation except as a result of an impacted calculus ; therefore no special description is necessary. Probably the position of the buccal orifice of their ducts explain their freedom. Salivary Calculi. 159 SALIVARY CALCULI. Salivary Calculi are not uncommon in Wharton's duct and are most often found near its orifice. They may, however, be present in any part of the duct and sometimes in the substance of the sub- maxillary gland. The patient's attention is usually directed to the affection by the pain on mastication or by the chronic enlargement of the gland. A fine probe may sometimes be passed along the duct and made to grate against the calculus, or the calculus may be actually protruding from the orifice of the duct or sinus. Sup- puration not infrequently occurs around or behind the stone. A sinus or an irregular ulcer simulating an epithelioma may be present in the floor of the mouth. The treatment is to remove the stone as soon as it is detected. If it is placed close to the orifice of the duct the mucous membrane should be painted with a 10 per cent, solution of cocaine. An incision is made directly down to the stone, which is then removed with sinus forceps. If the stone is placed more deeply a general anaesthetic should be given, and the mouth being gagged open, the stone is fixed by the finger pressing it against the inner aspect of the horizontal ramus of the jaw, the tongue being forcibly held over to the opposite side. The mucous membrane of the floor of the mouth is incised directly over the stone and the duct opened sufficiently to allow the stone to be easily removed. No attempt is made to sew up the incision in the duct, and all that is required in the after-treatment is a mouth wash, such as weak carbolic acid solution (1 in 80) or chlorate of potash (gr. 10 ad 33). The mouth washes should be employed at a temperature of 100 F. When the calculus is deeply situated in the substance of gland, the best treatment is to excise the gland and its duct by an external opera- tion. A curved incision of sufficient length is made over the gland, and a flap consisting of skin and all the tissues over the gland is turned upwards. The facial vessels are tied as they cross the jaw, and the fascia passing from the jaw to the gland is divided. The finger is passed between the margin of the jaw and the gland, which is then peeled off the hyoglossus and posterior belly of the digastric, from above downwards, and the deeper portion, which lies beneath the mylo-hyoid muscle, is shelled out. In doing this, the main duct will be exposed and is tied before being divided. Finally, the facial artery and vein are ligatured before they pass beneath the gland, which is then removed. The skin flap is replaced and stitched in position without a drainage tube, if all oozing of blood has been arrested. 160 Salivation. Calculi in the parotid gland are not common. Treatment is carried out on similar lines to the above. SALIVARY FISTULA. Salivary Fistula occurs almost always in connection with the parotid gland or Stenson's duct and more frequently with the latter. It is generally caused by a penetrating wound, or follows an opera- tion on or in the neighbourhood of the gland or its duct. A fistula once thoroughly established never closes spontaneously. If the treatment is to be successful a free passage for the saliva into the mouth must be made, and when this is accomplished the abnormal opening on to the external surface of the cheek will heal spon- taneously or require a simple plastic operation to close it. When the buccal portion of the duct is involved it may be possible to insert a fine probe from the orifice along the duct, which is then slit up from within the mouth, and by keeping the internal orifice open the fistula will rapidly close. If the masseteric portion of the duct is damaged, a large-sized trocar and cannula is passed obliquely forwards into the mouth through the external opening of the fistula. Through the cannula a silk thread is passed and to it is attached a large drainage tube, which is then, by means of the thread, drawn into the tract of the cannula after this has been removed. One end of the tube projects into the mouth and the other is placed at the fistulous opening so that the saliva flows along it. The tube is maintained in its position by means of a silk thread attached to each end of it, the ends of the thread being fastened together behind the ear or round the angle of the mouth. At the end of four or five days, the tube is shortened so that its outer end is close to the opening in the duct. The margins of the fistulous opening may now be refreshed and stitched together. As soon as the saliva begins to flow freely into the mouth the external opening will close and when sound union has occurred the drainage tube may be removed. SALIVATION OR PTYALISM. Salivation or Ptyalism (see also p. 129) is most frequently due to large quantities of mercury being administered, though in some patients the drug in small doses will produce salivation when given by the mouth. It is also produced by other drugs, such as tobacco, potassium iodide, and it occurs in certain affections of gastro-intestinal origin. Salivation is frequently a symptom of diseases of the mouth, e.g., stomatitis, carcinoma of the tongue. Tumours of the Salivary Glands. 161 After removal of half or the whole tongue for cancer, inability to swallow saliva is a troublesome symptom. The treatment, whenever possible, is to remove the cause or to substitute some other method of administering a drug, e.g., inunction or intramuscular injection of mercury instead of giving it by mouth. Not much can be done to relieve the salivation which follows removal of the tongue, but to diminish the liability to it, the submaxillary gland or glands should always be removed with the lymphatic glands of the neck. All decayed teeth should be stopped or removed, and astringent mouth washes, chlorate of potash (10 gr.) and alum (3 to 5 gr.) may be used frequently. The gums should be kept clean by a tooth brush, or by cotton-wool swabs, soaked in the mouth wash and carefully applied so as to get rid of any pus about the tooth sockets. Each individual tooth may require to be dealt with separately, and stronger anti- septics, such as carbolic (1 in 80) or hydrogen peroxide, may be necessary. TUMOURS OF THE SALIVARY GLANDS. Tumours of the Parotid Gland may be simple or innocent, and malignant ; the latter may be grafted on to the former or the gland may be involved secondarily to malignant disease beginning in adjacent structures. Hence before undertaking an operation, it is very essential to make a correct diagnosis of the nature and site of origin of the tumour. The mobility of the tumour, the skin not being involved, and the absence of facial paralysis, are points in favour of an innocent tumour. It is seldom possible to remove a malignant tumour on account of the early wide infiltration of the surrounding tissues, and early recurrence is the rule in those cases in which removal has been done. Operation for Innocent Tumour. A sufficiently large incision must be made in order fully to expose the growth. A curved transverse incision at the lower end of the tumour, enabling a flap to be turned upwards, is sufficient for small tumours. If the tumour is large, an incision along the posterior part of it and curving for- wards along its lower margin should be made. A flap of skin and subcutaneous tissue is turned upwards and forwards, and in raising it the branches of the facial nerve should be avoided. The capsule of the tumour is exposed and enucleation is carried out by blunt dissection. During this separation, and especially when the deeper parts are being attacked, the facial nerve may be damaged unless great care is taken to keep close to the capsule and great gentleness is exercised in the separation. The nerve is usually deep to the tumour, but it may occupy other situations, and therefore the wound S.T. VOL. ii. 11 1 62 Wounds of the Parotid Gland. must be kept as free from blood as possible and by inspection the nerve looked for. Any portions of capsule or of the tumour which may be broken off the main mass must be carefully removed, other- wise recurrence is certain to take place. The bleeding may be free, but is arrested partly by pressure forceps and partly by sponge pressure. Unless a large cavity remains, a drainage tube is unnecessary. Operation for Malignant Tumours involves removal of the whole gland. Often a wide area of skin has to be removed and the facial nerve must always be sacrificed. A temporary ligature may be placed around the common carotid, or the external carotid may be tied as high as possible at the beginning of the operation, because it may be necessary to remove a portion of this vessel with the tumour. The skin incision begins just below the lobule of the ear, is carried downwards parallel to the ramus of the jaw around the angle and forwards for a sufficient distance along the lower margin of the horizontal ramus. When it is necessary to remove a portion of the skin appropriate incisions will be made. The removal of the tumour should be begun from the lower and posterior portion, and in separating the deep portions, the near proximity of the great veins should be remembered. Tumours of the Submaxillary Gland are less frequent than parotid new growths. They are dealt with in a similar way. WOUNDS OF THE PAROTID GLAND. These are of importance because haemorrhage may be severe ; the external carotid or one of its branches, or a large vein may be injured ; the facial nerve may be divided ; or a salivary fistula may follow if a main duct is wounded. To arrest the haemorrhage the wound may be somewhat enlarged, though in doing so care must be taken not to injure the facial nerve. It is therefore not advisable to make a deep and wide dissection to expose and ligature the bleeding points. If the haemorrhage is venous, plugging with gauze and firm pressure will be sufficient to arrest it. In severe arterial bleeding, if pressure forceps cannot be applied, the external carotid should be exposed at its origin and a ligature placed around it but not tied. By traction on the ligature the haemorrhage can be controlled sufficiently. The parotid wound is then sponged free of blood, and on relaxing the ligature it may be possible to see and secure the divided end of the injured vessels. If it is impossible thus to secure and tie the vessel, the ligature around the carotid is tied and the wound plugged with gauze for forty-eight hours, in order to Wounds of the Parotid Gland. 163 prevent haemorrhage taking place from the distal end of the injured vessel. After the removal of the gauze, the wound is sutured or is allowed to granulate. "When the branches of the facial nerve are damaged it is almost impossible to find and unite the ends. If, however, the main trunk is divided it may be possible by exposing the nerve to unite the two portions by means of fine silk or catgut sutures. T. P. LEGG. RANULA. (See p. 145.) 11- -2 164 DISEASES AND INJURIES OF THE NECK. CUT THROAT. THE immediate dangers of a cut-throat wound are : (1) Haemor- rhage ; (2) asphyxia. Even when the wound involves only the superficial structures, the loss of blood may be severe, and there- fore attention in the first instance must be directed to the arrest of the haemorrhage or, if it has ceased, to counteracting its effects by the infusion of saline solution into a vein, by the rectum or sub- cutaneously. General warmth must also be applied. Asphyxia arises from injury to the air passages, and may be caused either by blood passing into the trachea or from the nature of the wound in the air passages. If the former, the haemorrhage should be arrested as quickly as possible, the wound in the air passages being kept open by forceps or dilators and an attempt made to clear them of the blood by means of feathers or small sponges securely held in forceps. Immediate tracheotomy or laryngotomy will be required if the asphyxia is due to the nature of the wound of the air passages, e,y., when the epiglottis is divided and obstructs the glottis, or when the larynx itself is severely damaged. When urgent symptoms are absent the wound and the surround- ing parts should be disinfected and the extent of the injuries investigated. An anaesthetic should be given when the wound is extensive or deep and important structures are likely to have been damaged, so that a thorough examination may be made. If the wound is superficial the divided structures may \>e sutured at once. Whenever the wound extends deeper than the cervical fascia, drainage by means of tubes should always be provided for at least twenty-four hours. In the case of deep wounds above the hyoid bone the muscles of the tongue may be severed ; they must be carefully sutured. The lingual and facial vessels or their branches may have been divided and will require ligaturing. The superficial parts of the wound must be sutured in layers. Two drainage tubes, one at each extremity of the wound, are usually necessary, and they should be long enough to reach to the bottom of the wound. When the thyro-hyoid space is damaged, the epiglottis may be partially or completely severed from its attachments. It may be necessary to remove a portion or the whole of the epiglottis, but Cut Throat. 165 whenever possible it should be sutured in its proper position. If the larynx is injured the divided structures must be carefully united. After all bleeding has been arrested the wound is closed in layers, free drainage being arranged for. It is in these cases that dyspnoaa is an immediate urgent symptom, or it may super- vene (and not infrequently) suddenly in the course of a few hours, from oedema of the glottis ; therefore a high tracheotomy should be done at once. When the trachea is injured and the wound is a clean cut one the edges may be united completely by stitches. If the wound has lacerated or contused edges, a tracheotomy tube should be inserted for two or three days, after partial closure of the wound ; but if the trachea is wounded in such a position that it is impossible to put the tube in, the tracheotomy must be done in the usual position and the tracheal wound closed as accurately as possible. Wounds of the pharynx and oesophagus should be closed by careful suturing ; a drainage tube should always be inserted down to the site of the wound and the superficial parts left open. Any nerves which may be divided should be sutured if possible. After-treatment. The patient is propped up with pillows in bed with the head flexed on the chest. In suicidal cases a special attendant will be necessary to see that the patient does not tear the wound open or do further damage. The patient's mental state must be remembered and his general condition attended to. Sleep must be obtained by the use of bromides or morphia. Saline infusions either intravenously or per rectum will be required. Stimulants may also be necessary. When deep structures have been divided or food is refused, the patient must be fed through an cesophageal or nasal tube, which should be passed three or four times in the twenty- four hours. Fifteen to twenty ounces of milk, thin custard, etc., may be given at a time, and this method of feeding is continued till the deep portions of the wound have healed or the natural power of swallowing has returned. Kectal nutrient enemata may also be employed as required. Complications. These are mainly inflammatory. Septic cellulitis of the neck may occur and must be treated by free incisions. (Edema of the glottis, tracheitis and bronchitis, or broncho-pneu- monia and empyema are frequent complications and usually septic in origin. If the dyspnoea is due to oedema of the glottis high tracheotomy must be done without delay. Secondary haemorrhage may occur, and must be treated on the usual lines. Surgical emphysema may also occur, but does not require any special treatment. 1 66 Fistulae of the Neck. Sequelae. An aerial fistula may develop and require a plastic operation for its closure. Laryngeal or tracheal stenosis may require intubation or the permanent use of a tracheotomy tube. Aphonia from damage to the recurrent laryngeal nerve is usually permanent. Pharyngeal and oesophageal fistula generally close spontaneously and require no special treatment. FISTULA OF THE NECK. Aerial Fistula. Before undertaking treatment for the cure of this affection it must be ascertained that laryngeal stenosis or adhesions are not present. If these conditions exist, they must be rectified before the operation for the closure of the fistula is per- formed. This consists in separating the skin from the mucous membrane, the external wound being enlarged as much as may be necessary. The edges of the mucous membrane are refreshed and united by sutures. The superficial part of the wound is then closed completely or left partially open and packed with gauze and allowed to granulate. Branchial Fistulae are the remains of the branchial clefts, the exact site of the opening depending on the cleft from which the fistula originates. The commonest position is just above the sterno- clavicular articulation at the anterior border of the sterno-mastoid muscle ; the opening may be higher in the neck, but it is always along the line of the anterior margin of this muscle. Not infrequently these fistulae are bilateral. The track may be quite short or it may be long and tortuous ; in the latter case it often passes between the internal and external carotid arteries towards the pharynx, with which it may have a communication. At the external orifice there may be a tag of skin containing a small piece of cartilage. A thin viscid mucus is secreted, and occasionally an abscess may form as the result of inflammation of the canal. The treatment will depend on the amount of inconvenience which the fistula causes. When this is slight, it is best to leave it alone. Attempts to cure it should never be made by the use of agents which destroy the lining mem- brane. If any operation is deemed to be necessary a fine probe must be passed along the whole length of the canal. An incision is made over the anterior border of the sterno-mastoid and a careful dissection to remove the track throughout its whole length is carried out. The upper end is cut across and ligatured ; any open- ing into the pharynx should be carefully sutured, and it is advisable to put a small drainage tube into the wound before suturing the skin. The close relation between the track and the carotid vessels and nerves, especially the superior laryngeal, must not be forgotten. Cysts of the Neck. 167 Median Cervical Fistula ; Thyro-glossal Fistula. This is formed from a persistent thyro-glossal track. The opening is single and situated at some point between the hyoid bone and upper end of the sternum. If the fistulous opening does not cause inconvenience it should be left alone. Attempts to cure the fistula are always difficult, and an operation should not be under- taken unless it appears to be absolutely necessary on account of the discomfort or the amount of discharge. A median incision is made from the hyoid bone down to the orifice of the fistula, through which a probe has been passed along the whole length of the track, which is then dissected out. Great difficulty is likely to be met with at the upper end in the region of the hyoid bone, where it is absolutely essential to remove this portion of the track as it passes behind this bone. It may even be necessary to continue the dissection above the hyoid between the muscles at the base of the tongue. Exceptionally, the body of the hyoid may require to be divided to obtain a satisfactory removal. Thyroid Fistulae. These are usually the result of some opera- tive procedure in which a septic factor is present. Free drainage must be provided and the fistula laid open so as to convert it into an open wound, which is to be packed so as to enable it to heal from the bottom. When there is much surrounding inflammation, wet antiseptic dressings or fomentations should be applied and frequently changed. The fistula may be close to the large vessels or other important structures, so that a free laying open of the whole track may be impossible. In such cases the superficial part must be enlarged and the deeper parts drained. When the fistula is caused by the presence of infected ligatures it will not heal till these have been removed or cast off, and this may take a long time. If the fistula follows tapping and injection of a thyroid cyst or adenoma, healing will not occur until the tumour has been removed. CYSTS OF THE NECK. Blood Cysts are quite uncommon. They may communicate directly with a vein or be derived from a lymphatic cyst into which hemorrhage has taken place. If they arise in connection with a vessel they should be left alone unless they are increasing in size or causing symptoms. If it is decided to remove the cyst all the vessels passing into it must be ligatured and the wall of the cyst removed. Branchial Cysts. These cysts are situated along the line of the anterior margin of the sterno-mastoid muscle, and are derived 1 68 Cysts of the Neck. from the branchial clefts. They must be treated by removal, and in the dissection the close relationship of the cyst to the vessels and important nerves must not be forgotten ; therefore it is necessary to keep close to the wall, every portion of which must be removed. The operation may be difficult and prolonged when the cyst extends deeply into the neck. Bursal or Thyro-hyoid Cyst. A bursa is said to exist between the hyoid bone and thyroid cartilage and to become enlarged, giving rise to a median swelling. The treatment of such a cyst is to dissect it out through a median vertical or a transverse incision over the tumour. The overlying muscles are separated, and when the tumour is exposed it is enucleated. The cyst is placed on the thyro-hyoid membrane, which must not be damaged in separating the deep connections of the cyst. Dermoid Cysts in the neck are met with along the line of the anterior margin of the sterno-mastoid or in the middle line. In the former situation they are most frequent in the submaxillary region below the angle of the jaw. To remove such a cyst a transverse slightly curved incision is made over the tumour, and the deep fascia and platysma are divided. The cyst wall having been exposed, it is separated from the surrounding tissues, partly by dissection and partly by enucleation with the finger or a blunt dissector. The separation must be carried out close to the tumour, which may extend deeply and be in intimate contact with large vessels and the important nerves of the neck. These structures should not be damaged. All oozing of blood should be arrested before the skin incision is closed ; in most cases a drainage tube is not required. In the middle line these cysts are usually placed above the hyoid bone, though occasionally they are much lower and close to the sternal notch. "When situated above the hyoid bone they may extend between the genio-hyoglossus muscles, and bulge into the floor of the mouth as well as forming a tumour between the chin and hyoid bone. They should be removed through a transverse or longitudinal incision in the submental region. The mylo-hyoid muscle is divided, the deeper muscles are separated and peeled off the surface of the tumour, which is then enucleated. If the cyst is very large the contents may be evacuated before its wall is removed. Care should be taken not to wound the mucous membrane of the floor of the mouth, and if this accident occurs the hole should be closed by a stitch, and a drainage tube placed in the cavity in the neck before the skin incision is sutured. When the cyst is lower down a transverse incision is made over it, Cysts of the Neck. 169 and the tumour is removed in a manner similar to that for a cyst in the submaxillary region. The cyst may extend deeply, and if a large cavity is left a drainage tube will be required for twenty-four to thirty-six hours. Hydatid Cysts are occasionally met with, and if they require treatment they should be removed by dissection. Hydroceles of the Neck. The exact origin of these unilocular cysts is not certain. They may be derived from the deeper part of an unobliterated branchial cleft or from the lymphatics. They are congenital and are present at birth or are noticed soon afterwards. They may shrivel spontaneously and in some exceptional cases they are liable to suppurate. If it is very large, the cyst may be tapped with a fine trocar and cannula. The best treatment is to excise the whole of the swelling. This proceeding will necessitate a very careful and often a difficult dissection. It should not be done, therefore, on young infants ; the surgeon should wait till the child has grown older and is better able to stand the operation. Lymphangioma; Cystic Hygroma. These tumours consist of a multilocular mass, the locules or cysts being of varying size and bound together by fatty and connective tissue. The tumour is partly below the deep fascia and partly in the subcutaneous tissues. It may be situated in any part of the neck and may involve a very wide area. They are congenital and steadily increase in size. Unless the tumour is rapidly increasing in size or causing symptoms, it should not be interfered with in very young chil- dren. Tapping and injection with iodine are useless and cannot be recommended. Eemoval by dissection is the only method of treat- ment which should be attempted, and in carrying out the operation care should be taken to get beyond the limits of the tumour in every direction. The dissection may be difficult and prolonged, and the fact that the tumour often passes into the neighbourhood of important structures must be remembered. It is advisable to use a drainage tube for twenty-four to thirty-six hours, otherwise any serum or lymph, which is frequently poured out into the wound, will distend it and prevent the obliteration of the cavity remaining after the removal of the tumour. It may be pointed out that cystic hygromata are rather prone to spontaneous attacks of acute inflammation, and after such attacks the swelling may subside and undergo a form of spontaneous cure. Malignant Cysts occasionally arise in connection with the remains of one of the branchial clefts. Kemoval is usually impracticable. This kind of cyst also arises from a cystic 170 Cysts of the Neck. degeneration of malignant glands. It may then be possible to remove the mass. Sebaceous Cysts are not infrequent in the upper part of the neck. They are to be removed by dissection. The incision in the skin should be transverse, so that the scar may be almost invisible. These cysts cannot be enucleated owing to the close connection of the capsule with the surrounding subcutaneous tissue. Moreover, they are liable to become inflamed and suppurate. Under these conditions it is also necessary to remove the whole of the cyst wall, for if the cyst is merely opened and scraped it is certain to recur. If the inflammation is very acute and there is much cellulitis, it may be advisable in the first instance to open and drain the cyst and subsequently to remove its wall (see also Tumours). Thyroid Cysts. The treatment of these cysts is described in connection with tumours of the thyroid. Thyro-glossal Cysts. These cysts are derived from an un- obliterated portion of the thyro-glossal track, and may be placed in the neck anywhere between the hyoid bone and isthmus of the thyroid, lying either in the mid-line or just to one side of this line. They must be treated by complete removal. Tapping and injection are useless and are liable to be followed by a fistula. The opera- tion for complete removal is difficult on account of the connections of the cyst ; any portion extending up to the hyoid bone or down to the thyroid isthmus must be excised. If any part is left behind a fistula which is very difficult to eradicate will form. T. P. LEGG. DISEASES AND INJURIES OF THE (ESOPHAGUS. STRICTURE OF THE CESOPHAGUS. SIMPLE STRICTURE OF THE CESOPHAGUS. THIS affection is most frequently secondary to ulceration of the mucous membrane produced by swallowing caustic fluids or by the long-continued presence of foreign bodies. The stricture may be localised or involve a large extent of the mucous membrane. It is important to make the diagnosis from malignant stricture if treat- ment by dilatation is contemplated, for in carcinoma such treat- ment is inadmissible. Aneurysm and other mediastinal tumours should be also excluded. The treatment is partly medical and partly surgical. Medical treatment consists in giving the patient highly con- centrated nourishing food in a liquid or semi-solid form, if the patient is able to swallow the latter. The difficulty in swallowing is partly due to spasmodic contraction of the muscular wall, and therefore sedatives, especially opium, in the form of the tincture (10 to 15 min.) [U.S. P. 6 to 9 min.], in glycerine and water, should be given a short time before food is taken. Ee'ctal feeding may be empk>3 r ed to supplement the natural method ; if the patient is losing ground or is quite unable to swallow and it is impossible to pass a bougie, gastrostomy should be performed without delay and before the wasting is extreme. Surgical treatment consists in either dilating the stricture or performing gastrostomy. Other surgical operations are sometimes carried out, and are referred to hereafter. Dilatation of the Stricture is carried out either intermittently or continuously by suitable bougies. There is a constant tendency for the stricture to recur, and therefore the use of the bougies can never be discontinued ; the patient must either pass them himself or have them passed at intervals for the rest of his life. The intervals may be gradually increased as time goes on. Intermittent Dilatation. Great gentleness must be employed in using the bougie, and no attempt must be made to force it through the stricture, if it is tightly gripped. The calibre of the 172 Simple Stricture of the (Esophagus. stricture is not uniform, and there may be more than one stricture, each having a different calibre. Therefore a bougie may pass easily into or through one stricture and be tightly gripped by another. The bougie should be left in position for a few minutes and then 20INS FULL SIZE ENDS FIG. 1. A silk web oesophageal bougie. withdrawn. An attempt is then made to pass a larger-sized instrument, and as soon as it is arrested it is allowed to remain in position for a few more minutes and is then removed. The next day, or after two or three days, the same procedure is repeated, beginning with a bougie a size smaller than the largest passed at Fig. 2. A black elastic oesophageal bougie with a bulbous head. the preceding sitting. The number of bougies employed at each sitting depends on the progress of the dilatation ; as a rule, two or three are sufficient, and attempts must not be made rapidly or forcibly to dilate the stricture. In the intervals between the passage of the bougies opium should be given to allay the spasm. As soon FIG. 3. A conical-ended black elastic oesophageal bougie. as full dilatation has been reached and maintained by the daily passage of the bougie it may be passed twice a week, then once a week, then once a fortnight, and after three or four months more once a month. If there is any sign of re-contraction the intervals must be shortened. Each case must be treated on its merits, and after full dilatation has been obtained the patient can be taught to pass the bougies. Simple Stricture of the (Esophagus. 173 A silk-web bougie (Fig. 1) is the best form to use. It should be placed in a jug of hot water before lubricating it with glycerine or butter. A large size (No. 20) should be first used. Smaller sizes are then taken until one is found which will pass the stricture. The largest (No. 24) bougies are | inch in diameter. The distance the larger instrument passes before reaching the stricture should be noted ; this will enable its situation to be determined. Instead of a silk-web, a soft, black gum-elastic bougie may be used. A bougie with a hard solid end should never be employed. The end should be cylindrical or conical in shape (Fig. 3) ; it is generally easier to insinuate the latter kind of bougie into the orifice of a stricture. The patient sits upright on a chair with a high back to support the head, which is held erect or slightly flexed. The head must not be extended and must be kept firm with the face directed forwards. The mouth is widely opened, and, unless the tongue is very big or gets in the way, a depressor is not required. "With a little experience it is not usually necessary to use a gag or to pass the finger to the back of the mouth to feel for the epiglottis. The bougie is passed on till it touches the posterior pharyugeal wall in the mid-line ; gentle, yet firm pressure will then cause it to turn downwards, and, as it passes over the larynx, a certain amount of coughing and spasm will occur. The instrument should not be removed and the patient should be encouraged to keep as quiet as possible. Some resistance to the onward passage of the bougie from the cartilages of the larynx may here be felt, and this is often mistaken for the stricture. If the patient is told to swallow, the bougie will be carried onwards beyond the aperture of the larynx, and the spasm will diminish ; its further passage may be delayed for a moment or two while the patient inspires a few deep breaths. The instrument is passed on without any force being used, and rotated till the point is felt to be grasped by the stricture. When the bougie is firmly grasped, no attempt should be made to pass it on into the stomach ; it should be left in position for a few minutes, then withdrawn and a smaller-sized one inserted. Sometimes only a catgut bougie can be insinuated into the stricture ; it should be left in position as long as the patient will bear it. Several strictures may be present, and each one should be dilated in succession. It must not be forgotten that the wall of the oesophagus may be very thin, and therefore readily perforated if force is employed. When the patient is very intolerant of the manipulations a small dose of tincture of opium (10 to 15 mins.) [U.S.P. 6 to 9 mins.] in some glycerine and water may be given a short time previously, or 174 Simple Stricture of the CEsophagus. the throat may be sprayed or painted with 10 per cent, solution of cocaine. Continuous Dilatation may be employed if the stricture does not readily yield to intermittent dilatation and when it is very narrow. Soft, silk-web bougies should be employed, and at first it may only be possible to pass a catgut bougie. One of a size which is firmly gripped by the stricture is passed through it and is left in situ. The upper end lies outside the mouth and is fastened by a silk thread to the ear. At the end of twenty-four to forty-eight hours the bougie will lie more loosely in the stricture. Another of a larger size is then substituted, and this one is left in for a further period of two or three days, when it is changed for a still larger one, and so on till the stricture is fully dilated and the largest bougies can be inserted. The length of time required to accomplish this varies in different cases. The great drawback of the method is the annoyance to the patient by reason of the amount of saliva and mucus which are secreted and its uncomfortableness. At first the patient must be kept in bed with the head turned over to one side to allow the mucus and the saliva to escape. Liquid nourish- ment, milk and beef-tea, can usually be slowly swallowed, the fluid finding its way into the stomach alongside the bougie, and of course rectal feeding can always be employed if necessary. Instead of a solid bougie an cesophageal tube may be employed when some degree of dilatation has been reached, and the patient may be fed through the tube by means of a funnel attached to its upper end. The same treatment to prevent re-contraction will be required as in cases treated by intermittent dilatation. Operative Treatment. Many methods of operating directly on the stricture have been devised. These consist of opening the oesophagus in the lower part of the neck (external cesophagotomy), and then dividing or dilating the stricture ; or, if the stricture is low down, of opening the stomach (gastrotomy), and dilating it by means of bougies passed upwards through the opening in the stomach. All these operations are attended with considerable risks and are difficult to perform. Hence in most cases where intermittent or continuous dilatation cannot be carried out, it is better to perform a gastrostomy. This operation will at least prevent starvation, or, if the patient has been brought so low as to be on the point of absolute starvation, his condition may be improved to such an extent as to allow other methods of treatment to be carried out subsequently. Moreover, the gastrostomy may benefit the patient in another waj', inasmuch as the rest given to Malignant Stricture of the (Esophagus. 175 the oesophagus is followed by so much improvement in the local condition of the stricture that the patient may regain the power of swallowing, and an impassable stricture may become amenable to intermittent or continuous dilatation. Whenever gastrostomy has been done attempts should be made, after an interval of two or three weeks, to dilate the stricture by bougies, and if these fail and the patient's condition permits, the possibility of benefit accruing from an external cesophagotomy may be considered. When the stricture has been dilated and is kept dilated, the gastrostomy opening may be closed. Spasmodic Stricture chiefly occurs in women and in association with other neurotic manifestations. The treatment consists in the passage of a full-sized bougie, if necessary under an anaesthetic in FIG. 4. Symonds' short cesophageal tube with a lateral opening The silk threads enable the tube to be extracted easily. the first instance, and subsequently as may be required. The general neurotic condition of the patient must also be treated. MALIGNANT STRICTURE. This is almost invariably a squamous-celled carcinoma, and its most common seat is at the upper end of the oesophagus ; the next most frequent seat is opposite the bifurcation of the trachea. The treatment is palliative, and is carried out either by the use of tubes placed through the stricture or by gastrostomy. Treatment by Tubes. In this method the patency of the stricture is maintained by means of a tube permanently retained in the stricture. The tube may be a Symonds' short tube (Fig. 4), or a long, soft tube. The former is suitable when the disease is in the middle portion of the oesophagus, and the latter when the disease is in the upper part. The long tube may be employed if the Symonds' tube is not tolerated or cannot be introduced or if it is frequently blocked, and it has the advantage that it need not be changed. The disadvantages of the long tube are that the patient is unable to swallow food naturally, saliva cannot pass into the stomach, and it is unsightly, as the end projects from the mouth. The long tube is introduced precisely in the same way as an oesophageal bougie. 176 Malignant Stricture of the (Esophagus. Symonds' short tubes are made of silk-web in different sizes and are 4 to 6 inches long. The upper end is funnel shaped, and has attached to it two silk threads, by which the tube may be with- drawn and by which it is fastened to the ear or cheek. The lower end has a terminal or lateral opening which lies below the lower- most limit of the stricture when the tube is in position. The upper funnel-shaped end prevents the tube slipping downwards. A special introducer (Fig. 5) is provided, and the tube is passed in the same manner as an cesophageal bougie. These tubes allow FIG. 5. Special form of introducer for Symonds' short tube. food and saliva to be swallowed naturally. They cannot be employed for growths at the upper end of the oesophagus (and it is in these cases that the distress and cough produced by the mucus and excessive salivation are most severe), nor when the stricture is at the lower end of the ossophagus. They are not always easily introduced, and may become blocked by coagulated milk, etc. They cause a certain amount of irritation, and are often only tolerated for a short period. The constant presence of the tube in the stricture increases the amount of sloughing and the secretion of mucus. Once the tube has been placed in the stricture it should SCALE 5 FIG. 6. Symonds' short resophageal tube with a terminal opening. The silk threads enable the tube to be extracted easily. not be removed unless the patient is quite intolerant of its presence. If it becomes blocked, the whale bone introducer should be used to clear it. In choosing a Symonds' tube, one with a terminal opening should always be selected (Fig. 6). Gastrostomy. At the present time gastrostomy is the most preferable method of treating a patient with malignant stricture of the oesophagus, and it should be done whenever the patient becomes unable to take sufficient food in the natural manner and before starvation and excessive emaciation are present. After a properly performed operation the patient is far more comfortable than with any sort of tube. There is practically no escape of the contents of the stomach at the opening, and therefore there are none of the Malignant Stricture of the CEsophagus. 177 discomforts from the excoriation of the skin which were formerly so prejudicial to the operation. Not uncommonly some power of swallowing returns, at least, for a time. Many methods of performing the operation have been devised. A modification of Frank's procedure, Semi's and Witzel's methods are the best. One of the two latter is employed when the stomach is contracted. The Modified Frank's Operation (Figs. 7, 8, 9, 10, 11) consists in splitting the rectus abdominis muscle into an anterior and a posterior layer, and plac- ing a conical portion of the stomach between these two planes of muscle fibres. The opening at the apex of the cone of stomach is situated on the surface of the abdomen instead of over the costal margin. The operation is done as follows : An incision, 3 inches long, is made to the left of the linea alba, its upper extremity being a short distance below the cos- tal margin (Fig. 7). The rectus is split in the direction of its fibres and the peritoneal cavity is opened (Fig. 10). The stomach is drawn up into the wound, and is examined to find out if it is contracted or is sufficiently large to enable a conical portion, with a length of 3 to 4 inches, to be drawn up readily into the parietes (Fig. 8). The next step is to make an incision, 1 inch long, parallel to and 2 inches to the left of the first incision (Fig. 7). The sheath of the rectus is opened and the muscle is split in a direction parallel to the fibres (Fig. 10). A stiff probe or director is then passed through the substance of the muscle from the second to the first incision, so that half the muscle thickness is behind the probe and half in front of it. The probe or director is then carried upwards and downwards in the substance of the muscle, thus separating the superficial from the deep fibres. This separation must be sufficiently wide to enable the cone of stomach to be easily carried between the muscle fibres from the first to the second S.T. VOL. II, 12 ']<;. 7. -The modified Frank's method of performing gastrostomy. A is the incision which opens the peritoneal cavity and through which the cone of stomach is withdrawn. B is the second incision placed just below the costal margin and inside the linea semilunaris : it opens the sheath of the rectus. 178 Malignant Stricture of the CEsophagus. FIG. 8. The modified Frank's method of performing gastrostomy. The cone of stomach of sufficient length to lie without tension between the incisions has been withdrawn from the abdomen. Fio. 9. The modified Frank's method of performing gastrostomy. The cone of stomach has been placed between the fibres of the rectus muscle. The stitches fixing the base of the cone to the parietal peritoneum and rectus muscle are shown. The apex of the cone has been opened and the catheter passed into the stomach. The stitches fixing the apex to the parietes have been inserted. incision. The portion of stomach selected should be as close to the cardiac end as possible, the apex of the cone being nearer the lesser curvature. A couple of silk threads are inserted through the sero-muscular coats at the apex of the cone. A pair of forceps is then passed from the second to the first incision ; the threads are Malignant Stricture of the (Esophagus. 179 grasped in the blades of the forceps, which are then withdrawn. By a little manipulation the cone of stomach follows the forceps and thus comes to lie between the layers of the rectus muscle, the apex of the cone being at the second incision and its base at the first incision. The stomach is thus completely surrounded by muscle fibres which act as a kind of sphincter and effectually prevent any leakage of the contents. The base of the cone is fixed FIG. 11. FIGS. 10 and 11. The modified Frank's method of performing gastrostomy. Transverse section through the anterior abdominal wall. Semi-diagrammatic. In Fig. 10 A is the parietal incision exposing the stomach. B is the second parietal incision just inside the linea semilunaris; it opens the sheath of the rectus muscle, the fibres of which are separated into anterior and posterior layers by means of a probe or director passed from A to B through the substance of the muscle. In Fig. 11 the cone of stomach is shown surrounded by fibres of the rectus and the catheter C has been passed into the stomach. A stitch closing the superficial part of the incision A is shown. D is the linea alba ; P is the peritoneum ; M is the abdominal muscles ;