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 <!. /,'. Ihtrner .
Mr. 6'. T. Dent .
Mr. Harold J. Stiles
Mr. Ernest W. Hey Groves
359
360
370
375
382
389
391
395
398
399
400
400
401
42G
428
432
439
479
483
493
498
528
541
550
Table of Contents.
XI
DISEASES AND AFFECTIONS OF THE COLON.
ADHESIONS OF THE COLON
COLITIS
THE SURGICAL TREATMENT OF
COLITIS
CANCER OF THE COLON
CONGENITAL ABNORMALITIES OF
THE COLON ....
MULTIPLE POLYPI OF THE COLON
PERFORATING ULCER OF THE
COLON
TUBERCULOSIS OF TIIK COLON .
VOLVULUS OF THE COLON .
PAOI
Mr. P. Lockhart Mummery . 551)
Dr. W. Hale While . . f62
Mr. P. L<>ckh<irt Mummery . 570
Mr. P. Loekhart Mummery . 578
.)//. /'. Lockliftrf Mummer// . 685
Mr. P. Lu<-l>hart 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 /'/></<'//</. Wa//is
Sir Freilerick Wallix
Sir Freilerick WU is
Sir Freilfrifk Wai I is
Sir h'reilerick Wallis
Sir Prctlerich Wai Us
5'J3
613
6U
615
621
625
DISEASES AND AFFECTIONS OF THE PERITONEUM.
ASCITES
ACITE PERITONITIS .
SUBPHRENIC ABSCESS
TUBERCULOUS PERITONITIS
In: If. D. RoUeston
Mr. Ldred M. Corner
Mr. Ldreil M. Corner
/>/. .\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 7<S5
Table of Contents.
Xlll
DISEASES AND AFFECTIONS OF THE KIDNEY-
A.OUTB NEPHRITIS (ACUTE
BRIGHT'S DISKASK)
CHRONIC INTERSTITIAL NEPHRI-
TIS
CHRONIC DIFFUSE PARENCHY-
MATOUS NEPHRITIS
SURGICAL TREATMENT OF Nox-
SUPPURATIVE NEPHRITIS
PERINEPHRITIC ABSCESS .
PYELITIS
PYELITIS OF INFANCY AND CHILD-
HOOD
PYKLITIS (PYELONEPHRITIS OF
I'KKCNANCV) ....
PYELONEPHRITIS (INFKCTIVK)
I'YONEPHROSIS ....
TUBERCULOSIS OF THE KIDNEY .
TUMOURS OF THE KIDNEY IN
ADULTS
TUMOURS OF THE KIDNEY IN
CHILDREN ....
URJEMIA
AMYLOID DISEASE OF THE KID-
NEYS
Dr. W. P. Herringham . . 7!2
Dr. W. P. Herringham . . 794
Dr. W. P. Herringham . . 796
.)//. ./. H'. Thomson Walker . 798
Mr. ./. IF. Thomson Walker . 801
Mr. J. W. Thomson Walker . 803
Mr. J. W. Thomson Walker . 805
Mr. J. W. Thomson Walker . 806
Mr. J. W. Thomson Walker . S07
Mr. J. W. Thomson Walker . 814
Mr. J. W. Thomson Walker . 819
Mr. J. W. Thomson Walker . 830
Mr. ./. Jr. Thomson Walker . 836
///. II'. P. Herringham . .837
Dr. W. P. Herringham . . 839
DISEASES AND AFFECTIONS OF THE URETER.
WOUNDS OF THE URETER .
FISTULA OF THE URETER .
STONE IN THE URETER
Mr. J. W. Thomson Walker
Mr. J. W. Thomson Walker
Mr. J. W. Thomson Walker
DISEASES AND AFFECTIONS OF THE BLADDER.
CALCULUS OF THE BLADDER
CYSTITIS ...
TUBERCULOUS CYSTITIS
DlVKKTK TI.A AND SACCULI OF
THE BLADDER
ECTOPIA VESIC.E
I N.I Ul! IKS OF THE BLADDER
TUMOURS OF THE BLADDER
J//-. Sydney G. MacDonald . 852
Mr. Sydney G. MacDonald . 858
Mr. Sydney G. MacDonald . 861
Mr. Sydney C. Mtirl tonal >l . 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<i yoitre, that
is, a patient may have had a goitre for a long or a short period and
then subsequently develop signs of exophthalmic goitre ; or it may
be atypical, and in this group may be placed a large number of
cases where the patient has either a parenchyrnatous or adeno-
matous goitre, with a rapid pulse, tremor, and perhaps slight
prominence of the eyeballs. These latter cases are not really
genuine examples of the disease and should be excluded in dis-
cussing the value of surgical treatment. In them the gland has
neither the naked-eye nor the microscopical appearances of the
exophthalmic variety. They are to be treated by unilateral extir-
pation or an enucleation operation, and the symptoms then rapidly
disappear. So that really there is left the true primary form and
the secondary form of the disease. In the latter, operation should
be undertaken at once before the signs become pronounced ; the
prognosis is good and the risks of the operation are not much
greater than those of any other goitre operation. In these cases,
too, the goitre may be so large as to cause pressure on the trachea,
giving rise to dyspnoea, and this will be a most important indication
for operating. Moreover, in these patients and those with atypical
signs of the disease, complete rest in bed will often cause the
symptoms to disappear or alleviate them, but they reappear as
soon as the slightest exercise is taken. The patient thus becomes
a chronic invalid and operation should be therefore advised.
It may be insisted upon that a patient with primary exoph-
thalmic goitre should not be operated upon unless medical measures,
including absolute rest in bed, have been tried and found to be
ineffective. How long such treatment should be carried out must
Surgical Treatment of Exophthalmic Goitre. 59
be determined for each particular case by the stage of the disease
and by the progress which is made. If the disease is steadily or
rapidly becoming worse in spite of medical treatment, operation
should not be too long delayed and it should be done before there
are definite organic changes in the heart with more or less dilata-
tion of its cavities and orifices, because the greatest risk of the
operation is sudden cardiac failure. It must not be forgotten that
these patients, apart from operation, are liable to die suddenly from
this cause.
Operation. Surgeons are not agreed as to the best ancesthetic ;
local anaesthesia is advocated by some, chloroform or A.C.E. mixture
is advocated by others, while ether by the open method is recom-
mended especially by American surgeons. If a general anaesthetic
is used the patient should never be deeply under its influence, and
whatever method is employed it is advisable to give -J- or \ gr.
morphia a short time before the operation, with the double object
of calming the patient's mental state and of reducing the amount
of anaesthetic which will be required.
The primary source of the disease being the thyroid gland, any
operative measures undertaken will be performed upon that organ.
At the present time extirpation of a portion of it, or ligature of
some of the vessels, are practically the only operations which need
be considered.
Ligature of the thyroid arteries is not very often employed except
as a preliminary to extirpation. The ligation of these vessels does not
produce, as a rule, such a permanent amelioration of the symptoms
as a partial thyroidectomy, and it may be as difficult an operation,
especially the ligation of the inferior thyroid artery, as thyroid-
ectomy. The two superior thyroid and one of the inferior thyroid
arteries are usually ligatured. It was hoped that by ligaturing
the vessels to cut off the blood supply the gland would produce
a lessened amount of secretion.
Partial thyroidectoiny is the better operation, the amount of the
gland removed consisting of one lobe and the whole or part of the
isthmus. The operation is carried out in the usual manner.
Especial care must be taken to ligature or otherwise control all
vessels before they are divided or death may occur on the operating
table from haemorrhage and cardiac failure, as these patients are less
able to stand a loss of blood than a patient with an ordinary goitre.
The isthmus or other line of division should never be crushed with
forceps. Free drainage by a large tube should be provided for
thirty-six or forty-eight hours.
After the operation the great danger is " acute thyroidism," which
60 Surgical Treatment of Exophthalmic Goitre.
may follow any kind of operation on an exophthalmic goitre.
There is a sudden rise in temperature which may reach 105 or
more in a short time ; a rapid increase in the pulse rate ; great
restlessness, excitability, severe sweating and diarrhoea. If the
heart has been already weakened by degenerative changes or if it
is dilated, it may rapidly or suddenly fail and death quickly follows.
This sudden failure of the heart may also occur unexpectedly
in a patient who appears otherwise to be progressing favourably.
The explanation is probably, that in addition to the influence of the
exaggerated sensibility of the vascular nervous system, there is a
sudden increase of intoxication from increased resorption of the
thyroid secretion following the manipulation of the gland during
the operation (Kocher).
After-treatment. - - The patient is put back to bed in a
semi-recumbent position with the head well supported on the
pillows. A pint or a couple of pints of saline solution should be
given per rectum at once and repeated every three to four hours in
all cases where there has been any bleeding or when the pulse is of
low tension. If it is not retained the saline should be given sub-
cutaneously into the axilla or beneath the mammary gland. Plenty
of liquids should also be administered by the mouth. Restlessness is
controlled by hypodermic injection of morphia (J to J gr.) combined
with Y^J gr. of atropine. If the pulse is feeble and rapid, digitaliu
(TOO to ^o 8 r O mav be given hypodermically, but saline solution is
the best means of stimulating the heart. If the temperature rises
to a great height there is practically nothing to do directly to bring
it down ; attention must be directed to keeping up the action of the
heart in these cases. Sponging and cradling the patient may
however, be employed.
The immediate effects of the operation having been recovered
from, the patient will need to be kept in bed for two or three weeks
or longer, and when convalescent, should be kept away from all
excitement and lead a quiet, restful life, for some months.
Results. As to the ultimate results of the operation, complete
cure is by no means certain nor is it always permanent. A large
proportion of cases temporarily improve, especially if adequate rest
in the after-treatment is insisted upon, and the improvement may
be rapid. Thus the tremors may disappear, the tachycardia
diminishes ; the nervousness and restlessness of the patient are
lost and the general health may be greatly improved. The exoph-
thalmos is one of the last symptoms to disappear, and it is doubtful
if it ever entirely disappears. In considering the value of the
operation, it must not be forgotten that there is a tendency to
Surgical Treatment of Exophthalmic Goitre. 61
spontaneous improvement in a fair proportion of cases, and in any
case many months must elapse before the full benefit derived from
the operation can be estimated. The most unfavourable cases, both
from the operative point of view and as to ultimate recovery, are bad
acute cases of typical Graves' disease, whereas the more chronic
cases are much more favourable and benefit considerably from the
operation. The former type should not be operated on except after
a prolonged course of medicinal treatment. In the present state of
our knowledge much discrimination and a careful consideration of
all the aspects of the case is required before recommending a patient
to undergo an operation for this disease.
T. P. LEGG.
62
GOITRE.
THE treatment of goitre is either non-operative and medicinal,
or operative. In order to select the appropriate method the
diagnosis of the kind of goitre is of prime importance. A goitre
may be due to : (1) A general or parenchymatous enlargement of
the whole gland ; (2) the development of adenomata (including
cysts) in the gland; (3) exophthalmic goitre ; (4) malignant disease.
Combinations of these forms often occur ; thus there may be
adenomata with a parenchymatous enlargement of the gland, arid
it is not very uncommon for malignant disease or an exophthalmic
goitre to supervene on a parenchymatous or adenomatous goitre.
The treatment of exophthalmic and malignant goitres is discussed
in separate articles.
NON-OPERATIVE TREATMENT.
General Treatment. It is well known that goitre is prevalent
in certain districts, arid therefore if possible the patient should be
removed to a district where the disease is not endemic, especially if
the goitre is a small parenchymatous one, and if the patient is
young. If the removal of the patient is not possible and inasmuch
as it is probable that the cause of the goitre is contained in the
water, it is advisable that all water should be boiled and filtered, or be
distilled before being drunk, or an alteration in the supply may
sometimes be effected. Eain water which has been filtered and
boiled may also be substituted for the usual supply. Cysts and
adenomata, which have undergone secondary changes, will not be
benefited by such general treatment. When the goitre is of the
adeno-parenchymatous variety, some improvement may follow this
line of treatment from diminution of the size of the parenchy-
matous portion of the enlargement.
Medicinal Treatment. Iodine and its preparations are the
most useful drugs. It is advisable to begin with small doses ; thus
a mixture containing 5 min. of tincture of iodine [U.S. P. 1 min.]
and 5 gr. of potassium iodide may be given three times a day, the
quantities of each being gradually increased to three or four times
these doses if the patient can tolerate so much and symptoms of
iodism are not produced.
Thyroid extract is another very useful remedy ; at first it should
Goitre. 63
be given in small doses, 1 or 2 gr. daily, and the amount
may be increased to 5 or 10 gr. daily, if the pulse is not
unduly augmented in frequency and no other untoward symptoms
occur. Many goitres improve more rapidly by giving the iodine
compounds and thyroid extract simultaneously. If the goitre is
going to be amenable to this treatment, diminution in its size will
be manifest in thre'e or four weeks, and in favourable cases it
progresses until the goitre entirely or almost entirely disappears.
The parenchymatous variety which occurs in young people is the
most suitable kind for medicinal treatment. Long standing, tough
parenchymatous goitres as well as adenomata and cysts are un-
affected by these remedies. When adenomata or cysts are accom-
panied by a general enlargement of the gland, some improvement
may result owing to the absorption of the excess of gland tissue,
and thus operative treatment may be rendered more easy.
Local Treatment. External applications, such as the tincture
or liniment of iodine or a mercurial ointment, are often applied to
the neck over the tumour. It is only occasionally that any appre-
ciable benefit follows the application of such remedies. In India,
the red iodide of mercury ointment is thickly smeared over the
tumour and the neck is then exposed to the hot sun for some time.
Such a method is not usually available in this country.
OPERATIVE TREATMENT.
The treatment of a goitre by operation is by (1) extirpation,
(2) enucleation. The methods of performing these operations are
quite different, therefore it is essential to determine the nature of
the goitre before proceeding to operate. Parenchymatous goitres
cause a general and more or less uniform enlargement of the
whole gland, and the tumour maintains the general shape and
contour of the gland ; the trachea retains its position in the mid-
line of the neck and is bilaterally compressed. Adenomata are
encapsuled tumours composed of thyroid tissue; they may be
single or multiple and may be present in one or both lobes. They
are oval or globular in shape, elastic in consistence, and when large
they displace the trachea to the opposite side of the neck.
By extirpation (Fig. 1) is meant the removal of a part, generally
one lobe, of the gland. The vessels are ligatured and divided
outside the capsule of the gland ; especial care should be taken to
secure those entering the lower pole. This operation is performed
in cases of parenchymatous and adeno-parenchymatous goitre,
multiple adenomata, and sometimes for malignant disease and for
exophthalmic goitre. It is never necessary to remove the. whole of
6 4
Goitre.
both lobes for an 'innocent goitre, and only occasionally is it desirable
or possible to do so in malignant disease. If one lobe is removed
when the goitre is an innocent one, the other generally shrinks
rapidly and may almost disappear. When the isthmus is enlarged
it may be entirely or partially removed with the lobe. An impor-
tant and very useful modification of the operation of extirpation is
I.T.A.
i.r.v.
Liny.
FIG. 1. Operations on thyroid tumours. Semidiagrammatic.
In the right lobe of the thyroid an adenoma and its
capsule are shown. The dark line represents the incision
to enucleate the tumour ; it is made where there are not
any large vessels and where there is a thick layer of thyroid
tissue over the tumour. On the left lobe of the gland the
operation of extirpation for a parenchymatous goitre is
illustrated. All the vessels are ligatured outside the capsule
of the gland. Ao., aorta ; C.A., carotid avtery ; l.J. F., inter-
nal jugular vein ; /. T.A., inferior thyroid artery; I.T.V., in-
ferior thyroid vein; L.In.V., left innominate vein;
L.T.V., lateral thyroid vein; R.In.V., right innominate
vein; S.1\A., superior thyroid artery; S.T.V., superior
thyroid vein.
called resection-extirpation. In this method a part of the lobe on
its inner and posterior aspect is not removed, the knife being
carried through the gland in this situation. The advantages of this
operation are that the recurrent laryngeal nerve is not endangered
and enough of the gland remains to carry on its function, if it ever
becomes necessary to remove the opposite lobe.
By enucleation (Fig. 1) is meant the removal of a tumour from
inside the gland ; it is therefore used for adenomata and cysts. A
Goitre. 65
spot over the tumour where there are few vessels is chosen, and at
this place an incision is then made through the gland substance till
the capsule of the tumour is reached. This is opened and the
tumour rapidly enucleated. After the tumour is removed a cavity
is left, and in it there will he vessels requiring to be ligatured. The
bleeding, which may be smart for the moment, should be controlled
by packing the cavity with gauze. The vessels are then secured
with pressure forceps and ligatured, after which the walls of the
cavity are approximated by two or three sutures. Resection-
? u ltd i.' ttt ion is a useful modification of enucleation and is suitable for
large adenomata, when there is only a thin layer of normal thyroid
tissue over a large area of the tumour. In performing this
operation the affected lobe is displaced forwards and an incision is
made through it till the tumour is exposed. The tumour is then
enucleated on its inner and posterior aspect and in the latter
situation the gland tissue is again divided ; the portion of gland
over the tumour is removed with the tumour. All the vessels in
the capsule of the gland must be clamped before being divided and
will be subsequently ligatured. Care must also be exercised not to
damage the recurrent laryngeal nerve which lies on the inner and
deep aspect of the thyroid gland.
Details of the above Operations. In the majority of cases a
general anaesthetic may be given and chloroform for preference.
Ether given by Clover's inhaler is not advisable. Whatever
anaesthetic is employed, the patient should not be placed deeply
under its influence, and throughout the whole administration a
very careful watch must be kept over the breathing and pulse. An
operation is frequently required for the relief of dyspnoea from
pressure on the trachea, and the difficulty in breathing may
suddenly increase if the patient is deeply anaesthetised. Many
deaths during the operation have been due to too deep anaesthesia.
"When dyspnoaa is extreme, it is better to use a local analgesic such
as eucaine and adrenalin. In these cases, if the patient is very
nervous or excitable J gr. of morphia may be given an hour
before the operation ; a general* anaesthetic may be administered
after the removal of the tumour, as the danger of sudden pressure
on the trachea is then over.
A curved transverse incision placed over the lower part of the
tumour is the best (Fig. 2). Its length will be proportional to the
size of the tumour ; if necessary, the ends of the incision may
be carried upwards. Oblique and vertical incisions are not to be
recommended, as the scar often hypertrophies and becomes very
prominent, whereas the scar left from a transverse incision is
S.T. VOL. ii. 5
66 Goitre.
usually almost imperceptible. A flap consisting of the skin, deep
fascia and platysma, is dissected up for a sufficient extent to expose
the tumour fully. The infra-hyoid muscles are divided as high as
possible and turned downwards, and to obtain a complete exposure
of the tumour it is usually necessary to separate these muscles of
the two sides by a vertical incision. When the tumour is large
these muscles are often thinned and spread out over its surface in
a thin layer. The sterno-niastoid is firmly retracted if it overlaps
-.: "'' '
FIG. 2. To illustrate the situation ot the transverse curved
incision for removal of a thyroid tumour. The scar is
almost imperceptible.
the tumour, which is then gently raised into the wound by passing
the finger all round it. All vessels must be clamped by pressure
forceps before being divided, and special attention should be paid
to secure the inferior thyroid veins, which are apt to retract into the
loose cellular tissue behind the sternum, where they are very
difficult to pick up and a large amount of blood may be unneces-
sarily lost. Throughout the whole operation the greatest care
should be taken to prevent haemorrhage. The vessels should be
tied as close to the tumour as possible, and to make certain that
Goitre. 67
none have been unsecured it is advisable to allow the patient to
come round partially from the anaesthetic and make him strain.
Any unsecured vessel will at once bleed, and can be picked up by
pressure forceps and ligatured. A drainage tube should be placed in
the wound for twenty-four hours, as there is often a good deal of
oozing of blood and escape of colloid material from the gland tissue.
It is only when the cavity is quite small after the removal of the
tumour that drainage should be dispensed with, and these cases are
the exceptions. The infra-hyoid muscles should be replaced in
their positions and their cut edges united by sutures ; in young
people this should never be omitted. The platysma and deep fascia
are united by three or four interrupted sutures ; this enables the
skin edges to be more perfectly apposed and permits of the super-
ficial stitches being removed on the fourth or fifth day after the
operation.
The patient on being put back to bed is propped up with pillows
in a sitting posture. This is more comfortable than the recumbent
one, and as a rule the majority of patients may be allowed to get
up for a short time on the fourth or fifth day.
Indications for Operation. Dyspnoea is the most frequent
indication for operating on a goitre, and the more urgent it is the
greater is the need for an operation. In children, who develop a
goitre at or near puberty, respiratory trouble may develop very
quickly from the pressure on the trachea. A goitre in a child is
usually of the parenchymatous type, and if medicinal measures do
not speedily arrest its growth, operation should not be delayed. In
cystic adenomata, rapid increase in size from haemorrhage into the
cyst is likely to cause dyspnoea. Any long standing goitre which
begins to increase should be removed. Displacement, or compres-
sion, of the trachea is a frequent indication for operation, and other
reasons for advising an operation are the size of the tumour and the
deformity of the neck. A deep-seated adenoma should always be
removed, especially if it is low down in the neck or retro-sternal.
Tumours in this situation are liable to give rise to serious dyspnoea,
either from a rapid increase in size or because they become
impacted behind the sternum. Parenchymatous goitres, which are
not improved by medicinal measures, should be operated on.
When there is enlargement of the whole gland it is not always
easy to decide which lobe should be attacked. As a general rule,
however, that which extends the lower and the deeper in the neck
is the one to remove. When the operation is being done for
adenomata, the lobe causing the displacement of the trachea
should be dealt with. An mtra-thoracic goitre may be present at
52
68 Goitre.
the same time as one in the neck, and therefore the region behind
the sternum should always be digitally explored, otherwise only the
more prominent part of the tumour may be removed and the relief
of the symptoms does not follow.
Complications during the Operation. Haemorrhage is the
most frequent and important. An undue or excessive loss of blood
should not occur if care is taken to clamp the vessels before they
are divided. The near proximity of the internal jugular vein
should be remembered ; it should never be torn, and this accident
can be avoided by gentle manipulations of the tumour. Owing to
the thinness of the walls of the veins, even those of the large veins,
they may be easily torn unless gentleness is employed throughout
the whole operation.
Respiratory trouble, such as increase in the dyspnoea or cessation
of respiration, is liable to occur when the tumour is being lifted out
of the wound or it is being displaced to expose the vessels at the
upper and lower poles. It may be necessary to stop the operation
temporarily to allow the respiration to be re-established, and in
every case the operation should be carried out as quickly as
possible. The importance of having the patient only lightly
ansethetised has already been pointed out.
The air passages, more especially the trachea, may be wounded
if the relation of this structure to the goitre is not remembered,
and in those goitres which extend around the oesophagus or
pharynx, these structures may also be damaged. If the goitre is
closely adherent to any of these organs it is better to leave
a portion of it attached to them rather than to try and dissect it off
completely, if by so doing, a wound of these organs is likely to be
produced. Septic infection of the wound is almost certain to follow
injury to these structures and is a very dangerous complication.
The recurrent laryngeal nerve has often been damaged ; it ought
not to be injured, and can be avoided by dividing all the tissues
and vessels close to the tumour.
Complications after the Operation. Septic infection of the
whole wound, leading to cellulitis of the fascial planes of the neck,
is the most serious. The infection, of course, occurs during the
operation and can be avoided by taking the same antiseptic pre-
cautions as in any other operation. During the whole operation
the wound should be covered as far as possible with gauze wrung
out in 1 in 2,000 perchloride or biniodide of mercury. Whenever
infection occurs, free drainage must be provided without any delay
by taking out the stitches ; otherwise septic cellulitis of the neck
and of the mediastinum may occur. Wet dressings (1 in 2,000
Goitre. 69
perchloride of mercury) must be applied to the wound and
frequently changed. Large quantities of saline solution per rec-
tum may be given continuously or the saline may be injected
subcutaneously, a pint at a time, and repeated every three or four
hours. Cultures should be made from the wound, and a vaccine,
prepared from the organism, given, or the appropriate serum may
be used.
Hcematoma. After the wound has been sutured the deeper parts
may be distended with blood derived from a vessel which has
escaped being ligatured, or from a vessel from which the ligature
has slipped off or from a general oozing. Such a hsematoma is
a source of danger, (1) because it may cause severe dyspnoea from
pressure on the trachea, and (2) it may become infected. The treat-
ment of such a hsematoma is in the first place prophylactic, that is,
great care should be taken to ligature securely all vessels, and to see
that the wound is dry at the completion of the operation. In the
second place, a drainage tube should be placed in the wound in
all cases for twenty-four hours, thereby providing an escape for
any blood which may ooze from the raw surfaces of the tissues and
of the gland. If the haematoma develops soon after the operation
and causes dyspnoea, then the wound must be opened up and an
attempt made to discover and secure the bleeding points. If
it is impossible to find them the wound must be left open and
packed. Secondary suture of the skin may be done at a later
period.
A haematoma may also develop slowly at a later period after the
operation ; it is then necessary to open up the wound, remove
the clot and provide free drainage.
Pyrexia. It is not very uncommon to find the temperature
rising to 100'5 or even 101 during the day following or
on the second day after the operation. If no septic element is
present the fever subsides in the course of a few hours ; if, however,
the temperature remains persistently high, the wound should be
carefully examined and opened up freely if there is any sign of
inflammatory mischief.
Fistula. At a later period a sinus or fistula occasionally
develops from the presence of an infected stitch. They are often
troublesome to get to close and may persist for a long time.
Thyroidism (so-called), which is supposed to be due to the pouring
out of the secretion of the gland into the wound and its absorption
therefrom, very rarely occurs. The symptoms, viz., persistent high
temperature, rapid pulse and delirium, are more usually due to
septic infection, and it is exceedingly rare for the wound to
70 Goitre.
become distended with the secretion of the part of the gland which
is not removed. As a matter of fact, the remaining portion of the
gland usually rapidly diminishes in size.
Cachcxia strumipriva does not occur unless the whole gland
is removed or unless that portion of the gland left behind is so
diseased, that it is incapable of carrying on its function. In such
cases it is necessary to give thyroid extract after the operation.
The dose should be 1 or 2 gr. daily to begin with and increased
to 5 gr. or more if necessary. The patient will have to continue
taking the drug for the rest of his life.
Occasionally a late paralysis of the recurrent laryngeal nerve
occurs. This is due to compression of the nerve by scar tissue and
may be completely recovered from.
Other Operations. Many operations were formerly done for
goitres. Tapping of cysts, injections of iodine into the tumour and
division of the isthmus for the relief of dyspnoea, have been
performed. These operations are dangerous and not efficacious,
and therefore should not be carried out. Tracheotomy for the
relief of dyspnoea of an innocent goitre should never be performed ;
the proper method of treating such dyspnoea is by enucleation or
extirpation of the goitre ; and at the present time a goitre ought
not to be allowed to produce such urgent dyspnoea.
Results of Operative Treatment. Relief from dyspnoea is
complete and permanent. In very few cases will a second opera-
tion be necessary ; this depends to some extent on the nature of the
goitre and the method of operating. After enucleation of an
adenoma or the enucleation of several such tumours, any left
behind may continue to grow, especially if the patient is young.
When multiple adenomata are present, it is perhaps therefore better
to remove one lobe by extirpation and to enucleate accessible
adenomata from the opposite lobe. In a parenchymatous goitre
extirpation of one lobe is followed by diminution in size of the
remainder of the gland. Subsequently some increase of this
remaining lobe may occur, but rarely to such an extent as to
necessitate another operation.
When the general health has been affected its complete restora-
tion is the rule. Sometimes after an extensive removal of the
gland it may be advisable to give small doses (1 or 2 gr. daily)
of thyroid extract, combined with general tonics, such as arsenic
and iron, for a few months till the general health of the patient
has been restored and the effects of the operation have been
recovered from.
If the recurrent laryngeal nerve is damaged a permanent change
Infantilism. 71
in the voice may occur, but sometimes perfect compensation may
be effected.
When properly performed with the assistance of a careful anaes-
thetist, the risks of the operation are very slight and the mortality
low. If, however, the operation is done by one who is not familiar
with it, the risks are very much increased.
T. P. LEGG.
INFANTILISM.
SEVERAL types of this condition are described, all of which are
dependent upon some vice or deficiency in one or other of the
principal internal secretory glands. That which is most often
at fault is certainly the thyroid, and inasmuch as there is little or
nothing in the symptomatology to indicate with precision where the
fault lies, it is always well to begin the treatment of such cases
with the administration of thyroid extract. If this should fail to
yield satisfactory results it would be wise to try pancreatic extract,
as recommended by Byrom Bramwell. 1 Failing this, a trial should
be made of pituitary extract.
In addition to the all-essential specific remedies which are
demanded by myxoedema, cretinism and infantilism, the physician
should not forget to insist upon the importance of fresh air, suitable
clothing and good plain food. So far as the latter is concerned,
red meats and alcohol being recognised as depressors of thyroid
activity, they should be allowed sparingly if at all. Having .regard
to the fact that such patients are always cold, the prescription of
a warm bath (100 F.) at night is one which is eagerly followed,
and is very helpful in promoting metabolism. Physical exercise,
more especially of a vigorous kind, is to be discouraged. General
massage, on the other hand, skilfully performed for an hour three
times a week, is a very valuable adjunct.
LEONARD WILLIAMS.
REFERENCE.
"Clinical Studies," Edinb., 1904, II., p. 348,
MYXCEDEMA AND CRETINISM.
THESE conditions are now so well understood that it is not
necessary to notice anything in connection with them except their
treatment, which, with one important reservation, resolves itself
into the judicious administration of thyroid extract a matter
which is fully discussed in a special article (see p. 48). Inasmuch, how-
ever, as some writers have sought to draw a fundamental but highly
fanciful distinction between goitrous cretins and those who are
non-goitrous, it seems necessary to insist that the only difference
between these two classes is provided by the fact that in the former
a wholly inadequate thyroid has attempted to do the work demanded
of it and has become hypertrophied as the result of its futile
attempt; whereas in the other there never has been a thyroid of
any sort to which the fruitless appeal could be made. The presence
or absence of the goitre makes no difference in the essentials of the
disease, and points to no difference in the line of treatment to be
adopted, except in so far as the goitre itself may produce mechanical
complications. It is needless to say that the earlier the cretinoid
condition is recognised and treated the less likelihood is there of
the development of a goitre, and the better the prospect of per-
manent good being effected. The important reservation in the
treatment of myxcedema and cretinism above mentioned refers to
trie fact recently brought to light that inactivity of the pituitary
gland not infrequently produces conditions very closely allied
to those which develop as the result of thyroid inactivity. The
matter is not yet ripe for dogmatic statement, but it is safe to say
that where cretinism and myxoedema appear to be intractable to the
judicious exhibition of thyroid extract or where the extract is only
partially successful in ameliorating the condition, the probability
becomes great that some dereliction of duty on the part of the
pitituary gland is at least a contributory cause. In such circum-
stances the extracts of the two glands should be associated in the
treatment of the case. Indeed, if, as sometimes occurs, the thyroid
extract seems to produce only unpleasant symptoms, it is well to
suspend it altogether and substitute pituitary extract. The latter
is best given by intramuscular injection in doses of 1 gr. three
times daily, care being taken that it does not raise the blood
pressure to the point of danger. Such, however, is its only toxic
effect.
LEONARD WILLIAMS.
73
MALIGNANT DISEASE OF THE THYROID GLAND.
Radical Treatment. The only form of radical treatment
for this affection, when any is possible, is a free removal of the
whole of the disease. Successful treatment can be obtained only
by making the diagnosis in the early stages of the disease, and
therefore special attention should be directed to this point and
particularly to advise patients of middle age with a goitre, which is
beginning to increase in size or is causing pain, or which has
recently developed, to undergo an operation for its removal. The
method of performing the operation is to expose the tumour by
a free incision, and to ligature, before they are divided, all vessels
entering the tumour so that the operator may see exactly what
he is doing, otherwise severe injury may be inflicted on such
important structures as the larynx, trachea, oesophagus, and the
great vessels of the neck. Unfortunately, in the majority of
patients, at the time the operation is performed, the tumour will
be found to have extended through the capsule of the gland and to
have infiltrated the surrounding structures and lymphatic glands,
so that a complete extirpation is impossible and early recurrence is
frequent. If both lobes are involved in the disease, it has probably
extended outside the capsule, and therefore cannot be completely
eradicated, so that only rarely is removal of both lobes possible or
advisable. Similarly, operations which involve the resection of the
trachea, larynx or oesophagus in order to remove the tumour, are
of very little value to the patient.
The tumours known as papilliferous cysts and malignant
adenoma are different from the ordinary carcinoma and sarcoma
in that they are much less malignant locally and are less liable to
recur early after removal. They may require to be repeatedly
operated on, and the patient may live several years.
Palliative Treatment. 1. Partial removal may be advisable
sometimes when the growth presses seriously on the trachea or when
the pain and discomfort are very severe. It should not be done
unless it is probable that the external wound can be closed and that it
will heal ; otherwise a fungating mass will follow. Owing to the
vascularity of the growth there may be much haemorrhage, and
therefore all vessels must be secured before being divided. As
much of the growth should be removed as appears necessary to
74 Malignant Disease of the Thyroid Gland.
produce the relief of the symptoms. It must be remembered that
this operation is likely to give only temporary relief and therefore
should not be undertaken too early.
2. Tracheotomy should be performed when the dyspnosa has
become pronounced or very distressing to the patient. The opera-
tion may be very difficult on account of the enlargement of the
veins and because the trachea may be covered by the growth, so.
that the latter has to be cut through, or part of it may require to
be removed before the trachea can be found. Again, the trachea
may be considerably displaced to one or other side of the neck and
its relation to the great vessels altered. Especial care must be
taken to make the incision over the trachea wherever it is situated
and to do the operation as high as possible.
The ordinary form of tracheotomy tube is not long enough
FIG. 1. Komig's long flexible silver tracheotomy tube.
It has no inner tube.
and therefore a special form, such as Kcenig's long flexible tube
(Fig. 1), must be used. If it is not available, a soft catheter
may be employed.
Tracheotomy, as a rule, only prolongs the patient's life for a few
weeks, but it may give much relief to the symptoms. Bronchitis
or other pulmonary troubles, which are frequently septic in origin,
are the usual causes of death. If the tumour is one of the slow-
growing and less malignant types, the duration of life is much
longer, especially if the growth has not been cut into in performing
the tracheotomy.
3. Morphia and other sedatives may be given freely when
required. On account of the dysphagia food may be required to
be administered by a nasal or oesophageal tube. It is doubtful
if gastrostomy should be performed in these cases. The writer is
unaware whether radium has been employed in treating this
affection.
T, P. LEGG,
75
NOCTURNAL ENURESIS.
NOCTURNAL INCONTINENCE BED- WETTING.
THIS affliction, .when it occurs apart from malformations of the
genito-urinary tract, or disease in the central nervous system, is
commonly regarded as a functional neurosis. It may be correct so
to describe it in some cases ; but in the majority, the lines along
which it should be treated become much more clearly defined if it
is considered in its true light, namely, as one of the stigmata of
degeneracy. Most children who are the subjects of nocturnal
enuresis will, if carefully examined, be found to exhibit some, at
any rate, of the other recognised stigmata, such as facial asymetry,
ocular defects, rickets, cutaneous eruptions, adenoids, a tendency to
cretinism, infantilism, gigantism or epilepsy. As a general rule,
the more normal the child in other respects, the more intractable
to treatment will the enuresis prove to be.
In such, otherwise seemingly normal, children, successful treat-
ment depends upon (a) the discovery and removal of any source
of peripheral irritation to the nervous system, of which the most
common are intestinal worms, a tight prepuce, chronic constipation,
dental caries, nasal obstruction, and lastly, the most important
and that which is most frequently overlooked, namely, eye-strain,
(ft) Minute supervision of the general mode of life, such as
the avoidance of overclothing, sufficiency of exercise, suitability of
food. Fluids should be strictly limited three or four hours before
bedtime, and the child awakened and made to micturate, if possible,
within two hours of retiring. Tonics should be administered if
they seem to be required. The most efficacious in this condition
are undoubtedly Parrish's food and cod-liver oil. (c) The adminis-
tration of belladonna or its alkaloid, atropine. The latter is
regarded by many as the more reliable on account of its greater
uniformity. Professor Emmett Holt, of New York, extols a
solution of atropine ( gr. to the ounce of water), of which
one drop containing ^(^ gr. is given for every year of the
child's life. This dose is given at 4 p.m. and at 10 p.m. After
a week an extra dose is interpolated at 7 p.m. The dose is then
gradually increased until double the quantity is being taken.
When the physiological effects are produced the dose should be
gradually diminished. If the drug has been successful in controlling
j6 Nocturnal Enuresis.
the enuresis it must be continued for at least two months after the
last act of incontinence, (d) Simple suggestion, failing which,
hypnotic suggestion. If the child is old enough to be amenable
to simple suggestion, every effort should be made to encourage it
to educate and exercise the necessary control. Punishment of any
kind is wholly inadmissible. Hypnotic suggestion should be left
to experts.
In cases where nocturnal enuresis is accompanied by other
evidences of degeneracy the treatment is much more hopeful, for
the degeneracy itself will very frequently be found to depend upon
defect in the activities of one of the internal secretory glands.
That which is most commonly in fault is the thyroid, in which
case the enuresis will be associated with evidence of defective
development. The child will be undersized and weigh less than
the average for its age. Its temperature will be subnormal and
its pulse rate unduly slow. The bones, especially those of the jaws,
are unduly soft, giving rise to the open bite or to the high-arched
or gothic palate so often falsely attributed to adenoids. Adenoids
and enlarged tonsils may or may not be present. The mental
processes may be dull, more often however, except in extreme
cases, they are normal. The skin is generally very dry, and shows
chronic eruptions which are obstinate to treatment. The hair is
lustreless and badly developed. The eyebrows have a ' decided
tendency, which is more marked in fair children, to fail in develop-
ment in their outer thirds. In older children puberty is delayed.
Where these or other evidences of thyroid inadequacy co-exist with
the nocturnal enuresis treatment by thyroid extract or the salts of
calcium (which stimulate thyroid activity), or both, may be appealed
to with considerable confidence. Thyroid extract should be given
at first in very small doses. The tabloids sold by Messrs. Burroughs
Wellcome, containing gr., are generally very reliable. One
such tabloid may be given once a day to a child of five years,
and if well borne, may be repeated until the dose is being taken
three times a day. During the administration a careful watch
must be kept upon pulse rate, body weight and temperature. A
rise in all three, while of hopeful augury, proclaims that the dose
is sufficient, and all that is necessary is patience and perseverance.
If the weight falls the dose is excessive. As soon as the evening
temperature reaches normal caution is required, and in any case
the pulse rate must not be allowed to become unduly quick for the
child's age. It is, as a rule, well to suspend the drug for one week
in every month unless the patient is under very constant super-
vision. An excess of thyroid extract is almost as deleterious as
Nocturnal Enuresis. 77
an insufficiency, so that it is of the utmost importance that the
initial dose should he small, more especially as those suffering from
thyroid insufficiency are often at first very intolerant of thyroid
extract. During the period in which thyroid extract is being
administered, the occurrence of a nasal catarrh should be regarded
as an indication for the temporary cessation of the drug. The
thyroid gland is stimulated by calcium, arsenic and iodine. The
following mixture may therefore advantageously be given along
with the thyroid: 1^. Calcii lodid., gr. 2 ; Liq. Arsenicalis, ni2;
Tr. Nucis Vom., nil; Syrup Auranti, 5J ; Aquam, ad 388 [U.S.P.
Iy. Calcii lodid., gr. 2 ; Lig. Potassii Arsenitis, iii2; Tr. Nucis
Vom., ni 2 ; Syr. Aurantii, 5] ; Aquam, ad jss] ; M. Sig. ter.
die post cib. The above doses are suitable to a child of eight
years. Not infrequently, in cases of minor severity, this mixture
alone will be found to control the enuresis.
It must be admitted that, successful as the thyroid treatment is
in the vast majority of cases which show the stigmata of degenera-
tion, there are nevertheless a few such children in whom the enuresis
proves quite as intractable to this treatment as the otherwise
normal children above referred to. It is probable that in these
cases some internal secretion other than that of the thyroid is at
fault. Zanoni and Ferrari have used suprarenal extract with very
conspicuous success in children aged from four to fifteen years.
The doses employed were from twenty to thirty drops a day, but
the preparation is not specified. Pituitary gland has been tried
without any success. The experiments with thymus gland, on the
other hand, so far as they have gone, are encouraging. In cases
which resist thyroid treatment it is well to make trials of extracts
of some of the other internal secretory glands before having
recourse to atropine, which has very obvious disadvantages.
LEONARD WILLIAMS.
THYROID INADEQUACY.
THE thyroid gland may be congenitally wanting in vigour.
Such a gland, although it may be capable of supplying to the
economy enough of its peculiar essence to protect the individual
from cretinism or infantilism, may nevertheless fail to supply enough
to enable a child to develop along lines which are quite satisfactory.
This parsimony of tribute is a very strong predisposing cause, even
if it is not an active factor in the production of rickets, adenoids,
nocturnal enuresis, and similar affections of backward children, and
it probably accounts for the readiness with which some of these
children contract mumps, measles and other infectious diseases.
Unsatisfactory babies are usually deficient in thyroid; "delicate"
boys and girls are not infrequently so, and when the age of puberty
is reached the difficulties which so often ensue may in a large
number of cases be confidently attributed to this cause. In adults,
bad teeth, premature baldness or greyness, mental and physical
lethargy and certain types of obesity are some of the symptoms
which suggest thyroid inadequacy. The diagnosis is established if,
in addition to the so-called stigmata of the condition, the patient
presents an unduly slow pulse and a persistently subnormal tem-
perature. 1 The treatment is by administration of thyroid extract
(see p. 48).
LEONARD WILLIAMS.
EEFEREXCES.
1 "Thyroid Inadequacy," Folia Therapeutica, October, 1909, and "Thyroid
Insufficiency," Clin. Journ. 190910, XXXV., p. 167.
79
INJURIES AND DISEASES OF THE SPLEEN.
INJURIES OF THE SPLEEN.
Two types of injury to the spleen are to be met with clinically :
(1) Contusion of the spleen ; (2) laceration of the spleen tissue.
In order to form an opinion, and to be in a position to treat
a case, one will have to rely, to a great extent, on the history of the
case, paying special attention to the character of the injury and to
the agent which determines the lesion. These two sub-divisions,
although somewhat arbitrary, are yet extremely important clini-
cally, because in the first instance, rest, combined with strapping
the lower half of the left thorax, will very rapidly give relief,
whereas, in the more serious lesion of laceration, unless recourse is
had to immediate operation, the patient will inevitably die.
These injuries are not infrequently due to compression accidents,
such as are met with amongst railway employees or in large works,
where men are jammed against some resisting wall, etc., by a moving
object, or to direct blows over the organ, such, for example, as in
kicks or stabs. The cardinal points to be noted are great pain
accompanied by shock. To make a differential diagnosis between
contusion and laceration it is essential to observe very carefully
and frequently the facial characteristics and the pulse rate. On
the other hand, it is absolutely essential to exclude left renal injury.
This latter can easily be accomplished by establishing the presence
or absence of haematuria. In the case of the lacerated spleen
increasing dulness in the left hypochondrium will occur, whereas
if the lesion is renal the colon note persists whilst the flank
becomes fuller and more resistant.
It is evident from the foregoing that the treatment in the two
conditions must vary widely. In contusion, rest (both general
and local) is all that is required; in laceration, on the other hand,
operative interference at the earliest moment is imperative.
Operative procedure consists in either suturing the rents or com-
plete removal of the organ.
In case the practitioner is compelled to operate, owing to
circumstances from which he has no escape, the following method
should meet his requirements. After the administration of a general
anaesthetic the skin of the abdomen is prepared, and an incision is
8o Injuries of the Spleen.
made in the left semi-lunar line, commencing well above the
thoracic border ; the peritoneum is quickly reached and opened.
Blood and blood clots will readily escape. After sponging the
region in order to locate the ruptured parts and to facilitate
reaching the organ it is advisable to turn the patient towards the
right side, and by placing a sand-bag along the back to maintain
that position during the search for the rents. These can either be
sutured with catgut or be packed with gauze, after which the
wound is quickly closed up to the gauze, which is allowed to pro-
trude through it. Saline injections per rectum (1 pint every four
hours) will aid in combating shock.
ARTHUR CONNELL.
8i
SURGICAL TREATMENT OF DISEASES OF THE
SPLEEN.
"Wandering Spleen. This is a condition which causes dragging
pain and inconvenience, and if allowed to exist untreated, not
uncommonly gives rise to alarming symptoms of acute pain,
accompanied by vomiting, with marked tenderness of that part of
the abdomen occupied by the displaced organ.
This train of symptoms is brought about by torsion of the pedicle.
When the lesion occurs in the female beware of tight-lacing and
see to it that the corset is abandoned. The condition yields in
some early cases to a well-fitted abdominal support. If, however,
this does not answer, then it is necessary either to fix the spleen
(splenopexy) or to remove it, especially in cases where torsion of
the blood-vessels has taken place, as this condition is always
accompanied by a local peritonitis.
Cysts of the Spleen. These are uncommon; they may be in
order of frequency, hydatid, haemorrhagic or lymphatic. They give
rise to increase in the size of the organ and a tense swelling in the
left hypochondriac region. The only treatment is removal of the
spleen.
Abscess of the Spleen. This condition arises in connection
with some infective diseases, e.g., endocarditis, enteric fever, etc.,
and is most frequently due to an embolus. It causes painful
enlargement of the organ, with extreme tenderness in the left
hypochondrium. The abscess is dealt with by incision and
drainage, rarely by excision, as the patient is invariably in such a
critical condition from general toxemia that such a severe operation
'is contra-indicated.
Sarcoma of the Spleen. This is the primary neoplasm met
with ; it grows very rapidly and is very painful. Treatment is
immediate removal if the condition is recognised early.
Splenomegaly with Leucopenia and Progressive Anaemia.
The operation of splenectomy for this condition would appear to
be strongly indicated, as there are an increasing number of cases
in which a favourable result has been obtained (sec pp. 42 and 83).
ARTHUR CONNELL.
S.T. VOL. II. 6
82
SPLENOMEGALY.
UNDER the name of " splenomegaly " there are generally included
a group of diseases in which primary enlargement of the spleen is
associated with anaemia. The exact relationship of these maladies
to each other has not as yet been accurately determined. Primitive
splenomegaly, splenic anaemia and Banti's disease are often used
as synonymous terms.
Sir W. Osier describes three stages of Banti's disease. In the first
there is simple splenomegaly, in the second there is in addition
secondary anaemia, pigmentation of the skin and a tendency to
hsematemesis, in the third there is cirrhosis of the liver with
ascites. The term " Banti's disease " is most frequently applied to
cases in this third stage, in which cirrhosis of the liver and ascites
are associated with the splenomegaly and anaemia. The disease is
a very chronic one and may last for ten or even twenty years.
We know nothing as to the cause of the malady, so that treatment
is directed to the improvement of the general condition of the
patient and the relief of symptoms as they arise.
General Treatment. It is of much importance in this disease
to maintain the general condition of the patient at as high a level
as possible. Rest or only a limited amount of exercise should
be advised. Freedom from laborious occupation and w r orry should
be secured as far as possible according to the circumstances of the
patient. As much time as possible should be spent in the open-air,
preferably in a climate where the sun shines frequently. The food
should be good but plain and abundant. If the spleen is much
enlarged and causes discomfort in walking the support given by
a suitable belt will be helpful.
Medicinal Treatment. When the anaemia is well marked
arsenic and iron may be given. Liquor arsenicalis [U.S.P. Liquor
potassii arsenitis] may be prescribed in doses of 5 min. three times
a day. This dose may be gradually increased up to 7 or 10 min.
The results obtained by the use of arsenic are however not nearly
so striking as in spleno-medullary leukaemia. Haematemesis, when
it occurs, should be treated by rest in bed, rectal feeding for two or
three days and the administration of adrenalin chloride solution
(1 in 1,000) in 10-min. doses every two or three hours.
X-rays maybe applied to the spleen in just the same manner as
Splenomegaly. 83
in spleno-medullary leukaemia (q.v.). Beneficial effects have been
obtained by E inborn. As far as my own experience goes, however,
the diminution in the size of the spleen is only slight and not to be
compared with that which takes place in spleno-medullary
leukaemia.
Surgical Treatment has proved to be of great value in this
disease. In suitable cases the enlarged spleen can be removed
with a good prospect of a complete recovery taking place. In
thirty-two cases of operation collected by Armstrong there were
twenty-two complete recoveries (69 per cent.) and nine died after
the operation. The chief risks are from haemorrhage and shock.
As long as there is not a severe anaemia the risks of the operation
are probably well represented by the above series. After a
successful operation the anaemia disappears, the haemorrhages no
longer recur and the liver, if enlarged, decreases in size. In the
later stages of the disease when ascites has developed, it may be
treated by repeated tapping, or the operation introduced by Dr.
Drummond and Professor Morison, for the relief of ascites, may be
combined with splenectomy, as in a successful case recorded by
Tansini.
GEORGE R. MURRAY.
BEFEREXCES.
Hutchison, E., Allbutt and Rolleston's "System of Medicine," 1909, Vol. V.,
p. 777. Osier, Sir W. L., " Principles and Practice of Medicine," 7th ed., New
York and London, 1910, p. 762.
62
8 4
CHRONIC POLYCYTHJEMIA WITH CYANOSIS AND
ENLARGED SPLEEN.
THIS disease is characterised by an increase in the number of
the red corpuscles up to as many as 7 or even 12 millions per cubic
millimetre of the blood, and is a result of a morbid activity of the
erythroblastic function of the bone marrow. The blood is also
increased in volume and is more viscous than in health. The
spleen is enlarged and the skin and mucous membranes are
cyanosed.
The cause of the disease is unknown and so the treatment con-
sists chiefly in the avoidance of anything which may tend to
aggravate the condition and in the relief of sj'mptoms as they arise.
Improvement has been observed to follow spontaneous haemorrhages,
and Dr. F. P. Weber mentions that in a case under the care of Dr. T.
D. Acland bleeding was followed by temporary relief of symptoms.
The removal of (5 or 8 oz. of blood from time to time will there-
fore give some relief, but it is doubtful whether the course of
the disease can be materially affected by this treatment.
The amount of food, and more especially of red meats, should be
limited and no excessive eating permitted. Over-exertion must be
carefully avoided. No alcohol should be taken.
Removal of the spleen is not advisable, as the operation is
dangerous and of doubtful benefit. X-ray Treatment has on the
whole yielded the most satisfactory results, as in favourable cases
the spleen may decrease in size and the red blood corpuscles
diminish in numbers. The treatment is carried out in the same
manner as in leukaemia (q.v.).
Herschfeld advises the administration of iodides in these cases.
All preparations of iron or arsenic should be avoided. The head-
aches which are sometimes troublesome may be relieved by the use
of nitrites. A 3-min. capsule of amyl nitrite may be used for
inhalation ; a tablet containing T ^Q gr. of trinitin may be taken or
1 or 2 gr. of sodium nitrite may be given in an ounce of pepper-
mint water when the headache comes on.
GEORGE R. MURRAY.
BEFEREXCE.
Weber, F. P., Allbutt and Bolleston's " System of Medicine," 2nd ed., 1909,
Vol. V., p. 836.
DISEASES OF THE LIPS.
HARELIP.
THE only treatment is by operation, the edges of the cleft being
pared in a suitable manner and united by means of sutures.
Simple as the operation is, there are many points of detail to which
attention must be paid if a really good result is to be obtained.
The chief difficulties to be encountered are those connected with the
prominence of the premaxillary bone or bones, in cases in which
the harelip is associated with cleft in the palate.
Preliminary Considerations. Age at which the operation should
be jH'i-formed. Provided that the infant is otherwise healthy and
in good condition, the sooner the operation is performed the better.
It should certainly be performed within the first few weeks of
life, and there is no objection to its performance within the first
few days.
Owing to the inability of the infant to take the breast (except in
slight cases), it often happens that the subject of this deformity
wastes rapidly unless great care is exercised in feeding by artificial
means. A very early operation may prevent this if it enables the
child to be breast fed instead of hand fed. On the great advantage of
breast feeding whenever possible it is unnecessary to dwell. Many
a harelip infant is not seen by the surgeon until it is already in an
emaciated condition. Such children should not be operated on at
once. They should be carefully and judiciously fed with milk
(administered best by means of a spoon and very slowly), until a
better condition of nutrition is attained. Even a week or two of
careful preliminary feeding by a skilled nurse will often make all
the difference between success and failure of the subsequent opera-
tion. If an infant is so wasted and feeble that it is likely to die of
marasmus, the performance of any surgical operation will not
improve its chance of life. But careful feeding will do so, and will
frequently effect so much improvement in the general condition
that the operation may then be performed with every prospect of
success. Similarly, if the child is suffering from catarrh, diarrhoea,
or other infantile ailment, treatment should be directed to the cure
of these before operation is undertaken.
The main object of a harelip operation should be, not merely to
86
Harelip.
restore the lip to its normal condition as regards both height and
thickness, but also to insure that no notch is left either in the free
edge of the lip or, much more important, in the lower border of the
skin area.
But in most cases of harelip the deformity to be remedied involves
not only the lip but also the nostril. In cases of harelip associated
with complete cleft palate, and in a few others, the treatment of the
premaxillary bones also requires consideration. We will deal with
each of these three parts separately.
THE LIP.
Single Harelip. The edges of the cleft should be pared with a
very sharp knife in such a manner that the raw surfaces involve
the whole thickness of the lip.
If this is not done the lip will
afterwards be thin and unsightly
along the line of union.
In cases of incomplete harelip
it is rarely sufficient to pare
merely the edges of the actual
cleft. The incisions should be
prolonged upwards to the nostril
in the form of an inverted V, the
apex of which should be at the
margin of the nostril. The thin
and sometimes discoloured tissues
which often exist between the
nostril and the apex of the actual
cleft, should always be cut freely
away (Figs. 1, 2 and 3). An opera-
tion sometimes advised for incomplete harelip consists in making an
inverted V incision close to the margin of the cleft. This V is
thus converted into a diamond-shaped space by simply drawing
downwards the tissues below the incision. This operation affords
but a poor result, and is not to be recommended. "When the sides
of the diamond are sutured laterally an ugly prominence will be
found at the upper end of the line of union. The only cases in
which such an operation may be permissible are the very slight ones
in which just the edge only of the lip is cleft, and some few cases of
secondary operation in which, after a harelip has been sutured, a
small triangle of mucous membrane has been left by error projecting
upwards into the area of white skin. But even in these last com-
plete excision of the red triangle generally yields a better result.
FIG. 1. Single incomplete harelip.
Note the thinness of the tissues
below the right nostril.
Harelip. 87
Mere paring of the actual edge of a harelip is not enough. If
nothing more is done it will be found that after suture a notch has
been left in the lower margin of the lip. There are several methods
by which the occurrence of this notch may be avoided.
(1) The incision may be carried for some little distance downwards
and outwards beyond the actual cleft along the line of junction of
skin and mucous membrane. The incision is then turned sharply
inwards at an acute angle, cutting nearly transversely through the
red margin of the lip. By this means little triangles of red lip are
formed which when sutured together fill up the notch that otherwise
would be left.
(2) If these triangles of red tissue are not sufficient the lower part
of the incision should be carried for a short distance into the white
FIG. 2. Lines of incision.
FIG. 3. Single incomplete harelip,
showing bridge of normal tissues
above the cleft and lines of incision.
portion of the lip, before being turned inwards. The flap thus
formed is covered partly by skin and partly by mucous membrane.
In each case the longer limb of the incision should be equal to the
height of the normal skin-covered lip and mucous membrane.
(3) A similar object is attained by paring the sides of the cleft in
a curved direction. The incision in this case is carried with its
convexity outwards, with the substance of the lip well outside the
mucous margin of the cleft. The curved surfaces thus produced,
when straightened out, equal the vertical height of the normal lip.
By each of the above methods, two symmetrical flaps are formed,
one on each side of the cleft.
(4) Another method consists in cutting a single and somewhat
larger flap from one side only (Figs. 2 5). On the inner side of the
cleft the incision is made from the nostril downwards along the line
of junction of skin and mucous membrane, and thus carried in a
88
Harelip.
sloping direction towards the middle line at the free margin of the
lip. The whole of the paring is then removed. On the other
(outer) side of the cleft, the incision beginning at the nostril, is
FIG. 4. Single complete harelip.
FIG. 5. Lines of incision.
carried at first vertically downwards. It then slopes gradually
downwards arid outwards into the substance of the lip. At a point
some little distance above the lower margin of the skin it is turned
abruptly inwards and downwards to the free margin of the lip. A
FIG. 6. Double incomplete harelip.
FIG. 7. Lines of incision.
triangular flap covered partly by skin and partly by mucous
membrane is thus formed. The angular raw surface is then sutured
to the raw surface on the opposite side of the cleft. Whatever
method of incision is adopted, care must be taken to insure that
Harelip.
after suture the lower edge of the skin-covered area forms an
unhroken line.
Various other more complicated methods have been described by
which Z-shaped and other incisions have been used in the paring
of the edges. The sup-
posed object of most of
them is to enable the
edges of a wide cleft to
be brought together.
They are unnecessary,
and they leave irregular
unsightly scars.
It cannot be too
strongly insisted upon
that, if the cleft is wide,
it is by free undercutting
of the outer portions of
FIG. 8. Double complete harelip.
the lip and nostril that
relief of tension is to be
obtained, not by ingenious and complicated methods of paring the
edges. The curved incisions sometimes made through the skin and
round the lower margin of the aia of the nostril are never necessary.
Double Harelip. The incisions in this case have to be planned
so that the outer edges of the clefts can be united partly to each
other and partly to the central portion of the lip which remains
attached to the septum of the nostril.
This portion can generally be utilised
to form the upper part of the centre of
the new lip. If it is drawn too far down-
wards, the tip of the nose becomes de-
pressed in an unsightly manner (Figs.
G 9). Occasionally it is advisable to
dissect up this little flap of skin and
utilise it in the formation of a better
columna nasi. The outer sides of the
cleft are then united directly to each other. The paring of the outer
margins of the cleft is a little more complicated than in single harelip.
The best procedure is that of paring vertically downwards along
the skin margin until the red mucous lower border of the lip has
been reached. The upper twcvthirds of the flap thus formed is
then cut completely away. The lower third is turned downwards
and joined with its fellow of the opposite side to form the central
prominence of the lip.
FIG. 9. Lines of incision.
9 o
Harelip.
THE NOSTRIL.
In all cases of complete and in many of incomplete harelip the
nostril of the affected side is widened and flattened. In remedying
Right nostril
Bony edge of [
left nostril J
R. Maxilla
/"Inner surface
- of splayed
^ left nostril
~ Lip everted
- Incision for re-
flection of lip
and cheek
Premaxilla j \ L. Maxilla
Septum nasi L. turbinate bones
FIG. 10. Single complete harelip and cleft palate, showing on the left side the incision
for reflection of the lip and cheek. Cheek compressor shown on the left side only.
the deformity care must be taken to round up the nostril and so to
make it of the same shape as its fellow. To do this it is necessary
Raw surface of
pared lip
Intra-nasal suture
Raw surface of
pared lip
FIG. 11. Single complete harelip, showing pared edges and insertion of intra-nasal
suture.
to undercut the ala of the nostril and the neighbouring portion of
lip where it is attached to the gum.
The wider the cleft the more undercutting is necessary to enable
Harelip. 91
the parts to be brought together without undue tension. On the
inner (median) side of the cleft very little undercutting is desirable
or possible, since the soft tissues are thin and division of the artery
of the septum is apt to cause troublesome haemorrhage. The outer
margin of the cleft being everted, an incision is made in the
direction shown in Fig. 10. The edge of the knife must be kept
quite close to the bone to prevent undue haemorrhage, and the soft
parts of the lip, nostril and cheek dissected up as far as may be
necessary. Haemorrhage is checked by sponge pressure.
The point of the needle is first inserted on the inner aspect of the
ala and passed deeply into its substance (Fig. 11). The needle is then
carried across the cleft and passes in a similar manner through the
inner margin of the nostril. The soft tissue in this situation being
thin, it is often advisable to pass the suture deeply so as to include
part of the cartilaginous septum. When this suture has been tied,
the knot will lie wholly within the nostril. The ends should be cut
long so as to facilitate subsequent withdrawal. This suture should
be left in situ for several days, as it is very important that the
tissues which it unites should adhere firmly. Premature with-
drawal is likely to be followed by gaping of the wound. This
means an unsightly red area near the nostril and a permanent
widening of the nostril itself. The scar left by the suture, being
within the nostril, is not visible and is of no importance.
THE PREMAXILLARY BONES.
Single Harelip. In those cases in which the harelip is
associated with complete cleft plate the premaxillary bones project
forward, carrying with them the central portion of the lip. As a
rule, it is not necessary to do anything to replace these bones
(Figs. 12 14). Provided that the soft tissues on the outer
side of the fissure be undercut sufficiently, it will be possible to
bring the edge of the harelip together without undue tension.
But in some few cases of very marked projection of the bones and
unusually wide cleft it is desirable to attempt some reposition of
the bones. This is best done with a pair of bone forceps, the blades
of which are inserted between the maxillary and the premaxillary
of the unaffected side. By closing the blades very slowly the
tissues are partly cut and partly crushed, and the united pre-
maxillary bones are forced backwards towards the cleft in the
palate by a rotary movement of the forceps.
The chief objection to this proceeding is the damage which
is likely to be inflicted on the teeth and the consequent irregularity
in their subsequent eruption.
Harelip.
If the margins of the cleft in the alveolar margin can be closely
approximated it is sometimes advisable to pare them and to fasten
them together by means of
a stout, silver wire passed
through the bones. But
this proceeding is rarely
necessary, and is also open
to the objection above
mentioned, that of causing
damage to the teeth.
Double Harelip. The
bony deformity in these
cases is much more serious
and usually demands some
operative interference be-
fore the soft tissues of the
lip can be sutured (Fig. 15).
It may be dealt with by
operation (1) upon the pre-
maxillary bones themselves ;
(2) upon the septum.
(1) The easiest method
is that of removal of the
premaxillary bones. This,
although often performed,
is open to very serious ob-
jection. The loss of the bones leads to the falling together of the
neighbouring maxillaries, and a contracted, pointed arch ensues.
The unsupported upper lip falls in and
produces a most unsightly prominence of
the lower lip. A somewhat less unsatis-
factory result is produced by scooping out
the incisor teeth and leaving the rest of
the bones in situ. But here, too, the loss
of the teeth leads to more or less faulty
development of the alveolar arch.
(2) A better method is that of operat-
ing upon the septum, by removing a V-
shaped portion. The projecting pre-
maxillary bones can then be pushed back-
wards into the normal position. It is not necessary to remove any
of the soft tissues of the septum.
A straight incision about 1 inch long (see Fig. 16) is made
FIG. 12. Single complete harelip with marked
prominence of the premaxillary bones.
(From a photograph taken just before the
operation on the lip at the age of three
months. No attempt was made to replace
the projecting bones or to interfere with
them in any way.)
FIG. 13. Lines of incision.
Harelip.
93
***** ,
l
FIG. 14. The same patient nine
years later, showing that the pre-
maxillary bones have spontane-
ously returned to the normal posi-
tion and that there is no undue
falling in of the upper lip. (The
irregularity near the right nostril
is merely an accidental patch of
Herpes.)
along the anterior part of the
free lower margin of the septum.
With a raspatory the perios-
teum and the other soft tissues
are detached on each side. With
a pair of sharp-pointed bone
scissors a triangular piece of the
cartilaginous septum is then
removed. The piece of septum
removed must be large enough
to allow of the premaxillary bones
being pushed back into place.
This method is, on the whole,
the best for most really bad
cases of double harelip. The chief
objection to it is that owing to
the rotation of the bones the
incisor teeth when erupted tend
to project backwards towards the
cavity of the mouth. This irregularity must be corrected later by
ordinary dental means.
A method that I have of late years adopted in a few cases
with considerable success is that of
preserving the septum and pre-
maxillaries intact and uniting the
lip in front of them. But to do this
without producing undue tension
requires very free undercutting on
both sides, and the operation is not
always possible. It is generally best
when attempting this operation to
unite one side only of the lip at first
to the central portion. After a delay
of a few weeks it is usually possible
to close the remainder of the cleft
without causing too much tension.
The result obtained by this method
when it is successful is superior to
that of any other, as the falling in
of the upper lip is wholly avoided.
After - treatment. -- The best
dressing for a harelip operation is a
layer of flexible collodion. Over this
FlG. 15. Side view of a case of
double complete harelip and cleft
palate showing the usual projec-
tion of the premaxrllary bones,
and of the central portion of the
Up.
94 Harelip.
a dumbbell-shaped piece of strapping may be applied to relieve
tension. This should have broad ends which are applied to the
cheeks. The soft tissues of the lips and cheeks should be approxi-
mated with finger and thumb before the strapping is applied. The
strapping is apt to become sodden by secretions from the nose and
mouth, and may become a source of infection. For this reason,
especially in cases where there is not much tension, it is often
better to dispense altogether with its use.
The child should be fed with milk administered slowly and
carefully by means of a spoon.
One or more of the stitches should be removed on the third or
FIG. 16. The same case as Fig. 15 seen from below. The dotted
line shows incision for removal of a wedge of septum. Note the
usual deviation of the septum to one side. The mouth is held
open by a Smith's gag.
fourth day and the remainder of those in the skin a day or
two later. The stitch in the nostril and any that have been
inserted on the mucous surface may be left in situ for several days
longer. It should be remembered that stitches in the white skin
surface, if left more than three days, are likely to leave visible
scars. On the other hand, if they are removed prematurely the
edges of the wound are apt to separate.
SECONDARY OPERATIONS.
If within a few days of the operation separation of the line of
union has occurred in part or the whole of the wound, it may still
be possible at once to repair the mischief, at any rate partially.
Harelip. 95
One or more stitches should be passed through the lip and the
granulating surface again brought into apposition.
If the separation has been caused, however, as it usually has, by
marked septic infection of the raw areas, it is better to clean the
wound by means of some simple dressing, and to postpone further
operative measures until the parts have healed.
Most secondary operations for harelip are done at a later stage
for the improvement of a badly united harelip. The common
faults that most often require remedy are undue flattening of the
nostril, the occurrence of a notch or of a red triangle at the upper
or lower border of the lip, or an undue thinness of the lip along the
whole line of union.
In really bad cases where much deformity exists it is best to cut
right through the whole lip, excise the scar, and do the whole
operation over again. If the fault is merely the existence of a
small red triangle in the cutaneous area, it may suffice to excise
this, and to treat by one of the methods already described under
incomplete harelip.
Faulty union in the neighbourhood of the nostril usually requires
considerable reconstruction of the lip, with free undercutting of the
lip and nostril.
JAMES BERRY.
%* The Illustrations in this article are taken from Berry and Legg's "Hare-
Lip and Cleft- Palate."
OTHER AFFECTIONS OF THE LIPS.
AFFECTIONS of the lips other than congenital malformations may
conveniently be considered under three divisions : (1) Acquired
deformities ; (2) inflammatory affections ; (3) new growths (innocent
and malignant).
(1) Acquired Deformities demanding surgical treatment are
those due to (a) injuries of various kinds, including burns and those
produced by surgical operations for the removal of tumours ; (/>) 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 ; <S is the skin and subcutaneous tissue.
to the abdominal wall by four or five interrupted sutures which
penetrate the sere-muscular coat of the stomach and the parietal
peritoneum and rectus muscle (Fig. 9). The apex of the cone is
fixed in the second incision by four sutures passing through the skin
and anterior layer of the rectus sheath and the sere-muscular coats
of the stomach (Fig. 9). A nipple- like process of the stomach will
project above the level of the skin (Fig. 9). An opening sufficiently
large to take a No. 9 or 10 soft rubber catheter is made into it ;
the cut edge of the mucous membrane of the stomach is fixed by
122
180 Malignant Stricture of the (Esophagus.
two or three stitches to the opening in the peritoneal coat (Fig. 9).
The catheter is passed into the stomach, and it is a good plan to
anchor it by a stitch to the skin in order to prevent it being
displaced. The operation is completed by suturing the skin of the
first incision and putting on a collodion dressing. The patient
should be fed at once through the catheter with 4 or 5 oz. of
peptonised milk, with some brandy (gss to j) if necessary.
Senn's Method (Figs. 12, 13, 14, 15) is performed in the follow-
ing manner : A vertical incision, 2^ inches long, commencing just
below the costal arch, is made over the outer part of the left rectus
muscle (Fig. 12). The muscle fibres are separated and the
peritoneum being opened, the
stomach is sought for and iden-
tified by its smooth walls and
the attachments of the omenta
to its greater and lesser curva-
tures. When the organ is con-
tracted it may be very deeply
placed on the posterior abdom-
inal wall. A portion of stomach
midway between the two curva-
tures and as far from the pylo-
rus as possible, is selected and
brought up to or out of the wound
in the parietes and packed around
with gauze. A small incision
which will admit a No. 9 or 10
soft rubber catheter is made
FIG. 12. Senn's method of performing through all its coats ; the cathe-
gastrostomy. The site of the parietal .
incision is shown. ter is passed into the stomach
for 3 or 4 inches, and is fixed
to the margin of the opening by single silk or catgut stitch. At
a distance of \ i nen from the catheter a purse-string suture is
put in so as to form a circle round it (Fig. 13) ; this suture
passes through the sero-muscular coat, and as it is tightened,
the included portion of stomach and the catheter are pushed
inwards. A second purse-string suture is now introduced about
\ inch from the tube, and as it is tightened the stomach
and catheter are invaginated again. A third similar suture
may be required. The result is that a portion of the stomach
wall becomes invaginated into its cavity, the catheter being in
the centre of this portion (Fig. 15). Two stitches, which include
the parietal peritoneum and posterior sheath of the rectus on each
Malignant Stricture of the (Esophagus. 181
FIGJ13. Senn's method of perform-
ing gastrostomy. The stomach
has been opened and the catheter
has hoon passed into its cavity.
The stitch fixing the catheter to
the stomach is shown. The first
purse-string suture has been
inserted and is being tightened.
FIG. 14. Semi's method of perform-
ing gastrostomy. The purse-string
sutures have been tightened
around the catheter and the
stitches fixing the stomach to
the parietes have been inserted.
FIG. 15. Senn's method of performing gastrostomy. To show the
invaginated portion of the stomach around the catheter. The
position of the purse-string sutures is indicated.
side and a broad piece of the sero-muscular layer of the stomach,
are then inserted, one below and the other above the catheter
1 82 Malignant Stricture of the CEsophagus.
(Fig. 14). They fix the stomach to the parietal peritoneum and
prevent leakage into the general peritoneal cavity when the catheter
comes out. The superficial portion of the parietal incision is closed
in the usual way. The patient may be fed through the catheter at
the end of the operation with 4 or 5 oz. of peptonised milk and
some brandy. The stitch fixing the catheter generally loosens at
the end of ten days. The catheter may be withdrawn for cleansing
FIG. 16. Witzel's method of performing gastrostomy. The position of the
catheter lying in a groove on the anterior wall of the stomach is shown. The
folds forming the margins of the groove are being united by a continuous
suture, thus converting the groove into a canal lined throughout by
peritoneum.
purposes, but should always be replaced, as there is a tendency for
the opening to close.
Witzel's Method (Fig. 16). The catheter is buried for a dis-
tance of about 2 inches in a gutter on the stomach wall formed by
raising up a fold on each side of the instrument as it lies on the
peritoneal coat of the viscus. The eye-end of the catheter is placed
in the stomach through an opening at one end of the gutter and
the other end is brought out through the parietal incision. The
Malignant Stricture of the (Esophagus. 183
stomach is fixed to the parietes by one or two sutures beyond the
ends of the tube. It will thus be seen that the greater part of the
track leading to the stomach is lined by peritoneum and the catheter
must be kept always in position to prevent the surfaces of
peritoneum adhering to one another. The disadvantage of both
Senn's and Witzel's method is that the catheter must always be
kept in the opening, whereas in Frank's method it need only be
passed when the patient is fed.
After-Treatment. The feeding is carried out by means of a glass
funnel to which is attached a piece of rubber tubing, which is joined
to the catheter by means of a piece of glass tubing about 1 inch
long. The funnel is filled with the nutrient fluid, which is allowed
to slowly run into the stomach. At first 4 to 5 oz. of peptonised
milk with oz. of brandy may be given every four hours. It is
not necessary to disturb the dressing. Later, the amount of milk
may be increased by degrees to 12 oz. or more, if no discomfort is
caused. Eggs may be added, and thin gruel or Benger's food may
be given ; the peptonisation of the milk may be gradually
diminished. As soon as the patient is able to swallow he should
be encouraged to do so, provided coughing is not thereby set up.
Minced meat or fish, custard, bread and milk, etc., may often be
taken in the natural manner.
It is quite impossible to foretell the length of time the patient
will survive after the operation. The most promising case may
die suddenly from septic broncho-pneumonia due to perforation of
the growth into the air passages, while other patients in whom the
outlook appeared to be bad will live in comfort for months. The
writer has had one patient who lived comfortably for two years,
another for eighteen months, and several for six or seven months.
Other Methods of Treating Stricture of the CEsophagus.
Innocent fibrous strictures have been treated by injections of
fibrolysin ; it is doubtful if much benefit follows the use of this
preparation. Malignant stricture may be treated by radium. The
tube containing the salt is passed down to or into the stricture by
means of the oasophagoscope, and it is left in position for some
hours. More than one application will be required. Good results
have been reported though it is too early to be certain that they
are permanent.
T. P. LEGG.
1 84
INJURIES AND MALFORMATIONS OF THE
(ESOPHAGUS.
FOREIGN BODIES IN THE OZSOPHAGUS.
THESE are not at all infrequent ; masses of food, pins, needles, fish
bones, coins and tooth plates are met with from time to time. Large
bodies are most likely to be arrested where the canal is narrowest,
viz., at the upper and lower ends. Bagged irregular bodies may
become impacted and those with sharp projections, such as tooth
plates, are liable to penetrate the walls. Small bodies, such as
coins, may cause no symptoms, and unless impacted may be passed
onwards to the stomach. Pins, needles and fish bones which pene-
FIG. i.-
-(Esophageal forceps for the removal of foreign bodies high up
in the gullet.
trate the walls may lead to fatal haemorrhage or cause extensive
septic cellulitis in the neck and thorax.
The treatment to be adopted depends upon the nature of the
foreign body and the seat of its arrest. If possible, extraction
should be carried out through the mouth. Whenever the symptoms
are urgent and when the foreign body is impacted at the beginning
of the oesophagus, the mouth must be gagged open and the finger
passed rapidly to the back of the pharynx and hooked round the
foreign body, which is removed. If this is unsuccessful, various sorts
of forceps with different curves must be employed (Figs. 1 and 2) .
Foreign Bodies in the CEsophagus. 185
The throat may he painted with cocaine (10 per cent.) and a large
laryngoscope mirror and a bright illumination is a great help.
FIG. 2. Another form of oasophageal forceps.
Inversion and violent shaking may be tried if the patient is a child,
but these measures must not be attempted or prolonged in the
presence of severe dyspnoea. Laryngotomy or tracheotomy must
Kit;. :!. The umbrella or expanding probang. The upper figure shows the instru-
ment closed and the lower the bristles expanded by means of the handle at the
end of the instrument. At the other end a small round sponge is fixed.
then be performed and the attempts to remove the foreign body
postponed till respiration is re-established. When the symptoms
are not urgent, the foreign body should be localised by using X-rays
SCALE. "5
FIG. 4. The ordinary form of coin catcher. At one end is the cage
and at the other a small round sponge.
for such things as coins and tooth plates, the passage of the
oesophageal sound or by direct examination with a Briining's
cesophagoscope. Unless the foreign body is quite smooth or very
1 86 Foreign Bodies in the CEsophagus.
soft, it should not be pushed onwards into the stomach. If the
foreign body is small and pointed, e.g., a fish bone or a pin, it may
be removed by means of the umbrella or expanding probang
(Fig. 3), which is passed closed and by traction upon its upper
end, the horsehair is expanded. The instrument is then slowly
withdrawn carrying with it, in the expanded portion, the foreign
body. Coins which are usually arrested edgewise may be removed
by the coin-catcher (Fig. 4). The instrument is well lubricated
and passed gently down till its strikes the coin. The head of the
instrument is then manipulated past the coin and slowly withdrawn
after the coin has been caught in the cage. When the coin is high
up, it may possibly be removed by cesophageal forceps. A large
bolus of food or a plate of false teeth may be removed from the
up'per part of the oesophagus by forceps. When the foreign body
is irregular in shape and has sharp projecting edges, e.g., a tooth
plate, much difficulty may be experienced in removing it. It must
not be pushed onwards as great damage may be caused to the
O3sophageal walls. It may be impossible to reach it from the
mouth. An external operation is then required, cervical oeso-
phagotomy when the foreign body is in the upper part or gastrotomy
when it is in the lower part of the oesophagus. In such cases the
oesophagoscope may be employed instead of an operation to extract
the foreign body.
Cervical CEsophagotomy is performed through an incision
along the anterior border of the left sterno-mastoid. The incision
extends from the sternal notch to the level of the thyroid cartilage
and will be about 3 inches long in an adult. The sterno-mastoid
is retracted backwards and the omo-hyoid muscle is displaced
upwards or divided. The sterno-hyoid and sterno-thyroid muscles
are pulled inwards. The thyroid gland and trachea are displaced
towards the mid-line and the carotid vessels in their sheath are
retracted outwards. The oesophagus will be seen lying behind and
projecting into the wound on the left side of the trachea. Great
care must be taken not to damage the recurrent laryngeal nerve
which passes in front of the oesophagus to gain the groove between
this structure and the trachea. The foreign body may now be felt
in the oesophagus and a sufficiently long vertical incision should be
made over it to permit of its easy extraction. Suitable forceps are
introduced and the greatest care must be employed to avoid bruising
the oesophageal walls. If the foreign body is lower down, the incision
in the oesophagus must be held widely open so that a good view is
obtained of its position and the way it is lying ; a good bright light
is essential. Forceps are then introduced and seize the body,
Foreign Bodies in the CEsophagus. 187
which is carefully extracted. It may be necessary to divide the
foreign body by means of cutting forceps and remove each portion
separately. The oesophageal incision is closed by silk or catgut
sutures which do not involve the mucous membrane. A large
drainage tube must always be put down to the oesophagus at
the lower end of the neck incision. Provided free drainage is
arranged for through the superficial part of the wound, any leakage
through the oesophageal incision is unlikely to cause extensive
cellulitis and a permanent fistula is improbable.
After-treatment. The patient may be fed through a medium-
sized (No. 16) oesophageal tube or by a nasal tube passed three or
four times daily or rectal feeding may be employed for the first
three or four days. When there is no tendency for fluids to escape
through the wound liquids may be swallowed in the ordinary way.
The patient should be kept from the first in a sitting posture in
bed. The drainage tube is removed at the end of five or six days.
Gastrotomy. When the foreign body is low down, near to the
cardiac end of the oesophagus, the stomach may be opened suffi-
ciently freely to admit the hand through an abdominal incision. The
cardiac orifice is then stretched by the fingers or by dilators passed
upwards and the foreign body is removed by suitable forceps.
It is always advisable before doing an operation to remove a
foreign body, to be sure that it is still in the oesophagus, and
therefore a bougie should be passed, and, if possible, an X-ray
examination should be made immediately prior to operating. A
patient may have all the symptoms of a foreign body in the
oesophagus even though it has passed into the stomach. When it
has been passed into the stomach, and is small and not irregular
in shape, purgatives should be avoided and the patient should be
fed on porridge, bread and milk, and such like foods. The stools
should be examined carefully for the presence of the foreign body.
Briining's CEsophagoscope. During the last few years, this
instrument, which is fully described in Volume III., has been
more and more used to remove foreign bodies from whatever part
of the oesophagus they may be situated in. By its employment
the operative measures above described may be obviated, and this
is the most important practical point ; there is no wound to heal,
for as soon as the foreign body is removed the patient is well
again. The disadvantages are that the instrument is not always
at hand ; it is expensive and requires the use of an electric
accumulator or other apparatus for the illuminating lamp. More-
over, the foreign body may not be easily seen or recognised, it may
be hidden by blood or mucus ; or the instrument may be passed
1 88 Wounds of the CEsophagus.
by it and therefore it must be looked for both during the introduc-
tion and during the withdrawal, any blood and mucus being care-
fully mopped away. There may be a good deal of difficulty in
introducing the instrument, which should be passed from the side
of the mouth between the last molar teeth to the lateral wall of the
pharynx, the patient lying over on one side, with the head extended
and inclined to that side. A general anaesthetic will be necessary
and great gentleness must be employed so as to avoid lacerating
the mucous membrane, which would cause bleeding and thereby
obscure the view, and also so as not to perforate the oesophageal
walls. It may be impossible from the size and shape of the foreign
body to seize it or to remove it if it is impacted ; but, whenever
possible, before resorting to an external cutting operation, an
attempt should be made to remove the foreign body by this
instrument.
WOUNDS OF THE CESOPHAGUS.
Wounds may be inflicted from without or within. The former
are due to stabs, etc. If the injuries are not fatal from damage to
other structures, such as the great blood-vessels, the wound should
be thoroughly explored. It may occasionally be possible to close
the wound in the oesophagus by sutures, but whether this is done
or not, provision must be made for free drainage, as suppuration
frequently occurs.
Injuries from within are due usually to the presence of a foreign
body, or from swallowing some sharp or angular body, or the rough
passage of a bougie. The treatment has already been described.
BURNS OF THE CESOPHAGUS.
Burns are due to caustic fluids. If not immediately fatal, a
tight stricture follows from cicatrisation after the separation of the
sloughs. The stricture is often extensive and irregular in calibre
and is usually narrowest at the upper and lowest portions of the
oesophagus.
Treatment. The caustic must first be neutralised ; if it is an
acid, alkalies such as bicarbonate of soda or powdered chalk, should
be given ; if it is an alkali, dilute acetic acid (vinegar and water)
should be administered. Lemon juice and citric acid may also be
given. In neither case should a stomach tube or an emetic be
given. When the caustic is neutralised, olive oil (^ pint), or milk
and egg should be given. The next indication is to give the
oesophagus rest, and therefore at first, all food should be adminis-
Malformations of the (Esophagus. 189
tered by nutrient enemata. The pain is often severe and should
be relieved by morphia hypodermically ( gr.), or tr. opii (20 niin.)
[U.S.P 12 min.] in an ounce of glycerine and water may be pre-
scribed, a few drops being placed on the tongue and allowed to
trickle down the oasophagus.
Contraction is prevented by the passage of bougies. Only soft
instruments must be employed, and they should be first passed
in about three or four weeks. One of medium size should be
chosen and -the frequency with which they are to be passed will
depend on the degree of contraction. The bougie must be very
gently insinuated, and if much pain is produced, the patient may
swallow a few drops of the glycerine and opium mixture just
mentioned.
MALFORMATIONS OF THE OESOPHAGUS.
These are usually not amenable to treatment, with the exception
of the following.
Diverticula of the CEsophagus. These are similar to those
met with in the pharynx and are nearly always situated at the
upper end of the tube at its junction with the pharynx. The
diverticulum is usually placed on the postero-lateral and left
aspects of the oesophagus. It may exist for many years and tends
to enlarge owing to distension from the food which passes into it.
Treatment is by removal of the pouch, carried out through an
incision similar to that for oesophagotomy. After the pouch has
been removed, the oesophageal opening is closed by two rows of
sutures. A tube, passed through the mouth, for feeding the patient
may be left in situ till healing has taken place or nasal feeding may
be employed. The after-treatment is the same as for oasophagotomy.
T. P. LEGG.
190
DISEASES OF THE ALIMENTARY TRACT,
ABDOMEN AND PERITONEUM,
THE PRINCIPLES OF DIETETICS.
THE food supplies all the energy needed for the various activities
of the cells of the body ; it must, therefore, contain material which
is capable of oxidation in the body ; further, as living cells are
continually changing their own substance, the food must also
supply those elements which are necessary to replace that sub-
stance. The oxidisable materials of the food which can furnish
energy to the body are proteins, carbohydrates and fats. Protein
food is also needed for the structure of the tissues. Other
materials, such as mineral salts and water, furnish no energy, but
are essential for the maintenance of the structure and functions
of the body. Foodstuffs are subjected to digestion in order that
they may be offered to the mucous membrane of the intestine in a
form capable of absorption into the tissues.
Although the evolution of dietetic habits has led to the selection
by civilised man of foods which are, on the whole, easily digested
and absorbed, there are, nevertheless, differences in the complete-
ness with which food materials are absorbed. Analyses of the
faeces in patients fed upon different foods show that animal foods
are more fully utilised than vegetable. Thus from meats, milk,
cheese and eggs, 100 per cent, of the protein is absorbed, and
95 per cent, of the fat, and from milk and cheese 100 per cent, of
the carbohydrates ; whilst from vegetable flours and meals the
proportion is about 85 per cent, for protein and 95 per cent, for
carbohydrate. From coarse flour and from potatoes, cabbages
and turnips the percentage of protein absorbed is about 75 per
cent. In estimating, therefore, the value of a vegetable diet,
allowance must be made for the loss of 15 to 25 per cent, of the
protein. The reason for the loss is that the nitrogenous matter
of vegetables is mixed with masses of cellulose and starch, so that
the digestive juices cannot easily reach the protein and dissolve
it. With an ordinary mixed diet over 90 per cent, of the total
energy of the food is<used, with a fruitarian diet about 86 per cent.
Different individuals do not show much variation in the power
of digesting and absorbing food ; indeed, when the food has once
The Principles of Dietetics. 191
passed from the stomach into the intestines it appears to be
absorbed naturally, even though the patient observed may be the
subject of dyspepsia. The clinical term " indigestion " refers,
therefore, to the gastric symptoms which food may cause ; it does
not follow that digestion in the intestine is deficient. The
nutrition is poor in chronic dyspepsia because insufficient food is
taken, not because assimilation fails.
The proteins of the food are broken down in digestion into
smaller molecules, which apparently split after absorption into
a nitrogenous and a non-nitrogenous part. The molecules of the
nitrogenous part, if needed for the formation or the repair of
tissue, are built up into the protoplasm of the cells ; if not needed
for such purposes they are converted into urea and passed out
in the urine, together with the urea formed from the wear and
tear of tissue. The non-nitrogenous part is oxidised to furnish
energy to the body.
The fat of the food is either oxidised at once or is deposited in
the connective tissue cells in the fat depots under the skin, in the
omentum, about the kidneys and elsewhere ; before oxidation,
fats are converted, probably chiefly in the liver, into more complex
substances.
The carbohydrates are taken up from the portal vein as
dextrose and oxidised without great delay. A certain quantity
remains stored as glycogen in the liver and to a less extent in
other organs. The glycogen of the liver is reconverted to dextrose
before it is oxidised.
For the formation or repair of protein tissues nitrogenous food
is necessary. Fat can be formed from carbohydrate food, but
it is not clear at present whether it can be formed from protein.
Carbohydrate can be formed from protein and from fat, though
it is uncertain to what extent these transformations occur in
normal nutrition.
Each of the foodstuffs when burnt in a calorimeter gives out
a definite quantity of heat for every gramme burnt ; precisely
the same amount of energy is supplied to the tissues when the
foodstuff is fully oxidised in the body. The energy value of the
food may, therefore, be expressed in units of heat, or calories.
The amount of heat required to raise a gramme of water through
1 C. is called a small calorie. For dietetic purposes a thousand
of these small calories give a more convenient unit, the large
calorie or kilocalorie, and this unit is denoted when the term
" calorie " is employed in writings on diet. The heat values of the
different carbohydrates range from 3'7 to 4'2 kilocalories for each
The Principles of Dietetics.
gramme, the average in an ordinary diet being 4'1 ; the fats range
from 9'2 to 9'5, with an average of 9*3. As both fats and carbo-
hydrates are fully oxidised in the body these figures represent the
energy which they yield when taken as food. Proteins give an
average heat value of 5 '7 when burnt in a calorimeter, but they
do not give all of this to the body, because their end products,
namely, the urea and other nitrogenous substances in the urine,
are not fully oxidised and, therefore, still possess a heat value.
The subtraction of the heat value of these excreta from that of the
original protein gives a measure of the energy which the protein
food yields to the body and is known as the " physiological heat
value " of protein ; it is equal to 4'2 kilocalories for every gramme
of dry protein in animal food, and 3'9 in vegetable food, in which,
as we have seen, absorption is less complete. The average value
for protein in a mixed diet may be taken as 4'1 kilocalories per
gramme. Hence, in an ordinary diet,
1 gramme of dry protein gives 4'1 kilocalories of energy.
1 fat 9-3
1 ,, ,, dry carbohydrate ,, 4-1 ,,
COMPOSITION OF FOODS.
The composition of the chief foodstuffs is given in the following
table, which is compiled from the analyses of At water and Bryant.
The last column of the table gives the physiological heat value of
a pound of the food :
TABLE I.
Chemical Composition of Food Materials.
In all cases the edible portion of the food is referred to.
Food Materials.
Wat*r.
Protein.
.\\.-.-i-;..
Fat
Total
Carbo-
hydrates.
Ash.
Fuel value
per pound.
ANIMAL FOOD.
Per
Per
Per
Per
Per
Cals.
Beef, fresh
cent.
cent.
cent.
cent.
cent.
Ribs, lean
71-3
19-5
8-3
1-0
715
medium fat
62-7
18-5
18-0
1-0
1,105
fat
52-0
16-5
31-1
0-8
1,620
Round, medium fat .
65-5
20-3
13-6
:
1-1
950
Sweetbreads, as pur-
chased
70-9
16-8
12-1
1-6
825
Tongue .
70-8
18-9
9-2
1-0
740
Beef, cooked
Roast
48-2
22-3
28-6
1-3
1,620
Loin Steak
54-8
23-5
20-4
1-2
1,300
Beef, corned
Corned Beef .
51-8
26-3
18-7
4-0
1,280
Tongue, whole
51-3
19-5
23-2
4-0
1,340
The Principles of Dietetics.
193
Food Materials.
Water.
Protein.
NX 0-25.
Fat.
Total
Carbo-
hydrates.
Ash.
Fuel value
perjKJund.
ANIMAL FOOD contd.
Per
Per
Per
Per
Per
/~i i
Veal, fresh
cent.
cent.
cent.
cent.
cent.
Cals.
Loin, medium fat
68-9
20-5
10-4
1-0
820
Liver
73-0
19-0
5-3
1-3
575
Lamb, fresh
Forequarter
55-1
18-3
25-8
1-0
1,430
Lamb, cooked
Chops, broiled.
47-6
21-7
29-9
1-3
1,665
Mutton, fresh
Leg, hind, medium fat
62-8
18-5
18-0
1-0
1,105
Shoulder, medium fat
61-9
17-7
19-9
0-9
1,170
Mutton, cooked
Leg, roast
50-9
25-0
22-6
1-2
1,420
Sheep's Kidneys
78-7
16-5
3-2
1-3
440
Pork, fresh
Ham
50-1
15-7
33-4
0-9
1,700
Loin Chops
50-7
16-4
32-0
0-9
1,655
Liver
71-4
21-3
4-5
1-4
1-4
615
Pork, pickled, salted
and smoked
Ham, smoked, me-
dium fat
40-3
16-3
38-8
4-8
1,940
Bacon, smoked, lean
31-8
15-5
42-6
11-0
2,085
Bacon, smoked, me-
dium fat
18-8
9-9
67-4
4-4
3,030
Bacon, smoked
20-2
10-5
64-8
5-1
2,930
Sausage
Pork
39-8
13-0
44-2
1-1
2-2
2,125
Poultry and Game,
fresh
Chicken .
74-8
21-5
2-5
1-1
505
Fowls
63-7
19-3
16-3
1-0
1,045
Goose, young .
46-7
16-3
36-2
0-8
1,830
Turkey .
55-5
21-1
22-9
1-0
1,360
Poultry and Game,
cooked
Capon
59-9
27-0
11-5
1-3
985
Turkey, roast .
52-9
27-8
18-4
1-2
1,295
Turkey, roast, light
and dark meat and
stuffing
65-0
17-1
10-8
5-5
1-6
870
Fish, fresh -
Cod, whole
82-6
16-5
0-4
1-2
325
Eels, salt water (head,
skin, and entrails
removed)
71-6
18-6
9-1
1-0
730
Hake (entrails re-
removed)
83-1
15-4
0-7
1-0
315
Haddock (entrails
removed)
81-7
17-2
0-3
1-2
335
Halibut, steaks
75-4
18-6
5-2
1-0
565
Herring .
72-5
19-5
7-1
1-5
660
Mackerel
73-4
18-7
7-1
1-2
645
Mullet .
74-9
19-5
4-6
1-2
555
Salmon .
64-6
22-0
12-8
1-4
950
S.T. VOL. II.
13
194
The Principles of Dietetics.
Food Materials.
Water.
Protein.
NX 6-25.
Fat.
Total
Carbo-
hydrates
Ash.
Fuel value
per pound.
ANIMAL FOOD contd.
Per
Per
Per
Per
Per
Polo
Fish, fresh contd.
cent.
cent.
cent.
cent.
cent.
i^ais.
Smelt .
79-2
17-6
1-8
1-7
405
Trout, brook .
77-8
19-2
2-1
1-2
445
Turbot .
71-4
14-8
14-4
1-3
885
Fish, preserved and
canned
Haddock, smoked
72-5
23-3
0-2
3-6
440
Herring, smoked
34-6
36-9
15-8
13-2
1,355
Mackerel, salt, dres-
sed
43-4
17-3
26-4
12-9
1,435
Salmon, tinned
63-5
21-8
12-1
2-6
915
Sardines, tinned
52-3
23-0
19-7
5-6
1,260
Shellfish, etc., fresh
Crabs
77-1
16-6
2-0
1-2
3-1
415
Crayfish, abdomen .
81-2
16-0
0-5
1-0
1-3
340
Lobster .
79-2
16-4
1-8
0-4
2-2
390
Mussels .
84-2
8-7
1-1
4-1
1-9
285
Oysters .
86-9
6-2
1-2
3-7
2-0
235
Scallops .
80-3
14-8
o-i
3-4
1-4
345
Turtle, green .
79-8
19-8
0-5
1-2
390
Lobster, tinned
77-8
18-1
1-1
0-5
2-5
390
Eggs
Hens', uncooked
73-7
13-4
10-5
1-0
720
,, boiled .
73-2
13-2
12-0
0-8
765
boiled whites
86-2
12-3
0-2
0-6
250
boiled yolks .
49-5
15-7
33-3
1-1
1,705
Dairy Products, etc.
Butter .
11-0
1-0
85-0
3-0
3,605
Cheese, Cheddar
27-4
27-7
36-8
4-1
4-0
2,145
Cheshire
37-1
26-9
30-7
0-9
4-4
1,810
,, American,
pale
31-6
28-8
35-9
0-3
3-4
2,055
American,
red .
28-6
29-6
38-3
3-5
2,165
Dutch
35-2
37-1
17-7
10-0
1,435
,, Limburger .
42-1
23-0
29-4
0-4
5-1
1,675
Eoquefort .
39-3
22-6
29-5
1-8
6-8
1,700
Swiss .
31-4
27-6
34-9
1-3
4-8
2,010
Milk, condensed,
sweetened .
26-9
8-8
8-3
54-1
1-9
1,520
whole
87-0
3-3
4-0
5-0
0-7
325
,, skimmed
90-5
3-4
0-3
5-1
0-7
170
Whey .
93-0
1-0
0-3
5-0
0-7
125
Miscellaneous
Gelatine .
13-6
91-4
o-i
2-1
1,705
Calf's-foot Jelly
77-6
4-3
17-4
0-7
405
Lard, unrefined
4-8
2-2
94-0
0-1
4,010
The Principles of Dietetics.
195
Food Materials.
Water.
Protein.
Fat.
Total
Carbo-
liyilrati's,
including
Fibre.
Ash.
Fuel value
per pound.
VEGETABLE FOOD.
Per
Per
Per
Per
Per
/~i i
Flours, Meals, etc.
cent.
cent.
cent.
cent.
cent.
Cals.
Barley meal and flour
11-9
10-5
2-2
72-8
2-6
1,640
Barley, pearled
11-5
8-5
1-1
77-8
1-1
1,650
Corn flour
12-6
7-1
1-3
78-4
0-6
1,645
Corn Preparations
Hominy
11-8
8-3
0-6
79-0
0-3
1,650
Oatmeal
7-3
16-1
7-2
67-5
1-9
1,860
boiled
84-5
2-8
0-5
11-5
0-7
285
gruel
91-6
1-2
0-4
6-3
0-5
155
Rice .
12-3
8-0
0-3
79-0
0-4
1,630
,, boiled .
72-5
2-8
o-i
24-4
0-3
525
,, flaked .
9-5
7-9
0-4
81-9
0-3
1,685
Wheat Flour, Cali-
fornia fine
13-8
7-9
1-4
76-4
0-5
1,625
Wheat Flour, en-
tire wheat
11-4
13-8
1-9
71-9
1-0
1,675
Wheat Preparations
Shredded
8-1
10-5
1-4
77-9
2-1
1,700
Macaroni
10-3
13-4
0-9
74-1
1-3
1,665
,, cooked .
78-4
3-0
1-5
15-8
1-3
415
Vermicelli .
11-0
10-9
2-0
72-0
4-1
1,625
Bread, Biscuits, Pastry,
etc.
Bread, brown .
43-6
5-4
1-8
47-1
2-1
1,050
Rolls, French .
32-0
8-5
2-5
55-7
1-3
1,300
Vienna .
31-7
8-5
2-2
56-5
1-1
1,300
Toasted Bread
24-0
11-5
1-6
61-2
1:7
1,420
White Bread .
35-3
9-2
1-3
53-1
1-1
1,215
Gingerbread
18-8
5-8
9-0
63-5
2-9
1,670
Sponge Cake .
15-3
6-3
10-7
65-9
1-8
1,795
Lady Fingers .
15-0
8-8
5-0
70-6
0-6
1,685
Macaroons
12-3
6-5
15-2
65-2
0-8
1,975
Pie, apple
42-5
3-1
9-8
42-8
1-8
1,270
,, mince
41-3
5-8
12-3
38-1
2-5
1,335
Pudding, tapioca
64-5
3-3
3-2
28-2
0-8
720
Sugar, Starches, etc.
Honey .
18-2
0-4
81-2
0-2
1,520
Starch, arrowroot
2-3
97-5
0-2
1,815
sago
12-2
9-0
0-4
78-1
0-3
1,635
,, tapioca
11-4
0-4
o-i
88-0
o-i
1,650
Vegetables
Artichokes
79-5
2-6
0-2
16-7
1-0
365
Asparagus
94-0
1-8
0-2
3-3
0-7
105
Beetroot, fresh
87-5
1-6
o-i
9-7
1-1
215
Cabbage
91-5
1-6
0-3
5-6
1-0
145
Carrots, fresh .
88-2
1-1
0-4
9-3
1-0
210
Cauliflower
92-3
1-8
0-5
4-7
0-7
140
Celery
94-5
1-1
o-i
3-3
1-0
85
Cucumber
95-4
0-8
0-2
3-1
0-5
80
Leeks
91-8
1-2
0-5
5-8
0-7
150
Lentils, dried .
8-4
25-7
1-0
59-2
5-7
1,620
Lettuce .
94-7
1-2
0-3
2-9
0-9
90
Mushrooms
88-1
3-5
0-4
6-8
1-2
210
13-
196
The Principles of Dietetics.
Food Materials.
Water.
Protein.
Fat
Total
Carbo-
hydrates,
including
Fibre.
Ash.
Fuel value
per pound.
VEGETABLE FOOD contd.
Per
Per
Per
Per
Per
r^ rt irt
Vegetables contd.
cent.
cent.
cent.
cent.
cent.
Lais.
Onions, fresh .
87-6
1-6
0-3
9-9
0-6
225
Parsnips
83-0
1-6
0-5
13-5
1-4
300
Peas, green
74-6
7-0
0-5
16-9
1-0
465
dried
9-5
24-6
1-0
62-0
2-9
1,655
Potatoes, raw .
78-3
2-2
o-i
18-4
1-0
385
Potatoes, cooked,
boiled
75-5
2-5
o-i
20-9
1-0
440
Potatoes, cooked,
chips .
2-2
6-8
39-8
46-7
4-5
2,675
Potatoes, cooked,
mashed & creamed
75-1
2-6
3-0
17-8
1-5
505
Eadishes
91-8
1-3
o-i
5-8
1-0
135
Rhubarb
94-4
0-6
0-7
3-6
0-7
105
Spinach, fresh
92-3
2-1
0-3
3-2
2-1
110
Tomatoes, fresh
94-3
0-9
0-4
3-9
0-5
105
Turnips .
89-6
1-3
0-2
8-1
0-8
185
Vegetables, tinned
Peas, green
85-3
3-6
0-2
9-8
1-1
255
Tomatoes
94-0
1-2
0-2
4-0
0-6
105
Pickles, Condiments,
etc.
Olives, green .
58-0
1-1
27-6
11-6
1-7
1,400
ripe .
64-7
1-7
25-9
4-3
3-4
1,205
Pickles, mixed
93-8
1-1
0-4
4-0
0-7
110
Fruits, Berries, etc.,
fresh
Apples .
84-6
0-4
0-5
14-2
0-3
290
Apricots .
85-0
1-1
13-4
0-5
270
Bananas .
75-3
1-3
0-6
22-0
0-8
460
Blackberries .
86-3
1-3
1-0
10-9
0-5
270
Cherries .
80-9
1-0
0-8
16-7
0-6
365
Cranberries
88-9
0-4
0-6
9-9
0-2
215
Currants .
85-0
1-5
12-8
0-7
265
Figs, fresh
79-1
1-5
18-8
0-6
380
Grapes .
77-4
1-3
1-6
19-2
0-5
450
Oranges .
86-9
0-8
0-2
11-6
0-5
240
Pears
84-4
0-6
0-5
14-1
0-4
295
Pineapple
89-3
0-4
0-3
9-7
0-3
200
Plums
78-4
1-0
20-1
0-5
395
Strawberries .
90-4
1-0
0-6
7-4
0-6
180
Watermelons .
92-4
0-4
0-2
6-7
0-3
140
Fruits, dried
Apples .
28-1
1-6
2-2
66-1
2-0
1,350
Apricots.
29-4
4-7
1-0
62-5
2-4
1,290
Currants
17-2
2-4
17
74-2
4-5
1,495
Dates
15-4
2-1
2-8
78-4
1-3
1,615
Figs
18-8
4-3
0-3
74-2
2-4
1,475
Prunes .
22-3
2-1
73-3
2-3
1,400
Raisins .
14-6
2-6
3-3
76-1
3-4
1,605
Peaches .
88-1
0-7
0-1
10-8
0-3
220
Pears
81-1
0-3
0-3
18-0
0-3
355
The Principles of Dietetics.
197
Food Materials.
Water.
Protein.
Fat.
Total
Carbo-
hydrates,
including
Fibre.
Ash.
Fuel value
perpuiuul.
VEGETABLE FOOD contd.
Nuts-
Per
cent.
Per
cent.
Per
cent.
Per
cent.
Per
cent.
Cals.
Almonds
4-8
21-0
54-9
17-3
2-0
3,030
Brazil Nuts
5-3
17-0
66-8
7-0
3-9
3,265
Chestnuts, fresh
45-0
6-2
5-4
42-1
1-3
1,125
dried
5-9
10-7
7-0
74-2
2-2
1,875
Cocoanuts
14-1
5-7
50-6
27-9
1-7
2,760
Filberts ..
3-7
15-6
65-3
13-0
2-4
3,290
Walnuts .
2-5
18-4
64-4
13-0
1-7
3,300
Miscellaneous
Chocolate
5-9
12-9
48-7
30-3
2-2
2,860
Cocoa
4-6
21-6
28-9
37-7
7-2
Table II. will enable the reader to see at a glance which foods
owe their energy value mainly to protein, which to carbohydrate,
and which to fat. It will be noted that milk occupies a fair
place in each of the three lists.
TABLE II.
Common Foods Arranged in Order according to their Value
in Protein, Carbohydrate and Fat.
Percentage of Total Heat Value
of Food Furnished by its
Protein.
Percentage of Total Heat Value
of Food Furnished by its
Fat.
Percentage of Total Heat Value
of Food Furnished by its
Carbohydrate.
P.c.
P.O.
P.c.
Lean beef (boiled]
. 90
Butter
99
Tapioca (cooked) 98
Chicken
. 79
Bacon
94
Prunes (dried) . 97
Mackerel
. 50
Cream
87
Figs (dried) . 95
Skim milk
. 37
Brazil nuts
86
Rice (boiled) . 89
Eggs .
. 32
Fat ham .
81
Oysters . . 89
Beef with fat
. 25
Fat beef
75
Potatoes (boiled) 88
Cheese
. 25
Cheese
73
Bread . .81
Fat ham
. 19
Eggs
68
Peas. . . 72
Milk .
. 19
Boiled mutton .
65
Milk . . 29
Bread .
. 13
Milk
52
Cream . . 8
Potatoes
. 11
Mackerel .
50
Brazil nuts . 4
Boiled rice .
. 10
Chicken
21
Cheese . . 2
Brazil nuts .
. 10
Boiled lean beef.
10
Bacon .
6
Bread . ' .
6
Cream .
5
Bananas .
5
Bananas
5
Potatoes .
1
Butter .
. -5
In Table III. representative foods are arranged in order
according to their total energy value.
198
The Principles of Dietetics.
TABLE III.
Common Foods in Order of their Caloric Value.
Amount con-
Amount con-
taining 100
taining 100
Cals. in
Cals. in
Ounces.
Ounces.
Butter
0-4
Mackerel .
2-0
Brazil nuts
0-5
Eggs
2-1
Bacon
0-5
Boiled rice
3-1
Cheese
0-8
Chicken
3-2
Sugar
0-9
Baked apples
3-3
Fat ham
1-0
Bananas .
3-5
Beef or mutton with fat
1-2
Boiled potatoes .
3-6
Bread
1-3
Milk
4-9
Cream
1-7
Apples (raw)
7-3
The following table (from Hutchison) shows (1) the amount of
food value ; and (2) the amount of protein which can be bought
for a shilling in ordinary foodstuffs.
cals. of
energy,
supplies 10,764
8,921
3,796
3,000
2,884
2,856
2,638
953
839
829
grammes
of protein.
supplies 572
283
272
218
127
114
79
54
27
3-5
It is seen that bread holds the first place for energy value,
and dried peas for protein.
Cooking destroys bacteria and makes food nicer. It may or
may not render it easier of digestion. Cooked meat is slightly
less digestible than raw. If it is cooked by any form of dry heat
TABLE IV.
(i)
1 shillingsworth of Bread at l^d. per Ib.
Peas 2d.
5>
Potatoes
Id. .
Milk
\\d. per pint
Butter
1/3 per Ib.
Apples
Id.
>
Cheese
6d.
J>
Fish
4d.
Eggs
I/ per dozen
Beef
9d. per Ib.
(2)
J>
, Peas .
. .
, Bread
.
, Cheese
. .
J>
Fish .
. .
Beef .
t
>
Milk .
-T-\
.
>
Eggs .
. .
>
, Potatoes
. .
)
, Apples
. .
,
, Butter
.
The Principles of Dietetics. 199
its nutritive properties remain about the same ; if boiled, some,
though not much, of the food material passes into the broth, but is
not wasted if the broth is used for soup. The cooking of vegetables
renders them more digestible by breaking up the starch grains.
It is most economical to steam and not to boil them, for in boiling
quite a large fraction of the nutritive material, a quarter or more
in the case of cabbages and carrots, is extracted. With potatoes,
the loss is least when they are boiled in their skins, and greatest
when they are peeled and soaked in water before cooking.
The study of the amount of food needed by a healthy person
in different circumstances has yielded much matter of scientific
and economic interest. I need not go into the subject in detail
here, because in the dietetics of ordinary practice when a suffi-
ciency of suitable food is available the appetite of each individual
tells him how much food he requires.
The main considerations affecting the quantity and quality
of the diet in health may be summarised under the headings of :
(1) The total food value needed, as affected by (a) build ; (6) rest
or activity ; (c) climate. (2) The proportion of the different
foodstuffs required, (a) protein ; (6) carbohydrates ; (c) fat.
(1) The total food value needed must be sufficient to maintain
the temperature of the body and supply the energy needed for
the work of the muscles and other organs. It will vary with
(a) the build of the individual. Firstly, it must be proportional
to the weight, for a large man will require more food, other things
being equal, than a small one ; secondly, it must vary with the
extent of surface, for the loss of heat from the body is much greater
in a thin person with a large surface relative to the weight than in
a stouter, more spherical person with a small surface relative to
the weight. Thin babies and thin children often require a large
amount of food on this account.
As regards the average food requirement, a person living a
quiet, non-muscular life needs about 35 kilocalories for every
kilogramme of body weight (a kilogramme is 2 Ibs. 3 oz.). This
is supplied by 4| pints of milk, or by 1 Ib. 2 oz. of bread and 8 oz.
of meat. A man living a life of ordinary activity takes about
40 calories per kilogramme, that is 3,000 calories for a man of
11 stone.
(6) The influence of rest and activity. If much muscular work
is done the total amount of food must be increased in proportion
to supply the necessary energy. Men engaged in especially hard
and continuous labour have been observed to take 5,000 to 7,000
calories in the day. The requirements of ordinary labour are
2oo The Principles of Dietetics.
met by adding about 1,000 calories to the diet, thus raising its
value from 3,000 to 4,000 calories.
A person resting entirely in bed needs, on the other hand, less
food : about two- thirds of that taken by an individual* leading
a sedentary life is enough, that is, about 25 calories a kilogramme,
which for a person of 8 stone is supplied by 3 pints 2 oz. of milk,
or by 13 oz. of bread and 5^ oz. of meat. Even with the most
complete inactivity in bed a fair supply of food is needed to
maintain the indispensable activities of the organs of respiration,
circulation, digestion, secretion and excretion, without which life
cannot be supported. If the supply of food is insufficient the
body draws upon its tissues and weight is lost.
(c) The effect of climate. In cold climates the loss of heat from
the body is increased and more food is needed, whilst in tropical
countries the reverse is the case. These differences are neutralised
to a large extent by the clothing, which is varied so that the skin
is kept at approximately the same temperature.
(2) The proportion of the different foodstuffs required. -
(a) Protein. Most people who can choose their food select a diet
which contains not less than 100 grammes (3| oz.) of dry protein
in the day. Only in conditions of poverty does the amount taken
by workers fall below 80 to 90 grammes. Many people take much
more than 100 grammes ; for instance, 150 grammes in the day.
The minimum amount necessary to make good the wear and tear
of the tissues is probably about 50 grammes. Some observers,
following Chittenden, believe that it is unnecessary and even
harmful to exceed this amount. The balance of opinion is,
however, in favour of an allowance midway between extremes,
namely, about 100 grammes a day. Both in man and animals the
most active and successful races take a fair quantity of protein
food.
As examples of these figures, the following diets may be quoted :
(1) A diet taken by Chittenden containing about 50 grammes
of protein : Milk, 2| oz. ; cream, 5 oz. ; sugar, 1 oz. ; biscuit,
3 oz. ; bread, 2| oz. ; butter, ^ oz. ; meat pie, 7| oz.
(2) A diet containing 90 grammes of protein : Bread, 19 oz. ;
meat, 4 oz. ; potatoes, 8 oz. ; milk, 1 pint ; butter. 1 oz. ; milk
pudding, 4 oz. ; tea, 1 pint. Total, 2,300 calories.
(3) A diet containing 130 grammes of protein: Bread, 16 oz. ;
beef, 10 oz. ; potatoes, 16 oz. ; milk, 1 pint ; butter, 1 oz. ;
oatmeal, 4 oz. ; sugar, 3 oz. Total 3,500 calories.
The energy required for muscular work is not, however, supplied
from protein, but from the oxidation of non-nitrogenous material,
*
The Principles of Dietetics. 201
which may be derived from carbohydrate or fat. When,
therefore, a large amount of muscular work has to be done, the
bulk of the energy may be supplied by the addition of these
foodstuffs to the diet. But, as a matter of fact, those doing
severe work alw r ays take care to add considerably to the protein
of their food as well as to the carbohydrate and fat. Horses
can do more work, and do it more quickly, on beans, which are
rich in protein, than on hay. Hence it is probably wise to
increase the protein also to a moderate extent.
(a) A large excess of prot ein should be avoided. An exclusive diet
of protein cannot be taken for long without causing disturbances
of digestion. Unless fat is added to the diet, it would be difficult
to take and digest enough to supply the caloric needs. When a
mixed diet is changed to a protein or' to a protein and fat diet,
diacetic acid and acetone usually occur in the urine, from the
incomplete oxidation of fats (see article on Diabetes ^ellitus).
Some races, however, exist on a diet of protein and fat.
(6) Carbohydrate. The bulk of the food is most conveniently
and most cheaply made up of carbohydrate food. In an average
diet containing 100 grammes of protein of a caloric value of 410
calories, the balance of 2,000 to 2,500 calories would be supplied
by carbohydrate and by fat, chiefly the former.
(c) Fat has the advantage that it is a more concentrated food
than carbohydrate, since weight for weight it supplies more than
twice as much energy as carbohydrate. On the other hand,
there is a definite limit to the amount which most people can
stomach, and it is more expensive than starchy foods ; for the
latter reason, fat is commonly deficient in the dietary of the very
poor. The ideal diet should contain about as much fat as protein,
say 100 grammes of each, the remainder of the energy needs being
supplied by carbohydrate.
An average diet for a man of 11 stone would contain :
Protein . .100 grammes 410 kilocalories
Fat . . 100 930
Carbohydrate . 360 1,480
2,20
This gives for every kilogramme of bodyweight 40 kilocalories
of energy and T4 gramme of protein. It is contained in :
Bread, 1 Ib. ; meat, 4 oz. ; eggs, 4 oz. (two small ones) ; cheese,
2 oz. ; potatoes, 1 Ib. ; butter (or other fat), 2 oz. ; milk, pint ;
sugar, \ oz. ; tea, coffee.
2O2 The Principles of Dietetics.
The ordinary diet at St. George's Hospital for an average
weight of 9| stone is : Bread, 12 oz. ; meat, 6 oz. ; potatoes,
| Ib. ; butter, 1 oz. ; milk, 1 pint ; sugar, 1 oz. ; milk pudding,
8 oz. ; soup, 1 pint.
DIET IN CHILDHOOD.
In childhood a larger amount of food is needed, relatively to
the bodyweight, than in adult life. I found, for instance, that
a boy of four weighing 2 stone 4 Ibs. in hospital was eating food
of the value of 121 calories per kilogramme. In a school of 540
boys, of an average weight and age of 12| years and 5 stone 5 Ibs.
respectively, food giving 94 calories per kilogramme was con-
sumed. At sixteen years of age a child will often eat as much as
a man.
The diet of childhood should be simple but varied, consisting
mainly ^}f milk, porridge, bread, puddings, an egg, fresh vegetables
and fruit, jam, butter, dripping, with a little meat or fish once a
day. Fat is the element which is most likely to be deficient, and
should be supplied in the form of butter, dripping, in suet puddings
and in milk. The meals should be three in number, with the
addition of a slice of bread-and-butter and some milk at bedtime,
and must be eaten slowly. As age advances, the helping of meat
or fish is increased, but is not needed more than once a day, until
the child is eight or nine years old, when the more strenuous
school life may justify the addition of bacon or fish to the break-
fast fare. Children should be allowed to drink freely at the end
of the meal, and, if they are thirsty, between meals. Milk and
water may be just flavoured with tea or coffee if desired after the
age of five years.
DIET IN DISEASE.
Acute Fevers. It is seldom possible to supply sufficient food
in acute fevers to maintain the full nutrition of the body. It is
important, however, to furnish as much energy as possible in the
food, especially in protracted fevers, for experimental observations
have shown that when plenty of suitable food is supplied collapse
is less likely to occur, convalescence is shorter, and the loss of
nitrogen saved to a considerable extent. Water should be given
freely in all fevers to replace that evaporated from the skin, and
to promote diuresis ; even very large quantities improve rather
than diminish the absorption of food.
Typhoid Fever. In this disease the diet is of special import-
ance. Milk must form the chief food, but should only be given at
The Principles of Dietetics. 203
regular intervals. The taste should be continually varied by the
addition to it of barley-water, weak tea and coffee. To make up
the loss of nitrogen from the toxic breakdown of protein, plasmon
may be added to one or two feeds a day. As soon as the patient
has an appetite there is probably nothing but advantage in supply-
ing more satisfying food, provided that it is of a nature which will
be of a fluid or semi- solid consistence when it reaches the diseased
intestine. Soups, prepared meals, strained gruels, soft eggs,
minced meat, jelly, blancmange, biscuit soaked in milk, thin
bread-and-butter, and sponge cake all satisfy this requirement.
Such foods should be allowed in small quantities at first, the
digestion and the temperature being carefully watched. Sugar
may also be given freely, dissolved in water and flavoured with
a little lemon-juice. It has been shown that sugar can save the
tissues from being used up in febrile conditions as it does in
health.
Tuberculosis. The wasting of pulmonary tuberculosis is due to
an insufficient appetite and, in the active disease, to a breakdown
of nitrogenous tissues by the bacterial toxins, as in other infective
diseases. It may be generally stated that the absorption of the
plentiful diet prescribed is good. According to the work of
Mircoli and Soleri, a phthisical patient needs a diet having 30 per
cent, more heat value than that of a healthy person in order to
put on weight. The protein should be increased in at least the
same proportion. Bardswell and Chapman recommend that
this should be maintained until the weight becomes stationary at a
few pounds above the usual weight of the individual ; it should
then be somewhat reduced to a value about 15 per cent, above
that of the physiological diet, and kept at that value until the
disease is obsolete. The meals should not be bulky, concentrated
foods being used ; they should be given at considerable intervals,
and be as well cooked and varied as possible. The following
foods formed a sample diet : Milk, 2| pints ; bread, 6 oz. ; por-
ridge, 4 oz. ; butter, 1| oz. ; bacon or fish, 1 oz. ; meat, 6 oz. ;
pudding, 10 oz. ; vegetables.
The diet must not be increased to a degree which will set up
dyspepsia and loss of appetite.
It was formerly stated that an excess of meat had a beneficial
effect, but it appears that the value of meat lies in its being a
concentrated and digestible form of protein food rather than in
the possession of any specific property. Bardswell and Chapman
found that vegetable protein is satisfactory if a sufficient amount
is taken, but a meat-free or meat-poor diet must only be
204 The Principles of Dietetics.
prescribed for patients with normal appetites and digestions,
owing to its bulky nature.
The following (Bardswell, " Sutherland's System of Diet ") is
an outline of a dietary for a well-to-do consumptive :
Breakfast. Two breakfast-cups of milk flavoured with coffee ;
four pieces of toast or bread with butter ; one egg ; a helping of
bacon, ham, tongue or fish. Porridge with milk or cream may
be taken in place of half the toast or bread.
11 a.m. A tumbler of milk.
Lunch. A tumbler of milk ; a helping of fish or entree ; a
large helping of meat ; two potatoes, the size of an hen's egg ;
green vegetables, as desired ; half a thick round of bread with
butter ; a large helping of milk or other pudding, stewed fruit
and custard or creams, etc.
Tea. Tea, thin bread-and-butter and cake, etc.
Dinner. A tumbler of milk ; soup if desired ; fish or entree ;
meat, vegetables, pudding, bread or toast and butter, as at
lunch ; savoury or cheese and dessert, as desired.
Bedtime. A tumbler of milk.
If dinner be taken in the middle of the day, cold meats will be
substituted at supper time.
The following is an example of an economical diet for poorer
people, which Bardswell and Chapman state can be bought for
just under a shilling a day : Milk, 24 oz. ; meat (as purchased),
8| oz. ; liver, fish, 2 oz. ; butter, 1 oz. ; dripping, | oz. ; egg
(one per week) ; cheese, | oz. ; bacon, 2 oz. ; bread, 9 oz. ;
potatoes, 8 oz. ; pulse, 3 oz. ; oatmeal, 2 oz. ; sugar, 5| oz. ;
jam, 1 oz. ; rice, | oz. ; flour, 2 oz. They recommend such a
diet as suitable for convalescent consumptives who are doing
some muscular work.
Nephritis. (a) In acute nephritis there may be an almost com-
plete suppression of urine. In such a condition it is eminently
reasonable to give no protein at all. The body will then break down
a certain small proportion of its own protein and the kidneys will
have quite enough to do to pass out the disintegration products
of this. Adding protein increases the quantity of urea, whereas,
on the other hand, the excretion of nitrogenous bodies can be
pushed to its lowest limits by a liberal allowance of fat and
carbohydrate foods, the metabolism of which do not throw work
on the kidney. Hence, while the urine is scanty, the following
foods, served in various ways, should form the basis of the diet :
Arrowroot, rice with added dextrine (v. Noorden), jam, sugar,
cream, and butter ; a certain amount of milk may also be given,
The Principles of Dietetics. 205
but the less the better, and certainly not more than 1 pint in the
day, as milk contains a good proportion of protein. Such a diet
can, of course, only be prescribed for a few days, after which the
diet of chronic nephritis should be given. The drinking of water
in acute nephritis does not usually lead to diuresis ; enough
should be allowed to satisfy thirst, but not more.
(6) In sub-acute and chronic nephritis the power of the kidney
to excrete nitrogen is impaired. In a healthy person, if extra
protein be added to the food, the corresponding nitrogen is passed
out in a few hours ; in nephritis it may not all appear in the urine
for a few days ; there is, in fact, an oscillation of excretion,
normal periods alternating with periods of retention.
It is clear from these considerations that only a limited amount
of protein should be allowed ; experimental observations show
that this should be about 60 to 70 grammes, which is contained
in 2 1 pints of milk. Such a quantity of protein does not usually
impose a greater strain upon the kidney than it is able to bear,
and it is sufficient for an individual living an inactive life. On
the other hand, the amount of protein should not be allowed to
fall below this figure, for patients with nephritis must, like other
people, be supplied with a sufficient proportion. The following
diet (v. Noorden) contains 60 grammes of protein and 2,900
calories : Milk, 1| pint ; cream, 12 oz. ; rice, If oz. ; biscuit, 1| oz. ;
butter, If oz. ; sugar, 1 oz. It may be ordered after the diet for
acute nephritis given above. Many patients cannot manage so
much cream, but as the total caloric value is greater than that
necessary for a patient in bed, the full amount need not be
insisted upon.
As to the kind of protein which may be ordered as the patient
improves, or in cases of granular kidney, careful experiments
have shown that ordinary simple foods, such as fish, fowl, veal,
lamb, mutton and beef, do not injuriously affect the albuminuria
or the kidneys. Beef and mutton only do harm when given in
too great quantity or in an unsuitable form. The following diet
contains a little over 60 grammes of protein and furnishes 2,100
calories : Milk, If pint ; cream, 4 oz. ; potatoes, 8 oz. ; bread,
12 oz. ; meat or fish, 4 oz. ; milk pudding, 4 oz. ; butter, 3 oz.
Boiled meats are better than roast, because they contain less
extractives. No highly seasoned and indigestible foods, green or
pungent vegetables, salt or preserved meats or fish, or strong
cheeses should be included in the diet.
The following scheme of diet may be useful :
Breakfast. Gruel with cream ; fat bacon or fat ham in plenty ;
206 The Principles of Dietetics.
bread with abundant butter ; weak tea, coffee with cream and
milk.
Midday. Two oz. of fish with melted butter, plenty of potato ;
bread, biscuit and butter ; water or aerated water.
Tea. Weak tea flavouring milk and water. Bread or toast
and butter, jam, cake.
Dinner. Strained vegetable soup ; 2 oz. of meat or chicken,
with potato ; pudding ; stewed fruit ; water or aerated water.
Starchy and fatty foods may be allowed freely.
Eggs do not increase the albumin in the urine when eaten with
other foods in a mixed diet. An egg may, therefore, be substi-
tuted when desired for an equivalent amount of protein in milk
(7 oz. of milk) or meat (1 oz.).
Salt should be limited, for in many cases of nephritis the urine
does not excrete it so freely as in health. This is another reason
for restricting the amount of milk, which contains 1 gramme to
1 pint. Ordinary bread contains 5 to 7 grammes to the pound, and
should be baked specially without salt. If this is done, and sea
fish, lentils, and, of course, salt itself are excluded both at table
and in cooking, the diet will be nearly free from salt, for most other
articles of food, for instance, flour and meals, meat, poultry, one
or two eggs, tea and coffee, contain very little.
The salt-free dietary is most useful in cases with oedema : it
should be tried for a week or two, but need not be persisted in
strictly if no improvement follows. In all cases of nephritis,
however, it is wise to prohibit the use of salt at meals.
The allowance of water in nephritis should vary with the type
of disease. When oedema is present, the tissues are overloaded
with a saline solution : it is uncertain in any given case whether
the cause of this is poisoning of the capillary walls, inability of
the kidney to excrete water, or inability to excrete salt. In some
cases, at all events, inability to excrete salt appears to be primary ;
in such, a salt-free diet with a free supply of water is likely to help
the reduction of the oedema, because such salt as the kidneys can
still excrete will be more easily passed out if there is a free supply
of water. In parenchymatous nephritis it is a good plan to allow
a measured amount of water, adding an extra | pint or pint on
one or two days. If the quantity of urine is correspondingly
increased there is no need for restriction of fluid ; if, on the other
hand, oedema is increased, the urine remaining the same, a smaller
quantity of fluid should be given.
In chronic granular kidney, water should usually be allowed
freely, for the diuresis of this disease may be regarded as
The Principles of Dietetics. 207
advantageous to the kidney, less work being involved in passing
out the solids of the urine in a weak solution than in a strong one.
There is no evidence that the cardio-vascular changes of granular
kidney are due to overwork thrown on the circulation by the
passage through the body of so much water, as v. Noorden
suggested, for in diabetes, where much greater quantities of fluid
are dealt with, no such cardiac hypertrophy is found.
In other diseases of the kidney in which the active tissue is
reduced in quantity the diet should be of a similar nature to that
recommended in chronic nephritis.
Calculous Disease. Renal calculi are commonly composed
of uric acid, calcium oxalate or calcium phosphate. When a stone
has once formed, dietetic treatment is not likely to lead to its
removal ; but when a stone has been passed or removed, and when
symptoms of renal irritation with the passage of gravel are present,
the food should be adjusted to the particular condition present.
The deposition of uric acid usually takes place from a highly
acid urine. The diet should contain but little purin bases (see
diet in Gout) and plenty of vegetables. It is doubtful wisdom,
however, to take so much vegetables that the urine is alkaline in
reaction, as phosphates are then likely to be deposited upon any
particles in the pelvis of the kidney.
If the calculus is formed of calcium oxalate, foods rich in calcium
and those which give rise to an excess of oxalates in the urine
should be avoided. The bulk of the diet should consist of bread,
butter, dripping, potatoes, with meat or fish at two meals in the
day. Of fruits, apples may be taken freely, raw or cooked. Eggs,
milk, alcohol and vegetables should be taken sparingly. The
following articles of diet should be avoided altogether : Rice,
rhubarb, tomatoes, radishes, asparagus, spinach and hard water.
Soft water, or, if that is not available, distilled water, which
may be aerated if desired, should be drunk freely, at least a
tumblerful being taken after each meal in addition to what is
drunk during the meal. Tea and coffee are allowed.
The urine of twenty-four hours should be measured once a week,
and if its quantity does not exceed 2 pints, more fluid should be
taken.
Gout. The food should be free from purin bases, so far as is
compatible with the proper nourishment of the patient. If meat
is entirely excluded, some people, though not all, suffer in their
general health from the change to an unaccustomed diet. A
purin-free diet may be constructed from bread, butter, milk, eggs,
cheese, meals, sugar, jams, sweets, and fruits, and is to be advised
2o8 The Principles of Dietetics.
during attacks of acute or subacute gout. All alcohol should be
forbidden, and in stout persons sweets also should be limited, and
in others with whom much starchy or sweet food disagrees.
Between the attacks meat need not be excluded. The meals
should be simple and the food thoroughly and slowly masticated.
Care should be taken not to eat larger meals than are necessary
to satisfy the appetite, and to avoid any food which experience
has shown to disagree. One meat meal a day is sufficient,
but this rule does not exclude the use of bacon at breakfast. The
following foods may be allowed : Bread, butter, fish, chicken,
game, meat, fried fat bacon, milk, cheese, nuts, fruit, spinach,
cabbage, French beans, salads, simple puddings, and sweets ; rice,
tapioca, sago, and floury potatoes in moderation only, no new
potatoes. It is better to avoid the following : Rich meats, soups,
salted fish, lobster, crab, eels, duck, goose, high game, cured or
pickled meats, and meats cooked more than once, the roe of fish,
rich pastry and sweets, rhubarb, mushrooms, and beetroot.
Two or three pints of water should be drunk in the day, either
as water or as Imperial drink, or still lemonade made by pouring
boiling water on lemons. If the water is hard, distilled aerated
water, Malvern or Evian water, should be used. If alcoholic
drinks are desired, one or two glasses of well-diluted spirits may
be taken in the day, or a glass of light sherry. It is essential to
take regular exercise, short of fatigue.
Diseases of the Stomach and Intestines. A most striking
fact, which analyses of the excreta have established, is that
the more common gastro-intestinal disorders have but little
effect upon the absorption of food. When nutrition fails it is
usually because appetite is wanting ; but if in spite of this food is
introduced into the alimentary canal and is not rejected by
vomiting it is made use of. Even after the stomach has been
excised or gastro-enterostomy performed no marked effect upon
assimilation has been observed in animals or in man, except that
when digestion in the stomach is in abeyance undigested connec-
tive tissue occurs in the faeces ; in such conditions, therefore, the
meat should be well cooked, and it is better to mince it.
In the treatment of dyspepsia it is a great advantage if the
diagnosis of the kind of dyspepsia has been confirmed or corrected
by a microscopical and chemical examination of the gastric
contents after a test meal. As a general rule, dyspeptics should
avoid potatoes, pastry, greens, new bread, alcohol and tea ; they
should take their fluid at the end of the meal, or in severe cases
an hour before meals.
The Principles of Dietetics. 209
In hyper-secretion meals should consist of solid food only,
and be given every three or four hours, with at least \ Ib.
of meat at chief meals, and plenty of butter and other forms of
fat, with a moderate allowance of starchy foods. Fluids are
drunk an hour before meals.
In chronic gastric catarrh the bulk of the dietary should consist
of milk with cream, butter and eggs. Very hot and very cold food
or drinks should be avoided. If the hydrochloric acid is in normal
proportion or in excess, protein may be taken more freely in such
forms as eggs, tender chicken or mutton, and fish. Meats must
be minced or very tender. If the acid is diminished or absent,
flavoured soups and foods may be given to arouse a secretion, but
no peppers or irritating spices.
If, in the absence of catarrh, there is deficiency of secre-
tion, spicy foods should be ordered in minced or semi-solid
form.
In milder cases of dyspepsia with some deficiency a diet such
as the following may be prescribed :
7 a.m. -Glass of milk, biscuit.
Breakfast. Toast, butter, ham or devilled kidney, lightly
boiled egg.
Lunch. One tablespoon of meat soup, fish or chicken cutlet,
pigeon or game or mutton or undercut of beef, omelette or milk
pudding, dry toast, spinach.
Tea. Milk with a little tea, dry cake or biscuit.
Dinner. As lunch. Stewed apple, fruit 'compote, a little
sound raw fruit.
Spicy foods and condiments are ordered to be taken, especially at
the beginning of the meal. The following foods must be avoided :
Preserved fish or meats, sausages, buttered and fried eggs, new
bread, hot rolls, buttered toast, entrees, pies, pork, duck, goose,
any stringy greens, potatoes (except a little as puree), suet
puddings, cheese (except in very small quantity), ices, black
coffee, alcohol.
Half a pint of water or aerated water should be drunk an hour
before each meal. No fluid to be taken at meal times, except a
cup of weak tea at tea time, and one small cup of coffee made with
milk at breakfast time. The patient should rest half an hour
before and after each meal.
Motor insufficiency is often due to obstruction at the pylorus,
which should, if possible, be treated surgically. The meals should
be small, fluid being taken between and not at them and restricted
to 2 pints a day. The stomach should be washed out regularly
S.T. VOL. ii. 14
2io The Principles of Dietetics.
to ensure that decomposing material does not remain. Such foods
as milk, cream, eggs, minced underdone meat, fish, toast or dry
bread, and butter are ordered.
In gastric ulcer the patient may either be fed by means of
nutrient enemas followed by a graduated milk diet or may be
given a protein and fat diet of milk and egg by the mouth from
the beginning, or the two methods may be combined.
If no food be allowed by the mouth at first, the following enema
may be ordered three times in the twenty-four hours at six-
hourly intervals, to be given slowly from a funnel (F. D.
Boyd) :
The yolk of two eggs, 1 oz. of pure dextrose. 8 gr. of salt,
peptonised milk to 10 oz.
At the fourth six-hourly period the bowel should be washed
out with saline solution. In well-nourished women the nutrient
enema may be dispensed with, an enema of normal saline solution
being given three times a day. The enemas are continued for
from three days to ten days. Milk is then ordered by the mouth
in 2 oz. doses every two hours, diluted with water, barley-water
or lime-water in the proportion of 2 of milk to 1 of the diluent,
the enemas being discontinued.
The milk is then increased until 4 to 6 oz. at a time and 3 to
4 pints in the day are being taken ; after some days on milk,
additions are gradually made to it, beginning with arrowroot,
bread and milk, rusks and milk, cornflour or Benger's food, and
then thin bread and butter. Later eggs are allowed, with milk,
soup and beef tea followed by fish and chicken. The time taken
in passing through the regime will vary with the severity of the
case : many cases reach fish and chicken in three weeks ; in others
it is wise to make the period six weeks.
On the Continent this plan is modified as follows (v. Leube) :
The period of rectal feeding is two or three days only, then for
ten days boiled milk, soup and unsweetened biscuits are allowed ;
for the next seven days soups, rice and sago cooked with milk, raw
and lightly boiled eggs, boiled calves' brains and boiled chicken ;
for the next five days, minced underdone beefsteak, potato or
rice soup, a little tea or coffee ; from the twenty-second day to
the twenty -eighth, beef, chicken, pigeon, macaroni and white bread
are added.
If the patient is fed on protein and fat food from the beginning
(Lenhartz), 8 oz. of milk and one egg are mixed and given in
teaspoon sips spread over the first day ; the second day 12 oz.
of milk and two eggs are ordered, and 4 oz. of milk and one
The Principles of Dietetics. 211
egg added each day until If pints of milk and six or eight
eggs are consumed in the day. From the third to the eighth
day 1 oz. of raw, or almost raw, minced meat is added in
divided doses, either with the egg and milk or alone, and, if
well borne, increased to 2 oz. On the seventh day boiled rice is
given, followed later by softened bread and then by bread and
butter. By the eighth day one or two of the eggs may be lightly
boiled. Meat and pounded fish are now gradually substituted for
the eggs and the patient led to an ordinary mixed diet. The objects
of the method are to ensure that protein shall be constantly in the
stomach in the first few days to neutralise the acid of the gastric
juice and prevent it from digesting the surface of the ulcer, and
to lessen the flow of juice by the inhibitory effect of the fat in the
milk and in the yolk of egg.
Each of these dietetic methods has given good results when
carefully carried out, with reasonable modifications to suit the
individual case. Whichever plan be adopted, the patient should
be entirely in bed and should remain there if possible for
three weeks or a month. The diet must also be controlled
for at least three months afterwards, as relapses are liable to
occur.
In duodenal ulcer the Lenhartzdiet given above may be employed
with success, but in patients who can take it the treatment by
olive oil (Cohnheim, Walko) is to be recommended. Half an ounce
of olive oil is taken every three hours, and increased on the second
day, if possible, to an ounce. Extreme thirst develops in two or
three days and may be met by frequent tablespoon doses of water
made just alkaline with bicarbonate of soda. After three days a
graduated diet of egg and milk is begun as in gastric ulcer, the oil
being continued but the quantity reduced as may be necessary.
Even when the patient has reached a full diet \ oz. of oil should
still be taken half an hour before meals. Oil diminishes the
secretion of gastric juice, is non-irritating and of a high caloric
value.
In ulcerative colitis an entirely fluid bland diet consisting chiefly
of milk and custard is given. In non-ulcerative muco-membranous
colitis one of two kinds of diet is commonly ordered, either
nourishing, non-irritating food, or food containing much cellu-
lose. In severe cases with a little blood with the membrane,
in which ulceration may supervene, a milk diet like the early
diet of gastric ulcer should be employed. In milder cases follow-
ing obstinate constipation the opposite plan is often successful.
Bulky and irritating foods are given with the object of relieving
142
212 The Principles of Dietetics.
the colitis by preventing constipation. The following is a suitable
regime for such a case :
Before Breakfast. Half a pint of water.
Breakfast. Milk half a pint, bread, butter, honey, one egg or
fat bacon, one baked apple or fruit, such as strawberries, rasp-
berries, pears, according to season.
Lunch. Scrambled eggs, or an omelette or some light food,
bread or toast, butter ; a moderate helping of beetroot, parsnips,
cabbage, turnips or French beans ; half a pint of water.
Tea. Half a pint of freshly made tea ; bread or toast, butter.
Dinner. Milk soup ; fish or meat, vegetables as at lunch ;
apple fritters or stewed apples, prunes or figs ; bread or toast,
butter ; half a pint of water or still fresh lemonade.
Brown or wholemeal bread is to be preferred and must not be
new. Exercise should be taken daily.
In constipation due to a slow passage of the food residues along
the large intestine, owing to deficiency of bulk, of fluid or of
irritative constituents, dietetic treatment is of great value. The
following foods should form a large part of the dietary : Brown
bread, gingerbread, apples (stewed or raw), and other fruits,
especially stewed prunes, and figs, cooked or raw ; cabbage,
sprouts, spinach, salads ; suet pudding with golden syrup ; butter,
dripping and fatty foods. A large glass of water should be
sipped on rising and plenty of water or still lemonade taken with
meals. Tea should be weak, freshly made, and not taken more
than once a day. Jams and sweets may be eaten in modera-
tion.
The following should be avoided or eaten very sparingly : New
bread, pastry, eggs, nuts, milk and milk puddings. Cream may
be taken in tea or coffee.
In Obesity many dietetic cures are practised and are suitable
to various cases. I shall confine myself here to simple directions
which, if carried out with reasonable care, will often be found
effectual. It is important to begin by small restrictions ; if too
much is asked of the patient at first there is risk that all effort
will be abandoned.
The clothes should be light and the rooms cool. A good
amount of exercise should be taken every day.
The following foods should be avoided : Sugar, potatoes,
parsnips, carrots, turnips, beetroot, salmon, turbot, eels, preserved
herring or mackerel, sardines, cream ; pork, beer, wines (except, if
desired, a little claret or sherry).
The following foods may be eaten freely : Eggs, meat and fish
The Principles of Dietetics. 213
(except as above stated), unsweetened stewed fruits, green
vegetables.
Wholemeal bread, toast and rusks, and all puddings and cakes
made with flour should be taken in great moderation. It is well
to ascertain the amount of bread taken each day by weighing.
No fluid should be drunk at meals until all solid food has been
taken.
E. I. SPRIGGS.
214
INFANT FEEDING.
THE proper food of the infant is its mother's milk. Should the
mother, from physical or moral incapacity, fail to feed her child,
the milk of the cow, modified in imitation of human milk, is used.
The quantity of milk which the child needs can only be given
in average figures, for it varies with the weight, the conformation,
the activity and the age.
A heavy child will naturally require more food than a light
one. The effect of conformation is less obvious, but not less
important ; other things being equal, a thin child needs more food
than a fat child, because its surface in relation to its weight is
so much greater. The greater the surface relatively to the weight,
the greater the loss of heat and the more food required, for a
large part of the energy of the food is used in keeping up the body
heat. The plumper a child is, and the nearer its contours approach
the spherical, the less surface it has as compared with the thin
child, with hills and hollows over and between its bones. The
non-conducting layer of fat beneath the skin also protects the plump
infant from an undue loss of energy in the form of heat.
An active or a restless infant needs more food than a placid one,
to provide energy for the muscular work done. Carbohydrate is
the food chiefly used by the muscles, but does not need to be
increased in infancy so much as when the child begins to run
about.
The effect of age on the food requirements of the baby is such
that whilst the older the child is the more it needs, yet the amount
of food required for each pound of body weight becomes smaller.
This is partly because the baby's surface, as compared with its
weight, gets less as the baby grows larger, and partly because the
rate of growth also diminishes.
The energy required for proper growth has been estimated by
weighing a child before and after it has been put to the breast
during the early months of life, or, in hand-fed children, by
measuring the cow's milk taken. A plump child should receive a
minimum of about 100 calories per kilogramme soon after birth ;
this is furnished by 2| oz. of cow's milk for each pound weight,
or a pint of milk a day for a child of 9 Ib. A very thin
or premature child may require 125 to 150 calories, or 3J oz.
Infant Feeding. 215
of cow's milk to the pound. At six months of age the average
figure sinks to 80 or even 70 calories per kilogramme : expressed
in quantities of milk, 80 calories per kilogramme is If oz. to
each pound. A healthy hand-fed infant should, therefore, receive
daily from 1 to 3-oz. of cow's milk for every pound of its weight.
Premature infants cannot always assimilate the amount of food
necessary to maintain their body heat, especially as their nervous
mechanism for the regulation of temperature is not properly
developed. Loss of energy in the form of heat may then be
prevented by keeping the baby in an incubator at about body
temperature: the amount of food required will now be less, and
may fall within the limit of what can be digested.
BREAST FEEDING.
Every healthy woman ought to feed her own child. No personal
or social inconvenience, nothing, indeed, but the necessity of
earning wages, should prevent the fulfilment of this duty to the
child and to the nation. The modern tendency among mothers
of all classes to bring up babies artificially is unfortunately
pandered to by some medical men, who have perhaps been
misled by their own skill in prescribing imitations of human
milk. But any doctor who is accustomed to deal with the
digestive troubles of babies of all classes knows that the great
majority of infants brought for consultation are being hand-fed.
In other words, breast-fed babies seldom need the doctor.
Recent observations also show that the good effects of breast feeding
are continued long after infancy in the ultimate development of the
man or woman. Monthly nurses, except the very best, are often to
blame in this matter. They do not follow the babies after the first
month of life, and they take a great pleasure in giving them food
out of a bottle. The mother, with very likely the best will in the
world to feed her baby, is obliged to listen to the nurse's statements
that the baby is hungry every time it cries, and, impressed by the
relation of former " cases," she becomes convinced before long that
she cannot feed it. Bottle feeding is then begun, with the result
that the nurse gets a quiet month, whilst 'the unconscious victim,
the baby, has to run the risk of digestive troubles later on.
The infant needs but little food in the first day or two, until the
breasts have begun to secrete. It should be put to the breast four
times on the first day and six times on the second. A little boiled
water, sweetened with sugar, should be given out of a spoon in
between. During the first month the baby should be fed every two
hours during the daytime. Between nine at night and seven in
216 Infant Feeding.
the morning it should be allowed to sleep as long as it will, being
fed twice in the night w r hen it wakes. The breasts should be used
alternately. The nipples should be cleansed after nursing with
warm boric acid lotion and dried. The baby should not be allowed
to take the milk too quickly or to remain longer than a quarter of
an hour or twenty minutes at the breast. The baby must not be
fed when it cries, but only at the proper hours. It may cry from
cold, from heat, from the discomfort of a wet napkin, of tight clothes,
or the scratch of a pin, or from an uncomfortable position, from
the boredom of its cot, and want of a little nursing, from wind or
colic, from hunger or thirst. If, after investigation, the baby is
thought to be hungry or thirsty, and the time for food has not
arrived, then oz. of boiled sugar water, or plain boiled
water, may be given from a teaspoon, and will often make it
content.
In the second and third months the infant should be put to the
breast every two and a half hours in the daytime, and after the
third month every three hours. By this time the baby will
probably only want feeding once in the night ; after the age of
five or six months it should sleep without a feed from ten at night
to seven in the morning. It is important to keep the intervals
between the feeds both in the day and night, not only because the
digestion of the child must not be overworked, but also because the
breasts of the mother must be allowed time to produce a proper
supply of milk between the feeds. Especially are the long night
intervals valuable ; if the mother gets good sleep she will usually
have a sufficient supply of milk.
In judging of the adequacy of the mother's milk the chief points
to be attended to are the weight and condition of the baby. A baby
may seem dissatisfied at the end of its feeds and in want of more
milk, and yet be in good health and put on weight regularly. It is
a good and not a bad sign for such a child to be hungry ; it may
object to leaving the breast, but will be comfortable in a few
minutes when it has brought .the wind up. The actual amount of
milk taken at each feed, as ascertained by weighing the baby on
delicate scales before and after it is put to the breast, should be
about 2 oz. at the end of the first month, 3 oz. in the third month,
and 4 oz. in the fourth. Amounts above and below these figures
are, however, compatible with health.
If there is no doubt that the milk is scanty and the baby's weight
diminishes for more than a week (excluding the first week in
which a loss of weight is natural), or is stationary, then steps
must be taken to improve the supply. The food of the mother
Infant Feeding. 217
must be abundant and contain a good proportion of meat and fat.
Nitrogenous food is more efficient than fat in increasing the fat of
the milk. In all but the poorest homes we may assume that
enough food of good quality is available. We then have to see that
the mother has appetite and leisure for her meals, sufficient rest,
fresh air and suitable exercise. Of these I put rest first. If the
mother lies down on a couch for half an hour before and after her
meals and takes a sleep in the afternoon the quantity of milk
becomes greater at once. A moderate walk out-of-doors in the
middle of the morning is also of great value, and a short walk or drive
in the late afternoon. Such measures are sometimes as much
needed by stout healthy women as by delicate ones. Strong
emotions, such as anger and sorrow, are prejudicial to a proper
supply of milk. >If the child does not suck strongly, light
massage of the breasts for ten minutes three times a day may
stimulate the flow. In anaemic mothers an iron pill should be
ordered two or three times a day.
The opinion that benefit follows the addition of some alcoholic
drink to the diet of the nursing mother does not appear to be
confirmed by the careful observations of late years. The alcohol
itself is of doubtful value, especially in those unused to it. But
some beverages containing alcohol may be useful, if by improving
the appetite they help the mother to make a good meal. For
this purpose a light bitter ale or stout is allowed, or a glass of wine
if the mother is accustomed to take it. Strong tea or coffee is
best avoided.
Sometimes the milk is too rich : the baby suffers from pains
and undue sickness ; curds and many small yellow particles of fat are
observed in the stools. An analysis of the milk drawn off shows
that it contains more than about 1 or 2 per cent, of protein and
4 per cent, of fat. The mother should then be allowed rather less
meat, no alcoholic beverages, and should take more exercise. A
tablespoonful of lime-water may be given to the baby before each
feed to dilute the milk. A little regurgitation of milk after a feed
is natural to many infants and need not be treated.
The progress of the baby must be estimated from its general
condition, increase in weight, capacity for sleep and the state of
the motions. An infant growing well will put on 3 or 4 oz. a
week. Common troubles are flatulence with colic, and consti-
pation. Flatulence is often due to the child taking the milk too
quickly, or being allowed to drop to sleep before the wind is brought
up after feeding. If it persists when these points have been
attended to, it will usually be relieved by a mild carminative,
218 Infant Feeding.
such as a teaspoonful of dill water. The most important measure
for constipation is to have the baby held out at the same hour
every day in order that a proper habit may be formed. If no
motion is passed, a stimulus may be applied by inserting a piece
of soap, but this should only be done after the infant has made
unsuccessful muscular efforts. If the motions are hard, water
should be given two or three times a day between the feeds, or,
if this fails, a teaspoonful of olive oil once or twice a day mixed
with milk and sugar.
If, in spite of all care and precautions, the baby does not steadily
increase in weight, then the mother's milk must be supplemented
by one or two feeds a day of modified cow's milk. This change
should not be made hurriedly, or until careful trial has proved that
the mother is unable to give the child enough food, as shown by the
scales, for the baby fed on the breast alone is usually immune from
the severer forms of indigestion and from many of the infectious
diseases which are so dangerous in infancy. Slight illness of the
mother, even if accompanied by fever, does not make it necessary
to give up breast feeding ; neither does the appearance of
menstruation. The condition of the child must be the guide. In
any prolonged illness, such as enteric fever, the child must, of
course, be weaned. Neither should mothers who are more than
three months pregnant or are the subjects of constitutional disease,
such as tuberculosis, nurse their babies.
If it is decided to supplement the breast milk, the bottle may be
given in the afternoon, about four o'clock : this allows the mother
a longer interval to provide a natural feed for the baby when it
goes to bed. If a second bottle is needed, it should be given for the
last feed at night at about ten o'clock. A full meal at that hour
ensures the mother's rest during the first hours of the night : she
will then have a good supply for the baby when it wakes up. When
a third bottle is needed, it is given in the middle of the morning.
The milk in the bottle should be prepared by the directions given
below (p. 222), according to the age of the baby. It should always
be sterilised.
WEANING.
The child should be weaned gradually at about the age of nine
months. In a hungry, dissatisfied baby the bottle may be begun
at six or seven months in addition to breast milk. The feed will
be prepared according to the table on p. 223, the bottles being
increased in number as the mother's milk diminishes. At nine
months a little starchy food may be added, with gravy or meat
Infant Feeding. 219
juice. If for any reason it is necessary to wean suddenly,
or, indeed, when any change from one food to another is
made, the bottle feeds should he fairly dilute at first ; the
strength is then gradually raised to that suitable to the age and
development of the baby. It is unwise to wean a child during very
hot weather, because cow's milk is then especially liable to be
contaminated.
Wet-Nursing. If a mother can give her child no milk at all, the
best substitute is the milk of a wet-nurse, who should be a young
adult free from suspicion of tuberculosis or syphilis, shown to be
healthy by a thorough medical examination, not nervous or
anaemic. She should have a good supply of milk, her own child
being well nourished ; according to Holt, it is not essential that her
child should be of the same age as the infant to be nursed, except
that if the latter is only two or three weeks old, her child should
not be more than about six weeks old. If the infant is six weeks
old, a wet-nurse " whose milk is anywhere between one and five
months old will usually answer perfectly well." Wet-nursing is
not justifiable if the infant to be nursed is suspected of syphilis.
FEEDING WITH COW'S MILK.
The only practicable substitute for mother's milk in most cases
is the milk of the cow. The composition of cow's milk is similar
to, though far from identical with, human milk. It is often,
moreover, exposed in transmission to contamination, which may
render it a dangerous food for children. It is to be hoped that in
the near future the State will take over the duty of ensuring a pure
milk supply, for experience has shown that private enterprise
cannot be relied upon. Until, however, medical officers of health have
greater control than at present, it must remain the duty of the family
practitioner, acting with the parents, to ascertain so far as possible
that the milk is derived from sound cattle and is protected from
infection. The dairy must be clean, and all working in it healthy.
The cows should be groomed as horses are groomed, and milked in
a stall devoid of litter ; the udder of the cow and the hands of the
milker must be cleaned before milking, and the milk received in
vessels sterilised with steam. As soon as drawn it should be
covered over and artificially cooled.
Cow's milk, as delivered, is usually an acid fluid, unless alkali
has been added to it, whereas mother's milk is amphoteric or
alkaline. Cow's milk contains millions of bacteria, mother's milk
being sterile, or nearly so. Many of the bacteria are not known to
be pathogenic, but they are associated with putrefactive processes
22O Infant Feeding.
which may be very harmful in the child's intestine. Not infrequently,
however, the germs of disease, especially of tuberculosis, enteric
fever, scarlet fever and diphtheria, are conveyed by milk.
Sterilisation of Milk. The greatest care must be taken to
prevent the bacteria with which cow r 's milk swarms from harming
the infant. Their growth can be prevented to a great extent by
keeping the milk cold. The living bacteria in milk may be killed
by boiling or by pasteurisation.
It follows that milk should be as fresh as possible, should be
artificially cooled directly it is drawn, and kept cold both in
transmission and in the home until it is used, and should be
sterilised. This counsel of perfection, however, cannot always be
followed, for various reasons. Eeally fresh milk is unobtainable in
towns, where delivery is not made until the milk is twelve hours
old. The second precaution, that of keeping the milk cold, can and
ought to be taken. In the home, vessels containing milk should be
stood in cold water, or in summer upon ice. This applies to milk
which has been boiled or pasteurised just as much as to fresh milk.
If milk is boiled directly it reaches the house, strained and cooled,
the fear of infection through the milk is reduced to a minimum.
Boiled milk has not, however, quite the pleasant taste of fresh milk,
and children fed upon it entirely may develop scurvy. Pasteurisa-
tion consists in heating the milk in a double saucepan, or in a special
apparatus, to 150 to 160 F., and keeping it at that temperature
for twenty minutes. It should then be covered and cooled. Nearly
all living bacteria are destroyed and the taste is not altered so
much as by boiling. It is claimed that pasteurised milk does not
produce scurvy, and, if this is so, it is certainly always to be recom-
mended. There is, however, still some doubt on the matter. If the
child is obtaining any milk from the breast, all cow's milk should be
boiled, as the mother's milk will protect it from the danger of
scurvy. For this additional reason it is advisable to keep on breast
feeding as long as possible. In children fed entirely upon cow's
milk the advice differs according to the circumstances. In cleanly
homes, when the source of the milk is known to be safe, as in many
country houses, I recommend that a feed should be given from the
fresh milk immediately it is brought in, the remainder being boiled.
In poorer homes and where the source of the milk is uncertain it is
safer to boil all milk directly it reaches the house. A watch will be
kept upon the health of the children, and a little orange juice or
raw meat juice given two or three times a week to prevent scurvy.
In all cases the milk is warmed to body temperature before it is
taken by the infant.
Infant Feeding. 221
Attention must be paid to the bottle, which should be of a form
in which the teat is directly attached to the neck. The bottle and
teat should be washed after each feed, and the bottle boiled in a
saucepan once a day. Between the feeds both the bottle and teat
must be kept in clean cold water.
COMPOSITION.
The milk of individual cows varies greatly, but the mixed milk
from a herd should give the following composition (the figures for
woman's milk are placed below for comparison) :
Protein.
Fat.
Milk Sugar.
Cow's milk
3-5
4-0
4-5
Woman's milk
1-5
4-0
7-0
These figures show that cow's milk contains more than twice the
protein and about two-thirds of the sugar of mother's milk. The
average amount of fat is the same. Further, cow's milk contains
three times the salts and six times the calcium, but only one-half
the iron of human milk.
The protein of cow's milk is nearly all caseinogen, whilst in
mother's milk more than half of it is lactalbumin, which does not clot
in the stomach. Many infants find it difficult to digest the casein-
ogen of cow's milk, not only because of its greater quantity, but
also because the clots of casein, which are formed from it in the
stomach, are harder and larger than those of the casein of mother's
milk. The formation of hard clots may be modified by dilution,
especially with lime-water or soda-water, or by thickening with
arrowroot or cornflour. Barley-water renders the clot a little softer,
in virtue of the starch which it contains. Lime-water, with or
without ordinary water, is the most useful diluent to use for
infants.
Cow's milk may be given in various forms, which will be
considered under the following headings : (1) Whole milk ;
(2) Diluted milk ; (3) Milk diluted and modified by adding sugar
and fat ; (4) " Top milk," diluted and modified by adding lactose and
lime-water; (5) Citrated milk ; (6) Eredigested milk ; (7) Whey and
cream.
(1) Whole Milk. No argument is needed to show that the
infant's stomach may acquire the power of digesting milk which
differs considerably from that natural to it, for innumerable
children have been brought up on unmodified cow's milk in the
222
Infant Feeding.
past. Professor Budin has been a modern advocate of the use
of sterilised whole milk for hand-fed babies. The method has
the advantage over methods of dilution that a smaller bulk of milk
suffices to furnish the food value which the child needs. Unfortu-
nately, a great many infants at the present day are unable to digest
cow's milk properly unless it is modified.
(2) Diluted Milk. The dilution of cow's milk approximates the
strength of protein to that in human milk, and renders the clot
more friable. The milk is consequently more digestible. Since the
protein of cow's milk, consisting chiefly of caseinogen, is less easily
dissolved than that of human milk, of which, as we have seen
above, lactalbumin forms the major part, it is sometimes necessary
in young infants to carry the dilution to such a degree that the
percentage of protein is even less than in human milk. When we
turn from the protein to the other constituents of milk the effects
of dilution are seen to be far from beneficial. The fat and sugar
are brought to a strength far below that in human milk, and the
heat value of the milk is lessened in proportion to the dilution. In
short, we must beware lest in making the food digestible we starve
the baby. The dilutions which experience has shown that most
infants can digest are one of milk to three of water in the first
month, one to two in the second and third months, half and half in
the fourth, two of milk to one of water in the fifth and sixth, and
three to one after the sixth month. If we take the average
weight of a child in the first months of infancy we can, knowing
the average number of calories per unit of weight required at those
ages, calculate how much whole milk the baby should receive at
each month. These figures are placed in a column below, and are
compared with the amount of diluted milk required to supply the
the needs of the child :
(1)
(2)
(3)
(4) (5)
(6)
(7)
Month.
Oz. of
Whole Milk
Required.
Dilution
Commonly
Recommended.
Oz. of Diluted
Milk Necessary.
Amount of
Feed Suitable
to Age.
1
18
13
72 = 10 feeds of
7 oz.
2 oz.
2
21
12
62= 9
7
34
3
24
12
72 = 8
9
45
4
27
11
52= 7
7*
6
5 and 6
29
21
43= 7
6
6
7, 8, and 9
m
3 I
43 = 6
7
8
Column 2 gives the average amount of whole milk required at the
various ages, and columns 7 and 5 the quantities at a feed and the
number of feeds suitable to the age, as established by experience.
Infant Feeding.
223
Columns 4 and 6 show in a striking manner that if enough milk is
to be supplied with such dilutions, the amount taken at each feed
must be far in excess of what an average baby can manage in the
first four months. At the fifth month the dilution is less and the
capacity of the baby greater.
We may conclude that the simple dilution of milk is not likely
to provide enough food for the baby until the age is reached at
which a strength of two parts of milk to one of water can be given
in feeds of 6 oz. at a time.
(3) Milk Diluted and Modified by Adding Sugar and Fat.
The diluted milk may be made stronger in sugar and fat by the
addition of these foodstuffs. The sugar and the fat of milk, namely,
lactose and cream, are easily obtainable. Cream as sold, however,
cannot be looked upon .as a desirable food for a baby, because it has
been kept longer than milk, and generally contains either enormous
numbers of bacteria or an excess of some preservative. " Centri-
fugal " cream is less objectionable, though the best way to provide
a larger amount of fat is by the use of " top milk," as described in
the next section. But it is useless to recommend any method of
preparing milk which needs time and care for poor homes with busy
and perhaps ignorant mothers. For these it is better to adopt the
less perfect but simpler plan. To this end the dilution mentioned
above should be advised, with the addition of a dessertspoonful of
milk sugar and a dessertspoonful of cream to each bottle. In the
poorest homes, instead of cream, half a teaspoonful of cod-liver oil
should be used. The prescriptions will then be written according
to the following table :
Amount of
Alilk
Water
Oz.
1st month .
1
3
910
l*-2
'2nd and 3rd months
1
2
8
4
4th month .
1
1
7
6
5th and 6th months
2
1
6
8
7th to 9th mouths
3
1
5
8
9th to 12th months
7
1
5
8
To each feed will be added one dessertspoonful of milk sugar and
a small teaspoonful, or half a larger teaspoonful, of cod-liver oil.
Further, in each feed one tablespoonful of lime-water should replace
an equivalent quantity of the water used for dilution. For instance,
if 4 oz. of water are to be added to 2 oz. of milk, the 4 oz. will be
made of 3J oz. of water and ^ oz. of lime-water.
224
Infant Feeding.
(4) " Top Milk " Diluted and Modified by Adding Lactose.
In all homes where care and cleanliness may be expected, the milk
should be prepared so that it may resemble as closely as possible
the mother's milk, in composition, in total heat value, and in
digestibility. The chief difficulty in preparing imitations of human
milk is to obtain a product rich enough in fat to bear the dilution
which the amount and character of the protein in cow's milk
renders necessary. Objection has already been made to the use of
commercial cream. But if the new milk be allowed to stand in a
cool place, the upper layers become rich in cream and may be used
to prepare the feeds. If milk has been standing for four hours, the
upper third of it will contain on the average 10 per cent, of fat, the
upper half 7 per cent. From this " top milk " milk of any com-
position within the limits required may be obtained by the addition
of suitable quantities of lactose and water. The method is some-
times known as the " percentage " method, because of -the ease with
which the percentage of the fat, protein and sugar can be varied :
we are indebted to Eotch, of the United States, for its elaboration.
A milk suitable to the age of the infant may be made as follows :
Top milk is prepared by allowing new milk to stand in a cool
place, as above mentioned. The top milk must not be poured off the
lower milk, but taken off by a cup or dipper. To prepare food for
infants up to the age of three months the top third is used ; from
the fourth to the ninth month the top half. Of this milk a quantity
depending upon the age and development of the baby is taken,
according to the table below. To that quantity 1 oz. of lime-water
and 1 oz. of milk sugar is added, and the whole then made up to
1 pint with water. The number of feeds and the amount to be given
at each feed are shown in the table, as are the percentages of
protein, carbohydrate and fat which the product contains :
(1) (2)
Month. Oz.
1 (3)
No. of
Feeds.
(4)
Amount of
Peed.
(5) (6) (7)
Percentages of
Protein. Pat. Carbohyd.
1 \ Top Milk ( 2
10
\\ 3 oz.
3
1-0
5'5
2 - (upper < 6
9
34
1-0
3-0
6-0
3 ) third) (7
8
35
1-2
3-5
6-5
4 , } Top Milk ( I
o and 6 f , F ] 8 9
7
7
45
56
1-2
1-5
2-5
3-0
6-5
6-8
7 and 8 j ^ P f f ? r j 1011
7
67
1-8
3-7
7-0
9 / \ 12
6
78
2-0
4-0
7-0
Mother's inirk contains .
1-5
4-0
7-0
Full cow's milk contains .
3-5
4-0
4-5
Infant Feeding. 225
Take the quantity of milk given in column 2, add 1 oz. of milk
sugar dissolved in water, 1 oz. of lime-water, and water to 1 pint.
Order feeds according to columns 3 and 4.
The night feeds in the early months will be given as described
above under Breast Feeding.
A consideration of columns 5, 6 and 7 shows that in this scheme,
which is adapted from Holt's " Diseases of Infancy and Childhood,"
the percentage of fat is very low at first, as the newly-born infant
may not digest the fat of cow's milk well, but is rapidly raised, and
kept at 3 per cent, and above for the second and third months. The
protein is increased much more gradually, and its percentage does
not reach that of mother's milk until the fifth month. The pro-
portion of sugar is kept high throughout. The above outline will
be found to work well in practice. If the infant seems hungry and
is doing well, the strength should be gradually increased throughout
by using more of the top milk ; for instance, the 2 oz. mentioned in
the first month should be gradually changed to the 6 oz. of the
second. Increases in the quantity given at a feed should be
made alternately with changes in the strength until a total
amount in the day of If pints to 2 pints is reached, after which
the strength should be increased and not the quantity. An altera-
tion should not be made on account of slight and passing
disturbances of digestion ; but when made it should be persisted in
for a few days, even if the weight is stationary, in order that the
infant may become accustomed to it. The physician will not
follow the table blindly, but will be guided in prescribing the food
by the condition of the child as well as its age. He will pay special
attention to whether it is comfortable or restless when awake, to its
sleep, and to the stools.
If the baby must be fed artificially in the first week of life,
peptonised milk or whey should be used.
(5) Citrated Milk. It has long been known that the clotting of
milk is prevented by the precipitation of its calcium. Sir Almroth
Wright suggested the use of sodium citrate for this purpose. The
milk may be diluted as well (Poynton), or whole milk may be used
(Langmead). The curd of milk to which citrate of sodium has
been added (in the proportion of 2 gr. to 1 oz.) is soft and flocculent.
The advantage of this modification is obvious, for it is the tough
curd of cow's milk which otters the chief difficulty to the digestive
powers of the infant. Another advantage is that infants can often
take citrated milk whole, and thus are more likely to get enough
food than when diluted milk is used. A third advantage, and by
no means the least, is the simplicity of the preparation. Hence the
S.T. VOL. ii. 16
226 Infant Feeding.
method is of especial value for infants of weak digestion living in
poor homes.
A solution of the sodium citrate is prepared of the strength of 20 gr.
to 1 drachm of water. The milk is brought to the boil and 1 drachm of
the solution added to each ^ pint of milk. The amount of the feed
must be judged by the weight and condition of the child ; if the
milk is undiluted it will not need to be great, and, especially in
ill-nourished children, may be less than the quantities in column 7
of the table on p. 222. The baby may be thirsty, and should be
given warm water from a teaspoon between the feeds. I have used
this method with success. If the whole milk gives rise to
indigestion it should be diluted ; but it is not necessary to add so
much water as when citrate of sodium is not used. Dr. Lang-
mead saw no untoward results in 150 cases with the proportion of
sodium citrate mentioned above. Distress after food may be
relieved by the addition of 1 grain of bicarbonate of soda to 1 oz.
of milk. Citrated milk should not be employed in the first three
weeks of life ; in the fifth month the citrate should be gradually
lessened, and at the sixth month omitted.
(6) Predigested Milk. The difficulty which the infant finds in
dissolving the coagulated protein of cow's milk may be got over by
partially digesting the milk beforehand with pancreatic ferment.
For this purpose one-third of its bulk of water is added to the milk,
so that 1 pint then consists of f pint of milk and pint
of water. Peptogenic powder is put into the milk in the quantity
mentioned in the manufacturer's directions, the vessel placed in
hot water, and the temperature raised to 104 F. and kept there
for twenty minutes. The milk is then brought to the boil to arrest
the action of the ferment. It is probably better, .though more
laborious, to prepare each feed separately, in which case the milk
need not be boiled, but may be given at once, the ferment action
going on for some time in the stomach. The terms peptonised
milk or predigested milk are not strictly accurate when applied to
milk which has been digested for twenty minutes, for only a par-
tial conversion to albumose or peptone takes place in that time.
Albumoses have a bitter taste, and, if they are formed in quantity,
the child may refuse the milk at first, though it soon becomes
accustomed to it. Peptonised milk need not be used for healthy
children, except, perhaps, in the first week or two of life ; in such a
case the period of peptonisation should be made shorter and shorter
until the process is omitted. The prolonged use of predigested
food may be expected to lead to a weak digestion. In digestive
disorders and in malnutrition peptonised milk is a valuable food.
Infant Feeding.
227
(7) Whey and Cream. In the first few days whey is sometimes
given alone, though its food value is, of course, low, less than a third
of that of milk. In the later life of a healthy infant whey will not
be needed. But if cow's milk, even when modified, is associated
with vomiting, and poor nutrition, and there are abundant curds in
the stools, it is often a good plan to avoid giving any caseinogen
at all for a few days, and to give only whey and cream. A mixture
of these may be made of considerable nutritive value, as the sub-
joined table (from Holt) shows. The cream used is gravity cream
of medium thickness, containing 20 per cent, of fat :
Fat.
Whey 19 parts :
Cream 1 part gives
1-0
1-8
4-9
15
,, 1 ,, ,,
1-0
2-2
4-9
9
1 ,,
1-1
2-8
4-9
7
1 ,,
1-2
3-3
4-8
o
1 ,,
1-2
4-0
4-8
The protein in these mixtures, consisting of lactalbumin, is low,
but not lower than in the humanised milk for the first month or
two mentioned on p. 224. The fat increases rapidly as the cream
is added. The amount of each feed should be rather larger than
the amount of milk recommended on p. 228, column 4.
PREPARED FOODS.
Many prepared foods for infants are placed upon the market.
They are more expensive than milk when the food value of the two
is compared ; that is to say, no artificial fluid roughly corresponding
in heat value and composition to human milk can be prepared so
cheaply as by the use of fresh cow's milk and milk sugar. The high
relative cost of infant foods is largely due to the huge sums which
the manufacturers spend on advertising, all of which the consumer
pays. We may consider such foods under the headings of (1) Con-
densed milk ; (2) Dried milk ; (3) Foods, added to fresh milk,
which, when prepared, contain no starch ; (4) Floury foods.
It is beyond the scope of this article to describe all the better-
known foods ; I shall, therefore, confine myself to a few remarks on
each group. The statements made about the various brands are
founded mainly upon the analyses quoted in Cautley's article on
Patent and Proprietary Foods in Sutherland's " System of Diet
and Dietetics," and in Hutchison's " Food and the Principles of
Dietetics."
(1) Condensed Milk. Genuine condensed milk should be made
152
228 Infant Feeding.
from good fresh milk and have nothing added to it. Unsweetened
condensed milks are sold under the names Ideal, First Swiss, Viking,
and Hollandia. The last-named is relatively poor in fat. When
preparing these milks for infants they should first he diluted to the
strength of cow's milk, then further diluted according to the age of
the child with the addition of cream and sugar, in the same way as
cow's milk is treated to make it comparable to human milk.
Many condensed milks have cane sugar added, which acts as a
preservative. They have the disadvantage, when used for infants,
that they are too sweet to take unless diluted to such a degree that
the protein and fat are much reduced. Well-known brands, such as
Nestle's, Milkmaid, Rose, Full Weight and Anglo-Swiss, contain five
times as much sugar as they do fat, the protein being a little less than
the fat. The Peacock brand contains less cane sugar, and is, there-
fore, intermediate between the unsweetened and sweetened brands.
(2) Dried Milk. Various brands of desiccated milk can be
obtained. The milk is passed over hot rollers, w r hich drive off the
water, leaving a sterile powder. " Full cream " and " half cream "
brands are supplied. When mixed with water a fluid is obtained
with a biscuit-like, boiled-milk taste, by no means unpleasant. The
fat tends to separate out in globules and float to the top of the fluid.
Glaxo and Lac Vituni are the names of two brands. The Tru-milk
brand is made by concentrating the milk at a reduced pressure, and
then spraying it into a vacuum chamber ; by this means the
remaining moisture is evaporated and the solids fall like snow on
the floor. I have used dried whole milk with success for severe cases
of malnutrition in hospital practice, especially in hot weather. It
has the nutritive properties of condensed unsweetened milk, with
the advantage that it does not go bad so quickly after a tin is
opened ; it is also lighter for travelling. As a regular food for healthy
infants, it is inferior to food prepared from fresh milk, but may be
recommended when good milk cannot be obtained. The various
forms of dried caseinogen separated from the sugar and fat of milk,
such as Plasmon, are not suitable for infant feeding. Allenbury No. 1
is made from dried milk, modified to contain less protein and more
fat and sugar ; it is nearer the composition of human milk than
plain dried milk, but is still deficient in fat and protein. This may
be an advantage in digestive disorders. The food is useful as a
temporary expedient in disease occurring in the early months.
Certain infant foods consist of dried or condensed milk to which
inverted starch, that is, dextrin and maltose, has been added. Such
are Allenbury No. 2 and Horlick's Malted Milk.
In hot weather, when good milk is not obtainable, and in the
Infant Feeding. 229
digestive disorders of infancy condensed or dried milks are of great
value. They have the advantage of not forming a hard clot of
casein in the stomach as cow's milk does. Children take them well,
hut to form a suitable food for young infants they require to be
modified as above mentioned by the dilution and addition of sugar
and fat. The risk of scurvy must be met by the use of fruit or
meat juice. Of the condensed milks the unsweetened brands are
to be preferred. The sweetened brands of condensed milk, when
used as the regular diet, are harmful to the proper development of
the child on account of the great deficiency of protein and fat and
the excess of sugar. The child may become fat, but will be flabby,
anaemic, inactive, and prone to bronchitis, intestinal disorders and
rickets. Many condensed milks are made from skim milk ; these
are still more unsuitable for infants.
(3) Foods which when Prepared Contain no Starch. These
contain flour, which is either inverted by the manufacturer or
becomes so during the preparation by the action of a ferment,
usually maltose. Such are Mellin's Food, Paget's Malted Farina,
Diastased Farina, Cheltine Maltose Food, Hovis No. 1 Food.
Benger's Food is wheat-flour and pancreatic extract ; when mixed
with warm milk the starch is inverted. These are wholesome foods,
but are not suitable for the regular diet of infants on account of
their excess of carbohydrate and deficiency in fat.
(4) Floury Foods. These are foods made with starch which is
either incompletely inverted to maltose or is not changed at all.
In the following the starch is partly inverted : Carnrick's Soluble
Food, Nestle's Milk Food, Manhu Infant Food, Milo Food, Savory
and Moore's Food (starch nearly all inverted), Allenbury No. 3,
Coombs' Malted Flour, Theinhardt's Infantina and Hygiama, Chel-
tine Infant's Food, Hovis No. 2 Food, Albany Food, Worth's Perfect
Food, John Bull No. 2 Food, and Nutroa Food. The last-named
contains much more fat than the others, though far less than in
cow's or human milk.
In the following there is little or no pre-digestion of starch : Eidge's,
Neave's, Frame Food, Anglo-Swiss, Franco- Swiss and American-
Swiss Foods, Opmus, Falona, Albany, Imperial Granum, Robinson's
Groats, Robinson's Patent Barley, Chapman's Whole Flour, Scott's
Oat Flour, Nichol's Food of Health, Triticumina Food, " I. and I."
Food, Muffler's Food.
Floury foods are in no case suitable for infants under seven
months ; further, even for older children most of them merely
supply that element of the food which is cheapest and which the
child has least difficulty in obtaining, namely, carbohydrate. For
230 Infant Feeding.
children able to take starch in any quantity, rusks, rice-flour, bread
pap or bread-and-butter are more convenient and equally nutritious
additions to the milk. When advertising and manufacturing
expenses are taken into account it is probably not worth any manu-
facturer's while to sell a food containing protein and fat in the
proportions required, except perhaps dried milk, for the price would
be so high that even ignorant parents would see that they could
feed their children more cheaply on milk, cream or cod-liver oil,
rice or wheat flours, bread, butter and meat, according to their
age.
MODIFICATIONS OF DIET IN SIMPLE DIGESTIVE DISORDERS.
The treatment of gastro-enteritis, marasmus and other diseases
of infancy will be found described under the appropriate headings.
I shall here only refer briefly to modifications of the diet which are
called for in the treatment of slight disorders of digestion in
infancy.
In all digestive disorders the first care must be to see that the
meals are given at the proper hours, in the proper quantities, and
at the right temperature ; feeding at irregular times, because, for
instance, the baby cries, is a frequent cause of disorder. Alterations
of the diet should not be made without due thought. A child may
be fretful and uncomfortable from many other causes besides
unsuitable food, especially from want of fresh air, of proper
exercise and rest, or of entertainment, from incipient disease of
any kind, and from want of cleanliness. If it is decided to change
the food it is well to make a definite change, not a slight one.
Vomiting. Many babies regurgitate a little food after a meal
and are none the worse. Others are sick soon after a meal because
the ritual designed to " bring up the wind " is not properly performed,
or because they are not kept quiet after feeding, or their clothes are
too tight. Or the food may be taken too quickly because the per-
foration in the teat is too wide. If vomiting persists after these
points have been attended to, the amount of the feed should be
lessened until a quantity is reached that is retained ; the baby
should then be given this quantity for a time, after which a gradual
increase may be made. The interval between the feeds may also be
lengthened. Constipation, if present, must be corrected. If large
curds are vomited the amount of protein should be reduced by the
use of the table on p. 224. This will usually be successful ; if it is
not, a good plan is to peptonise the milk for a few days ; if this
fails, a milk should be prepared from an unsweetened condensed or
dried milk, and used with the addition of lactose and cream or
Infant Feeding. 231
cod-liver oil. If reducing the curd does not arrest the vomiting, a food
poor in fat, such as diluted peptonised cow's milk without any addi-
tion of cream, should be ordered. As a rule a weaker milk than that
which has been taken should be prescribed in digestive disorders.
In severe vomiting it is well to take the child off milk entirely for a
day or two, supplying whey and cream, or whey alone, or albumen-
water, and, if necessary, washing out the stomach with a 1 per cent,
solution of sodium bicarbonate.
The treatment of vomiting with diarrhoea is described in a special
article.
If there are flatulence and colic with stools containing curds
the feeds must be given with the strictest regularity, the quantity
being not too great ; the protein in the milk may be reduced,
or the clot softened by adding barley-water or gelatine, or by
peptonising. The addition of a little alkali, such as bicarbonate
of soda (1 or 2 gr. to 1 oz.), is often beneficial, or a teaspoonful of
dill water may be given after, or a tablespoonful of lime-water
before the feed. If these measures are not successful the use of
modified dried milk or condensed milk or Allenbury No. 1 food may
give relief, but should not be resorted to unless the child is losing
weight, and if used should be gradually replaced by fresh modified
milk in the course of two or three weeks. Whenever the infant's
food is changed there may be a slight loss of weight for the first few
days of the new diet, to which too much attention need not be paid.
The giving of starchy foods to infants is a frequent cause of
flatulence and pain.
Loose green stools without large curds may be due to an excess of
fat or sugar, and should be treated by modifying the milk in these
respects. Very large and light-coloured stools of a bad odour are
associated with an excess of fat. If mucus is present in the stools,
a dose of castor oil should be given before any alteration is made in
the diet.
Constipation is commoner in hand-fed than in breast-fed infants.
It is treated by allowing water between the feeds and massaging the
colon along its course just before the hour at which a motion should
l>e passed. The fat of the milk may be increased, or 1 drachm of
olive oil mixed with milk and sugar given once or twice a day. In
older infants the addition of a teaspoonf ul of ground oatmeal or of
some farinaceous food to each bottle is often effectual.
DIET IN LATER INFANCY.
At the seventh or eighth month the milk should be thickened
with well-boiled oatmeal or barley gruel (one tablespoonful of the
232 Infant Feeding.
meal to 1 pint of water), or one of the prepared farinaceous foods,
the milk and sugar being correspondingly reduced ; the addition
should not be made to every feed, but only two or three times in the
day. As soon as a tooth appears the baby may be allowed to bite
at a crust occasionally, so that when the time comes it will not
refuse solid food. After the ninth month whole milk will be taken
with the addition of a tablespoonful of lime-water to each bottle.
At twelve months the lime-water may be omitted. At about the
tenth month a dessertspoonful of raw meat juice is added to the
bottle and a little orange juice given every morning. The next
step will be to allow bread and milk at one meal ; after that a little
gravy and bread-crumb at the midday meal, followed later by
some milk pudding ; then come bread-and-butter and a lightly
boiled egg, the infant being gradually introduced to the diet of
childhood (p. 202). The child will now drink water at dinner, but
milk at other meals.
E. I. SPRIGGS.
233
FOOD FEVER.
FOOD fever is a name given to a derangement which is far from
uncommon in growing boys and girls. It begins with an attack
of acute indigestion, accompanied by fever ; but at the end of the
attack, when the temperature .falls and convalescence may be
expected to begin, the temperature instead of remaining at the
level of health is curiously unsettled and subject to sudden rises.
In the morning it is normal or even below the normal standard,
but later in the day, usually after the midday meal or in the
evening, it becomes febrile and may rise to 102, 103 F., or
even higher. It remains at this point for an hour or two and
then sinks again to its former level. This state of things goes
on day after day, and all the time the patient's condition is unsatis-
factory. He shows by his pasty complexion, his listlessness, his
loss of appetite and the unhealthy state of his evacuations that
his normal digestive activity has not yet been restored. Even
when the temperature has finally become normal the appetite,
although it may improve to some extent, often remains poor, and
the child shows no sign of beginning to regain flesh. Moreover, at
any time he is liable to a renewal of the febrile state and a return
of the more acute symptoms with which his illness had begun.
This state of things may continue for months, being marked
by febrile attacks of varying duration, followed by intervals in
which, although the temperature is not abnormal, the feet are
habitually cold, the appetite is poor, and the patient remains pale
and thin ; but at the same time between the attacks his spirits are
good as a rule, and he joins eagerly enough in all the sports of
his age. When the attacks of fever recur frequently, as they often
do, the anxiety they occasion is usually in proportion not to the
severity but to the mildness of the general symptoms with which
they are conjoined ; and the family practitioner remarking the
daily rise of temperature, and finding no striking indications of
local distress by which to explain the failure of health, begins to
suspect that there must be a tuberculous cause for the child's
continued indisposition. The subjects of the complaint are usually
spoken of as " delicate" ; but if the expression is used to imply a
constitutional weakness or special morbid tendency, it is here mis-
applied. The children, as a rule, are healthy enough and naturally
234 Food Fever.
strong. Their nutritive failure is the direct consequence of per-
sistent gastric derangement, for owing to their languid circulation
and chilly extremities the resisting power of the body to cold is
reduced to a minimum. The patient remains curiously responsive
to atmospheric changes and becomes a chronic sufferer from
mild catarrh of the gastric mucous membrane, which is maintained
or continually renewed by a succession of little chills. As a con-
sequence the appetite remains poor, the nutritive needs of the
system are insufficiently supplied, and the bodily heat is subject
to frequent fluctuations, owing, probably, to re-absorption from the
bowel of injurious products of decomposition.
In many cases of food fever the symptoms remain indefinite
and mild, and anxiety is occasioned only by the fluctuating tempera-
ture, the poor appetite, and the persistent thinness and pallor of
the patient. It may happen, however, that special symptoms
arise. A highly neurotic child may have his nervous system so
disturbed by the acute attack that he is thrown into a fit of convul-
sions, and the seizures may be repeated again and again. I have
seen this happen in impressionable children up to the age of
eleven or twelve years. In other cases the gastro-intestinal derange-
ment may be marked by violent and repeated vomiting, and for
two or three days the patient rejects almost immediately every
form of liquid nourishment which he can be induced to swallow ;
or there may be marked signs of intestinal irritation, and the child
passes loose stools containing mucus and blood. Another com-
plication may be sharp abdominal colic, with or without vomiting
or looseness of the bowels, and the patient may remain for several
days crying out with the pains and showing a temperature of
103 or 104 F. But whether a complication is present or not,
and whether the symptoms are mild or severe, the stools are
never satisfactory. They may not be increased in number or
even especially loose, but they are unhealthy and offensive and
often contain mucus. Such unhealthy evacuations are proof of
gastro-intestinal derangement, and point at once to a definite cause
for the febrile movement. When we notice also that the course of
the complaint is curiously uneven, that the patient is better or
worse as the catarrh varies in intensity, and that sometimes for a
week or so the improvement is such that he seems to have thrown
off his indisposition completely, we may exclude tuberculosis
without the least hesitation.
The above sketch of the symptoms which mark the course of
food fever has been necessary in order to make clear the means
by which the complaint may be brought to an end. But to be
Food Fever. 235
successful it is necessary fully to realise the conditions with which
we have to deal. It is not enough to put an end to the prevailing
disturbance and set up a merely temporary improvement, for that
can do little to bring the illness to a definite close. We must
remember that what we have to do is to cut short not one single
attack but a series, and that the persistence of the gastric difficulty
and consequent check to nutrition is the result of repeated renewals
of the original derangement. In order, then, to make improve-
ment permanent we must not merely put an end to the actual
attack, but must take the necessary steps to prevent its return.
This we can only do by recognising the remarkable susceptibility
to atmospheric conditions and vicissitudes shown by the subjects
of this complaint, especially if the indisposition is of some standing.
The patient's resistance diminishes with each fresh attack, so
that as time goes on he becomes less and less able to withstand
sudden changes of temperature, and is upset by an impression of
cold which would be powerless to harm a child who retains his
normal resisting power.
In the management of these cases, then, we must take immediate
steps to protect the child's sensitive body from chills. We must
dress him warmly in substantial woollen underclothing, and cover
up his legs and knees with long stockings. Even in the heat of
the summer light woollen combinations should be insisted upon,
for it is at this season that changes of temperature occur with such
startling suddenness, and a quick fall in the thermometer is often
found to be followed at once by a fresh outbreak of catarrh. In
addition, special care must be taken to keep the feet warm if the
weather is cold. The nurse should be instructed to feel them with
her hand several times a day, and warm them if necessary. In
the winter particular attention should be directed to this point
before the child leaves the house for his daily exercise, for he must
never be allowed to go out-of-doors with cold feet.
Care must also be taken that the patient does not get chilled in
his daily bath. Owing to his heightened sensitiveness to cold the
whole process must be carried out with the utmost expedition, so as
to avoid evaporation from the surface of the body. In bathing
these subjects it is the soaping which involves the greatest risk,
for the unavoidable exposure thereby entailed is often attended by
ill consequences. The safest method is to bath the patient in hot
soap-suds (100 F.) as directed elsewhere. 1 I make no apology for
insisting upon these domestic details, for attention to such matters
constitutes the main treatment of this stubborn derangement ;
indeed, without extreme care in this respect all other measures,
236 Food Fever.
however well-intentioned, are bound to fail. We cannot put an end
to a catarrh as long as we allow it to be continually renewed. We
may diet and dose such a child for weeks and months together
without permanent good if we take no steps to counteract the
continually recurring cause of the complaint. The cause is chill,
and we must see that the child is properly protected against it.
The prevailing objection to covering up the legs of young children
is one of the difficulties against which we have to contend, and it is
necessary to insist firmly that recovery is impossible as long as the
legs are allowed to be bare. This precaution applies to in-door life
as well as out-of-door exercise. For their walks, indeed, the
children in cold weather are usually dressed warmly enough with
long thick gaiters, but when they return to the house these are at
once thrown aside. It is necessary to explain that the patients are
far more likely to get chilled in the house, exposed as they are with
uncovered limbs to cold staircases and draughts from doors and
windows, than in the open air, where care is taken that they are
fully and warmly clothed.
But in addition to the obvious precautions, which apply equally
to all subjects of the complaint, we must be careful not to disregard
exceptional sources of chill which may be peculiar to the individual
sufferer. These we can only discover by special inquiry into the
prevailing nursery arrangements, for there are very many ways in
which a sensitive child may take cold. To give an example : in
some families it is a custom to beautify the heads of young
children with a long and large curl. This is done with a wet brush,
and leaves the hair damp, and I have known a catarrh of the
stomach to be maintained for weeks together by this simple
operation. Minute inquiry will often discover some unsuspected
imprudence, which throws a sudden light upon a baffling case and
suggests the means by which it may be brought to an end.
By the above measures we do much to lessen the difficulties
before us and ensure the success of our treatment. It is one thing
to cure an actual catarrh but quite another thing to put a stop to a
series of such attacks, for the latter object is not to be achieved by
means which are efficient enough in the case of the former. When,
therefore, we have taken the necessary care to lighten our task,
the next step must be to put the patient upon a rigid diet. We
strictly limit the quantity allowed of carbohydrates, such as
starches and sweets, and forbid all articles of food which are
capable of undergoing an unwholesome fermentation in the
alimentary canal. Starches and sweets are especially liable to
disagree, for, owing to the excess of acrid mucus in the stomach, they
Food Fever. 237
quickly undergo a noxious change. Potatoes are bad, as they con-
sist of pure starch in its most indigestible form, and the ordinary
milk pudding of the nursery, made as it is of a pure starch cooked
in the oven with milk and sugar, is highly deleterious. The
admixture of milk with starch greatly increases the instability of
the latter, as is explained elsewhere, 2 and the common addition,
when it comes to table, of baked apple composes a mess which in
this derangement is little short of explosive. Sago and tapioca,
used as a thickening to soup, I have not found to be equally
injurious, and plain boiled rice is usually digested without difficulty.
Acids, such as oranges, grapes, apples and all the summer fruits,
are also to be avoided ; and jams, fruit jellies and marmalade, which
all contain the acid of the fruit with a quantity of added sugar, can
on no account be allowed. Pounded white sugar may be permitted
in moderation, if added cold at table, but sugar cooked as in sweet
puddings and sponge cakes is inadmissible. The cooking of sugar
develops in it a number of unstable compounds, which undergo an
unwholesome change when taken into the stomach quickly. This
is especially the case with beet sugar, which is much less to be
trusted than that made from the cane, and the latter should
always be preferred for nursery use.
In obstinate cases the inclusion of milk in the diet is a matter
which requires careful consideration. It is one of the prevailing
superstitions of the nursery that milk at all times and in all states
of health is a sufficient and sustaining food. In the case of a child
of normal constitution and average health this may be an accurate
statement of fact, but it is certainly incorrect in the case of
children who are subject to such digestive derangements as that
under consideration. Milk is a fermentable food, and like other
articles of the same class should never be given to these patients
lightly and as a matter of course. In the treatment of children
(and I include infants) it is a good rule, whenever the stomach is
disordered, to regulate with care the quantity of milk allowed in
the diet. Some can take a moderate amount without obvious
harm, while others after the smallest quantity begin at once to
show signs of discomfort, and in many cases of food fever the
temperature continues to be subject to daily alternations as long as
milk, in however small a quantity, is retained as a part of the
patient's daily fare. When milk disagrees fresh whey is usually
well borne, but it must be clear and quite freshly made, for after
only a few hours, especially in warm weather, it becomes stale and
no longer fit for use. In young children a good substitute for milk
is fresh whey diluted with an equal quantity of barley- water, and
238 Food Fever.
sweetened with white cane sugar. If thought desirable, it may be
flavoured with a spoonful of extract of malt or a pinch of cocoatina.
As long as the temperature continues high without any decline
the diet must consist of liquid foods, such as that just mentioned,
and alternated with veal or chicken broth thickened with barley
and strained ; but when the temperature returns to a normal level,
with only a single daily rise, more solid food may be allowed, and if
milk and the more fermentable things above referred to are put on
one side, the digestive disorder is very quickly brought to an end.
Mutton, chicken, and white fish, such as sole, plaice and whiting,
agree well ; and the salted things, such as bacon, thinly-sliced ham.
bloaters and all the salted pastes, are not only harmless, but
actually useful to children of the age of six years and upwards in
restoring tone to the relaxed mucous membrane. Sardines, if of
good brand, agree well in most cases. If they do not it is probable
that the oil has become rancid. Certain fresh vegetables, such as
cauliflower, vegetable marrow, stewed cucumber and Spanish onion,
stewed for five hours with frequent changes of the water, are all
harmless additions to the diet. Bread may, of course, be allowed
if not new and spongy ; and toast need not be forbidden if cut thin
and toasted through. Fresh butter is also unobjectionable. In the
matter of puddings, those made from flour and rusks are to be pre-
ferred to the pure starches, and therefore as the patient's condition
improves he may be allowed batter pudding, boiled or baked,
bread-and-butter pudding, light suet pudding made with bread-
crumb instead of flour, and all the cabinet puddings which are
made of biscuits and rusks. These, however, ought not to be
admitted into the dietary until convalescence is advanced.
It is well in all cases to write out a dietary, and to caution the
mother that it is to be adhered to very strictly. Partial
dieting in these cases is quite useless, for our object is to put a
stop to the fermenting process, and a small excess of fermentable
material will prevent this object being achieved. In the diet as
above prescribed the fermentable material is reduced to its
narrowest limits, and any addition to it can only be made at great
risk. Sweet cakes and sweets and acid fruits, in however small
a quantity, keep up the fermenting process and prolong the dis-
turbance.
Of the treatment so far recommended, the essential part lies in
the domestic management of the patient upon reasonable and
healthy lines. Much of this is, of course, outside our own personal
control, and we have to look to others for the accurate carrying out
of that for which we cannot ourselves be personally responsible.
Food Fever. 239
It is then of great importance not to be slack in reminding mothers
and nurses of their duties. The medical attendant ought, at his
visits, himself to feel the patient's feet with his hand, and should
never leave the house without renewing his caution against the
danger of chill. In bad cases, when the child is confined to his
bed, the use of the bed-pan must be insisted upon. If the patient
is allowed to leave his bed even in a warm room, he is more than
likely to suffer from the change of temperature, for the attendants
can rarel}" be trusted to take adequate precautions to avoid it.
One of the chief obstacles to success in these cases is the difficulty
we often find in getting the mothers and nurses to realise the
curious susceptibility to impressions of cold shown by these patients
after they have suffered for only a few months from a rapid
succession of acute catarrhs.
In the administration of drugs, our attention must be confined to
the gastric trouble, and our prescriptions directed to put an end to
this as quickly as possible. Iron and other tonics are absolutely
useless until this primary object has been achieved. In the acute
attack, when the temperature is high, it is advisable to begin with a
dose of calomel (2 gr.) at night, and to follow this up with an
aperient saline in the early morning ; afterwards an alkaline
stomachic draught must be ordered, to be taken three times a day
half an hour before food : 3^ Sodii Bicarb., gr. 5 to 9 ; Spirit.
Ammon. Co., ni.5 to 10; Tinct. Aurantii, ttj.15; Glycerini, iri.15 ;
Infus. Calumbae Recentis, ad sij to jss. M. ft. haustus. [U.S.P.
1^ Sodii Bicarb., gr. 5 to 9 ; Spirit. Ammon. Aromat., Tii5 to
10; Tinct. Aurantii Amari, ir\12; Glycerini, fftl5; Infusum
Calumbae, ad 3ij to 5 as.]
Another useful drug is sulphate of zinc in minute doses. A
child of six years old may take gr. in a teaspoonful of freshly
made infusion of calumba three times a day before food. This
remedy is of especial value when there is any tendency to vomiting.
If the latter symptom is distressing and any. liquid taken returns at
once, the best treatment is to forbid all attempts to feed the
patient and to allow nothing by the mouth but hot water taken
freely at short intervals, giving no medicine at all. At first the
water will be returned almost immediately, but gradually as the
acrid mucus gets washed out of the stomach tolerance becomes
established, and the patient is able to retain iced whey or thin veal
broth in very small quantities at a time. When the intake is thus
restricted to hot water it is often advisable, in order to satisfy the
relatives, who will express their fears that the child may be starved,
to prescribe some nutritive suppositories to be used several times a
240 Food Fever.
day. This precaution, although not required in the patient's own
interests, is a harmless procedure, and will often render the task of
the medical attendant an easier one. It is wise in all cases where
the anxieties of the relatives are aroused to keep in mind their
natural apprehensions and misgivings, however groundless these
may be. It must be remembered that to be successful in our work
we have not only to manage the patient, bringing to his service all
the skill and resource at our command, but we have also to satisfy
the patient's friends ; and the latter is often the more difficult task
of the two. If the vomiting is very obstinate, small doses of
calomel (gr. ^ to gr. , given every half-hour for six or eight
doses) will often effect a remarkable improvement.
Severe abdominal pains are best controlled by codeine in suitable
quantities. This sedative has but little constipating effect, and is,
therefore, greatly to be preferred to morphia or opium in most
cases of functional abdominal derangement. Most children of six
years old will take gr. -^ three or four times a day without any
feeling of drowsiness. If, however, any such consequences follow,
the dose of the remedy must be reduced, and the forthcoming dose
held over until the effect of the last has been recovered from.
If mucous colitis occurs, with straining and the passage of
thin stools containing mucus and blood, the disturbance is
usually of a mild character, easily controlled by small doses of
castor oil and opium: 1^ Olei Kicini, iri4; Tinct. Opii, Tl2;
Vini Ipecac., rn.2 ; Glycerini, rn.15; Aquam Carui, ad 5J. M. ft.
haustus (for a child of six years). To be taken every four
hours.
It is necessary to inquire very carefully into the state of the
stools, for unless their number or appearance is obviously abnormal,
they are unlikely to be referred to ; indeed, the bowels will pro-
bably be described as " nicely opened." But the passage in the day
of only one loose and offensive stool is a sure indication that the
digestive conditions are not satisfactory, and if the temperature
continues unsettled there will be no prospect of bringing things
back to a normal state until the derangement has been overcome.
Often the child in these cases is still allowed a certain quantity of
milk, although in other respects very strictly dieted. This indiscre-
tion must be remedied at once, and nitrate of silver with opium
should be given without loss of time : 1^ Argenti Nitratis Cryst.,
gr. \; Acidi Nitrici Dil., in2; Tinct Opii, rn.1 ; Glycerini, in 15;
Aquam, ad 5j. M. ft. haustus. To be given to a child of six years
every four hours.
In all abnormal stages of the digestive organs in the child, after
Food Fever. . 241
the acute stage has passed off and the derangement is threatening
to persist in a modified degree or to become chronic, this remedy
may be turned to with confident expectations of a satisfactory
result. The nitrate may be continued for ten months without any
fear of inducing pigmentation of the skin.
By the means thus described all cases of food fever may be
certainly brought to an end and permanent good health restored.
It is, however, necessary to warn the mother that attention to
all the points enumerated must be persevered with for many
months. If these precautions are relaxed, relapses are almost
certain to follow as long as any abnormal susceptibility remains,
and in ordinary cases twelve months at least must pass before we
can expect the patient to have recovered his normal resisting
power against rapid changes of temperature.
EUSTACE SMITH.
REFERENCES.
1 .See " General Hygiene and Care of Young Children," Vol. I.
2 Loc. cit.
S.T. VOL. II.
16
242
ABDOMINAL INJURIES.
THE subject of the treatment of abdominal injuries is a large and
complicated one. One or more of the various and numerous
abdominal injuries may be present in any one case. All necessitate
careful treatment and the great majority require active surgical
measures ; therefore part of the treatment of abdominal injuries
consists in recognising what particular injuries are present and
treating them accordingly. Thus, in the class of case under
consideration, diagnosis has a peculiarly close relationship to the
treatment. For instance, it is easy in theory to describe the treat-
ment a certain condition A ; but if in practice the condition
diagnosed as A turns out to be B, C or D, or any combination of
them, then the treatment becomes complicated, and it is neces-
sary to take into consideration the various sub-conditions B, C
and D, and their recognition.
The Incidence of Abdominal Injuries. Experience is the
only guide we have in adjudging to the various abdominal injuries
their relative importance. It gives what may be called " clinical
perspective," enabling us to place our cases in due proportion.
Moreover, this method is eminently practical, la}dng emphasis on
the more frequent conditions and proportionately less on the
infrequent, according to their clinical importance. No one surgeon
or practitioner has sufficient practice to gain full experience of
abdominal injuries. Hence it is necessary to consult the method
of collective investigation, the material being available in the
excellent surgical reports of St. Bartholomew's, St. Thomas's,
University College, Middlesex and Westminster Hospitals. From
these sources I have been able to find records of over 2,500
instances of abdominal injury, the mildest of which was sufficiently
severe to necessitate the patient's admission to hospital.
Table of the Incidence of Abdominal Injuries in over
2,500 Cases :
Contusion of the Abdomen .
Wounds of the Abdominal Wall .
Injuries to the Kidney
Injuries to the Alimentary Canal.
Injuries to the Liver .
Injuries to the Spleen .
65 -0 per cent.
8-5
7 '8
4-8
4-6
Abdominal Injuries 243
Injuries to the Bladder . . . 1 '2 per cent.
Injuries to the Mesentery ... -6 ,,
Ruptured Rectus Abdominis Muscle
Foreign Bodies in the Abdomen .
Injuries to Gall-bladder and Bile-ducts
Injuries to the Diaphragm, Suprarenal Capsule, Pan
creas, and Omentum 1 -0
Injuries to Ureter, the most infrequent visceral in
jury, and to Abdominal Vessels ... -4
Haemorrhage into Lesser Sac, Traumatic Peritonitis,
1 lii'inatoma of Abdominal Wall, etc. . . . . 2'2 ,, ,,
The mortality for over 2,000 cases of abdominal injury, which
were severe enough to be admitted to hospital, was no less than
23 per cent. About 30 per cent, of abdominal injuries require
active surgical intervention.
Contusion of Abdomen. A contusion of abdomen is a wide
term given to injuries sufficiently severe to merit clinical considera-
tion, and not severe enough to be complicated by any recognisable
internal injury. In our table the contusion was sufficiently severe
in 65 per cent, to demand the admission of the patient to the
hospital. There is great variety in the possible consequences of an
abdominal injury. It does not depend only on the force of the
blow, but on the strength and preparedness of the abdominal
muscles to receive it. For instance, an expert boxer will allow a
heavy blow to be received on his abdomen without causing him any
inconvenience ; or a cart may pass over the abdomen, leaving the
mark of the wheel, and do no great harm. On the other hand, a
trivial blow may rupture an enlarged liver or spleen ; hence it is
difficult to draw any further conclusion from the character of the
injury than the broad generalisation that "severe damage may be
expected to result from a severe injury." Every abdominal injury
must be regarded as serious until it has been proved to be other wise.
In order to treat these cases it is necessary to understand their
possible causation. In a paper on spinal concussion in the Lancet,
September, 1906, it was suggested that some of the symptoms and
signs of contusion of the abdomen are explained by the violence or
shaking, producing a " molecular disturbance " in the abdominal
ganglia, and consequently a functional derangement, abdominal
concussion. Shaking of the various abdominal viscera must also
produce some functional disturbance. Stimulation of the nerve
endings will also produce reflex acts, such as cessation of the heart's
beat and fainting.
It will be necessary to consider the clinical features in some
detail because they form the fundamental groundwork of rational
treatment. And, in addition, the diagnosis of contusion of the
162
244 Abdominal Injuries.
abdomen is only made if no definite lesion is found. Clinically
there are three stages.
The first stage consists in shock and collapse, which in one
extreme produce sudden death, in another fainting. Sometimes
there is tetanic contraction of the diaphragm, as when an athlete
is " winded."
In this stage the treatment consists in recumbency, wrapping in
warm blankets, hot water bottles or bricks carefully protected,
raising of the foot of the bed, stimulants particularly if given hypo-
dermically, and warm saline per rectum. The temperature is sub-
normal and the pulse rapid. The saline per rectum can be given
in to 1 pint doses every hour or every two hours.
The second stage is that of reaction. The temperature rises and
the pulse is less rapid. It is during this stage that the concomitant
conditions, such as the rupture of a viscus, may make their presence
recognisable. Everything which comes from the " inside " of the
patient must be carefully kept and inspected, such as vomit, urine,
motions, or returned saline. During this stage it is well to avoid
giving food by mouth, except in small quantities, and purgatives
must not be administered unless it is certain that there is no lesion
of the alimentary canal. Thirst must be controlled by the adminis-
tration of saline solution per rectum or hypodermically.
At this stage there are four possibilities. Firstly, signs and
symptoms of internal htemorrhage may appear, such as a falling
and subnormal temperature, a rising pulse-rate, a softer pulse,
restlessness, blanching, the non-secretion of urine, a clammy skin,
the appearance of an increasing dull area in the abdomen, occa-
sionally shifting dulness in the abdomen, etc. Such symptoms
point to a ruptured spleen, liver, mesenteric vessel, etc.
Secondly, the signs and symptoms of peritonitis may appear ;
such as a rising temperature, a small harder pulse, a rigid
abdominal wall, diminution or cessation or respiratory move-
ments, distension, sickness, inactive bowels, etc. Such symptoms
suggest the rupture of a hollow viscus.
Thirdly, the signs and symptoms of reaction may pass away
and convalescence begin.
Fourthly, the abdominal signs and symptoms do not clear up
satisfactorily, but the patient remains with slight fever, a raised
pulse-rate, occasional sickness, and bowels which are difficult to
move ; he sleeps badly, takes little or no food, is querulous and
not restful, complains of abdominal discomfort rather than pain ;
generally, the patient's condition is " not satisfactory," rather than
" definitely unsatisfactory."
Abdominal Injuries. . 245
This condition, which may be termed chronic peritonism, is not
sufficiently recognised, is not uncommon, and presents great clinical
difficulty. If such cases are operated upon some definite lesion
is almost always found. Such lesions are a " low " form of peri-
tonitis, bruised mesentery and bowels, a small amount of blood in
the peritoneal cavity, etc. But it is certain that such operative
treatment is not always a benefit to the patient.
The treat mi' nt of cases of abdominal contusion or concussion may
be easily summed up : (1) Treat shock and collapse as already
indicated ; (2) watch very carefully for early signs of internal
haemorrhage or peritonitis ; both demand immediate operation ;
(3) watch for the persistence of unsatisfactory symptoms ; opera-
tion is demanded in the great majority of such cases ; (4) the
only other consequence is convalescence, which demands common-
sense treatment.
It is as well to remember that abdominal contusion or concussion,
in addition to the risks of very serious internal complications, has a
mortality of its own. Such fatal ending may occur at once or
shortly after the injury. Yet at an operation or a post-mortem
examination no cause of death can be found. Such a mortality for
about 1,600 cases was 3 per cent.
Wounds of the Abdominal Wall. These cases constituted
8'5 per cent, of abdominal injuries, and were divisible according to
the case records into three classes, penetrating, the peritoneal
cavity being opened ; non-penetrating, the peritoneal cavity not
being opened ; and doubtful, it being uncertain if the peritoneal
cavity has been opened ; the last forming almost one-third of the
cases.
The Treatment of Penetrating Wounds (50 per cent, of cases).
The treatment must vary according as to whether there is any
prolapse of viscera or not.
(1) No prolapse of viscera : (a) First dressing : Eemove the
clothes and any obvious uncleanliness, and cover the wound with a
dry sterilised antiseptic dressing, such as double cyanide gauze, held
in position by a bandage, (b) Second dressing (to be done as soon
as can be arranged) : Anaesthetise the patient, cover the wound
with a dry sterilised pad, shave and wash the skin around with
soap and water, followed by spirit lotion, and paint with 2 per
cent, iodine dissolved in spirit. Having done this, cleanse
the wound with a wool pad and saline, cut away the soiled
skin edges, enlarge and explore the wound for foreign material.
Paint with 2 per cent, iodine solution. Enlarge the opening
in the abdomen sufficiently to allow a thorough inspection of
246 Abdominal Injuries.
the underlying parts, so that no internal lesion is overlooked.
Sponge away all blood and check all bleeding. If the wound is
reasonably clean the peritoneum may be closed with sutures. The
abdominal wall is then reconstructed, and the skin wound closed ;
the area covered with a dry dressing held in position by a many-
tailed bandage. Such cases must be watched with great care for
the occurrence of suppuration. If it is considered undesirable to
close the wound completely, as it will be in the majority of cases, a
gauze drain is introduced into the peritoneal cavity and the wound
closed around it. Such a drain is removed in thirty- six to forty-
eight hours, and, all being well, a fresh one is not inserted. But
if all is not well another drain may be inserted for twenty-four
hours.
In those wounds which heal with suppuration the scar is weak,
and a ventral hernia may develop later requiring an aseptic opera-
tion for the reconstruction of the abdominal wall. An abdominal
belt does practically nothing to stop the development of a hernia.
It gives support and confidence to a patient with a hernia.
The mortality for penetrating wounds of the abdomen is about
30 per cent, when there is no concomitant internal injury, death
being due to the introduction of sepsis and the resulting peritonitis.
(2) When prolapse is present : (a) First dressing : Eemove the
clothes and obvious uncleanliness ; do not reduce the prolapsed
viscera unless the patient appears to be dying of shock ; cover with
a large dry dressing, (b) Second dressing : Anaesthetise the patient
as soon as the necessary arrangements can be made. Wash the
prolapsed viscera carefully with a plenteous supply of sterilised
saline solution. Reduce the viscera into the peritoneal cavity.
Cover the wound with a pad, cleanse and shave the abdomen
around, remove the soiled skin edges, paint with 2 per cent,
iodine solution, explore and cleanse the wound. A drain must
be introduced into the peritoneal cavity and the wound closed
around it. This drain is removed within thirty-six to forty-
eight hours, and, if necessary, another is inserted.
The Treatment of Xon-pcnetratnif/ Wounds. (a) First dressing :
Remove the clothes arid all obvious uncleanliness ; cover the part
with a dry dressing ; as a rule it is not necessary to ligature any
vessels, (b) Second dressing : Administer an anaesthetic. Place a
pad over the wound. Wash and shave the abdomen around.
Cleanse the wound with saline solution, followed by spirit
lotion and painting with 2 per cent, iodine solution. Remove
the skin edges and explore the wound to prove it to be non-
penetrating, remove all dirt, stop all haemorrhage, and reconstruct
Abdominal Injuries. 247
the abdominal wall, draining the wound if it is unclean, suturing
it if clean. Use a dry dressing and a many-tailed bandage. When
a drain is used it should be removed, and replaced if necessary, in
thirty- six to forty-eight hours.
The object of most importance in these cases is to restore the
abdominal wall and make it as strong as possible. But it must not
be forgotten that there is a mortality even amongst cases of non-
penetrating wounds of the abdomen. It was about 10 per cent.,
the deaths being due to sepsis or traumatic peritonitis, produced by
auto-infection, most probably by the passage of organisms through
the bowel wall.
Tin' Treatment of Wounds of the Abdomen, tchen it is uncertain if
tltet/ are ]>enet rating or not. In the two former sections there is no
doubt as to the course of treatment to be pursued, though opinions on
the technique may vary. As a consequence it was possible to speak
somewhat dogmatically, two precepts in particular being emphasised ;
when a wound is closed watch more carefully for complications
than if it were not closed, and use normal saline solution rather
than antiseptic chemicals to cleanse the peritoneum. But when it
is uncertain if an abdominal wound has opened the peritoneum, the
practitioner has to think more carefully before he acts. To overlook
a " penetration " is to make the patient incur a serious risk to life
that might have been obviated. To make a perforation is to make
the patient incur a grave and additional risk. In such case the
line of treatment must be to regard every icound as penetrating
until it lias been prored to be non-penetrating. Thus at the first
dressing the case is treated as has been recommended for a
penetrating wound without prolapse of viscera. At the second
dressing commence as though for a penetrating wound, but be very
careful not to convert a non-penetrating into a penetrating wound ;
when its real nature is discovered treat it accordingly. An
anaesthetic should always be given, and the surgeon must be pre-
pared to deal with a penetrating wound of the abdomen with
internal complications. In giving a prognosis in case of wound of
the abdomen it must be remembered that : (1) Penetrating are more
fatal than non-penetrating wounds ; (2) an overlooked penetration
is a grave source of danger ; (3) either wound may be complicated
by an internal injury ; (4) the other immediate complication to be
feared is sepsis ; (5) a ventral hernia may occur later.
All patients with wounds of the abdomen involving the abdominal
muscles, and possibly nerves, must be kept in bed for at least three
weeks if the wound is perfectly clean. If the wound is unclean,
the convalescence must be much longer.
248
Abdominal Injuries.
Bullet "Wounds of the Abdomen. For practical purposes
these may be regarded as penetrating -wounds, complicated by
multiple internal injuries, such as injuries of the vessels, mesentery
and bowel. Yet it was proved by experiences in the South African
War that such cases generally recovered if no operation were done ;
the entrance and exit wounds made by the bullet were dressed, and
the patient was only allowed to take food and liquid nourishment
very sparingly at first. This may be accepted as a correct state-
ment with regard to abdominal injuries inflicted with the modern
small projectile. With the old-fashioned bullet the wounds are
larger and more severe, so that it is better in civil practice to open
the abdomen through the "aperture of entrance" and to deal with
the injuries found. Still, the action taken in a particular case
must be decided by the circumstances of that case, and not by pre-
conceived notions. If operation can be undertaken under favour-
able conditions within a few hours of an injury by a modern bullet
it should be done. Operation should be performed in all cases of
wounds made with less modern projectiles (see Gunshot Wounds,
Vol. I.)-
Abdominal Injuries complicating Thoracic Injuries. It is
not generally recognised that thoracic injuries can give rise to
abdominal injuries. Such a complication is more frequent in
animals than in man, as often the ribs are greater in number and
extend further down towards the pelvis. Amongst 300 cases of
broken ribs admitted to St. Thomas's Hospital, there were thirty-
six with abdominal injuries (12 per cent.) . These abdominal injuries
are extremely important and commonly fatal. Indeed, if a thoracic
injury is complicated by an abdominal injury, the patient is likely
to die. The exceptions to this rule are cases of abdominal con-
cussion or contusion, or a contusion of kidney.
Abdominal injuries which complicate a thoracic injury, unless
produced by an accident which may affect more than the thorax,
are confined to the viscera in the upper part of the abdomen. The
following table shows their order of frequency :
Injury to Kidney (particularly the right)
Liver . . ...
Spleen
Liver and Spleen .
Liver, Spleen and Kidney
Stomach .....
Diaphragm alone .
14 Cases.
9
6
3
1 Case.
1
1
The most frequent injury, that to the kidneys, is the one most
amenable to treatment. For successful treatment the diagnosis
Abdominal Injuries.
249
must be made at once and operation performed quickly. For the
treatment of the specific injuries reference must be made to the
sections devoted to them.
Injuries to Other Parts of the Abdominal Parietes. The
abdominal parietes not considered already are the hernial rings,
the pelvis, the loins, lumbar spine and perineum. It is not usual
for these to be included in abdominal injuries. Indeed, no further
mention will be made of the hernial rings, perineum, or loin. But
fractures of the pelvis have some
special interest, as they may
involve abdominal viscera. In
the last seventy-seven cases of
fractured pelvis admitted to
St. Thomas's Hospital 4 per cent,
were complicated by rupture of
an abdominal viscus, the bladder.
From time to time there are
cases in which the violence of
the accident has been so gene- ''^^^^^m^^l
rally distributed that abdominal
and thoracic injuries occur as
well as a fracture of the pelvis.
In this series of seventy- seven
cases the urethra was ruptured
in five of the cases, the bladder
in four, the vagina in one,
the rectum and bowel not
once.
The loin is practically never
injured except as a contusion,
when the kidney generally suffers
and the injury to the loin becomes
merged clinically into a contu-
sion or rupture of the kidney.
Incised "Wounds of the Abdominal Wall. Incised wounds, if
made under surgically clean conditions and sutured properly, heal
by first intention, and never dispose to hernia. But if the
reconstruction of the abdominal wall or the healing is imperfect,
a hernia is prone to develop. This is particularly true of wounds
in the loins or the lower part of the abdomen. When the wound is
unclean from the beginning and has to be drained the reconstruc-
tion of the part is necessarily imperfect, and a hernia is prone to
develop.
FIG. 1. Tetanic Rupture of rectus
abdominalis.
250
Abdominal Injuries.
The treatment of these cases consists in an attempt at a
surgically perfect reconstruction of the part, and if it is impossible
to do this the aperture must be closed by a fine metal filigree net-
work or a silk " skein." An abdominal belt supports and gives
comfort to the patient, but in no wise prevents the formation of a
hernia.
Injuries to the Kidneys (7-8 per cent.). Next in frequency of
occurrence to injuries of the abdominal walls come injuries to the
kidneys, for the treatment of
which reference must be made
to the section dealing with them.
Injuries to the Alimentary
Canal (4-8 per cent.). Next in
frequency to injuries of the kid-
neys come the injuries to the
alimentary tract, for the treat-
ment of which reference must be
made to the proper section.
Injuries to the Liver (4-6 per
cent.). Following close in fre-
quency to the injuries of the ali-
mentary canal come the injuries
of the liver. Out of 105 cases
of ruptured liver, in 70 per cent,
the injury (or serious injury)
was confined to that viscus. The
viscus most frequently injured
at the same time as the liver was
the right kidney. The gravity of
a ruptured liver depends upon
the extent of the rupture. When
the rupture is single it is often
large and deep. When multiple the ruptures are usually smaller and
more superficial. Being a soft structure the liver is sometimes practi-
cally torn in half, and stitches in its substance cannot be tied firmly
as they " cut through." In consequence, it is usually impracticable
to suture ruptures in the liver. Ruptures of the liver chiefly cause
death from internal haemorrhage. If the patient escapes this he
may die from peritonitis from the extravasation of infected bile, or
he may develop abscesses in the various subdiaphragmatic or sub-
hepatic loculi. Ruptures of the liver practically always involve
the surfaces of the organ covered by peritoneum, so that the extra-
vasation takes place into the peritoneal cavity, being in consequence
FIG. 2. Tear of Liver.
Abdominal Injuries.
251
unlimited in extent. Naturally, it is a very fatal injury, only 3 per
cent, recovering when the injury is limited to the liver, and none
recovering when the results of the injury are more widespread.
The death of the patient may occur in the first clinical stage of an
abdominal injury, when no special treatment is required. In the
second stage, reaction, the increasing internal haemorrhage may
make itself obvious. The abdomen is opened above the pubes, the
source of the haemorrhage ascertained, a second opening made over
the injured viscus, all blood removed, and the rupture plugged with
gauze. The surgeon now returns to the original opening, removes
all blood from the loin and
pelvis, fills the latter with
warm saline solution, and
closes the wound. The
gauze in the liver is re-
moved and more inserted
on the third day after opera-
tion, the patient being par-
tially anaesthetised. After
this it is again changed on
the fifth day, when it is
usually bile-stained ; and
daily afterwards. It is very
disappointing to treat these
cases, as it is not so infre-
quent to save the patient's
life from the haemorrhage,
and at the end of a week
after the operation the tem-
perature begins rising, due
to infection of the various
loculi of extravasated blood
and bile above, under, and around the liver. Sometimes no bile is
secreted, as indicated by the dressings and pale stools, the patient
becoming drowsy in a condition of acholia.
Injuries to the Spleen (2-7 per cent.). Injuries to the spleen
come next in frequency, and, if uncomplicated by other injuries,
form one of the most readily and certainly diagnosable classes of
abdominal injury, and are most amenable to treatment. Of 100
injuries to the spleen about sixty involve that viscus alone and
forty have multiple injuries, rupture of the liver being the most
frequent complication, followed by that of the left kidney. The
mortality for uncomplicated rupture of the spleen, all cases in
FIG. 3. Gunshot wound of liver.
252 Abdominal Injuries.
hospital practice being considered, is about 65 per cent., whilst
in the hands of some operators the mortality is as low as 34 per
cent.
For the details of treatment of ruptures of the spleen reference
must be made to Surgical Affections of the Spleen.
Injuries to the Bladder (1-2 per cent.). These may be intra-
peritoneal or extra-peritoneal, the latter being usually associated
with fractures of the pelvis. For the treatment of these injuries
reference must be made to Affections of the Bladder.
Injuries to the Mesentery (-6 per cent.). These injuries are
quite undiagnosable before operation and are found on exploration
of the abdomen for haemorrhage, peritonitis, or an " unsatisfactory
condition " of the patient as mentioned below. The dangers
are haemorrhage or necrosis of the bowel, of which the former is
the greater ; indeed, on several occasions it has been my fortune to
find the mesentery of the small intestine distended by a huge
haematoma on the top of which the bowel is placed. Under such
conditions the source of the haemorrhage is unknown and the
bleeding uncontrolled, yet the abdomen has been closed and, in
the instances I have seen, the patient has always recovered, the
bowel failing to necrose in spite of the impairment of its vascular
supply. 1
Rupture of Abdominal Muscles (-5 per cent.). The rupture
of an abdominal muscle by its own contraction is only seen in
the recti muscles. The rupture usually occurs in the lower
part of the muscle, but occasionally near the ribs. It is accom-
panied by pain and swelling ; later the rupture may be felt.
It is rarely necessary to operate on account of haemorrhage.
Occasionally it is necessary to incise the haematoma to evacuate
clot and expedite the healing. Attempts to sew up the
muscle are not made often, as it is generally understood
that stitches do not hold in muscular tissue. This is perfectly
true of inflamed muscle, such as that undergoing repair, but it is
not true of freshly divided muscle sutured aseptically ; hence the
treatment for a ruptured rectus abdominis should consist of the
immediate suture of the muscle, provided that the circumstances
allow of it being done with surgical cleanliness. If this cannot be
done apply an ice-bag, or ice in a sponge-bag wrapped in flannel.
When the bleeding has ceased order massage with dry starch
powder and dry heat in between times. It is unusual for a ventral
hernia to develop, but owing to the injury the protective valvular
mechanism of the inguinal canal is apt to be destroyed and the
patient may develop an inguinal hernia on the affected side.
Abdominal Injuries. 253
Wounds of the Diaphragm. Except in cases of stab or bullet
wounds abdominal injuries are not often complicated by wounds
of the diaphragm. The abdominal injuries complicated by wounds
of the diaphragm are of necessity severe, and are further com-
plicated by wounds of viscera adjacent to the diaphragm. Thus, in
two cases, both the loin and the right kidney were ruptured, and in
one case the spleen was ruptured. These injuries are naturally
very fatal, death being caused by the concomitant lesion rather
than the injury to the diaphragm ; hence, if these patients are
too ill for operation, the treatment must be directed to that of the
viscera injured. Eecovery from such extensive injuries must be
very rare.
With incised or stab wounds of the chest or abdomen recovery is
not infrequent, although the diaphragm may have been pierced.
Such patients are liable to develop a diaphragmatic hernia when
the lesion is on the left side, the most commonly herniated viscera
being the stomach, omentum and transverse colon. The presence
of a scar low down on the left side of the chest or high up on the
left of the abdomen should give rise* to the suspicion of the presence
of a diaphragmatic hernia. The liver prevents the formation of
similar herniae on the right side.
Wounds of the omentum, suprarenal capsule and the pancreas
are found from time to time at operation or post-mortem examina-
tion on patients who have sustained an abdominal injury. The
most infrequently injured structure in the abdomen is the ureter.
A blow on the abdomen may so bruise and injure the bowel as
to allow the passage of organisms from its interior, starting a
traumatic peritonitis, the infective organism almost always being
the Bacillus coli communis.
A further group of cases must be mentioned in which blood and
clots are found in the abdomen, the source of their origin never
being discovered. It may be bruised bowel, mesentery, a small
peritoneal rupture in the parietal or visceral peritoneum, or small
rupture of liver, etc. As a rule it is useless, and sometimes indeed
harmful, to the patient to make a prolonged search for the point
which has bled.
GENERAL CONSIDERATIONS AND RULES FOR THE TREATMENT
OF ABDOMINAL INJURIES.
Cases of abdominal contusion should begin to recover as soon as
the initial shock and collapse have passed off ; that is to say, in the
period of reaction. In this same period of reaction after an
254 Abdominal Injuries.
abdominal injury the signs of internal haemorrhage or peritonitis
begin to appear. Hence it is in this period, usually three or four
hours after the injury, that the patient must be most carefully and
repeatedly examined, so that it can be decided whether the patient
is improving (recovery), getting rapidly worse (free internal
haemorrhage), getting slowly worse (slow internal haemorrhage or
peritonitis), or remaining in an unsatisfactory condition (still
slower haemorrhage, a low form of peritonitis, prolonged peritoneal
shock and other peritoneal functional disturbances). If surgical
interference is indicated the following procedure should be adopted :
Operation. (1) Open the abdomen in the middle line between
the umbilicus and the symphysis pubis. This incision will always
be required for cleansing the pelvis and perhaps for drainage.
(2) On incising the peritoneum look for free gas, debris of diges-
tion, blood and urine. If the former two are found examine the
bowel, beginning with caecal end of the ileum, as the ileum is the
part most often injured, and working upwards to the duodenum.
The small bowel is more frequently injured than the large bowel,
and the extravasated contents are likely to be liquid in the former
case and solid in the latter. If no rupture is found in the small
bowel examine the large bowel, beginning at the rectal end, as
injuries are more frequent there and get progressively less frequent
higher up in the colon.
(3) If blood is found on incising the peritoneum see if it is
coming from the lower or upper part of the abdomen. If from the
lower part of the abdomen in a woman the injury is probably a
ruptured tubal gestation. If from above and the right side of the
abdomen suspect a ruptured liver. If it comes from the upper and
left side of the abdomen suspect ruptured spleen.
. (4) If on incising the peritoneum blood-stained urine is found in
the pelvis feel for an intra-peritoneal rupture of the bladder.
(5) An injured kidney is dealt with most easily through the loin,
when operation is required.
The above rules will suffice as guides for about 93 per cent, of
the cases met with in practice. The remaining 7 per cent, consist
of unusual occurrences which, as a rule, are not benefited by
treatment.
(6) The abdominal wounds are then closed or drained as is
thought best.
(7) In cases where the mischief has been in the upper part of
the abdomen the patient had better remain recumbent.
(8) When the injury is in the lower half of the abdomen sit
the patient up in the semi-erect Fowler position and administer
Abdominal Injuries. 255
saline per rectum, either by continuous irrigation (p. 635) or by
the administration of ^ to 1 pint through a tube and funnel at
hourly intervals.
(9) In abdominal injuries the infective organism to be feared is
the Bacillus coli communis, so that 25 cubic centimetres of the
anticolon serum may be administered shortly after the patient has
returned to bed.
(10) Do not press food by mouth or increase it rapidly.
(11) Open the bowels by enema on the third day after opera-
tion ; a purgative may be given by mouth on the fifth day.
(12) All abdominal plugs and drains should be removed, and if
advisable replaced, within forty-eight hours of insertion. On the
first occasion the patient should have an ansesthetic, only light
anaesthesia is required to enable the surgeon to do his work expe-
ditiously and well without paining the patient, who should not be
allowed to return to consciousness until the bandages have been
replaced.
(13) When closed the wounds should be sealed with a " gauze
and collodion " dressing, 2 the whole abdomen being covered with
wool maintained in position by a many-tailed bandage. This allows
the practitioner to examine the abdomen freely without fear of
infecting the wounds and with a minimum of disturbance to the
patient.
COMPLICATIONS.
It may be mentioned that in popular and many professional
minds abdominal injuries are responsible for many more troubles
than have been already narrated, such as appendicitis. Whilst it
is perfectly true that an injury may have been the final factor which
enabled the infective agent to start the appendicitis it must be very
rare for the injury to be so beautifully timed and graduated as to
do no further harm.
Of the more chronic abdominal conditions which may demand
treatment a few days after the injury, intestinal obstruction is the
chief guise under which they appear. Ruptured spleens have come
under treatment as cases of intestinal obstruction or peritonitis
some days after the apparently slight injury.
Badly fitting trusses allow the bowel or omentum to come down
so that they lie between the truss and the pubes. If a blow, such
as the kick of a horse, is given to the truss the bowel or omentum
is compressed against the pubic bone and grossly injured, after
which and when the patient is in bed it returns to the abdomen.
I have met with two such cases, both fatal ; only being diagnosed
256 Abdominal Injuries.
after the incidence of a fatal peritonitis. If the practitioner takes
the trouble to examine patients before the truss they wear is
touched it is astonishing how very frequently the truss is found to
be resting on a piece of omentum, although the patient thinks
that the " rupture is up."
EDRED M. CORNER.
BEFERENCES.
1 Corner, E. M., " Clinical and Pathological Observations in Acute Abdominal
Diseases," Lond., 1904.
* Corner, E. M., and Pinches, H. I., "Operations of General Practice,"
3rd edition (Oxford Medical Publications), Lond., 1910, pp. 17 19.
257
THE PREPARATION OF PATIENTS FOR
ABDOMINAL OPERATIONS.
THE details of the preparation of a patient for an abdominal
operation vary with the practice of the operator. This section
will deal with the main principles and with procedures in common
use.
The cases may be divided into two groups : (1) Those in which
the surgeon is able to fix the time for operation ; and (2) " emer-
gency " cases, in which the operation must be performed as early
as possible.
CASES IN WHICH THE SURGEON IS ABLE TO FIX THE
TIME FOR OPERATION.
In fixing the day and time for an abdominal operation,
the surgeon must take several matters into consideration. As
a rule, when an operation has been decided upon, the patient
is anxious to have it arranged for as early as possible. The
minimum time to be devoted to preparation is thirty-six hours,
and during this time the patient should be in bed. For
instance, if an operation is arranged for a Wednesday morning,
the patient should go into the nursing home or hospital not later
than the preceding Monday evening, and even before this prepara-
tion should be commenced by attention to diet and to the action
of the bowels. If the operation is likely to be severe, the patient
should be kept in bed for at least three or four days beforehand,
and defects in the general health, such as those mentioned below,
may make an even longer period of preparation advisable. Much,
however, depends on the temperament of the patient and the
nature of his trouble.
Certain climatic conditions are unfavourable to the performance
of abdominal operations, especially when the upper part of the
abdomen is to be opened, and when the patient is elderly or liable
to bronchitis. These conditions are fog, cold damp weather,
and very hot weather. Operations performed under these
conditions involve an increased risk from pulmonary complica-
tions.
In women laparotomies should not be undertaken shortly before
S.T. VOL. II. 17
258 Preparation for Abdominal Operations.
or during menstruation ; the most convenient time is about a
week after menstruation.
The general health of the patient should be as good as
possible. When several days are to elapse before operation,
fresh air, regular exercise, and careful feeding should be insisted
upon. In many cases a fortnight or so may be well spent in
improving the general health. An examination of the heart,
lungs, and urine should always be made ; if there is any doubt as
to the patient's ability to stand the anaesthetic, the anaesthetist
should be asked to examine him before the final decision is made.
If the patient has a cough, its cause should be ascertained and
treated ; this precaution applies especially to elderly subjects
with trouble in the upper half of the abdomen. If bronchitis is
present, it is usually advisable to postpone operation until the
condition has been cleared up or ameliorated. Ancemia should
be treated as far as possible, and it is often well to delay operation
until the anaemia has been lessened by treatment, for anaemic
patients stand shock badly. Jaundice, especially if of long
standing, may cause diminished coagulability of the blood, and,
as a result, persistent oozing during and after the operation.
This tendency to haemorrhage may be minimised or prevented
by giving calcium lactate in 10-gr. doses three times a day for
three days before the operation.
Preparation of the Alimentary Canal. It is important
that the alimentary canal should be as far as possible empty and
sterile. Emptiness greatly facilitates operation, and relative
sterility reduces the risk of intestinal infection to a minimum.
It has been proved that suitable preparation renders the stomach
and the upper part of the intestine sterile, and it is clear that
this preparation will also render the lower part of the intestine
less septic.
The teeth require special attention, and whenever practicable
they should be overhauled by a dental surgeon. All stumps
should be extracted, carious teeth should be removed or stopped ;
dental plates to be worn before the operation should be thoroughly
and regularly cleaned. A toothbrush and antiseptic tooth powder
should be used after each meal, and the mouth well rinsed with a
mouth wash, such as glycothyxnoline or listerine, at least three
times a day.
A few days should be devoted to the regulation of the diet and
bowels. The diet should be light, and foods which are likely to
leave much debris in the intestine should be avoided ; it is,
however, important that a patient should not be starved during the
Preparation for Abdominal Operations. 259
days preceding an operation, for starvation is especially conducive
to shock. On the day before operation meals must be light and
easily digestible ; milk and starchy foods should be avoided ; it
is not necessary as a rule to restrict the patient to fluids. Three
hours before operation a cupful of strong beef-tea or coffee
may be given.
In operations upon the stomach, all foods taken during the
preceding forty-eight hours should be sterilised and should be
la ken from sterilised vessels. It is not necessary to wash out the
stomach in all cases, and as a rule recent haematemesis and acute
inflammatory troubles contra-indicate lavage. If, however, there
is any degree of pyloric obstruction, the stomach must be washed
out ; boiled water is used for this process, which is best carried
out in the latter part of the day before operation, and after
this nothing is given by the mouth except sterilised water or tea.
If the stomach is greatly dilated, it may be well to wash it out
daily for three or four days before operation.
The bowels should act freely for a few days before operation, and
in those who are constipated it is well to start with a full dose
of salts or Liquid extract of cascara. Discretion is needed as to
the amount of medicine and the number of enemata to be given,
for whilst it is important that the intestines should be well
emptied, it is equally important to avoid setting up diarrhoea ;
the exhaustion which follows excessive purgation, especially in
elderly patients, is the worst possible preparation for an abdominal
operation. On the other hand, in cases of habitual constipation,
free purgation is necessary, and this process should be carried
out over a period of three or four days, and should not be left to
the twenty-four hours preceding the operation.
At 6 a.m. on the day before the operation castor oil should be
given ; this usually acts satisfactorily within a few hours ; if not,
1 pint of soap and water should be injected into the bowel.
The dose of castor oil must vary with different patients : in
healthy adults 1 oz. is given, but for elderly and feeble
subjects 4 to 6 drachms is usually quite sufficient. Patients
should not be allowed to choose the purgative, for it frequently
happens that the drug selected proves quite ineffectual on this
particular occasion. A common enema is administered in the
evening, and again two or three hours before the operation.
The Bladder must be emptied a short time before operation .
In most cases the passage of a catheter is unnecessary, but if
there is any doubt as to the bladder being empty, or if the operation
is to involve the pelvic organs, a catheter should be passed.
172
26o Preparation for Abdominal Operations.
The Preparation of the Skin is discussed in the chapter on
Surgical Technique. It is very important that a sufficiently
wide area of skin should be prepared. The preparation should
extend from the nipple line above to the pubes and upper part of
the thighs below, whatever region of the abdomen is to be opened,
and all hair on this area should be shaved off. Particular atten-
tion should be paid to the cleansing of the umbilicus, especially
in stout subjects.
Clothing. When the operation is likely to be prolonged or to
be attended with shock, warm clothing is essential. The limbs
and the upper part of the chest should be enveloped in wool or
woollen coverings ; long woollen stockings reaching to the upper
parts of the thighs are most convenient for the lower limbs, and a
woollen jersey may be used for the arms and chest.
Nervousness must be prevented as far as possible, and much
may be done by cheerful re-assurance on the part of the medical
man and the nurse : preparations for the operation should not
be obvious. A good night's rest before operation is of great
importance. Nervous patients may be given a dose of bromidia
(5ij), or bromide by the rectum, or a hypodermic injection of
morphia (gr. I or gr. ), and atropine (gr. ji^).
Many operators make a practice of giving morphia and
atropine shortly before operation, chiefly in cases in which ether
" by the open method " is to be given. Morphia diminishes the
amount of anaesthetic necessary, and is especially useful for
patients who are very nervous. Atropine checks the secretion of
mucus and counteracts the inhibitory action of the vagus ; it
has the disadvantage of increasing thirst after operation. If the
use of these drugs is decided upon, they should be injected
subcutaneously one hour before the time fixed for operation ;
morphia (gr. to |) and atropine (gr. T | o to T <^). (See
Anaesthetics, Vol. III.)
EMERGENCY CASES.
Many acute abdominal affections, such as perforation of a
gastric ulcer and acute intestinal obstruction, are accompanied
by considerable shock and collapse. These conditions must be
treated by the application of warmth, in the shape of warm
blankets and hot-water bottles, and unless there are signs of
internal haemorrhage, by a rectal injection of \ pint of saline
solution and \ oz. of brandy. In severe cases it is well to post-
pone operation for three or four hours, by which time some
improvement will usually have occurred.
Preparation for Abdominal Operations. 261
ti of the Skin. For these emergency cases the iodine
method of preparation is usually best ; the solution of iodine
(2 per cent, in rectified spirit) should therefore be in readiness
for urgent cases. The skin should be dry-shaved and swabbed
over with acetone ; the solution of iodine is then painted on
and a dry sterilised dressing applied. The iodine is again applied
immediately before the operation is commenced. If the iodine
solution is not available, the skin should be prepared in the
ordinary way. When there is acute tenderness the preparation
may be carried out after the patient has been anaesthetised.
An enema is advisable in most cases if there is time, whilst other
preparations for operation are being made ; a soap-and- water
enema is usually best.
In cases of intestinal obstruction with persistent vomiting the
stomach should be washed out before the administration of the
anaesthetic, unless the patient's condition is so serious that the
proceeding is likely to cause shock and great distress.
The details of the operation must be so planned that no time
is wasted when once the patient has been anaesthetised. All
instruments that may possibly be required must be ready; for
instance, a Paul's tube with rubber tubing should be at hand in
case it is needed. All ligatures and sutures must be prepared
before the anaesthetic is commenced.
In connection with this subject, the following sections should
also be consulted : Surgical Technique, Vol. I. ; The Prevention
of Shock, Vol. I. ; The Management of the Sick Room, Vol. I. ;
Anaesthetics, Vol. III.
T. CRISP ENGLISH.
262
THE TREATMENT OF PATIENTS AFTER
ABDOMINAL OPERATIONS.
UNCOMPLICATED CASES.
SATISFACTORY progress after abdominal operations depends
largely upon careful after-treatment, which also contributes
greatly to the patients' comfort.
There are three very important principles in the treatment of
those recovering from abdominal operations :
(1) Patients who are doing well after an operation should as
far as possible be left without active treatment. The best
recoveries take place in those cases in which stimulants, hypo-
dermic injections, rectal infusions and so on, are not necessary
and are not given.
(2) Patients who are doing badly should not receive too much
treatment. When patients are acutely ill, their strength may be
exhausted, and sleep may be prevented by the administration
of many medicines, frequent enemata, and constant changing of
dressings.
(3) If a patient is sleeping, he should not be disturbed for
any purpose whatever.
When the operation has been completed, the patient is carried
carefully to bed, and in most cases it is best to place him on his
back with a pillow under the knees. The head is turned to one
side, and if vomiting occurs the nurse must carefully support the
wound with her hand, to prevent undue strain upon the stitches.
If the abdominal wound is a large one, as in ovariotomy, a flat
sandbag about 4 inches by 8 inches by 1 inch, and weighing about
5 lb., placed over the line of the wound and lying on top of the
dressings, is of great value as a support to the wound. These
sandbags are often very comforting to the patient, so much so
that when removed, as they should be after forty-eight hours,
the patient frequently complains of the loss of support. After
the drainage of an appendix abscess it is better from the beginning
to keep the patient turned slightly on to the right side by means
of a pillow placed under the left flank and hip, as this assists in
the escape of the pus from the abscess cavity. As soon 'as the
effects of the ansesthetic have passed off, one or two pillows placed
under the head and shoulders will materially add to the patient's
comfort. A cradle is unnecessary unless the weight of the clothes
Treatment after Abdominal Operations. 263
causes discomfort or unless the weather is hot. The room should
be darkened and quiet, its temperature 65 to 70 F.
Pain in varying degree is usually complained of during the
first twenty-four hours. An attempt should be made to discover
the cause of the pain or discomfort, for attention to some small
detail or a slight change of position will often put matters right.
The loosening of a tight bandage, the emptying of a distended
bladder, or the re-adjustment of pillows may at once relieve the
discomfort.
General abdominal pain should be treated by the administration
of 10 gr. of aspirin or phenacetin, repeated in two or three hours if
necessary ; if pain is severe, a hypodermic injection of morphia
may be given, ^ gr. being usuaUy sufficient. In fact, in many
cases in which complications are not expected, such as gastro-
enterostomy and appendicectomy in the quiescent stage, ^ gr.
of morphia may be given in the evening, and will considerably
lessen the discomforts of the first night after the operation :
atropine (gr. T ^) should be given with the morphia.
Pain in the back is a common cause of distress. It may be
treated by change of position, and by tucking in small pillows
against unsupported parts, or by the application of hot-water
bottles, or by gently rubbing the painful region with rectified
spirit. These measures judiciously used will almost always give
relief.
Thirst is another symptom which is often very prominent.
It shows that the body requires fluid , and as a rule there is no
harm in allowing the patient to swallow a moderate amount of
fluid within twelve hours of operation. If the patient wishes it,
weak freshly-made tea may be given, and this will often do a
great deal to make a patient, especially if a female, more comfort-
able. After most severe abdominal operations the administration
of saline solution by the rectum can be adopted with great advant-
age, and is very effectual in preventing the distressing thirst,
which was formerly so common when fluids were withheld.
Half a pint of saline solution (1 teaspoonful of salt to 1 pint of
water) should be allowed to run slowly into the bowel every four
or six hours ; or, better still, continuous rectal infusion may be
employed (see Proctoclysis).
If anaesthetic vomiting is troublesome, the best plan is to
allow the patient to drink freely a solution of bicarbonate of
soda (1 drachm to 1 pint). This quickly and effectually clears
the stomach and usually stops the vomiting. The treatment
of persistent vomiting is discussed later.
264 Treatment after Abdominal Operations.
The mouth should be frequently washed out with weak
solutions of glycothymoline or listerine ; freshly made tea also
forms an excellent mouth wash, and later grape- juice or orange-
juice will be found refreshing. The teeth should be regularly
cleansed.
Flatulence is a frequent cause of complaint after abdominal
operations, especially when there has been much manipulation
of the intestines. If it is chiefly gastric, bicarbonate of soda
solution in frequent sips should be tried, or a carminative such
as tincture of ginger may be given ; a sodamint tabloid or a
peppermint lozenge crushed and given in a teaspoonful of milk
is often effectual. Granulated charcoal, given a few granules
at a time up to 2 drachms in the day, will relieve both gastric
and intestinal flatulence, and maybe given as a routine in abdominal
cases. When the larger bowel is involved, or in any case in which
there is much flatulent distension, the long rectal tube should be
used for fifteen or twenty minutes every four hours.
Bladder. A careful watch should be kept for retention of
urine, and on no account should the bladder be allowed to become
over-distended, since this may cause subsequent atony. The
application of a hot-water bag to the hypogastrium or slight
changes in position are often effectual in overcoming retention.
If these measures fail, a catheter must be passed under strict
antiseptic precautions, twice a day or more often if necessary.
Persistent retention of urine after an operation is often overcome
by giving ergot (ext. ergotae liquidum, nt5, ter. in die).
Bowels. If a patient is doing well after an operation, and if
there is no abdominal distension, the bowels may be left alone
until the morning of the third day, when a common enema with
2 oz. of olive oil should be given, and until the fifth or sixth day
enemata are perferable to aperients, especially when any part of
the bowel has been sutured, for purgatives may excite harmful
peristalsis and throw undue strain upon the sutured area. After
the sixth day, mild aperients such as cascara and salines should
be given.
For constipation during the later stages, abdominal massage,
fruit, and suitable aperients should be used. It is always well
to consult the patient upon the subject, as he is often the best
judge of the most suitable drug ; but it must be remembered that
larger doses will be required than those which the patient is in
the habit of using when in normal health. Useful preparations
in addition to stock Pharmacopoeal mixtures are purgen, one
tablet (adult size), at night, and Burroughs, Wellcome & Co.'s
Treatment after Abdominal Operations. 265
laxative tabloids, one at night. Purgatives must be used with
special care after abdominal operations upon old people, since
their abuse may *et up a diarrhoea which rapidly exhausts the
patient.
Feeding. Fluids only should be allowed during the first two
or three days. Any of the following may be given : Albumen water,
broths, beef-tea, whey, tea, coffee, Vichy water, soda water,
barley water ; the patient's tastes may be consulted in the matter.
If it is essential that he should have as much nourishment as
possible at the earliest moment, plasmon in small doses may be
mixed with the feeds of albumen water, etc.
Personally, I do not believe that milk should be given, until
the bowels have acted and any distension has disappeared ;
patients with thickly furred tongues cannot digest milk, and
under these circumstances, milk, even if peptonised, causes
flatulence, loads the intestines and produces constipation. As
soon as the bowels have acted and the tongue has become
moderately clean, milk, diluted with barley water or soda water,
may be given.
On the fourth or fifth day, if all is going well, the patient may
have thin bread-and-butter, custard, jelly, Benger's food, lightly
boiled pounded fish, toast ; a day or two later, pounded chicken
and fruit may be given. Rectal feeding is quite unnecessary in
the majority of abdominal cases, and its value at any time is
doubtful. Water or saline solution is, however, freely absorbed
by the rectum and colon, and if there is difficulty in giving
a sufficient amount of fluid by the mouth, it should be given
by the rectum.
Insomnia. Many patients complain that they are unable to
sleep. In all such cases a careful note should be made of the
actual time during which the patient has slept, and if the amount
of sleep is less than normal, or if the sleep is broken and disturbed,
steps should be taken to remedy this.
Insomnia is often due to a definite cause which is removable.
A change in position, or reassurance on some point about which
the patient is worrying, may be all that is necessary ; any such
cause as flatulence or pain in the back should be treated on the lines
indicated above. When there is no such definite cause, warm
sponging of the face and hands will often send the patient to
sleep ; re-arrangement of the pillows, a fresh cool sheet or pillow-
case to replace those which are hot and uncomfortable, may be
effectual.
If these measures fail, and the patient is evidently becoming
266 Treatment after Abdominal Operations.
distressed from want of sleep, drugs should be tried. It is usually
wise to keep from the patient the knowledge of what drug he is
having, and in most cases to give it in milk or other food, so that
he does not know when it is given. The most generally useful
drug in these cases is aspirin (in 10-gr. doses), or one of the follow-
ing drugs may be given : Chloralamide, gr. 30 ; trional, gr. 10 ;
bromidia, 3J. Chloralamide may be given in whisky, but the
taste is very difficult to disguise ; the other drugs can be readily
given in warm milk. Morphia should be avoided if possible ; if
it is given, a small dose is usually sufficient, unless actual pain is
the cause of the insomnia : | gr. may be given hypodermically,
or ^ gr. in a suppository. The paralysing effect of morphia on
peristalsis may be minimised by the addition of T ^ to T Q gr. of
atropine.
Position in Bed. After recovery from an anaesthetic, the
most comfortable position for the patient (provided there is no
marked shock) is the semi-recumbent position, piUows being
placed behind the shoulders and back, and a bolster beneath the
knees. After operations upon the stomach and in cases with any
tendency to chest complications, the patient should be well
propped up in a sitting position as soon as possible ; in cases of
diffuse peritonitis this position (the Fowler position) forms an
important part of the treatment.
The lateral position may be adopted to facilitate drainage, as
in cases of appendicitis with abscess ; pillows are placed under
the shoulder and hip of the opposite side.
If there is much shock the patient must be kept absolutely flat
in bed, with the foot of the bed well raised on blocks or chairs.
It is quite unnecessary to restrict the movements of the patient
after an abdominal operation, as was formerly the practice. As
a rule the position of greatest comfort should be chosen, and
change of position should be made from time to time ; this is of
especial importance in enabling the patient to sleep.
Visitors. In most cases no visitors should be allowed for the
first twenty-four hours. On the second and third days the
patient may see a relative, but on no account should he be allowed
to become over- tired or excited.
Men may smoke after operations, as soon as they have the
inclination to do so. They should be encouraged to shave or to
be shaved as soon as possible, on account of the self-respect and
comfort which this proceeding induces.
Dressings. In cases in which the wound is closed without
drainage the dressings as a rule should not be disturbed until the
Treatment after Abdominal Operations. 267
removal of the stitches. If, however, they are causing discomfort ,
they may be changed on the third or fourth day. Of course, full
antiseptic precautions must be taken.
Bandages applied firmly at the end of the operation often
become uncomfortably tight owing to flatulent distension ; if so,
the margin may be cut, but care must be taken that they are not
so loosened that the underlying dressing can be displaced.
Stitches which involve only the skin and superficial tissues
should be removed on the seventh day; stitches which pass
through the whole thickness of the abdominal wall are left undis-
turbed until the tenth to fourteenth day; if they are taken out
earlier than this, there is a risk of some sudden effort, such as
coughing, causing the wound to burst open. In those who are
stout or have a cough, it is well to apply broad pieces of strapping
to support the sides of the wound after removal of the stitches.
In cases in which the wound is drained, e.g., after the opening
of an abscess, the dressings should be changed four or five hours
after operation ; then they should be changed two or three times
daily for the first few days, according to the amount of discharge.
If a tube has been inserted into an abscess cavity, it is better not
to move it for three or four days, as there may be difficulty in
replacing it, especially if the cavity extends deeply into the pelvis ;
it may, of course, be shortened from above if necessary. After the
fourth day the tube may be removed daily for cleaning. Dis-
cretion must be used as to when it may be replaced by a smaller
one or be dispensed with.
Gauze plugging, if used, should be removed gradually; if care
has not been used in its insertion, the removal may be a very
painful proceeding. Gauze which has been used to pack off the
general peritoneal cavity should not be removed before the sixth
or seventh day, by which time it will have become loosened ; if
removed earlier, there is a risk that adhesions will be broken down
and clean surfaces infected. Gauze which has been used to drain
an abscess cavity should be taken out earlier ; its withdrawal
should be commenced after twenty-four hours, the last piece
being removed by the third or fourth day. Irrigation with
solution of hydrogen peroxide (10 volumes) assists in the loosening
of gauze.
Duration of Confinement to Bed. This depends upon a
great variety of circumstances, and especially upon the age and
muscular tone of the patient, the character and size of the incision,
the question of drainage and primary healing. In the absence of
complications, most cases may be allowed to get up on the
268 Treatment after Abdominal Operations.
fourteenth day, and may leave the hospital or nursing home on
the twenty-first day.
After appendicectomy in the quiescent period patients with
ordinary muscular development may be allowed up in eight to
twelve days, and may leave the home or hospital in fourteen to
eighteen days ; those with feeble abdominal muscles, such as
multipart, should be kept in bed for at least a fortnight. In an
acute case of appendicitis the patient should be kept in bed for
fourteen days if the wound is not drained, and if the wound is
drained he should be kept in bed until healing has occurred ; if
he is allowed to get up earlier than this, final healing is often
delayed and ventral hernia is apt to follow. Such a patient,
however, may be moved on to a couch and wheeled up to the
window or into another room after ten to fourteen days.
Massage to the extremities is a most excellent measure during
convalescence, especially for a patient who has had a long illness
and whose muscles have become wasted. Massage very con-
siderably hastens progress when the patient begins to get up, and
greatly diminishes the feeling of weakness which is usually
complained of.
A belt should be ordered when an abdominal wound has been
drained or when a primary union has failed ; it is also advisable
in very stout patients and in those with lax abdominal muscles.
The belt should be worn for six months, after which time the
operator should examine the scar, to decide whether the wearing
of a belt should be continued. In women with weak abdominal
muscles a carefully made surgical corset is often better than the
ordinary abdominal belt. For healthy muscular subjects, in
whom the wound is not unusually long and has healed well, a belt
is quite unnecessary and in fact may do harm.
"Final Directions to Patients. Careful directions should
always be given to patients, especially to those who have
been treated in hospital. The nature of the operation which has
been performed should be explained to them ; for instance, after
operations for acute appendicitis it is very important that they
should be told whether or not the appendix has been removed.
In general they should ,be advised as to the importance of avoiding
constipation and should be instructed as to the best means of
doing this ; they should also be warned that they may for a time
have occasional abdominal pain, which is most likely caused by
nothing more serious than adhesions. They should also be
informed as to what they may or may not do in the way of diet
and exercise.
Treatment after Abdominal Operations. 269
THE TREATMENT OF CERTAIN COMPLICATIONS.
Most of the complications which may follow abdominal
operations are dealt with in other parts of this System. This
>cction will be devoted to the treatment of certain post-operative
complications which require special mention, or which are not
dealt with elsewhere.
Shock. The treatment of post-operative shock is fully
described in the chapter on Shock. Prophylaxis is obviously of
the greatest importance ; careful preparation, quick operating,
gentleness in manipulation, a minimum amount of exposure, and
the careful control of haemorrhage, are the main points.
After severe and prolonged operations, the patient should be
very carefully carried back to bed, the head being kept low.
The foot of the bed should be well raised and warm blankets and
hot-water bottles should be applied ; care should be taken that
the bandages are not so tight that they interfere with respiratory
movements. Proctoclysis (continuous rectal infusion of saline)
is one of the most effectual methods of combating shock, and
this may be commenced as soon as the patient has been returned
to bed. If shock is expected, rectal infusion may be started
whilst the patient is on the operating table ; it can be carried
out without interfering with the operator, and is only contra-
indicated when considerable oozing is expected or is occurring.
Persistent Vomiting. Vomiting which persists after the first
twenty-four hours is very exhausting and distressing to the
patient, and may cause damage to the abdominal wound. Active
steps must be taken to arrest it.
Satisfactory treatment depends mainly upon the recognition
of the cause of the vomiting. Inquiry should be made as to the
effects of any previous anaesthetics, and also as to any liability to
sea-sickness. It must never be forgotten that persistent vomiting
may be a symptom of intestinal obstruction or of peritonitis
following upon or continuing after the operation ; under these
circumstances it is often an indication for reopening the abdomen.
Very rarely copious vomiting may be a symptom of acute
dilatation of the stomach.
When the vomiting is due to the irritative effect of the
anaesthetic, the stomach should be thoroughly cleared by allowing
the patient to drink as much as he likes of a solution of bicarbonate
of soda ( 1 drachm to 1 pint) : this induces copious sickness, and is
often successful in completely getting rid of the irritating material.
In more obstinate cases the stomach may be freely washed out
with the same solution, and this step is especially indicated when
270 Treatment after Abdominal Operations.
large quantities of bilious fluid are being ejected. No food
should be given by the mouth, and if necessary rectal injections
may be used.
If the trouble appears to be of nervous origin, a hypodermic
injection of J or | gr. of morphia should be ordered, or 2 drachms
of potassium bromide in 3 oz. of water may be adminis-
tered by the rectum. Early action of the bowels will frequently
stop the sickness ; a large soap-and-water enema is best, and a
purgative may be given at the same time.
The following remedies are sometimes successful : (1) Tincture
of iodine (1-min. doses in a teaspoonful of water every half hour
for six doses) ; (2) 10-min. doses of a 2 per cent, solution of
cocaine ; (3) bismuth subnitrate (in 30-gr. doses) ; (4) the
application of a mustard plaster or blister to the epigastrium.
Hiccough. Persistent hiccough is even more distressing and
exhausting to the patient than vomiting. It should be treated
on similar lines.
When not due to any serious complication, frequent sips of
hot water may stop it, especially if this results in thorough
clearing of the stomach ; small doses of tincture of iodine or
cocaine may prove successful, and nitroglycerin ( T ^ gr. three
times daily) is recommended. A spoon pressed firmly on the
dorsum of the tongue as far back as not to excite retching some-
times has the desired effect. In more severe cases, a large dose
of potassium bromide or a hypodermic injection of morphia should
be given.
Distension. This may be due to a great variety of causes,
and before treatment is commenced an attempt should be made
to determine the cause and the part of the alimentary canal
affected. The surgeon must quickly decide whether the condition
is due to obstruction or to peritonitis, for successful treatment of
these complications depends entirely upon prompt recognition. A
moderate degree of flatulent distension is common in those who are
stout and who suffer from chronic constipation. Undue handling or
exposure of the intestines will certainly be followed by distension,
and this is most marked in the colon. Gastric distension often
accompanies irritative vomiting.
When the stomach is the seat of the distension, it is usually
best to empty it by giving a large drink of bicarbonate of soda
solution, or by washing it out through a stomach tube. Simple
remedies which often afford great relief are strong peppermint
lozenges, ginger, and three or four drops of turpentine on sugar ;
placing the patient well on the left side is sometimes effectual.
Treatment after Abdominal Operations. 271
When the lower bowel is involved, a small turpentine enema
and the use of the long rectal tube for twenty minutes every
three hours should be tried. It is important that the nurse should
make certain that the tube is acting effectually, and this is done
by placing the free end of the tube in a bowl of carbolic lotion,
when the appearance of bubbles is an obvious indication of the
escape of flatus. The rectum should be emptied, if necessary,
by a common enema before the tube is first passed.
In Paralytic Distension prompt measures must be taken, for
otherwise the condition may pass on to complete obstruction. If
the rectal tube proves ineffectual, a large enema containing
i oz . turpentine should be given ; in obstinate cases the following
enema will sometimes succeed when others fail : Magnesium
Sulphate, =jss ; Glycerine, jij ; Turpentine, jss ; Water, to
5vj. At the same time, a purgative should be given. The best
plan is to order 4 or 5 gr. of calomel, to be followed by sodium and
magnesium sulphate (1 drachm of each), every two hours until the
bowels act.
Drs. Berkeley and Bonney 1 strongly recommend a rectal wash-
out. " A tube is passed into the rectum with a funnel fitted to
its free end : 2 pints of soap and water at a temperature of 105
are mixed with 1 oz. of turpentine, and 10 oz. of this solution
are passed into the funnel, which is held as high as possible. The
fluid is allowed to remain in the rectum for a few minutes, after
which the funnel is lowered and the injection is allowed to run
out, with the consequent aspiration of flatus from the intes-
tine. Another 10 oz. is then run in until the two pints are
used up."
If these measures fail to reduce the distension, T ^ to ^ gr.
of eserine salicylate should be given hypodermically every three
hours, or ^ gr. of strychnine may be given three hourly.
Pituitary extract (20 per cent.) is highly recommended by some
authorities 2 : it is given intra-muscularly in doses of 1 cubic
centimetre, and is said to strongly stimulate intestinal peristalsis
and to cause the expulsion of flatus in a short time.
The bandages should be kept tight in order that firm pressure
may be maintained, and in certain cases gentle massage is
indicated.
If the condition of paralytic distension passes on to actual
obstruction, as shown by the occurrence of vomiting, the abdomen
should be at once reopened. It will often be found that the
distension is in part due to mechanical causes, and the freeing of
adhesions may be all that is necessary ; in most cases, however,
272 Treatment after Abdominal Operations.
the intestine must be opened and drained, the most distended
coil being chosen for this purpose.
Retention of Urine. Retention is not uncommon after
abdominal operations, owing to the dorsal position of the patient,
nervousness, and the pain caused by contraction of the abdominal
muscles ; inflammatory conditions in the pelvis and operations
upon the pelvic organs especially predispose to retention. It
must be remembered that retention may be partial, a few ounces
of urine remaining in the bladder, and this condition if not
attended to may give rise to cystitis.
The amount of urine secreted during the twenty-four hours
after an operation is always less than under normal conditions,
especially if fluids by the mouth or by the rectum are restricted.
If urine is not passed within eighteen hours and the patient feels
no desire to pass urine, the hypogastrium should be examined to
ascertain whether the bladder is distended.
Catheterisation should be avoided if possible, but it is equally
important to avoid over-distension of the bladder, for this often
leads to atony. In female patients, much depends on skilful
management by the nurse ; hot fomentations to the hypogastrium
and perineum, syringing the vulva with warm water over a bedpan,
change of position and encouragement, are measures to be tried ;
encouragement, however, must never verge upon bullying, for
this does more harm than good. Patients are more likely to pass
urine if left alone than if watched. Small doses of ergot (ext.
ergotse liq., KY[5, t.d.) are sometimes useful in cases of persistent
post-operative retention. If the passage of a catheter becomes
necessary, there is no reason in the great majority of cases why
there should be any risk of exciting cystitis. Full instructions
for the passage of a catheter in the case of a female patient are
given in the article on the Management of the Sick Room.
The amount of urine passed during each period of twelve hours
should be measured and registered on the chart. Scanty, high-
coloured urine is always an indication that fluid is needed, and
sometimes points to impending suppression of urine.
Complications Involving the "Wound. Hcematomu. A
hsematoma is apt to form in the wound if haemorrhage is not care-
fully arrested before the wound is closed. Haemorrhage is most
easily overlooked when resulting from puncture of a vessel by a
needle carrying a stitch. In closing the wound after an operation
for appendicitis, the deep epigastric vessels and their branches
are especially liable to be injured.
Unless the heematoma is very small, it should be emptied by
Treatment after Abdominal Operations. 273
removing a stitch, passing a grooved director into the cavity, and
pressing out the blood ; a small scoop will materially help in
getting out clot ; a firm pad of sterile gauze is then applied. An
anaesthetic is not necessary as a rule, but the most rigid precau-
tions must be taken as regards asepsis, for haematomata are very
prone to become infected, in which case healing is considerably
delayed and a weak scar results. As a precaution against infec-
tion from the surrounding skin, a 2 per cent, solution of iodine in
rectified spirit may be applied to the wound each time the dress-
ings are changed.
Suppuration. This is shown by a rise of the temperature and
by pain about the wound ; when the dressings are removed,
inflammatory induration is obvious.
The removal of one or two stitches is usually indicated ; a pair
of sinus forceps is then gently passed between the skin edges to
allow drainage, and a small tube may be inserted. Fomentations
are applied to the wound every four hours until the temperature
is normal. The tube may then be left out and the cavity packed
with a small strip of ribbon gauze, so that it may granulate from
the bottom. Not more than one' or two stitches should be
removed, for if more are removed there is a risk of the whole
wound gaping.
The patient should not be allowed to get up until the wound
has firmly healed, and a well-fitting abdominal belt should be
ordered, for ventral hernia is especially likely to follow in cases
in which suppuration has occurred.
Sloughing of the Abdominal Wall. This complication is for-
tunately very rare, but is occasionally seen after prolonged
operations upon feeble subjects, in whom the abdominal wall has
been strongly retracted and bruised ; it may occur also in cases
of gangrenous appendicitis, the skin edges and superficial tissues
being involved.
Fomentations should be applied every three hours and the
patient's strength maintained by stimulants and frequent feeding.
Free drainage must be provided for, but most of the stitches must
be left in situ, even if there is considerable irritation about them,
for otherwise wide gaping of the wound will occur. The wound
should be irrigated twice daily, peroxide of hydrogen (5 volumes)
being particularly useful for this purpose.
Complete recovery usually follows, although the period of
convalescence may be very prolonged. The scar is invariably
weak, and an abdominal belt must be worn.
Bursting of the Wound. It occasionally happens that the
S.T. VOL. ii. 18
274 Treatment after Abdominal Operations.
recently closed wound bursts open, in which case omentum or
intestines prolapse. The causes of this accident are imperfect
suturing or suture material, excessive vomiting, coughing, or
straining as the result of purgation, too early removal of the
stitches, suppuration in the wound, and great distension, such as
that occurring in ileus and unrelieved obstruction.
Except in cases in which this accident is the result of suppura-
tion, an anaesthetic should at once be given ; the prolapsed parts
are bathed with warm saline solution and are returned to the
abdomen ; the wound is then carefully re-sutured and a firm
abdominal bandage is applied, elastic cotton bandages being
especially useful in these cases. Cough and any other condition
which may cause strain on the abdominal wall should be vigorously
treated. If the accident is the result of extreme distension, as
in peritonitis, it may be necessary to empty the bowel by puncture
or incision before it can be returned.
When suppuration has occurred and there is partial protrusion
of the intestine, the protruded parts should be gently pushed back
and kept in place by a gauze pack ; the sides of the wound are then
approximated as well as possible with broad pieces of strapping.
Thrombosis. Thrombosis of the femoral vein occasionally
follows abdominal operations. Mr. Warrington Haward 3 quotes
thirty-four instances in 3,774 collected cases of operation for
appendicitis ; pulmonary embolism occurred in eight cases. The
condition is seen almost entirely in cases in which there is some
septic focus and in those who are anaemic.
Prophylaxis. Potassium or sodium citrate, in doses of 10 gr.,
may be given to patients who seem likely to develop thrombosis.
Regular change of position in bed is also important for those whose
circulation is sluggish and who are anaemic.
Treatment. The main object of treatment is the prevention of
pulmonary embolism. The affected limb is placed on a splint,
all movements are made with the greatest gentleness, and the
patient is warned of the importance of keeping the limb absolutely
still. Lead lotion or hot fomentations are laid along the course
of the inflamed vein, or glycerine and belladonna may be applied.
Pain is often severe in the early stages, and small doses of morphia
are very beneficial in relieving the pain and keeping the patient
quite quiet. Best in the recumbent position for at least six weeks
from the date at which the last spread of the thrombosis occurred
is necessary, and after this firm bandaging will be required for a
long period, for re-establishment of the venous circulation is a
tedious process. (See also Thrombosis, Vol. I.)
Treatment after Abdominal Operations. 275
If pulmonary embolism occurs, as a rule little can be done.
Oxygen should be administered, and hypodermic injections of
brandy, camphor, or ether should be given. If breathing stops,
artificial respiration should be performed.
Post-operative Hsematemesis. Haematemesis after an
abdominal operation may be due to one of many causes. When
following operations upon the stomach, it is the result of imperfect
control of divided vessels by the sutures, or of manipulation of an
ulcer or growth for which the operation has been performed.
After other operations it may be the result of thrombosis of gastric
vessels, or of toxaemia, or of irritation of an unsuspected gastric
ulcer by the effects of the anaesthetic.
The cause of the bleeding should be determined, if possible.
No food should be given by the mouth ; stimulants and any other
measures which raise the blood-pressure should be avoided. A
hypodermic injection of | gr. of morphia should be ordered, and
an icebag applied to the epigastrium will help to keep the patient
quiet. As a rule no drugs, except morphia, should be given. In
persistent haemorrhage, however, the following remedies may be
tried, although their action is very uncertain : Adrenalin chloride
(1 in 2,000), 10 minims in 1 drachm of water every half hour for
four doses ; turpentine, 5 minims in an emulsion ; silver nitrate,
\ gr. in | oz. of water for four doses ; fresh serum or albumen
water.
Thirst must be treated by rectal injections of saline, | pint
every four or six hours. If the patient becomes profoundly
anaemic, the foot of the bed must be well raised, and infusion of
saline into a vein or subcutaneously should be carried out.
Intra-peritoneal Haemorrhage. This accident is usually due
to faulty control of haemorrhage during the operation, and is chiefly
met with after operations upon the pelvic organs. Clinically it
is shown by acute pain, pallor, a small quick pulse, cold limbs and
a subnormal temperature, sweating and restlessness. In some
cases the haemorrhage is sudden and severe, and the patient dies
after a short period during which his condition has been too
serious to allow re-opening of the abdomen. In most cases the
onset is more gradual.
Prompt measures must be taken. A hypodermic injection of
\ gr. of morphia is given, and the patient is carried carefully back
to the operating theatre, where the wound is reopened. A good
light and adequate assistance are essential. Blood clot is rapidly
sponged out, and the bleeding point is secured as quickly as
possible. If the bleeding comes from several points, ligatures
182
276 Treatment after Abdominal Operations.
should be applied to as many as possible, and a firm gauze plug
is then inserted. After closure of the wound, the patient is
returned to bed ; warmth is applied, and the foot of the bed is
well raised. No stimulants or saline injections are given, unless
it is certain that haemorrhage has ceased, or unless the bloodless-
ness is so profound that recovery is doubtful.
T. CRISP ENGLISH.
KEFEB.ENCES.
1 Berkeley, 0., and Bonney, V., " Gynaecological Surgery," 1911.
2 Bell, W. Blair, " Principles of Gynaecology," 1910.
3 Ha ward, Warrington, "Phlebitis and Thrombosis": Hunteriau Lectures,
1906.
See also McKay, W. J. Stewart, "The Preparation and After-treatment
of Section Cases," 1905.
277
AFFECTIONS OF THE UMBILICUS.
THE umbilicus, representing as it does the point of closure of
the abdominal cavity of the foetus and the point of entrance or
emergence of all those structures which pass between the embryo
and the placenta, is naturally liable to many congenital or develop-
mental errors. Three important blood-vessels and two viscera pass
through the umbilical ring. The two hypogastric arteries (from the
internal iliacs) take the foetal blood to the placenta, whilst the
umbilical vein returns the placental blood through the round
ligament of the liver to the portal circulation. In the adult, these
three vessels are represented by mere fibrous cords, but the
ligamentum teres is richly supplied with lymphatics along which
inflammatory or malignant processes readily make their way from
the interior of the abdomen to the umbilicus. The foetal viscera
connected with the umbilicus are the yolk sac and the allantois,
both of which normally disappear before birth, but by their
abnormal persistence may give rise to a great variety of tumours,
cysts or fistulas.
CONGENITAL MALFORMATIONS OF THE UMBILICUS.
(1) Failure of complete closure : hernia ; (2) persistence of
vitelline remains ; (3) persistence of urachal remains. The subject
of congenital umbilical hernia is treated elsewhere.
Vitelline Remains. In early foetal life, a small yolk sac lies
in the substance of the umbilical cord, connected by a tubular
stalk with the primitive intestine. If this vitelline duct persists,
it gives rise to the intestinal diverticulum known as "Meckel's."
But the connection of this with the umbilicus usually disappears.
In rare cases, however, the duct may not only persist, but its
opening at the navel may remain patent.
Congenital Umbilical Anns. In this condition there is, in addition
to a patent Meckel's diverticulum opening at the umbilicus,
a stenosis of the ileo-caecal valve or atresia of some part of the
large intestine, so that practically all the intestinal contents pass
by the umbilicus. Such a condition, usually, will permit of no
treatment, owing to the absence or atrophy of the bowel below the
patent duct. The point of importance is that in any case where
278 Affections of the Umbilicus.
the faecal discharge from an umbilical fistula is copious no attempt
should be made to close it until it has been ascertained that there
is no obstruction to the bowel below.
Vitello-intestinal Fistula. In this there is a small quantity of
mucous or faecal discharge from the umbilicus, and a probe can be
passed for a short distance down a fistulous track. Such a fistula
tends to close spontaneously, but this closure may be greatly
hastened by destroying the mucous lining with a cautery wire.
Umbilical Tumours due to Vitelline Remains. A small, bright
red, mucous adenoma is comparatively common. A section
shows it to be composed of glands similar to those of the small
intestine. It may be of larger size and present the appearance of
a prolapsed mucous duct, being, indeed, the vitelline duct bulging
outwards. This form is sometimes known as an entero-teratorna.
Lastly, there may occur various degrees of prolapse of the duct
and the gut to which it is attached. The treatment of all these
conditions should be conducted with considerable caution, in view
of the fact that the tumour of mucous membrane may contain a
peritoneal pouch or be connected with the intestine. When the
growth is small and solid it only needs to be cut off by scissors or
cautery. When evident bulging exists, it is better to cut cautiously
round the tumour and carefully ligature, sew over its connection
with the intestine and then close the parietes, as in dealing with
a hernia.
Persistence of Urachal Remains. The stalk of the placenta
is formed in early embryonic life by a hollow cord, the dilated end
of which is the urinary bladder. At various stages of this growth
development may be arrested, giving rise to extroversion of the
bladder or different kinds of urinary fistula opening from the
umbilicus to the bladder.
From the practical point of view these urinary umbilical
fistulas may be divided into three classes, that of infancy, adult
life, and certain rare cystic conditions.
The Urinary Fistula at the Umbilicus of Infants. This con-
sists of a narrow track lying behind the linea alba, in front of
the peritoneum opening into the fundus of the bladder at one end
and on to the navel at the other. A little leakage of urine at the
navel and the passage of a probe will indicate the diagnosis.
There is a tendency to spontaneous closure of this, which, together
with the patient's tender age, makes operative treatment inad-
visable. But, in any case, the passage of an electro-cautery wire,
so as to destroy the mucous lining of the canal, will be all that is
required.
Affections of the Umbilicus. 279
ACQUIRED AFFECTIONS OF THE UMBILICUS.
Urinary Fistulae at the Umbilicus in Adults. When a
urinary fistula forms and discharges at the umbilicus of an adult,
it is usually the result of some obstructive and inflammatory
condition in the bladder. A partially patent urachal duct has
remained connected with the bladder, and along this the infected
urine finds its way to the navel. In such a case, it is necessary to
remove any obstruction from the natural outflow channel of the
bladder and to cure the cystitis before attempting to close the urinary
fistula. When this has been done, the fistula must be dissected
out from the mid-line without opening the peritoneum. But if
the fistula is associated with some condition which necessitates
opening the bladder, e.g., a large prostate or a vesical growth, then
it can be dealt with in the first stage of the operation of suprapubic
cystotomy. An incision is made from the navel to the pubes, the
fistula dissected out from above downwards, and the upper part of
the wound closed. The bladder can then be opened by cutting off
the fistula where it joins that viscus.
Urachal Cysts. These are really tubulo-dermoids developed
in the remains of the urachus. They may form tumours of
moderate or large size which are fixed to the deep surface of the
parietes below the umbilicus. The treatment is excision.
Inflammatory Conditions of the Umbilicus. These are
comparatively common in infants and old people.
/// infants the inflammation is usually set up by a septic infection
of the cord during the process of its separation. This may
cause a slight local soreness with weeping granulation tissue and
an encircling patch of eczema. Such a condition will be cured
by touching the granulations with silver nitrate caustic and
dusting the skin with zinc oxide powder. But of far greater
importance is the general septic disease set up by infection of
the cord. Thrombosis of the umbilical vessels, general septicaemia
marked by jaundice, haemorrhage and diarrhoea, and tetanus in
the new-born, are all due to this portal of infection. It is
impossible to be certain of the actual infant mortality from these
sources, but it is highly probable that many cases of death from
convulsions, diarrhoea, vomiting, etc., are in reality due to this
cause. Of course, the prophylactic treatment is nothing more or
less than the observance of asepsis in tying, cutting and dressing
the cord.
Inliammatwn of the Umbilicus in the Adult. This is generally a
dirt eczema in obese persons in whom the navel has become
280 Affections of the Umbilicus.
sunk in a deep pit. In this, dirt, sweat and foreign bodies collect
and set up a skin irritation ; or an inspissated mass may be
formed by the agglutination of various debris with sebum and an
umbilical calculus will be the result. This must be released by
slitting open the orifice of the umbilical canal, and instructing
the patient to wash out the cavity daily.
Acquired Umbilical Fistulse. There is a marked tendency
for many intra-abdominal diseases to burst through the parietes at
the umbilicus, and hence the number and variety of umbilical
fistulae is very great.
They may conveniently be divided up as follows :
(1) Peritoneal, from acute peritonitis, local peritonitis, tuberculous
peritonitis, cancerous peritonitis, ascites ; (2) gastric, from trauma,
ulcers, cancer or operations ; (3) intestinal, from a gangrenous
umbilical hernia, foreign body, wound, or operations (also see
above for vitello-intestinal fistulse) ; (4) biliary, from the
adhesion of the gall-bladder to the parietes, with direct bursting
through the navel or more often through a sub-umbilical abscess ;
(5) vesical, usually congenital (see above).
The nature of the fistulae may be made quite evident by the
character of the discharge, gastric, intestinal, biliary and vesical
contents, all being so very distinctive from one another. When
the fluid has none of these definite characters but is clear or
purulent, the inference is that the fistula communicates with the
peritoneum.
Peritoneal Fistula. If these are secondary to cancer or ascites,
nothing of a directly curative nature can be done. If any diffuse
peritonitis, e.g., that due to the pneumococcus or tubercle, has
burst through the navel, there need be no hesitation in freely
opening the abdomen and evacuating the fluid contents. But if, as
is most often the case, the fistula leads into an irregular abscess
cavity, the utmost caution is required in dealing with it. A
grooved director is passed into the fistulas and the abscess cavity
opened by cutting along this and then packed and drained. The
other varieties of fistulse opening at the umbilicus must be treated
according to the general principles described under the headings of
the diseases of stomach, intestines, gall-bladder or urinary bladder.
Tumours of the Umbilicus. The following tumours occur in
connection with the umbilicus :
Innocent: Granuloma, papilloma, fibroma, myxoma, angeioma,
adenoma (from vitelline remains) ; cysts, vitelline, sebaceous,
urachal, and dermoid. Malignant: Sarcoma, carcinoma, primary
and secondary. It seems scarcely necessary to add anything to what
Affections of the Umbilicus. 281
has already been said about the innocent tumours. If they cause
any discomfort they should be removed.
Sarcoma growing at the navel is a deeply placed and well-defined
ovoid tumour covered with large veins. It does not grow very
fast and is only of comparatively slight malignancy. The mere
fact of any tumour steadily growing should be enough to demand
its removal without waiting for details to clear up the diagnosis.
Primary Epithelioma of the umbilicus may begin as a warty
mass or as an epithelioma with hard everted edges. It may be
caused by a patch of chronic eczema in the pit of the navel. Early
excision with a generous margin of healthy tissue is the necessary
treatment. The peritoneum need not be opened in this operation.
Secondary Cancer of the umbilicus is a very frequent sequela
of any form of intra-abdominal malignant disease, but especially
that of the liver, stomach and female genital organs. A hard red
nodule occurs at the navel, and this soon gives rise to an
ulcer or fungating sore. Usually the evidence of the primary
disease is so obvious that no unnecessary operative treatment will
be undertaken.
Umbilical Hernia (see Chapter on Hernia).
ERNEST W. HEY GROVES.
282
INJURIES OF THE STOMACH.
EXTERNAL INJURIES ASSOCIATED WITH WOUND.
(1) Stab-wound over Stomach Region. It is first necessary
to ascertain by means of a clean finger or probe whether the
abdominal wall has been actually pierced or merely wounded. If
the weapon has actually pierced the peritoneum it will be necessary
to perform abdominal section and then to repair the stomach or any
other viscus that may be injured.
The skin for some distance round the wounds must therefore be
thoroughly cleansed by washing with ether soap and water and
then painted with a solution of iodine in chloroform (15 gr. to the
ounce). All instruments having been^oiled, the wound having been
surrounded with sterilised towels and the hands of the surgeon
having been thoroughly cleansed and if practicable gloved with
rubber, the wound must be enlarged in such a way as to inflict the
least injury on muscular fibres, vessels or nerves, for instance,
vertically if over the recti, or obliquely if external to the recti.
Through the wound, which must be large enough to permit of
examination of the viscera (say 3 or 4 inches), the stomach,
omentum, colon, etc., can be examined and repaired if injured.
The presence of gas in the peritoneum will point to puncture of
a hollow viscus. If the gas is odourless it will indicate stomach
injury. If the puncture of the stomach is small and not bleeding
the readiest repair is effected by a purse-string suture, which can be
applied very quickly.
If the wound is bleeding, a through-and-through continuous
stitch, taking up all the coats, will at the same time effect approxi-
mation and haemostasis, and the wound can be made secure either
by a Lembert's or a purse-string suture.
If the wound is extensive the continuous through-and-through
suture covered in by a Lembert's suture will prove effectual. The
abdomen must then be cleansed of blood clots and stomach contents
and either drained by a rubber tube containing a strip of gauze
brought through the wound, or if the peritoneal cavity has not been
soiled the abdominal wound can be closed without drainage.
A dressing of sterilised gauze or of double cyanide gauze covered
Injuries of the Stomach. 283
with sterilised wool and held in place by strapping and a many-
tailed bandage is simple and efficient.
(2) Gunshot Injuries. If the injury is inflicted by a non-
expanding bullet from a modern, high velocity rifle and occurs on the
battlefield or where treatment cannot be efficiently carried out, it is
better to keep the patient quiet and avoid giving anything by the
mouth.
A subcutaneous injection of morphia to relieve pain and arrest
the peristaltic movement of the viscera is usually called for, and the
external wounds must be dressed with cyanide or simple sterilised
gauze. If, however, the injury should occur where it is possible to
obtain skilled help and the advantages of a properly equipped hospital
or nursing home, it is better not to trust to chance, but to treat the
case as just described for a stab wound, following up the track
of the bullet, repairing any injuries to viscera, ligaturing injured
vessels and carefully cleansing the track of the missile, removing
any foreign bodies, such as pieces of clothing, and, if it can be
readily found, removing the bullet.
On no account must a prolonged search be made for the bullet,
and it is not, as a rule, wise to wash out the abdomen or to use
anything but hot sterilised normal saline solution for the swabs
employed for cleansing the injured parts.
INJURIES WITHOUT EXTERNAL WOUND.
(1) Injuries of the stomach caused by a kick or blow with a
fist or blunt instrument are usually accompanied by such pro-
found shock that even instant death may result.
The treatment for shock will in any case be the first care, and
until a diagnosis of the extent of the injury has been made it is
better not to give anything by the mouth but to administer an
enema of hot normal saline fluid (about 1 pint) containing 1 oz.
of brandy, this to be repeated in half an hour or less if required.
The patient must be wrapped in blankets and have hot bottles
applied to the extremities. A subcutaneous injection of morphia
may do good, but the disadvantage of cloaking symptoms must be
borne in mind. A subcutaneous injection of 5 min. of solution of
strychnine [U.S.P. strychnin, hydrochlor. gr. -%] is to be preferred,
and this can be repeated in an hour or two if required.
If the symptoms of shock do not yield to treatment the occurrence
of haemorrhage from ruptured vessels must be considered, and if
there is a fluid thrill to be elicited across the abdomen or in the
loins, or if liver dulness is diminished or absent, the question of
immediate abdominal section must be considered.
284 Injuries of the Stomach.
Only a very small incision is required for diagnostic purposes, as
the escape of gas or blood will at once tell if it is necessary to extend
the opening for the repair of any laceration or for the arrest of
haemorrhage.
If the stomach is found to be lacerated the tear must be sutured
by a through-and-through continuous catgut suture, taking up all
the coats, this to be covered in by a continuous serous suture of
silk or Pagenstecher's thread. The abdominal toilet must then be
completed as described under gun-shot injury.
(2) Rupture from within, so-called " Spontaneous Rupture "
from over-distension, is an extremely rare event which demands
immediate laparotomy with repair of the laceration and cleansing
of the abdominal cavity.
(3) Puncture from within, as in the case of a sword-swallower,
is also extremely rare, and as the accident will be immediately
recognised no time need be lost in performing immediate laparotomy
and repair of the punctured viscus.
Should haemorrhage occur without puncture of the visceral wall,
as in a case under my care in which the patient had swallowed
nails, the stomach must be opened and the foreign body, " knife,
nails or whatever it may be," must be removed, any bleeding points
ligatured and the stomach wall closed by visceral and peritoneal
sutures.
In the after-treatment of these cases rectal feeding for two or
three days will be advisable, only water, albumen water, plasmon
and barley-water or weak tea being given by the mouth ; unless the
pain is severe morphia is best avoided, especially as 5 to 10 gr. of
aspirin repeated if needful will usually give relief. On the third or
fourth day the bowels should be moved by enema, but it is not
advisable to give an aperient until the end of the week.
INJURIES DUE TO SWALLOWING OF CAUSTIC FLUIDS.
As the shock is profound and the pain is intense, morphia subcu-
taneously will be necessary, and at the same time the caustic
swallowed must be neutralised by acid or alkali according to the
nature of the fluid taken. Emesis may be induced if the case is
seen at once by the administration of salt and water, which will
serve to dilute the poison.
All feeding for some days must be by rectum. The mouth and
throat must be kept clean by spraying or washing with some mild
antiseptic, such as boric solution. When feeding is begun the food
must be liquid and non-irritating, and only when epigastric pain
and tenderness have subsided must soft solids be allowed.
Foreign Bodies in the Stomach. 285
If there is extensive ulceration and sloughing of the mouth,
pharynx, resophagus and stomach the operation of jejunostomy
may be required, so as to be able to feed the patient without causing
irritation of the ulcerated surfaces. At a later stage further surgical
treatment may be demanded for stricture of the cardiac or pyloric
orifices of the stomach.
FOREIGN BODIES IN THE STOMACH.
The removal of foreign bodies lodged in the stomach by means
of the operation of gastrotomy has been attended with considerable
success when performed by surgeons of experience. It is the only
method of treatment available, and in this way nails, knives,
spoons, forks, razors, false teeth, safety pins, ordinary pins and
needles, coins, keys, hair balls, gall stones and other substances
have been successfully removed.
The indications for the operation are the presence of a foreign
body which can neither be safely dissolved nor allowed to pass
through the bowel, and which is actually producing or likely to
produce serious symptoms.
The mortality under improved technique ought not to exceed 5 per
cent., though of seventy-one cases collected from all sources by
Friedenwald and Rosenthal and reported in July, 1903, seven
died. The earlier the operation the greater had been the success
attending it.
Operation of Gastrotomy. After opening the abdomen as
described under gastro-enterostomy the stomach is brought for-
ward into the wound and surrounded by sterile gauze ; the anterior
wall of the viscus is incised transversely to its axis so as to avoid
unnecessarily wounding blood-vessels, the foreign body or bodies
are then removed by fingers or forceps and the wound in the
stomach is repaired by a continuous chromic catgut suture which
takes up all the coats. The line of suture is buried by a second
continuous stitch of silk or Pagenstecher's thread, which takes up
the serous coat. The exposed part of the stomach and the line of
suture are carefully wiped with normal saline solution and returned
to the abdomen, which is then closed.
A. W. MAYO-ROBSON.
286
DISEASES OF THE STOMACH AND
DUODENUM.
THE stomach is more prone to disturbances of function than any
other viscus of the body, and the symptoms with such derange-
ments are accompanied closely resemble those that ensue from
organic lesions of its structure. Moreover, the digestive apparatus
is of such delicate construction and perfect equipoise that failure of
one portion is invariably followed sooner or later by disturbance of
the whole, while its vicarious functions are so numerous and
diverse that it is injuriously affected by disease of any other
important organ. It is, therefore, obvious that no form of treatment
can be undertaken with assured success unless the primary dis-
order has been accurately determined, and that the selection of
medicinal remedies must be influenced by the state not only of
the stomach itself, but also of those other viscera upon which the
conservation of the general health invariably depends. In the
following pages the various disorders and diseases of the stomach
are considered under their appropriate titles, and due reference is
made to the prevention and management of the principal complica-
tions that are apt to ensue during their progress : (1) Atony ;
(2) Atrophy ; (3) Cancer ; (4) Dilatation ; (5) Displacements ;
(6) Haemorrhage ; (7) Inflammations ; (8) Nervous disorders ;
(9) Parasites, Concretions, etc. ; (10) Secretory disorders ; (11) Sym-
ptoms of gastric diseases ; (12) Ulcer of stomach and duodenum ;
(13) Sea- sickness.
ATONY OF THE STOMACH.
ATONY, or myasthenia as it is more appropriately termed, implies
an enfeeblement of the musculature of the stomach, combined with
a notable loss of elasticity. It seldom occurs as a primary com-
plaint, but is either associated with a similar condition of the entire
digestive tract or ensues from inflammations or displacements of
the stomach, fatty or lardaceous diseases of its muscular tissue or
from an obstruction to the passage of food through the pylorus.
Prophylaxis. Gastric myasthenia is very apt to develop during
convalescence from a febrile malady and in the course of debili-
tating diseases. Under these conditions special precautions must
be taken to preserve the motor power of the stomach. Overfeeding
Atony of the Stomach. 287
with fluid nourishment must be avoided, and milk should not be
given in quantities exceeding 6 oz. at a time, while concentrated
meat juices, essences and jellies are to be preferred to beef-tea,
soups and broths. Poached eggs, ham, bacon, lightly-cooked fish,
chicken and game which have been passed through a sieve, sheep's
brains, calf's head, tripe and sweetbreads may be allowed, while
raw meat pulp mixed with its own juice is easily digested. Bread
and starchy materials are apt to ferment, and should be omitted in
favour of toast, plain biscuits, or one of the patent cereal prepara-
tions. Uncooked vegetables and fruits are especially injurious, but
a baked apple may be allowed occasionally. Excess of fluid with
the meals must be prohibited, and only a little hot water should be
taken with the food. The application of a firm belt or binder to
the abdomen prevents sagging of the viscus in the erect position,
and both massage and electricity are of value in improving the
tone of the abdominal walls.
Massage is employed in the treatment of gastric myasthenia
with three objects : (1) To promote the evacuation of the contents
of the stomach and to increase its peristaltic activity ; (2) to relieve
the associated condition of intestinal atony ; (3) to strengthen the
abdominal wall.
(1) Gastric peristalsis may be excited by gentle stimulation of
the cutaneous nerves of the abdomen in the following manner :
The tip of the right thumb of the operator is placed upon the
abdominal wall over the centre of the stomach, and by rapid
rotatory movements of the wrist, the tips of the fingers are allowed
to describe a series of circles upon the skin. No pressure is
exercised, a light brushing movement being all that is required.
At intervals of a minute the thumb is moved to an adjoining spot
over the region of the stomach and the process repeated. This
treatment is practised night and morning for ten minutes when the
organ is empty, and is particularly useful when myasthenia is
accompanied by stagnation of food. Patients soon learn to per-
form it for themselves. It has been claimed by some authorities
that the contents of the stomach may be squeezed through the
pylorus by the adoption of the following method : The ulnar border
of the operator's left hand is firmly pressed into the abdomen
along the lower border of the stomach, so that the pyloric end lies
in the palm of the hand. The fingers and thumb of the right hand
are then pressed deeply into the fundus, and by a series of pushing
movements the contents of the viscus are forced toward the
pylorus.
(2) If the motions are hard and constipation troublesome,
288 Atony of the Stomach.
massage of the lower bowel should be undertaken first, but if the
stools are fluid the rubbing may be begun over the caecum. In the
former case, the right hand is laid flat over the upper part of
the descending colon, with the fingers of the left hand super-
imposed upon it, the two hands being slowly moved downward and
inward and being made to dip deeply into the pelvis. The right
is then placed upon the caecum, with the ulnar border pressing
more deeply than the radial ; the little finger and thumb are then
slightly approximated, and with the fingers in this position the
whole hand is moved along the course of the colon ; the procedure
being repeated three or more times a minute.
(3) To increase the tone of the abdominal muscles massage is
applied to the abdominal wall, and the patient performs regular
daily exercises with active and resisted movements.
Electricity. It was formerly the custom to employ a continuous
current to the stomach by means of an intragastric electrode. This
method, which is always distasteful to the patient, has been
superseded by the polyphase alternating current. When applied
percutaneously, the triphase current produces contraction of the
stomach and intestines, strengthens their peristalsis and promotes
the evacuation of chyme into the duodenum. The electrodes should
each possess the same area and must be well wetted before being
applied to the skin. The patient lies upon a couch with one elec-
trode at the side of the dorsal spine and the other placed over the
epigastrium. The current is applied for fifteen minutes each day
for a fortnight, and then on alternate days for another month.
Many of the most obstinate cases lose their symptoms after a
course of this character (see Herschell's " Manual of Intragastric
Technique ").
Lavage. This is only of value when myasthenia is accompanied
by retention of food and gastrectasis, and should then be performed
in the early morning before breakfast. As a rule warm water con-
taining 1 gr. of bicarbonate of sodium to the ounce is all that is
required, but if gastric fermentation is active some antiseptic
solution may be used, such as salicylic acid (1 in 1;000) ; sodium
salicylate (1 per cent.), potassium permanganate (1 in 1,000),
boracic acid (1 per cent.), or borax (5 per cent.). Some authorities
recommend that after the stomach has been washed out, a pint of
boro-salicylic solution (boracic acid 60 gr., salicylic acid 20 gr., dis-
solved in a pint of water) should be introduced into the organ and
allowed to remain for five minutes. A teaspoonful of glycerine
administered after lavage completes the process of antisepsis and
also acts as a useful aperient. The inner surface of the stomach
Atony of the Stomach. 289
may be sprayed by means of the needle-douche invented by Turck.
By the alternate use of hot and cold water, an important tonic
effect is said to be produced upon the secretory and muscular
structures of the organ.
Climate and Baths. When a change of air is considered advis-
able, a dry bracing place should be selected in preference to a low-
lying or enervating locality. For this reason Scotland, Yorkshire,
Malvern and the east and south-east seaboard usually agree, while
the southern and south-western parts of England almost invariably
increase the symptoms of the complaint. If the water is impreg-
nated with lime, Malvern water, Salutaris, or some other pure water
should alone be drunk. A visit to Switzerland is often attended by
good results. When myasthenia is accompanied by neurasthenia
or gastroptosis, Egypt or Algiers may be selected as a winter resort
with advantage.
Mineral waters are chiefly indicated when constipation or anaemia
is a prominent feature of the complaint, but should be prescribed
with caution when the disorder is accompanied by gastric dilata-
tion. In the former case, Kissengen or Brides-les-Bains may be
recommended, or if a more bracing climate is deemed necessary,
Tarasp may be tried ; while in the latter, the iron springs of
St. Moritz often afford good results. Carlsbad and Marienbad
should be avoided ; but a course of the waters of Harrogate or
Llandrindod is sometimes beneficial.
Diet. The quantity of the food as well as the frequency with
which it is administered must be adjusted to meet the requirements
of each case. Owing to the fact that liquids stagnate in the
inyasthenic stomach, many authorities recommend an entirely dry
diet, and only permit a small amount of fluid to be taken before or
after meals. As a matter of fact, however, water is an important
excitant of gastric secretion, and when given in moderate quan-
tities along with the food it also stimulates peristalsis. Unless
hyperacidity exists, milk usually disagrees and should never be
given in bulk. Tea and coffee should be prohibited, but cocoa made
from the nibs or husks may be allowed. In most instances, a little
stimulant taken at meal-times tends to relieve the subsequent dis-
comfort, and for this purpose a tablespoonful of good brandy or
whisky mixed with 4 oz. of hot water may be given at the end
of the meal twice a day. Malt liquors always disagree and wines
can rarely be tolerated. During the early stages of the complaint
when food stagnation alone exists, a meal may be allowed every four
hours ; but when retention is present five hours should be allowed
to intervene between each meal.
S.T. VOL. n. 19
290 Atony of the Stomach.
An excess of sweets must always be prohibited, and when the
stomach is dilated these substances should be eliminated from the
dietary. On the other hand, well-cooked rice or cornflour or one
of the patent digested cereal foods may be allowed, while toast or
the Brusson-Jeune rolls are preferable to wheaten bread or biscuit.
Green vegetables and fruits should be entirely avoided in severe
cases, but in mild instances a little well-cooked asparagus, celery or
spinach may be allowed. Meat-fat, fat bacon, ham and salad oil
are all injurious, since they hinder the secretion of gastric juice and
favour food retention ; but cream and butter may be permitted in
moderation. Lightly-boiled or poached eggs usually agree unless
some form of biliary or pancreatic disturbance exists. The white
kinds of fish, such as whiting, sole, cod, turbot, plaice, haddock and
hake, are to be preferred to the heavier and oily varieties, like
mackerel, salmon or herring, and should be boiled rather than fried.
Smoked and dried fish are inadmissible. Sweetbreads, tripe,
sheep's head and brains, calf's head and feet, chicken, pheasant,
partridge and tongue are all easy of digestion, but venison, hare,
duck, goose, pigeon, sausages, pork, veal, curries and meats twice
cooked usually excite discomfort. Meat essences, powders and
jellies may be given with impunity, but soups and broths must be
prohibited. Raw-meat pulp often agrees when all other meats give
rise to indigestion, and in certain cases of uncomplicated my asthenia
the so-called " Salisbury treatment" maybe pursued with advantage.
Milk curdled by means of lactobacilline is chiefly indicated when the
disorder is accompanied by a notable deficiency of free hydrochloric
acid, but it always disagrees when hyperacidity exists. When it
agrees half a pint should be taken twice a day for a period of three
months. In the tablet form the bacilli are useless.
Medicinal Treatment. The objects of medicinal treatment
are : (1) To prevent fermentation of the contents of the stomach ;
(2) to stimulate the muscular structure of the organ ; (3) to augment
the digestive powers of the gastric juice ; (4) to promote the evacua-
tion of the bowels.
1. Antiseptic treatment should always be adopted at the outset
and no stimulating remedies be employed until the tongue is clean.
The best plan is to administer a mixture containing carbonate of
bismuth, bicarbonate of sodium, glycerine of carbolic acid and
peppermint water, twice a day between meals. If the tongue is foul
1 drachm of the compound tincture of rhubarb or 2 drachms of
the infusion may be added with advantage, with 1 drachm of pure
glycerine should the stomach be dilated. Some authorities prefer
resorcin (10 gr.); bismuth salicylate (20 gr.) ; beta-naphtbol (3gr.);
Atony of the Stomach. 291
salicylic acid (10 gr.) ; creosote or guaiacol (3 min.) ; sodium
benzoate (5 gr.) ; sodium hyposulphite (20 gr.) ; sodium sulphocar-
bolate (15 gr.) ; a mixture of iodoform and charcoal, or the carbolic
acid pill. Charcoal biscuits and the Biscols Fraudin are sometimes
of use when the eructated gases are offensive. Excessive flatulence
may be relieved by peppermint, chloroform, ether, oil of cajuput or
the essence of Ricqles.
2. The chief drugs that stimulate the musculature of the stomach
are strychnine, hydrastin, quinine, ergot, ipecacuanha, and formate
of sodium. The first named is the most reliable and may con-
veniently be given in combination with quinine and phosphoric
acid, while in some instances the tincture of nux vomica with a
bitter infusion is serviceable. Hydrastin and ergot are very variable
in their action and are liable to produce nausea and impair the
appetite. Many practitioners favour powdered ipecacuanha in doses
of gr. three or four times a day after meals, but several weeks
usually elapse before any signs of improvement manifest themselves.
Latterly formate of sodium has come into fashion. It is most
conveniently prescribed in the form of the compound syrup or
of the tablets of the polyformates (Roberts & Co.). When the
nayasthenia is associated with anaemia a cautious trial should be
made of one of the salts of iron. As a rule the ammonio-citrate
combined with the solution of bismuth agrees best, but the dialysed
solution or the pill of reduced iron may be given if desired.
Zambelleti's hypodermic injections of soluble arsenic and iron are
a most valuable method of treatment in refractory cases, but care
must be taken to wash out the syringe with rectified spirit imme-
diately after use. If general neurasthenia exists, valerianate of zinc,
either alone or combined with dioxide of manganese, or the syrup
of the glycerophosphates (Robin) may be prescribed.
3. The adjuvants of the gastric secretion are pepsin, pancreatin,
papain, diastase and hydrochloric acid. Theoretically the adminis-
tration of pepsin and hydrochloric acid should relieve the symptoms
of indigestion, which depend upon a deficiency of gastric juice, but
as a matter of fact almost every disease of the stomach, with the
exception of achylia, is capable of producing sufficient ferment if the
secretion of the mineral acid is sustained, and hence the success of
pepsin in clinical practice is not commensurate with its reputation
in the laboratory. Of the various preparations, the pure powder,
the glycerine extract and Liebreich's essence are the most reliable
and should be given immediately after meals.
The wines of pepsin have no therapeutic value ; indeed, according
to the experiments of Hugouenenq, the addition of alcohol to
19-2
292 Atony of the Stomach.
pepsin greatly interferes with its action. Papain is able to convert
proteid into peptone in an alkaline medium, but its use is chiefly
confined to cases of achylia. Pancreatin is of little value unless
the myasthenia is secondary to atrophic gastritis.
In the myasthenia of childhood maltine given after meals is
sometimes of value ; but in adults takadiastase or diastase setterie
is often recommended with a view of promoting the digestion of
starches in the stomach. The tabloids of pentenzyme, which
consist of a mixture of all the digestive glands, are occasionally
of use.
As compared with the ferments, dilute hydrochloric acid is often
of considerable value when the gastric secretion is much reduced.
As a rule, 15 min. of the dilute solution may be given immediately
after meals, but sometimes half a tumblerful of 0'05 per cent,
solution taken with the food proves more efficacious. The addition
of a teaspoonful of pure glycerine appears to increase its digestive
activity. The acid should never be prescribed if the myasthenia is
accompanied by hyperacidity or secondary gastritis. The value of
lactic acid has already been mentioned.
4. No medicinal remedy exerts any permanent influence upon
the digestive disorder, unless care is taken to procure a daily
evacuation of the bowels. Saline aperients usually do more harm
than good, unless gastritis is present, and the mildest aperient is
usually the most efficacious. In ordinary cases a large enema or
an injection of glycerine two or three times a week may alone be
necessary, or the patient may be directed to take a home-made
infusion of senna-pods each night. In more advanced cases, a
combination of liquid extract of cascara with maltine and glycerine
taken each evening before the last meal will procure an easy
evacuation on the following morning, or a pinch of Turkish
rhubarb, a dose of confection of senna or a cup of Garfield's tea
at night will be found sufficient. Obstinate constipation requires
the exhibition of rhubarb and euonymin, aloes and iron, or some
other aperient, pill, the dose of which may be reduced as the case
improves.
W. SOLTAU FENWICK.
293
ATROPHY OF THE STOMACH.
A DIMINUTION or actual suppression of the gastric secretion is
an invariable result of an extensive atrophy of the mucous mem-
brane of the organ, while a similar condition occasionally presents
itself as a congenital nervous disorder (achylia, p. 368). In both
instances the symptoms of indigestion which ensue from the dis-
turbance of the gastric functions are intensified sooner or later by
those of a secondary intestinal derangement. The treatment of
atrophy of the stomach varies according to its causation.
In severe cases care must be taken to preserve the strength,
and consequently over-exertion must be prohibited and only
moderate daily exercise be allowed. Sufferers from this com-
plaint are unduly susceptible to cold, and the clothing should
therefore be warm and exposure to wet carefully avoided. Cold
baths and douches are sometimes of value in the nervous type
of the disease, but are not to be recommended in cases of inflam-
matory atrophy. Lavage is indicated whenever much mucus is
present in the stomach and when nausea or vomiting are prominent
symptoms, but care must be taken not to distend the viscus, and
antiseptics are rarely required. In the inflammatory cases the
bowels should be regulated by means of salines, with the occasional
use of a mild mercurial pill. Mineral waters, baths, massage and
electricity are useless.
Atrophy, with Pernicious Anaemia. In this variety both
the gastric disease and the anaemia probably arise from the same
cause. The meals should be taken at intervals of about three
hours, and all solid articles of food must be finely minced and well
masticated. As a rule, the red meats are difficult of solution in
the stomach and should be omitted in favour of well-cooked
chicken, game, sweetbreads, tripe, sheep's brains, white fish and
oysters. Farinaceous foods often agree well, and rice, tapioca, sago,
mealy potato, lentils, and oatmeal may be employed in the pre-
paration of soups and puddings. Soft-boiled and poached eggs
may be given with bread or toast. Butter and cream can usually
be tolerated if the intestines are healthy, but milk is apt to create
discomfort unless peptonised or diluted with lime water. Beer and
spirits must be prohibited, but sometimes a little white wine taken
with the meals improves the appetite.
294 Atrophy of the Stomach.
At an early stage of the complaint the administration of some
bland preparation of iron by the mouth almost invariably relieves
the symptoms of indigestion, and may often be advantageously
combined with arsenic. In severe cases, however, both these drugs
are apt to excite nausea and vomiting or diarrhoea. Zambelleti's
subcutaneous injections of iron and arsenic are extremely valuable
at all stages of the disease, the course of which is often materially
influenced by their employment. A single injection of the weak
solution should be given each day for a fortnight and one of the
strong solution every day subsequently for three weeks or a month,
the course being repeated when necessary. In addition to the use
of the ordinary antiseptic precautions, the syringe must be washed
out thoroughly with rectified spirit immediately after use, since by
this means the deposition of metallic iron upon the interior of the
instrument is prevented and the occurrence of abscesses avoided.
The fluid may be obtained in sterilised ampoules from Martindale
& Co. and other chemists in London, and is most conveniently
injected beneath the skin a few inches above the patellae.
Atrophy from Chronic Gastritis. This variety is usually met
with in the marasmus of infancy and in long-standing cases of renal
disease, pulmonary tuberculosis, diabetes and cancer of the breast.
It is never so complete as in pernicious anaemia, and the hydrochloric
acid and ferments seldom disappear completely from the gastric
secretion. The general treatment and dietary are similar to those
employed in cases of chronic gastritis. Quinine, arsenic and
other tonics are seldom tolerated, and the salts of iron usually
provoke vomiting or diarrhoea. If the secretion of hydrochloric
acid is markedly diminished, 15 min. of the dilute solution of this
acid may be administered immediately after meals, either alone or
combined with pepsin. As a rule, however, alkalies agree better
than acids, and a bismuth mixture containing glycerine and car-
bolic acid administered between meals serves to relieve the
distension and discomfort which ensue from the fermentation of
food. Only the mildest aperients should be prescribed.
Atrophy from the Ingestion of Corrosives. When recovery
occurs after the ingestion of mineral acids or caustic alkalies,
the mucous membrane of the stomach is replaced more or less
entirely by fibrous tissue and a chronic ulcer often persists in the
neighbourhood of the pyloric or cardiac orifice. Under these cir-
cumstances the diet should consist for several months entirely of
peptonised milk, digested cereal foods, toast, rusks, Brusson-Jeune
rolls, meat soups or essences thickened with vermicelli, rice or
sago, eggs, raw-meat pulp, chicken cream, well- stewed tripe or
Atrophy of the Stomach. 295
sweetbreads. A pint or more of Metchnikoff's curdled milk is
often a valuable adjunct to other forms of food. Owing to the
extensive destruction of the tissues and the possibility of an open
ulcer, lavage should not be undertaken unless the symptoms and
signs of pyloric obstruction exist, and even then should be per-
formed with caution. A large enema each day will suffice to relieve
the bowels, and drastic purgatives must be avoided. Although the
gastric secretion is greatly diminished, it should be remembered
that the cicatricial mucous membrane remains for a long time
intersected by areas of inflamed glandular tissue, and that con-
sequently indications of atrophy are almost always associated with
symptoms of chronic gastritis. Hydrochloric acid is therefore
rarely tolerated, and recourse should be had to bismuth combined
with alkalies. If much carbohydrate fermentation exists, takadias-
tase may be administered after meals, and if an artificial digestive
is considered advisable, the glycerine, or essence, of pepsin, or papain,
is preferable to the acid preparations. Failure of the general nutri-
tion is very apt to be followed by acute pulmonary tuberculosis, and
should intestinal compensation fail, an attempt may be made to
stimulate the secretion of the pancreas by duodenin or to assist its
action by pancreatin or pancreatic emulsion. Excessive fermenta-
tion in the intestines may be controlled by the exhibition of a suit-
able antiseptic, such as bismuth salicylate, iodoform and charcoal,
naphthol, or guaiacol.
W. SOLTAU FENWICK.
296
CANCER OF THE STOMACH.
General Treatment. During the early stages of the complaint
the patient should be encouraged to perform his usual work, and
when this becomes impossible it is better that he should dress and
lie upon a couch than remain in bed. Change of air is seldom
advisable, and spa treatments are useless. When the stomach is
much dilated, a firm binder should be applied to the abdomen so as to
support the enlarged and heavy viscus. Massage and electricity are
of no value when gastrectasis arises from a growth of the pylorus,
and recourse to these and other so-called " cures " is attended by
much disappointment. Up to the present time the employment of
the Rontgen rays and radium have not been attended by any
permanent benefit. The severe pain that ensues from the forma-
tion of metastases or perigastritis may often be relieved by stimulant
or sedative applications to the skin. In chronic cases the repeated
use of small blisters to the epigastrium, followed by dusting of the
raw surfaces with a powder composed of acetate of morphine (f g r -)
and hydrochlorate of cocaine (J gr.) is of much value, but in the more
acute conditions hot fomentations or poultices with the liniment of
belladonna or tincture of opium sprinkled upon them, are more
beneficial. Lavage may be employed with advantage in the
majority of cases, but it is chiefly indicated when obstruction of the
pylorus exists. The benefit derived from it is of a threefold kind.
In the first place, stagnation and decomposition of the food are con-
trolled, the tendency to secondary gastritis is diminished and the
progress of gastrectasis retarded. Secondly, the systematic cleans-
ing of the inner surface of the organ from the thick mucus that
adheres to it tends to promote secretion and to stimulate absorption.
Thirdly, the periodic removal of the products of fermentation
relieves the acidity and vomiting and greatly improves the appetite.
In order to obtain the best results, lavage should be commenced as
soon as possible, and be performed regularly and in an efficient
manner. As a rule, the stomach should be washed out before the
patient retires to bed, or about three hours after his last meal, by
which means retention of food during the night is obviated, and the
insomnia that arises from nocturnal indigestion is prevented. As
the disease progresses it is advisable that the stomach be cleansed
Cancer of the Stomach. 297
both night and morning. Warm water containing bicarbonate of
sodium (3 gr. to the ounce) is usually all that is required, but if an
antiseptic is considered necessary, one or other of those usually
employed for the purpose may be used. It is important to
empty the stomach completely at the termination of the operation,
since the retention of any of these solutions may produce toxic
poisoning. A soft tube is also of value as a means of introducing
food into the stomach in cases of cancer of the cardiac orifice. The
subjects of this complaint should not be permitted to exist solely
upon food that they can manage to swallow, but from the onset of
the dysphagia their nutrition should be maintained by forcible
feeding and nutrient enemata. The tube should be soft and of
moderate calibre, and must be inserted with the greatest caution.
As soon as it has entered the stomach a pint or more of peptonised
milk, egg and milk, clear soup, or other form of liquid nourishment
is poured in through a funnel and the instrument withdrawn. This
procedure must be repeated every six hours, and as the stricture
becomes more pronounced the size of the tube must be reduced.
Another plan which is more particularly of value when no ulcera-
tion of the growth exists, is to insert a Symonds' oesophageal tube
of convenient size through the stricture by means of a guide, and
to maintain it in position by a silk thread attached to the cheek by
a piece of sticking plaster. The chief contra-indication to the
employment of a tube for lavage or feeding is the existence of
haemorrhage. When the vomit frequently contains altered blood
or attacks of hsematemesis occur at short intervals, the neoplasm is
invariably ulcerated and usually extensive. In such cases the care-
less or even frequent passage of a tube may produce serious results,
and I have often seen dangerous bleeding ensue. Eectal feeding is
of great value when gastric intolerance exists, and also where it is
advisable to increase the nutrition before the performance of an
operation. In all cases the lower bowel should be irrigated with
normal saline solution each day, and the enemata be administered
through a soft tube at atmospheric pressure.
Diet. The appetite and powers of digestion vary so much in
different cases that it is usually advisable to favour, as far as
possible, the patient's natural inclinations, and to abstain from any
hard-and-fast rules concerning the dietary. The existence of severe
pain after meals usually indicates ulceration of the growth, and
cases which display this symptom should be treated on the same
lines as simple ulceration of the stomach. If raw milk agrees,
from 5 to 8 oz. may be given every two hours, but if it pro-
duces nausea or discomfort it should be peptonised, sterilised or
298 Cancer of the Stomach.
mixed with aa equal quantity of lime-water. Clear soups, the
Leube-Eosenthal beef solution, or the various meat essences, juices,
jellies, or extracts may be tried, and the diet may be varied with
eggs beaten up with milk, poached eggs, soft bread and butter,
bread and milk, or milk puddings. In less severe cases scraped
raw meat, boiled chicken and fish that have been passed through a
sieve, sweetbreads, calf's feet or brains, and tripe may be allowed.
Green vegetables are to be avoided, and in most cases raw or even
stewed fruits occasion pain or acidity. Stenosis of the pylorus
accompanied by vomiting must be treated by a light diet, which
includes a considerable quantity of peptonised milk and a limited
amount of farinaceous material. Only the strongest and most con-
centrated forms of meat essence or solution should be allowed, and
the animal food must be lightly cooked and finely minced. Cocoa
made from the nibs usually agrees, but tea and coffee are apt to
provoke acidity. A small quantity of good brandy taken with the
meals often aids digestion and relieves the sensations of fulness and
distension. In all cases the nutrition should be increased by the
administration of a large enema of peptonised milk each night. At
a late period of the complaint it may be necessary to peptonise the
greater part of the food and to administer it in small quantities at
frequent intervals.
Although the sour milk of Metchnikoff has proved disappointing
in the majority of gastric disorders, there can be no doubt that its
employment in cancer of the stomach is often of inestimable benefit,
and tends to relieve many of the most troublesome symptoms of the
complaint. A cautious trial should be made of it at first, and if it
agrees one or two pints may subsequently be given each day. If
the curds are found to be distasteful, they may be beaten up with
fresh milk until the fluid attains the consistency of thin cream,
arid sweetened with sugar. The tablets, chocolate and cheese,
which are supposed to contain living lactic acid bacilli, are quite
useless.
SYMPTOMATIC TREATMENT.
In the absence of a specific remedy it is necessary to direct
treatment to the relief of the various symptoms as they arise.
Anorexia. This may be combated by frequent changes of diet
and by the use of lavage. The various bitters are occasionally of
value in the early stages of the disease, but they are apt to disagree
when secondary gastritis has developed. Condurango is a favourite
remedy with some practitioners, and is best prepared according to
the directions of Friedreich. Half an ounce of the bark is macerated
Cancer of the Stomach. 299
for twelve hours with 12 oz. of water, after which the fluid is
reduced to half its bulk by boiling and strained. One tablespoonful
of this fluid, combined with syrup of orange, is given three times a
day between meals. Occasionally a few drops of the solution of
arsenic appears to improve the appetite in a remarkable manner.
The fact that free hydrochloric acid is usually absent from the
gastric contents in cases of carcinoma naturally suggests the
administration of this drug as an aid to digestion. It is chiefly of
use when the growth affects the central or cardiac portions of the
organ, but is apt to excite pain and vomiting when the pylorus is
contracted. Occasionally pepsin, lactopeptin, or papain seem to
increase the powers of digestion and the relish for food. Chlorate
of sodium in doses of 60 gr. three times a day, as recommended by
Huchard, is sometimes of value.
Pain. When this symptom continues severe in spite of careful
dieting and lavage, recourse must be had to sedatives. If it chiefly
occurs after meals, a mixture containing carbonate of bismuth,
bicarbonate of sodium and dilute hydrocyanic acid will often
relieve it, or a pill composed of belladonna, conium and stram-
monium may be given immediately after food. Cocaine is of use
only when the growth is situated close to the cardiac orifice. At a
late period of the disease opium is usually required. Codeine,
nepenthe, and the compound tincture of chloroform and morphine
[U.S.P. ^.Chloroform., 7'50; Morphin. Hydrochlor., I'OO; Acid.
Hydrocyanic. Dil., 5'00 ; Tinct. Capsici, 1'25 ; Tinct. Cannab. Ind.,
5-00; 01. Menth. Pip., 0-15 ; Glycerin., 25'00 ; Alcohol., ad lOO'OO],
are less apt to disturb the digestion than other preparations ; but
when vomiting prevents the administration cf drugs by the mouth,
hypodermic injections of atropine and morphine are indicated.
This latter method is also best adapted to procure sleep.
Vomiting. The treatment of this symptom varies with its cause.
If it arises from obstruction of the pylorus, daily lavage combined
with careful dieting is at once the most appropriate and successful
treatment. In all cases the administration of antiseptics is valuable
in the prevention of excessive fermentation of the food. For this
purpose carbolic acid is the most useful, and may be given either in
the form of the glycerine preparation (8 to 12 min.) or the pill.
Occasionally full doses of resorcin (15 gr.), hyposulphite of sodium
(60 gr.), or sulphocarbolate of sodium (15 gr.), creosote (3 rnin.), or
1 min. of the tincture of iodine every hour, also afford relief.
Vomiting due to secondary gastritis necessitates daily lavage
and a diet of peptonised milk or sour milk. If retching is an
urgent symptom, ^ gr. of calomel should be placed upon the
300 Cancer of the Stomach.
tongue every three hours, and J gr. of acetate of morphine
is given by hypodermic injection once or twice a day. The emesis
which occurs soon after food, and is preceded by pain, usually
indicates severe ulceration of the growth, and is best controlled by
the exhibition of morphine or nepenthe before meals, and the
repeated application of a small blister to the epigastrium. Chloro-
form, hyoscyamus, cocaine and glycerine have also been recom-
mended, but their effects are uncertain and usually disappointing.
The regurgitation of food that arises from a stricture of the cardiac
orifice must be treated by lavage and rectal feeding. The distressing
nausea that is sometimes a symptom of cancer of the body of the
stomach may often be relieved by a mixture of bicarbonate of
sodium, hydrocyanic acid and bromide of potassium.
Acidity. Acid eructations usually arise from abnormal fermen-
tations of the food and subside under lavage and antiseptic treatment.
When they persist, bicarbonate of sodium combined with calcined
magnesia, glycerine and carbolic acid may be prescribed, or a
bismuth lozenge may be sucked at intervals. Sometimes charcoal
biscuits, or charcoal and iodoform enclosed in a cachet, serve to
relieve this troublesome symptom.
Haematemesis. Severe haemorrhage is rarely encountered and
when it occurs must be treated like that arising from simple
ulcer. The patient is confined strictly to bed, fed exclusively
by the bowel, while an icebag is applied to the epigastrium in order
to control the movements of the stomach. If necessary, a small
dose of morphine may be given by hypodermic injection. The
constant small losses of blood that ensue from oozing from the
surface of the growth may be controlled by the administration of
ergot, hamamelis, gallic acid, perchloride of iron, alum, or calcium
chloride, but acetate of lead (2 gr.), combined with gr. of
extract of opium, and given in the form of a pill every four hours is
the most efficacious remedy. Extract of the suprarenal gland is
occasionally an excellent haemostatic when given by the mouth, the
adrenalin chloride in doses of 15 min. diluted with 2 drachms
of water being the most useful preparation. As its effects are
purely local, the drug should be given immediately after vomiting
has taken place.
Constipation. The tendency to constipation almost always
requires correction. At an early stage of the disease one or two
teaspoonfuls of phosphate of sodium dissolved in 6 oz. of hot
water and administered each morning before breakfast is an
excellent aperient for the purpose, or one of the natural laxative
waters may be prescribed. With the progress of inanition salines
Cancer of the Stomach. 301
are apt to induce exhaustion, and should be omitted in favour of
the liquid extract of cascara, the infusion of senna, or a mild pill
containing podophyllin and rhubarb. Occasionally the daily use of
a glycerine suppository or an enema is to be preferred. Mercury
and drastic purgatives should as a rule be avoided.
W. SOLTAU FENWICK.
302
THE SURGICAL TREATMENT OF CANCER OF THE
STOMACH.
IT is not long since patients with cancer of the stomach were from
the first condemned as hopeless. In the 'seventies, anyone with
carcinoma of the stomach was at once given up as doomed, and
only in 1879 was the first attempt made by Pean to remove a
malignant pylorus ; the first successful operation was performed by
Billroth in 1881, when the operation was looked on with as much
disfavour as was the first-attempted complete gastrectomy a few
years ago by Connor in America, when his patient died on the
table ; yet Schlatter's patient a little later lived fourteen months
after complete gastrectomy, and I can point to a patient in complete
and perfect health on whom I performed almost complete gastrectomy
nine years ago.
Nor was the palliative operation of gastro-enterostomy much
better thought of at first, for although Wolfler successfully per-
formed the operation in 1881, his patient surviving for four months,
yet the mortality of 65'71 per cent, in the years 1881 to 1885, of
47 per cent, in the period from 1886 to 1890, of 83'91 per cent,
from 1891 to 1896, though showing a steadily decreasing death-rate,
yet presented so doleful a picture as to deter medical men from
recommending their patients to submit to operation. Even so
recently as 1900, when I gave the Hunterian Lectures on the
Surgery of the Stomach, of the 1878 cases of gastro-enterostomy
that I was then able to collect from all sources, the mortality was
36*4 per cent. But since that time the surgery of the stomach has
made such rapid progress that I can now point to a long series
of posterior gastro-enterostomies personally performed in simple
diseases of the stomach with a mortality of 1'7 per cent., and even
in cancer of only 3 per cent.
Moreover, the operation of partial gastrectomy in cancer is one
that is attended with much more encouraging success immediate
and remote than is generally recognised.
I am firmly convinced that many deaths are ascribed to cancer
when the disease is inflammatory and perfectly curable by the
operation of gastro-enterostomy without removal of the tumour,
and this I can prove from my own experience.
No one has done more than Professor Osier in advocating the
Surgical Treatment of Cancer of Stomach. 303
early diagnosis of cancer in order that a radical operation may be
performed at a time when there is hope of cure ; and if only this
truth can be impressed on the minds of those engaged in general
practice, who usually see these cases at a time when diagnosis is
doubtful, and when perhaps the only symptom complained of is
indigestion, and if in such doubtful cases a consultation is insisted
on in order that the matter may be taken seriously at the earliest
possible moment, then we shall find that much can be done for
these otherwise hopeless cases in the way of relief or even cure.
Medical treatment cannot cure, and can do very little even to
prolong life ; it therefore applies only to cases too advanced for
surgical treatment or where operation is declined. It aims at
nourishing the patient as much as possible, and at relieving pain or
other symptoms as they arise.
Surgical treatment which offers the only chance of relief and the
only possibility of cure may be considered under the heading of
preventive, palliative and curative operations. In order that the
best results may be attained, the physician and surgeon must act in
concert, so that by a timely diagnosis an operation may be under-
taken at the earliest possible date.
There is ample evidence to show that for some length of time
cancer is a purely local disease, and just as in the breast, the
tongue, and the uterus one can point to patients living comfortable
and happy lives years after the removal of the disease, so in
gastric cancer it can now be proved that a like result may be
obtained. Here, however, we are faced with the difficulty of a
sufficiently early diagnosis being made, and it is not only necessary
for us to appeal for an early exhaustive and persistent investigation
into suspicious stomach cases, but that when the suspicions are
becoming confirmed an early surgical consultation may be held,
and, if needful, an exploratory operation carried out to complete
the diagnosis.
Whenever a patient at or after middle age complains somewhat
suddenly of indefinite gastric uneasiness, pain and vomiting,
followed by progressive loss of weight and energy and associated
with anaemia, the possibility of cancer of the stomach should be
recognised, and in a suspected case, if no improvement takes place
in a few weeks at the most, an exploratory operation is more than
justified.
Let us remember also that to prolong the investigation uselessly,
and to wait until a tumour develops into a recognisable quantity,
is to lose the favourable time for a radical operation ; and although
a clinical examination of the stomach contents and a general
304 Surgical Treatment of Cancer of Stomach.
examination of the patient may give us strong grounds for
suspicion, our diagnosis can only be rendered certain by a digital
examination, which may be effected through a small incision that
can, if needful, be made under cocaine anaesthesia with little if
any risk.
At the time of exploration it will be advisable to have everything
ready to follow up the exploratory procedure by whatever further
operation may be called for. It may be discovered that the disease
is manifestly not malignant, and that some curative operation can
be done, as in inflammatory thickening around chronic ulcer of the
pylorus leading to obstruction.
Or it may be discovered that the disease resembles malignancy
both in its history and physical signs and in the form of the tumour,
and is yet, if we may judge from the ultimate results, not malignant.
I would lay particular stress on this class of cases, for I think it
serves to explain some misconception about cancer generally. It
would be easy for anyone, looking at the subject from a one-sided
point of view, to raise a claim to having cured a number of cases of
cancer of the stomach by gastro-enterostomy ; but I do not for a
moment believe that these cases were more than inflammatory
tumours formed round chronic gastric ulcers ; nevertheless, I have
no doubt that they would have proved fatal just as certainly as if
they had been cancer had no operation been done. I feel sure that
many cases of this nature would have been certified as death from
cancer of the stomach had no exploration been done or necropsy
with microscopic investigation made, and I think we must take
such cases into account before hastily deciding that cancer is on the
increase.
Even though a tumour is palpable, and even though it is probably
too large for removal, it may be quite worth while advocating an
exploration, to be followed by gastro-enterostomy if that be practic-
able, in the hope that the disease may prove to be wholly or partially
inflammatory which the physiological rest secured by gastro-ente-
rostomy will either cure or materially relieve.
. Now, to pass to the genuine cancer cases, what can we do for
them ? This will depend : (1) On the position of the growth ;
(2) on its extent ; (3) on the presence of adhesions ; and (4) on
glandular invasion or secondary growths.
First, as to position. In irremovable growth at the cardiac end,
if it involves the cardiac orifice and adjacent portion of the stomach,
gastrostomy should be performed in order that starvation may be
staved off. The view that gastrostomy is both a dangerous and
useless operation is, I know, held by some, but I feel convinced that
Surgical Treatment of Cancer of Stomach.
305
Tube passing 1 )
down distal arrm--
o? Jejunal loopj
such views are erroneous. When these cases, either of cancer of
the cardiac end of the stomach or of the ossophagus, were handed
over to the surgeon in a moribund condition the mortality of
gastrostomy was of course terrible, and the short survival, even if
successful from an operative point of view, brought discredit on
the operation ; but when I myself can point to a long series of
gastrostomies performed since 1897 not only without any mortality,
but with comfort to all and great
prolongation of life to many, I feel
that I have good grounds for saying
that the operation is well worth
doing. The operation is quite a
simple one, and, if necessary, can be
performed under cocaine anaesthesia
in a very short time. In several
cases the patients have lived a year
or more and have gained considerably
in weight, even up to 2| stones, and
have lost their pain and the distress-
ing sense of starvation.
Jejunostomy is an operation occa-
sionally called for as a means of giving
relief and prolonging life in patients
suffering from advanced disease of
the stomach, when on exploration it
is discovered to be impracticable to
perform gastrectomy, gastrostomy,
or gastroenterostomy. The indica-
tions for operation are :
(1) Extensive cancer of the stomach
too advanced for gastrectomy, and in
which no healthy spot of sufficient
size on the stomach wall can be found for the purpose of gastrostomy
or gastro-enterostorny.
(2) General cicatricial contraction of the stomach, simple in
character, and due to the swallowing of caustic fluid, in which the
stomach has been so far damaged that it no longer performs its
functions, or even allows of the proper passage onwards of food.
(3) Extensive ulceration of the stomach or duodenum, the
operation being done in order to secure complete rest to the
ulcerated area.
For the operation to be a success the bowel must be so placed
that it will serve two purposes : (1) To permit the passage onward
S.T. VOL. n. 20
* ' l
306 Surgical Treatment of Cancer of Stomach.
of the bile and pancreatic fluid poured into the intestine above
the artificial fistula ; (2) to allow of food being introduced through
the fistula without fear of regurgitation, either of the food or of the
intestinal contents.
The operation that has given me the best results consists in
taking a loop of the beginning of the jejunum, just sufficiently long
to reach the surface without tension ; the two arms of the loop are
short-circuited about 3 inches from the surface, the short-
circuiting being done by means of a continuous suture taking
up all the coats and a continuous serous suture beyond the
marginal one. .
A small incision is then made into the top of the loop just large
enough to admit a No. 12 or 14 Jacques's catheter, which is inserted
and passed for 3 inches down the distal arm of the loop ; this
is fixed to the margin of the incision in the gut by a silk or
Pagenstecher's suture, and the entrance of the tube into the bowel
is further guarded by two pursestring sutures, one over the other.
The top of the loop is fixed to the skin by one or two stitches and
the wound closed. The patient can then be fed at once with some
peptonised milk and brandy. The whole operation can be done in
from fifteen to twenty minutes and with very little visceral exposure.
Should the patient be too ill to bear the little extra time occupied
by the short-circuiting, the tube may be inserted as directed and
surrounded by two or three pursestring sutures, a proceeding
which can be accomplished in a few minutes. In this case the
loop of bowel must not be brought to the skin, but had better be
fixed by sutures to the peritoneal margin and the aponeurosis, in
order to leave part of the lumen of the attached loop within the
abdomen for the direct passage onwards of the intestinal fluid with
the bile and pancreatic secretion.
The next class of cases to be considered is where the disease
involves the pylorus, and is producing obstruction to the passage
onwards of the gastric contents, but where, on account of the
extreme feebleness of the patient, or because of extensive
adhesions, secondary growths or involvement of glands, it is
considered unwise to attempt pylorectomy or partial gastrectomy,
though there is sufficient free stomach wall left to enable a gastro-
enterostomy to be performed. In such cases a gastro-enterostomy,
if performed with proper expedition and adequate precautions,
affords the greatest relief to the sufferer, who not only loses the distress
due to painful peristalsis and to the irritation of retained secretion,
but also becomes freed from the toxaemia due to absorption of the
poisonous fermenting stomach contents, which are drained away into
Surgical Treatment of Cancer of Stomach. 307
the intestine and there disposed of. Thus life is prolonged and made
more comfortable, flesh and colour are regained, and, even in cases of
cancer, the patient may have a new lease of life ; moreover, in some
cases where the condition of the patient, and not simply the extent
of the growth, has prevented a radical operation, the speedy
restoration to health enables a radical operation to be subsequently
undertaken.
The remaining class of cases is of great interest, and includes
those where the disease is limited to the stomach, and where the
lymphatic glands and adjoining organs have not been seriously
invaded, the patient being in a sufficiently good condition to permit
of the radical operation of partial or complete gastrectomy being
performed.
The cases that have been reported by myself and other surgeons
are sufficient to show that removal of even a considerable portion
of the stomach may be something more than a palliative operation,
and I think it justifies me in saying that although it is better to
have cases of cancer diagnosed and operated on early, yet we need
not take the pessimistic view which has been, and which is still,
held by some surgeons, that if a tumour is manifest it is too late
to perform a radical operation.
I hope I have advanced sufficient evidence to prove :
(1) How desirable it is to make an early diagnosis of cancer of
the stomach in order that a radical operation may be performed at
the earliest possible moment.
(2) That it may be needful to perform an exploratory operation
in order to complete or confirm the diagnosis.
(3) That such an exploration may be done with little or no risk
in the early stages of the disease.
(4) That even when the disease is more advanced, and a tumour
perceptible, an exploratory operation is, as a rule, still advisable in
order to carry out radical or palliative treatment.
(5) That where the disease is too extensive for any radical
operation to be done, the palliative operation of gastro-enterostomy,
which can be done with very small risk, may considerably prolong
life and make the remainder of it much more comfortable and happy.
(6) That some cases, thought at the time to be cancer too extensive
for removal, may after gastro-enterostomy clear up completely and
get quite well.
(7) That in cases of disease of the cardiac end of the stomach too
extensive for removal, the operation of gastrostomy may con-
siderably prolong life, and prove of great comfort to the patient by
preventing death from starvation.
20-2
308 Surgical Treatment of Cancer of Stomach.
(8) That even when the disease is too extensive either for
removal or for a gastro-enterostomy to be performed with a fair
chance of success, the operation of jejunostomy may occasionally
prove of service to the patient.
(9) That when a radical operation can be performed, the
thorough removal of the disease may bring about as much relief
to the patient as does the operation for the removal of cancer in the
breast, uterus, and other organs of the body, and that in some
cases a complete cure may follow.
Partial gastrectomy may have to be undertaken for cancer of
the pyloric end of the stomach when an exploratory operation shows
that the tumour is free from adhesions to the pancreas and that
there is no extensive involve-
ment of glands. The operation
is simplified by extending the
incision upwards to the notch
between the ensiforni cartilage
and the right costal margin and
by bringing the stomach nearer
to the surface, either by means
of a table which can be raised at
the liver level or by a sandbag
placed under the back opposite the
lower ribs.
An opening is made in the
lesser omentum, and through the
slit two pairs of forceps are passed
so as to grasp it. It is then
divided between the forceps and
ligatured above and below. This
gives free access to the lesser peritoneal cavity and to the blood
vessels which should either be caught up and tied as the operation
progresses or ligatured in their continuity near their origin.
These vessels are the gastric, which is best ligatured at a point 1
inch below the cardiac orifice, where it joins the lesser curvature ;
the pyloric, which can be taken up shortly after it leaves the hepatic
artery ; the right gastro-epiploic as it passes down behind the pylorus ;
and the left gastro-epiploic, which is taken up below the greater
curvature of the stomach. It answers well to seize the vascular
trunks in pressure forceps, and when the excision has been performed
to ligature them separately. The fingers of the left hand are then
passed behind the growth until the great omentum is reached, thus
raising the mass from the transverse colic vessels. The great omentum
FIG. 2. Diagram to show the stomach
after partial gastrectomy.
Surgical Treatment of Cancer of Stomach. 309
is then ligatured and divided in the same way as the lesser. Double
clamps are then applied to the duodenum and to the stomach, the
duodenum being divided between the clamps a full | inch from the
distal end of the growth, and the stomach being also divided between
clamps 1 inch or more beyond the proximal end of the growth. As
cancer usually advances further along the lesser curvature, the
clamps will have to be placed obliquely on the cardiac side. The
growth which is then free can be lifted away, any glands removed
and vessels ligatured. The gastric incision must then be closed by
a haemostatic suture of chromic catgut, which takes up all the coats,
and by an external suture of silk or Pagenstecher's thread, which
approximates the serous margins. The duodenal end may be
ligatured en masse where the clamp has crushed it, and the cut end
invaginated by a pursestring suture. A posterior gastro-enterostomy
is then performed in the ordinary way between the jejunum, just
beyond the duodeno-jejunal junction, and the posterior wall of the
stomach. I usually prefer to perform a gastro-jejunostomy first, as
should the patient's strength fail the operation need not be
persevered with at the time and may be completed later. As the
parts will not have been soiled, drainage is unnecessary.
If adhesions are extensive, especially to the pancreas, the
operation is attended with much more danger and, as a rule, is
unjustifiable.
A. W. MAYO-ROBSON.
3io
DILATATION OF THE STOMACH.
ENLAKGEMENT of the stomach may arise from several conditions :
(1) Stenosis of the pylorus or duodenum from cancerous or sarco-
matous growths, the contraction of a simple ulcer, kinking of the
first part of the duodenum or adhesions of the pylorus to the liver
or gall-bladder, pressure on the outlet by an aneurysm of the
hepatic artery or tumour of the liver, a papilloma of the pyloric
ring, or the impaction of a hair-ball or other foreign body in the
pyloric antrum ; (2) diseases of the muscular coat of the organ
which impair its contractility, such as cirrhosis, or fatty or
lardaceous degeneration ; (3) functional loss of tone, to which the
term "atony" or "myasthenia" is applied; (4) paralysis of the
nervous mechanism which gives rise to an acute distension of the
viscus (acute dilatation). Many of these conditions are discussed
under their appropriate titles, and it is only necessary in the present
section to consider the treatment of acute dilatation of the stomach
and of that chronic variety which ensues from mechanical
obstruction to the passage of food into the intestine (pyloric
stenosis).
ACUTE DILATATION OF THE STOMACH.
Acute dilatation of the stomach is a very rare complaint. It
is easily recognised by the repeated vomiting of immense quantities
of bile-stained fluid, despite the fact that no food is taken by the
mouth, and the sudden development of an immense gastrectasis.
Immediately the disease is recognised the organ must be emptied
by means of a soft tube, and thoroughly washed out. Owing to the
constant regurgitation through the patulous pylorus of bile and
intestinal fluids, the procedure is somewhat tedious, and as much
as 3 or 4 quarts of warm water are usually required before
the gastric fluid loses its bilious character. The lavage must be
repeated every hour until fluid no longer accumulates in the
distended viscus, and the efforts at vomiting cease. In the mean-
time, the concomitant symptoms of shock are combated by the
hypodermic use of strychnine while a continuous injection of warm
saline solution (a teaspoonful to the pint) is administered either
beneath the skin or by the bowel. In the latter case the same
apparatus is employed as that used for large nutrient enemata
Dilatation of the Stomach. 311
(p. 326), but instead of 15 oz. 2 quarts or more of the hot saline
are introduced slowly into the body. No food is allowed by the
mouth until the size of the stomach has diminished and the pulse
rate fallen. Should the case prove more tedious than the average
(twelve hours), it may be necessary to administer 10 oz. of
peptonised milk with oz. of brandy by the rectum.
When the collapse has disappeared and the gastric dilatation
subsides, whey should be given by the mouth and the amount
rapidly increased until 6 or 7 pints are consumed in the
twenty-four hours. The shrunken aspect of the patient betokens
the necessity for giving him this large amount of fluid. Sub-
sequently milk is substituted for whey, and the diet gradually
resumed. The danger of sudden heart failure must always be
borne in mind.
W. SOLTAU FENWICK.
ACUTE POST-OPERATIVE DILATATION OF THE STOMACH.
Some of the cases of ileus after abdominal operations are due to
acute dilatation of the stomach from primary gastric atony, which,
once initiated, tends to persist and get worse owing to the distended
stomach dragging on and kinking the duodenum, thus leading to
shock by pressure on the heart without there being any sign of
sepsis. In some cases the duodenum participates in the dilatation,
apparently owing to pressure of the superior mesenteric vessels on
the third part of the duodenum, which they cross transversely ; it is
in such cases that the prone position may afford some relief. In all
cases of ileus after operation the use of the stomach-tube should
not be neglected, and if repeated lavage, the prone position and
general treatment fail to bring about relief, the question of gastro-
enterostomy should be considered, provided that the intestines do not
participate in the paralysis.
A. W. MAYO-ROBSON.
CHRONIC DILATATION OF THE STOMACH (PYLORIC
STENOSIS).
General Treatment. The retention of food which accompanies
all varieties of the complaint indicates the necessity of systematic
lavage. The time of day at which the operation should be per-
formed depends upon the nature of the case and the degree of
stenosis. As a rule, the best time is before breakfast, since the
312 Dilatation of the Stomach.
organ is then cleansed from the secretion of mucus that has
accumulated during the night and is prepared for the ingestion
of food. When, however, sleep is prevented by nocturnal indiges-
tion or vomiting occurs in the early hours of the morning, it is
advisable to wash out the organ about 10 p.m. or even twice a
day. The apparatus required consists of a soft gastric tube having
an internal diameter of about f inch with a bevelled orifice at its
extremity and two or three small holes in the immediate vicinity.
A piece of glass tubing inserted into the opposite end serves to
connect the gastric tube with 2 feet of rubber tubing of similar
diameter to the free extremity of which a good-sized glass funnel is
attached. Many other and more elaborate forms of stomach siphon
have been invented, but with the exception of Gentile's evacuator
they are all inferior to that just described. In the performance of
lavage the patient lies upon a couch with his head and shoulders
raised upon a pillow and removes any false teeth he may possess.
The gastric tube is warmed by immersion in hot water and smeared
with glycerine, or, if preferred, merely moistened with water. It is
quite unnecessary to depress the tongue with the fingers or to use a
gag. The tube is merely inserted into the pharynx and the patient
is instructed to swallow, when the instrument becomes grasped by
the pharyngeal muscles and may rapidly be pushed into the
stomach. It is only in very nervous individuals and in those who
have been anticipating the operation with dread that an involuntary
retraction of the tongue prevents the downward passage of the tube,
which consequently curls up in the mouth. If the tube causes a
sense of suffocation or spasm of the glottis, the patient should be
made to inspire entirely through the nose, when these unpleasant
symptoms immediately subside. The fluid employed for lavage
should possess a temperature of about 70 F., and at least
2 quarts should be ready for use. As a rule, warm water alone is
sufficient, but if much mucus exists in the stomach bicarbonate of
sodium, in the proportion of about 2 gr. to the ounce, may be added
to it. When food decomposition is a notable feature of the case, it
may be advisable to use an antiseptic, of which the following are
the most reliable: Salicylic acid (1 in 1,000); sodium salicylate
(0'5 per cent.) ; permanganate of potassium (1 in 1,000) ; boracic acid
(1 percent.) ; borax (5 per cent.) ; resorcin(4 in 1,000); thymol (5 in
1,000); benzol (5 in 1,000); or a solution of hydrochloric acid (1 in
1,000). Some authorities recommend that after the organ has been
thoroughly cleansed with boiled water, a pint of boro-salicylic solu-
tion (boracic acid, 60 gr., salicylic acid, 20 gr. ; water, 1 pint) should be
poured into it and allowed to remain in contact with the mucous
Dilatation of the Stomach. 313
membrane for five minutes, before being withdrawn. A teaspoonful
of pure glycerine after lavage completes the process of antisepsis
and also acts as an aperient. It is always necessary that the
stomach should be carefully emptied at the end of lavage, lest the
antiseptic be absorbed into the general circulation and produce
symptoms of poisoning. In all cases a firm binder or belt should
be applied to the abdomen in such a manner as to elevate and
support the enlarged stomach, as by this simple measure the
traction of the heavy viscus upon its fixed pylorus is prevented and
the exit of its contents into the duodenum accelerated. The fact
that compensatory hypertrophy of the gastric musculature usually
exists renders the application of electricity and massage superfluous.
Diet. This must vary according to the cause of the pyloric
stenosis and the general condition of the patient. As a rule, a
mechanical obstruction to the exit of chyme from the stomach is
associated with diminished peptic digestion, and it is, therefore,
necessary to administer nourishment in a form which is capable of
passing with the least difficulty into the duodenum. Thin soups
and broths should be prohibited, but milk, either raw, peptonised,
sterilised or mixed with a suitable proportion of lime-water, usually
agrees, and may be permitted in considerable amount. Finely
minced fish, chicken, game, sweetbreads, tripe, or hashed mutton,
along with eggs, and a small quantity of potato, cauliflower or
asparagus may be allowed in suitable cases, but the material must
be well masticated and eaten slowly. Scraped raw beef often
answers well. Curdled milk is only suitable when the gastric
secretion is deficient in hydrochloric acid. In these latter cases, of
which the best example is cancerous stricture of the pylorus, the
increasing tendency to food stagnation soon renders a solid diet
inadmissible, and the meals must consequently be composed of such
fluids and semi-solids as are most easily digested. In this category
the various meat jellies, essences and juices, are important items.
In cases of benign stenosis, on the other hand, milk should form
the staple diet. Tea almost invariably disagrees, but unsweetened
cocoa is often digested without trouble. A little good brandy or
whisky given in hot water along with the food often relieves the
flatulence and other unpleasant symptoms. When vomiting is a
constant feature of the case rectal feeding may be necessary.
Medicinal Treatment. The chief indications for the adminis-
tration of drugs are : (1) To relieve the gastric symptoms ; (2) to
assist the processes of digestion and control excessive fermenta-
tion ; (3) to maintain an efficient action of the bowels.
1. Severe pain during the course of gastric digestion is either
314 Dilatation of the Stomach.
due to an excessive secretion of acid, such as ensues from cicatricial
contraction of the pylorus, or to the presence of an open sore,
whether simple or cancerous. In both instances it is necessary to
prescribe an alkaline sedative mixture and to avoid all tonics,
acids, bitters and other drugs which tend to augment acidity or to
irritate the inflamed gastric mucous membrane. The salts of
bismuth are indispensable in these conditions, but it is still the
usual custom to prescribe the subnitrate preparation in combination
with bicarbonate of sodium in a mucilaginous medium to retain
the heavy powder in suspension. The subnitrate is, however,
frequently acid in reaction, and produces decomposition of the
alkaline bicarbonate, while the mucilage favours bacterial fermenta-
tion. A better plan is to employ 15 gr. of the carbonate
of bismuth, with either a similar quantity of the sodium salt, or
12 min. of the solution of potash, and a drachm of pure
glycerine in some simple excipient like chloroform or peppermint
water. When hyperacidity exists the bismuth carbonate has the
further advantage of effecting partial neutralisation of the gastric
contents, and this property may be further enhanced by the
addition of 10 gr. of carbonate of magnesia. The solution of
bismuth is only of use in mild cases. If the pain is severe, 10 to
15 min. of the solution of morphine [U.S. P. morphine hydro-
chloride, gr. ^ to gr. ^5] may be incorporated in the prescription,
or tincture of opium or chlorodyne may be employed. Nepenthe
is also a valuable drug, but it should not be given along with
soluble alkalies. Excessive pain, such as accompanies the exten-
sion of cancer to the peritoneum or liver, may require the use
of opium pills or the hypodermic administration of morphine.
Cocaine, belladonna, chloretone and other analgesics are occa-
sionally prescribed, but they are not so reliable. When the pain
develops within half an hour of a meal the medicine should be
given immediately after food ; but if the symptom is deferred for
one or two hours, its administration midway between the meals
proves more efficacious. A deficiency of hydrochloric acid usually
accompanies cancerous stricture of the pylorus, and, theoretically,
demands the administration of this mineral acid by the mouth ;
but, as a matter of fact, alkalies always afford greater relief, since
they serve to neutralise the acid products of fermentation and to
soothe the inflamed mucous surface. The only acid which is really
of use is lactic acid, administered in the form of curdled milk.
Anorexia is chiefly met with in cancer of the pylorus, and should be
treated by systematic lavage (see Cancer of the Stomach). When
excessive flatulence occurs at night, thirty drops of the alcoholic
Dilatation of the Stomach. 315
essence of peppermint (Ricqles) in half a sherry-glassful of water
often affords relief, or a gingermint tablet may be sucked at
intervals. Nausea and vomiting usually subside when the general
and dietetic measures already described are carefully carried out.
2. Efforts to increase the digestive powers of the stomach in
gastric dilatation due to pyloric cancer are rarely attended by much
success, the incorporation in the dietary of 1 or 2 pints of the
curdled milk each day being of most service. Occasionally, how-
ever, pepsin, combined with dilute hydrochloric acid, the acid
glycerine of pepsin [U.S. P. 1^. Pepsin, 9'15 ; Acid. Hydrochloric.,
ri5 ; Glycerin., GO'OO ; Aquam Dest., ad lOO'OO] , papain, or one
of the other artificial digestives, appear to relieve the symptoms of
indigestion, or takadiastase may be prescribed before the meals.
To control the excessive fermentation, 10 to 12 min. of the glycerine
of carbolic acid may be added to the alkaline bismuth mixture, or
a pill containing 1 gr. of the acid may be given after each meal.
Creosote and guaiacol are apt -to produce unpleasant eructations,
and should be prescribed in 3-min. capsules after food. Cyllin does
not give rise to discomfort, and may advantageously be used in the
form of the gastric palatinoids, each of which contains 3 min.
Yanadine, in doses of 10 min., taken immediately after meals is
sometimes of use, while minim doses of the tincture of iodine, well
diluted, are sometimes successful when much secondary gastritis
exists.
3. In the early stages of the complaint the bowels usually react
to a full dose of the phosphate and dried sulphate of sodium (equal
parts), sulphate of magnesium, sulphate of sodium, Carlsbad salts,
or one of the natural aperient waters administered in hot water
before breakfast ; but at a later period the contraction of the
pylorus causes the saline to be retained in the stomach, and
recourse must be had to vegetable purgatives in the form of a pill.
Sooner or later enemata have to be employed, but lavage of the
large intestine is apt to prove exhausting. For the treatment of
the complications of gastric dilatation see Gastric Intolerance ;
Heematemesis and Tetany.
W. SOLTAU FENWICK.
316
SURGICAL TREATMENT OF PYLORIC STENOSIS
AND OBSTRUCTIVE DILATATION.
THE very process of cure in pyloric ulcer can only result in
stenosis, which if moderate in extent is overcome by hypertrophy
of the gastric muscle. "While this compensation is maintained
symptoms may be slight or even absent, but sooner or later com-
pensation fails and dilatation occurs, leading to stagnation of the
stomach contents, with fermentation and the generation of acrid
acids and offensive gases, giving rise to gastritis. Relief is obtained
for a time by vomiting, but as the stenosis increases less and less
food passes into the intestine, and death from starvation is the
inevitable result, should not tetany or perforation hasten the end.
In perhaps no other variety of so-called chronic indigestion are
the patients so miserable, and as the disease may drag on for
months, or even years, the sum-total of suffering probably exceeds
that from almost any other form of disease.
In the early stages of obstructive dilatation, when the symptoms
are slight, relief will doubtless have been given by semi-liquid diet
and lavage of the stomach ; but as soon as the symptoms are pro-
nounced it is a mere waste of time to persevere with the use of
drugs, massage, electricity, or even lavage.
Surgical treatment is alone of avail in order to remove the
cause of the stenosis, or to create a new channel by which the
contents of the stomach may pass onwards into the intestines.
It may sometimes be possible to remove the cause of the
stenosis by division of peritoneal bands or adhesions, or by the
removal of a tumour obstructing the pylorus, but in the majority
of cases it will be necessary either to enlarge the contracted pyloric
orifice or to perform a gastro-enterostomy.
The operations available are : (1) Pylorodiosis, or forcible
dilatation of the pylorus ; (2) Pyloroplasty ; (3) Finneys operation ;
(4) Kocher's gastro-duodenostomy ; (5) Pylorectomy ; (6) Gastrolysis ;
(7) Gastro-JKJunostomy.
It is not necessary to describe or dilate on the various opera-
tions that may be performed in case of dilatation of the stomach due
to simple pyloric stenosis, as the greater number of experienced
surgeons are agreed that gastro-jejunostomy is the procedure
that should be followed in such cases, not only because it can be
Pyloric Stenosis and Obstructive Dilatation. 317
done with very little risk, but also because the after-results of the
operation in these cases are extremely satisfactory. The risk is
under 2 per cent., and the cases permanently relieved or cured are
over 90 per cent.
Although pylorectomy or partial gastrectomy is a much more
severe operation than gastro-enterostomy, yet there is a certain
class of cases of pyloric stenosis associated with tumour in which
it is difficult to say whether the tumour of the pylorus is simple or
malignant.
If the obstruction of the pylorus is associated with a tumour due
to inflammatory disease, in all probability it will be so adherent to
the under- surf ace of the liver or to the pancreas that pylorectomy
will be extremely difficult and hazardous. In such cases it will
probably be deemed necessary to rest content with gastro-enterostorny,
in the hope that the rest induced by the operation will cause a
subsidence of the tumour. I have found this to apply in many
such cases in which, at the time, there was a question of malignant
disease, but in which, after gastro-enterostomy, complete and per-
manent recovery followed. If, however, under these circumstances,
the pylorus should be free and the disease limited, it may be quite
justifiable to perform pylorectomy in case of doubt. As pylorec-
tomy, even in cancer, can be performed with a mortality of 15 per
cent, or less, the risk of operation in simple ulceration should not
exceed 5 per cent.
My views on pyloroplasty and its modifications are given later
(see p. 385).
The operation of pylorodiosis, though recommended and per-
formed by Loreta in some cases of cicatricial contraction of the
pylorus, is not a procedure to be recommended, as, though it has
given good results in some cases of obstruction due to simple
spasm of the pylorus, the procedure is attended with much more
risk than either gastro-enterostomy or pyloroplasty, and the only
form of obstruction in which I should consider Loreta's operation
at all justifiable is in congenital hypertrophic stenosis, where spasm
is taking a share in the obstruction.
A. -W. MAYO-ROBSON.
DISPLACEMENTS OF THE STOMACH.
THE stomach may undergo displacement upward, laterally or
downward.
UPWARD DISPLACEMENT.
Care must be taken to correct, as far as possible, the con-
ditions that are responsible for this abnormal position of the
viscus. In the case of abdominal tumours or ascites, the removal
of the cause of the excessive abdominal pressure is at once
followed by a descent of the organ, while in cases of meteor-
ismus, the exhibition of suitable aperients, the prohibition of
green vegetables and fruit, and a course of intestinal antiseptics,
are usually followed by improvement. When the malposition
depends upon an abnormal shape of the thorax, the wearing of
tight corsets and of strings round the waist must be avoided, and
the patient should practise some form of breathing exercise which
augments the capacity of the chest.
Starches and sugars should only be allowed in strict moderation,
and all excess of fluid with the meals must be prohibited. Efferves-
cent drinks are especially harmful. The food must be thoroughly
masticated, and green vegetables should be taken sparingly. A
dose of euonymin, combined with rhubarb and cascara, forms an
excellent corrective of constipation, but salines should be given
with caution. When much cardiac or respiratory distress is
experienced after meals a carminative and antispasmodic mixture
may be prescribed, and in the event of a severe attack, the patient
should pass a tube into the stomach with the view of evacuating
the gas which is unable to escape through the displaced oesophagus.
Intestinal fermentation may be corrected by means of cyllin,
guaiacol, or salicylate of bismuth taken after meals.
VERTICAL DISPLACEMENT.
The main indications are to prevent further displacement of the
stomach, to support the organ, and to correct any secondary dis-
turbances of digestion that may occur. Tight corsets must always
be prohibited, especially in girls who possess a long, narrow chest,
and come of a tuberculous stock. In such cases the corset should
either be short and loose or be replaced by a band of some warm
Displacements of the Stomach. 319
and firm material. Exercises undertaken to strengthen the
muscles of the arms, chest and abdomen are extremely valuable,
and the patient should learn to inspire deeply through the nose,
so as to increase the capacity of the thorax. In every instance
a firm, well-fitting belt should be worn in such a way as to
elevate and sustain the stomach. The belt should be applied in
the recumbent posture, and be worn both night and day. When
anaemia and emaciation are prominent features of the case rest in
bed is essential, and should be maintained for a month or six
weeks. Abdominal massage and electricity are useful adjuncts
in some cases. The salts of iron rarely agree, but arsenic, nux
vomica and gentian are of value, and a dose of hydrochloric acid,
administered after meals, is an important aid to digestion when
the gastric secretion is diminished. Eegurgitation of bile into the
stomach should be treated by lavage at night, while a full dose of
sulphate of sodium is given in hot water at an early hour every
morning. Should these means prove ineffectual in relieving the
bilious vomiting, surgical aid must be invoked.
TOTAL DESCENT OF THE STOMACH (GASTROPTOSIS).
Much may be accomplished in the prevention of gastroptosis by
careful attention to the clothing and to the early correction of those
conditions which are commonly responsible for its development.
Young girls should never be permitted to wear tight corsets, and
at all ages tight lacing is to be discouraged. For the same reason,
strings and bands worn round the waist should be avoided and buttons
substituted for them when possible. During the lying-in period
special attention should be bestowed upon bandaging the abdomen,
so as to afford a firm support to the viscera and aid the belly to
regain its former shape. Any attempt subsequently to improve the
figure by tight lacing must be prohibited, since the chief effect of
the corset is to force the stomach and intestines downward, while
it fails to afford any support to the parietes below the waist. Care
should also be taken to reduce the gaseous distension of the bowels
that usually occurs after delivery, and to overcome the natural
tendency to constipation. The patient should never be allowed to
walk before the tone of the abdominal muscles has been restored.
The same rules apply to persons who have undergone abdominal
operations, and to those cases in particular where the intra-
abdominal pressure has been suddenly lowered by the removal of a
large tumour or an excess of ascitic fluid. The treatment of the
dislocated stomach itself is a purely mechanical one. In mild or
recent cases, confinement to bed for a month is invaluable, as it
320 Displacements of the Stomach.
not only tends to cut short the progress of the complaint, but
completely relieves the symptoms that emanate from it. Rest
cures also act advantageously, since the patient is forced to occupy
the recumbent posture ; while an excess of nourishment leads to
the accumulation of fat in the abdomen. Under all conditions
persons suffering from gastroptosis should be advised to lie down
for an hour after meals and at the same time to loosen the corsets
and clothing round the waist. By this simple procedure the
symptoms which develop during digestion are rendered much less
severe and stagnation of food is to a great extent prevented.
Lavage is of no value unless the condition is complicated by
gastrectasis or chronic gastritis, nor in ordinary cases do massage
and electricity produce any direct effect upon the stomach. As a
means, however, of strengthening the muscles of the abdomen
they are often beneficial.
The essential factor in the treatment of gastroptosis is the
application of a firm belt to the abdomen, which will support the
stomach and hold it in position. Many varieties have been devised
for the purpose (Glenard, Landau, Bardenheuer, and Teufel), but it
must be remembered that a belt that suits one person will not
necessarily suit another and that consequently no stock pattern can be
prescribed without previous trial. Many of the corset-belts now in
fashion either exaggerate all the ill -effects of the corset or fail to
afford support to the prolapsed stomach. As a rule, the binder or
belt should extend from the lower border of the twelfth rib to the
symphysis pubis, and should be made of some light but firm material
that will not easily stretch. Silk elastic makes an excellent belt, but
it requires constant renewal. The support should be applied with
the patient lying on his back and should be laced or tightened from
below upward. To prevent it from riding up, a perineal band may
be worn, or, in the case of a woman, the suspenders of the stockings
may be attached to it on either side. For some time the belt must
be worn both by day and night, but when considerable improvement
has taken place it may be left off when the patient retires to bed.
Diet. The food must be regulated according to the necessities
of each individual case and the existence of complications.
Gastroptosis associated with healthy intestinal functions and good
gastric compensation merely requires a full diet of substances that
are easily digestible. Moderately cooked and tender meats, fish,
game, eggs, sweetbreads, tripe, sheep's head, calf's head and feet,
well-boiled cereals, farinaceous puddings, and a small amount of
fruit may be allowed ; and the patient should be encouraged to
drink milk with her meals and to indulge in cream and fats. Raw
Displacements of the Stomach. 321
vegetables, pastry, sauces, pickles and cheese should be pro-
hibited. When emaciation is a marked feature of the case and
is attended by neurasthenia, a milk diet w is often of great value,
5 pints, mixed with a small proportion of lime-water, being given in
divided doses during the course of the day.
Gastroptosis accompanied by myasthenia requires a diet suited
to this important complication. The great principles to be borne in
mind are to supply the stomach with those forms of food which are
most easy of digestion, to avoid over-distension of the organ, and to
permit a sufficient interval to elapse between the meals in order that
the viscus may completely empty itself on each occasion. Sugars
and fats in excess are always injurious, owing to the tendency of the
former to ferment and of the latter to stagnate in the stomach.
Butter and cream may be allowed in moderation, as well as rice
and oatmeal porridge. Lean meats, white fish, fowl, game, and eggs
may be given, but soups and broths must be avoided. Spinach and
asparagus may be taken in small quantities, but raw and coarse
vegetables are difficult of digestion. An exclusive milk diet is
seldom advisable, owing to the distension of the stomach which
ensues from the introduction of large quantities of fluid, and at
most 8 oz. should be taken at a meal. Tea and coffee rarely
agree and most varieties of cocoa are unsuitable, owing to the
sugar they contain. A decoction of cocoa husks or cocoa nibs forms
a palatable drink and is free from the disadvantages that pertain
to the other preparations. If the patient is accustomed to take
alcohol, a little good brandy or whisky may be allowed ; but as a
rule a claret-glassful of hot water sipped at the end of the meal is
more beneficial.
When colitis complicates the gastric displacement the diet should
consist entirely of finely minced fish, poultry, tripe, sweetbreads and
sheep's brains, dry toast, meat juice, clear soups without vegetables,
potatoes and plain milk puddings. Green vegetables and fruits are
particularly harmful, and red meats should usually be avoided.
Vichy or Contrexeville water may be drunk with the meals.
Medicinal Treatment. In uncomplicated cases drugs are seldom
of much value and the treatment is chiefly symptomatic. If the
appetite is bad a dose of dilute phosphoric or nitro-hydrochloric
acid combined with a bitter infusion may be given between meals.
Occasionally, the sense of extreme weakness may require the exhibi-
tion of strychnine, nux vomica, cinchona or other tonic ; while in
many instances cod-liver oil, the compound syrup of the hypophos-
phites, the elixir of phosphorus or formate of sodium produce a bene-
ficial effect upon the symptoms of neurasthenia. Pain after food and
S.T. VOL. II. 21
322 Displacements of the Stomach.
flatulence usually depend upon some morbid condition of the gastric
secretion or an increased sensibility of the gastric mucous membrane,
and in such cases the compound bismuth mixture, with or without
morphine, affords relief. Sometimes a preparation of pepsin or
pancreatin, or the tablets of pentenzyme, appear to aid the processes
of digestion. The development of gastric rnyasthema requires the
addition of carbolic acid to the bismuth mixture, while in cases
complicated by colitis full doses of salicylate of bismuth, cyllin, or
guaiacol should be prescribed. The selection of a suitable aperient
is always a matter of importance. As a rule, purgation must be
avoided and reliance placed upon small doses of cascara and
euonyrnin, combined, if necessary, with belladonna and rhubarb.
In other cases a confection of cascara and maltine taken at bed- time
proves efficient, or one composed of guaiacum, senna and ginger
may be employed. When colitis is accompanied by constipation
nothing is so effectual as a small dose of castor oil each morning
before breakfast ; but if severe neurasthenia exists all purgatives
may have to be omitted, and a daily evacuation secured by an enema
of soap and water. Carlsbad salts and other salines are chiefly
indicated when myasthenia with stagnation of food exists, as their
employment in this condition effects a kind of internal lavage and
sweeps the fermenting contents of the stomach into the intestine.
In other respects the medicinal treatment of gastroptosis is
conducted upon the lines laid down for the management of chronic
gastritis and gastric atony.
W. SOLTAU FENWICK.
323
SURGICAL TREATMENT OF GASTROPTOSIS.
MANY cases of gastroptosis exist without symptoms, and therefore
require no special treatment, but when symptoms do occur it will
/- -LIVER
{/tTT/iCHMEHT OF
(GASTRO-HEMTIC
\OMEHTUM TO LIVER
'-LESSER CURVATURE
OF STOMACH
TURNED Uf
UTURES TIED
STOMACH
LI/EK.
FIG. 1. EVE'S OPERATION.
Of four cases, reported by Bier and twenty by Eve, all were
said to have done well.
usually be found that other abdominal organs participate in the
prolapse.
When the stomach is both dilated and prolapsed and shows sign
21 2
324 Surgical Treatment of Gastroptosis.
of stasis and catarrh, but without actual stenosis of the pylorus,
gastric lavage may be of service.
After failure of general treatment the operation of gastropexy
may be called for. It may be carried out effectually either by
FIG. 2. BEYEA'S OPERATION FOB GASTROPTOSIS.
Of eight reported cases, seven were apparently cured and one relieved.
Be} r ea's method of shortening the gastro-hepatic onientum, or by
Bier's or Eve's method of suturing the lesser curvature of the
stomach to the free border of the liver. These methods are shown
in Figs. 1 and 2.
A. W. MAYO ROBSON.
325
HAEMORRHAGE FROM THE STOMACH.
H&SMATEMB8I8 occurs in many diseases of the stomach, of which
the following are the most important : (1) Acute simple ulcer ;
(2) chronic simple ulcer ; (3) cancer ; (4) cirrhosis of the liver.
The milder forms which ensue from acute gastritis, malignant
fevers, peritonitis, purpura, scurvy, haemophilia, diseases of the
spleen, renal inflammations and severe antennas do not require
local treatment.
(1) Acute Gastric Ulcer. In this disease the walls of the ulcer
are not indurated nor are the blood-vessels thickened, so that the
natural cure of haemorrhage by contraction of the ulcerated vessel
and the formation of a protective thrombus almost invariably
occurs, and death is extremely rare. Only about | of the
total quantity of blood effused into the stomach is vomited, the
remainder being evacuated by the bowel. However slight the
haematemesis may appear, the existence of this masked haemor-
rhage must be borne in mind and careful treatment adopted.
Absolute rest in bed is essential, and the patient should lie flat
on his back with the head low, and no attempt should be made
to sit up or to get out of bed even for the purpose of micturition.
The atmosphere of the room should be kept at a temperature of
50 to 60 F., and talking to friends or other forms of excitement
prohibited. Physical examination should also be strictly limited,
and as few questions asked as possible concerning the history of
the previous illness. Pressure of the bed clothes upon the abdomen
should be removed by means of a cradle or other contrivance. The
first indication is to give the stomach complete physiological rest.
This is of the utmost importance, since the secretion of gastric juice
not only excites gastric peristalsis but also dissolves the protective
thrombus. It is usually advised that small quantities of ice be
sucked at intervals, or teaspoonful doses of iced water swallowed
if thirst is excessive. Inasmuch, however, as water is a powerful
excitant of the gastric juice, the fluid should only be used for the pur-
pose of cleansing the mouth and should not be swallowed. Nutrition
is maintained by the careful administration of nutrient enemata.
It was formerly the custom to limit the size of each injection to
2 fluid ounces of milk, to which the yolk of an egg, dextrose or pep-
tones were added when necessary, and to repeat the enema every
326 Haemorrhage from the Stomach.
two hours. These frequent injections are not only a source of extreme
discomfort to the patient and very disturbing, but are really insuffi-
cient to maintain the strength for many days, and there can be
little doubt that when death ensues a week or ten days after a single
haemorrhage, inanition rather than loss of blood is the immediate
cause. At the present day it is customary to administer nutrient
enemata of peptonised milk, commencing with 10 fluid ounces
every six hours, and rapidly increasing the amount until a pint is
retained and absorbed. The necessary apparatus consists of a soft
rubber catheter, about 3 feet of rubber tubing, and either a glass
reservoir capable of containing a pint of fluid, a Thermos flask used
in the inverted position, or a simple funnel. The patient reclines
upon his left side with the buttocks elevated on a pillow; the
catheter, previously warmed and oiled, is inserted into the rectum
for about 6 inches, and the warm (70 to 80 F.) peptonised milk is
allowed to flow slowly into the bowel from the reservoir, which is
placed not higher than 1 foot above the patient's body. The
main object to be kept in view is to ensure that the milk flows
sufficiently slowly into the bowel not to excite peristalsis, and con-
sequently one hour should be occupied in the administration of a
pint of milk, and no attempt made to hurry the operation. If
these precautions are taken, and the rectum is washed out with a
solution of common salt (1 drachm to the pint) night and morning
complete absorption of the milk takes place, and the nutrition may
be maintained efficiently several weeks, if necessary. There are
three conditions under which the enemata are evacuated instead of
being absorbed. In the first, the presence of decomposing blood in
the intestines is apt to excite excessive peristalsis, and in such cases
it is advisable to administer one or two large soap and water enemata
before the rectal alimentation is begun. Secondly, loss of blood in
highly nervous individuals induces active contractions of the rectum
and thus prevents the retention of the milk, so that it may be
necessary to add 10 min. [U.S.P. 6 rnin.] of tincture of opium to
the first two or three injections. Lastly, decomposition of retained
blood sometimes produces much flatus during the course of the
treatment, which proves inimical to the retention of the feed.
This condition may be allayed by the addition of 10 min.
of the glycerine of carbolic acid to each injection. Some
writers advocate more elaborate enemata, such as the following :
(1) Peptonised milk or beef-tea, 10 oz. ; the yolk of one egg;
peptone powder, 2 drachms ; bicarbonate of sodium, 5 gr. ; every
six hours. (2) Peptonised milk, 8 oz. ; the yolks of two eggs ;
a dessertspoonful of whisky or brandy ; every six hours. (3) Ten
Haemorrhage from the Stomach. 327
ounces of Leube's pancreatic milk emulsion or of Roberts' pep-
tonised milk gruel, or of freshly defibrinated ox-blood ; every six
hours. (N.B. Leube's emulsion is prepared as follows : Mix 6 oz. of
scraped and finely-chopped raw beef with 2 oz. of minced pig's
pancreas, and rub them up in a mortar with a little water until the
whole acquires the consistency of gruel. The syringe must have
a wide nozzle. To prepare Roberts' peptonised gruel, mix equal
quantities of well-boiled gruel and fresh milk, and add to the
enema 2 drachms of Benger's liquor pancreaticus and 5 gr.
of bicarbonate of sodium.) In those rare cases where extreme
irritability of the rectum exists, subcutaneous injections may be
given of peptonised milk, olive oil, or beef essence. Nutrient
suppositories are valueless.
The dryness of the mouth which accompanies prolonged rectal
alimentation is apt to give rise to suppurative parotitis from an
ascending infection of Stenson's duct. It is always advisable, there-
fore, to make the patient suck a rubber teat at frequent intervals
during the day, since by this simple procedure the secretion of saliva
is stimulated and the mouth maintained in a moist and clean state.
Antiseptic mouth washes or gargles may also be employed. It is
usually necessary to continue rectal feeding for at least one week
after the haemorrhage has ceased. A gradual increase in the
rapidity of the pulse with a diminution of tension is an invariable
indication of insufficient nourishment.
The haemorrhage from an acute ulcer ceases spontaneously, and
it is rarely necessary to administer any drugs with the view of
controlling the bleeding. Should the patient, however, exhibit
extreme nervousness despite the assurance that recovery will
occur, ^ to ^ gr. of morphine may be injected subcutaneously,
and repeated after a few hours if necessary. No aperients
should be administered by the mouth for a month. A steady
diminution of the pulse rate indicates a cessation of the haemorrhage,
and four weeks are usually required for the cicatrisation of the
ulcer, during which time a liquid diet should be maintained.
(2) Chronic Simple Ulcer. In this variety of the complaint the
process of healing is prevented by the adhesion of the base of the
sore to an organ in its vicinity, the induration of its edges which
prevent contraction, the frequent location of the disease close to
the pyloric or cardiac orifices, which are never at rest, and the
existence of a hyperacid gastric juice which irritates and erodes
healthy granulations. Haemorrhage in these cases is usually pro-
longed, and always exhibits a tendency to recurrence, owing to the
fact that the eroded blood-vessel is firmly embedded in fibrous
328 Haemorrhage from the Stomach.
tissue and incapable of that degree of contraction and retraction
which are necessary to spontaneous closure. The cessation of
bleeding, therefore, depends upon the formation of a clot in the
aperture and its subsequent organisation. The premature adminis-
tration of food or water, by stimulating gastric secretion, almost
invariably leads to the digestion of this protective thrombus, while
excitement or sudden movements of the body accelerate the action
of the heart and cause the .plug, which had formed in the orifice of
the artery, to be blown out like a cork, with consequent renewal of
the haemorrhage. A sudden rise of the pulse-rate is a sure sign
of this untoward accident. The general measures to be adopted are
similar to those employed in haemorrhage from an acute ulcer.
Absolute rest upon the back for a week or ten days is essential, and
no talking, attention to business or other forms of excitement are
to be permitted. The nutrition is maintained entirely by large
nutrient enemata of peptonised milk, and the mouth kept moist by
the frequent sucking of a rubber teat. The bowel is washed out
each night and morning with normal saline solution. As a rule
rectal alimentation is continued for a week or ten days, after which
time tablespoonful doses of iced whey are allowed every half hour
and subsequently changed to peptonised milk. The object of pre-
digesting the milk is to stimulate the gastric secretion as little as
possible. Two nutrient enemata in each twenty-four hours may
be continued with advantage for several weeks.
It is the custom to apply an ice bag to the region of the stomach
for a few days after an attack of haematemesis, and if the bag
is suspended from a cradle in such a manner as to exert only slight
pressure upon the epigastrium, it is probable that the cold applica-
tion does actually diminish the peristaltic movements of the organ
and thus favour the formation of a firm clot. A piece of lint should
be interposed between the bag and the skin to prevent the dripping
of moisture upon the body. Palpation of the abdomen must, of
course, be avoided.
It is a good plan to commence medicinal treatment by the sub-
cutaneous injection of J gr. of morphine, which can be repeated,
if necessary, three hours later. Should the haemorrhage be
severe and the rapidity of the pulse suggest continued leakage,
ergotin is usually administered beneath the skin, in a dosage varying
from 2 to 5 gr., which may be repeated in three hours if considered
advisable. In cases of profuse recurrent haematemesis many autho-
rities speak favourably of turpentine, given in the form of an
emulsion (a dessertspoonful or more beaten up with the white
of one egg) or in capsules. If the haemorrhage persists another
Haemorrhage from the Stomach. 329
30 min. may be given after the lapse of two hours. Adrenalin
chloride (1 in 1,000) is sometimes of value, when given in doses of
30 min. three or four times a day, but the presence of loose clot
over the ulcer, from beneath which the blood oozes, often prevents
the drug from coming into contact with the bleeding vessel. Thirty
minims of the solution of perchloride of iron [U.S. P. 8 min.
solution of ferric chloride] combined with one drachm of glycerine,
and given every hour, has been recommended, but it is apt to
excite vomiting. In obstinate cases a trial should always be made
of the gallic acid and opium pill (acid gallic or tannic, 2J gr., ext.
opii. gr.), two of which are given every three hours.
In cases of exceptional severity, several adjuncts to the medicinal
treatment may be tried. It is a good plan to apply ligatures round
the upper parts of the arms and thighs sufficiently tight to prevent
the iiow of blood through the veins but not to interfere with the
arterial circulation. In this manner a considerable amount of
blood becomes stagnant in the extremities, and the slight diminu-
tion of pressure in the gastric vessels which ensues from it favours
coagulation at the bleeding point. High rectal injections of water
at a temperature of 112 to 120 F. are also stated to be of value.
In a few desperate cases lavage with ice-cold water has been followed
by a cessation of the bleeding. The question of surgical interference
should always be considered.
Failure of the heart from excessive loss of blood must be combated
by the administration of ammonia, ether, strychnine, or camphor.
Injections of warm saline fluid, whether subcutaneous or intra-
venous, must be given with caution, as a sudden rise of blood pressure
often excites further haemorrhage, but the continuous rectal injection
is free from this disadvantage and should always be employed in
severe cases. It is probable that the modernised plan of direct
blood-transfusion will some day prove of the greatest advantage.
(3) Cancer. It is only in rare instances that sloughing of the
growth gives rise to an excessive and dangerous haemorrhage, and
in such the measures indicated in hsematemesis from chronic ulcer
must be adopted. The repeated vomiting of small quantities of
altered blood, which is so characteristic of an ulcerated carcinoma
or an oozing medullary growth, require that the patient be kept in
bed and fed exclusively on peptonised milk. Lavage should never
be performed, as the tube often injures the soft vascular growth.
A gallic acid and opium pill given three times a day, or the capsules
of turpentine, usually prevent excessive loss of blood.
(4) Hepatic Cirrhosis. In this disease the gastric haemorrhage
usually proceeds from the rupture of a varicose vein at the cardiac
330 Haemorrhage from the Stomach.
orifice ; it is, therefore, often difficult to stop and very apt to recur.
As a rule, 2 gr. of calomel, followed after a few hours by a full dose
of salts, is the most effectual treatment, by the relief it affords to
the portal engorgement, and may be repeated each day for a week,
if necessary. Otherwise the measures previously related should be
adopted in this and other forms of venous haemorrhage from the
stomach.
W. SOLTAU FENWICK.
SURGICAL TREATMENT OF H^EMATEMESIS.
THE complication of haemorrhage occurs in a greater or less
degree in from 50 to 80 per cent, of all cases of gastric ulcer, and
according to various authors is fatal in from 3 to 11 per cent.
From the point of view of treatment it seems convenient to
classify the cases under two divisions :
(1) The acute, always alarming, and sometimes, though rarely,
fatal attacks that occur without any warning and without any pre-
monitory symptoms pointing to ulcer ; attacks that, when occurring
in young anaemic women, usually cease spontaneously or under
treatment and do not tend to recur.
(2) The attacks associated with or preceded by definite symptoms
of ulcer, which may be (a) Acute, ending rapidly in death ; (b) acute,
temporarily subsiding and recurring in a few hours or a few days,
or after longer periods ; and (c) the chronic haemorrhages, often
slight in amount but frequently recurring and leading to serious
anaemia.
From the fact that medical and general treatment is successful in
arresting acute haematemesis in from 93 to 97 per cent, of all cases,
and that it is difficult in the present state of our knowledge to say
at first that the bleeding is not occurring from capillaries or small
arterioles, it necessarily follows that medical treatment should
always have a fair trial in every case of acute haematemesis. The
very fact of medical treatment being so often successful in cases of
apparently alarming haematemesis goes to show that capillary
oozing or bleeding from arterioles, as in the first division, accounts
for many cases of gastric haemorrhage. But while thoroughly
believing this, we must also not close our eyes to the experience
we have in general surgery of bleeding from medium-sized arteries,
such as the radial or ulnar, which we know would rapidly bleed a
patient to death if only perforated on one side and surrounded by
warm compresses, a condition that practically applies in all cases
of haematemesis where the larger vessels are eroded. If, therefore,
medical treatment and rest properly carried out are not successful
in arresting the bleeding, or if after being arrested it recurs, we
should be suspicious that a large vessel is perforated, and if a
surgeon has not been previously asked to see the case, I would say
emphatically tbat a surgical consultation ought to be held with a
33 2 Surgical Treatment of Haematemesis.
view to considering the question of operation and arrest of bleeding
by direct treatment, if the patient is in a fit condition to bear it.
Where there have been distinct signs of gastric ulcer, preceding
the haemorrhage, and where a sudden haematemisis has occurred with
great loss of blood, accompanied by an attack of syncope, a large
vessel will usually be found to be the source of the bleeding. In such
haemorrhages not speedily yielding to medical and general means,
or recurring, surgical treatment will probably be advisable, though
there can be no absolute rule formulated that will apply to every
case, and each must be considered on its merits. The present
condition of the patient, the previous history, the surroundings, the
possibility of skilled surgery and of good nursing, and other circum-
stances, will all help in the decision.
Although both surgical and medical treatment in cases of
fulminating haemorrhage have so far yielded disappointing results,
in the acute cases not immediately fatal, where repeated bleedings
occur and the interval between the first seizure and death varies from
a few days to two or three weeks, medical treatment will have been
fully tried and failed, and there can be no question as to the advis-
ability of surgical procedures being adopted.
At present, with the exception of Dieulafoy, who advocates opera-
tion during the first bleeding if as much as ^ litre of blood is lost,
all other surgeons who have written on the subject agree that
general means ought to be relied on during and after a first attack,
as in from 93 to 97 per cent, of cases such treatment succeeds, and
until our means of diagnosis as to the size of vessels injured is
rendered more reliable we must advise assent to this rule ; but after
a second bleeding I have no hesitation in advising surgical treat-
ment as soon as the condition of the patient will permit operation
to be done, for experience tells us that further haemorrhages are
almost certain to occur unless preventive measures be adopted.
The surgical treatment of haematemesis may be direct or
indirect.
By the direct method is meant : (a) Excision of the ulcer or of
the ulcer-bearing area ; (b) arrest of haemorrhage by ligature of the
bleeding vessels, by cauterisation of the ulcer, or by ligature of the
mucous membrane en masse. By the indirect method gastro-
enterostomy is meant.
Any operation for haematemesis must as a rule be at first
exploratory, and when the condition of the stomach is made out the
question of direct or indirect treatment can be decided on.
In all the early cases of operation for haemorrhage from the
stomach the direct method was adopted, as it had not then been realised
Surgical Treatment of Haematemesis. 333
that by securing physiological and physical rest to the stomach hy a
well-executed gastro-enterostomy not only could bleeding as a rule
be arrested, but the condition of ulceration giving rise to it could be
cured.
An extensive experience, and the consideration of a large number
of cases operated on by others whose work I have had the oppor-
tunity of seeing and studying, has convinced me that the operation
of gastro-enterostomy is usually an efficient means of treating
haemorrhage from the stomach, and it is only under exceptional
circumstances that I should now think it worth while to open the
stomach and treat the ulcer directly ; but even should'! deem direct
treatment of the bleeding-point necessary, I should also think it
equally desirable to perform a gastro-jejunostomy in order to secure
rest to the stomach and to the ulcer, so as at the same time to stop
the bleeding and cure the condition giving rise to it.
Gastro-jejunostomy possesses the advantages that it is applicable
to both acute and chronic haemorrhage, that it avoids the necessity
of a prolonged search through a gastrotomy opening, that it is
quickly performed, and not least, that it involves little shock and
has a very small mortality.
To put the matter succinctly I would say :
(1) In a case of acute haematemesis from ulcer or erosion, when
the onset of bleeding is sudden and the previous history of ulcer is
absent, medical and general means should be carried out thoroughly
and persistently until the ulcer has healed.
(2) In case of recurrence of bleeding, or if the bleeding persists
despite treatment, surgical measures are called for.
(3) In case of bleeding from a chronic ulcer, whether the bleeding
be slight or severe, surgical treatment is demanded, not only for
the arrest of haemorrhage, but also for the curative treatment of the
ulcer itself.
(4) As the risk of operation during the quiescent period is less than
if undertaken while the bleeding is continuing, it is desirable, if
possible, to secure arrest of the haemorrhage even in chronic ulcer
before undertaking operation ; but if the haemorrhage is persisting,
the surgeon is not justified in waiting until the patient is reduced
to such a condition that it is too late to operate.
A. W. MAYO-ROBSON.
334
HOUR-GLASS STOMACH.
HOUR-GLASS STOMACH owes its origin to definite organic disease
chronic gastric ulcer, cancer, or perigastritis, but the greater number
of cases are caused by the cicatricial contraction due to ulcer.
Doubtless very rarely the condition may be congenital, just as
congenital narrowing may be found at the pylorus, in the intestine,
or in the rectum. As yet, however, I have not met with a single
instance in which I could say that the case was one of congenital
hour-glass contraction.
For chronic gastric ulcer to be allowed to pursue its course until
this extreme deformity, hour-glass stomach, occurs can only be
described as a disgrace to modern medicine, for the disease
giving rise to the conditions has definite signs and symptoms,
and is one attended by considerable suffering. In nearly all my
cases the patients had been ill for years, some of them for ten,
twelve, or sixteen years, whereas by a timely operation they might
have been cured before the development of the deformity.
Surgical treatment is alone of service in this disease, and the
conditions to be aimed at are to overcome the obstruction and to
secure physiological rest for the healing of the ulcer, which is by
far the most frequent cause of this deformity.
The operations available are : (1) Gastroplasty, (2) gastro-
enterostomy, (3) gastrolysis, (4) gastro-gastrostomy, (5) excision of
the ulcerated area or partial gastrectorny, (6) divulsion of the
stricture, and (7) jejunostomy.
As the disease is usually associated with active ulceration in
the centre of the stomach, no operation will be likely to be
permanently effective that does not provide for efficient drainage of
both pouches, in order to secure healing of the ulcers ; hence a
double operation is often necessary, and a gastro-enterostomy into
one or both pouches is generally advisable.
Of seven cases in which I performed posterior gastro-enterostomy
for hour-glass contraction, all recovered, and five are well at the
present time, three to six years later ; one died of cancer of the
sigmoid flexure of the colon four years and one of cancer of the
stomach a year after operation.
Of ten cases in which I performed simple gastroplasty all the
patients recovered, and six are known to be in good health at the
Hour-Glass Stomach.
335
present time, from three to six years later ; one was well a year after,
but cannot be traced ; one required gastro-enterostomy two years
later for ulcer of the pylorus ; one was well for four years, had
recurrence of ulceration and died of haematemesis ; and one writes
FIG. 1. Partial gastrectomy for hour-glass stomach.
to say that after five years she has had some gastric pain but has
not needed medical attendance.
Since gastroplasty has been followed by 25 per cent, and
gastro-gastrostomy by 30 per cent, of relapses, while gastro-
enterostomy alone has given much better results, and the com-
FIG. 2. Partial gastrectomy for hour-glass stomach.
binatiou of either of the two former operations along with gastro-
enterostomy has been uniformly successful, it seems quite clear that,
whatever procedure is adopted for making a communication between
the two stomach cavities, a gastro-enterostomy ought to form part
of the operation, in order that the ulceration giving rise to the
disease may be cured.
336 Perigastritis.
The operation of partial gastrectomy for hour-glass stomach is
virtually the same as that described under partial gastrectomy for
cancer of the stomach, except that the clamps are applied well
beyond the growth at the centre of the stomach. Both ends are
closed in the same way after excision of the growth and a posterior
gastro-enterostomy is performed ; or if preferred, the proximal and
distal parts of the stomach may be united by a double row of
sutures, the first embracing the whole of the coats and the second
simply the serous coats.
A. W. MAYO-ROBSON.
PERIGASTRITIS.
PERIGASTRITIS leading to disabling adhesions is so commonly
associated with ulcer that I must mention it among the principal
complications.
When the adhesions tie up the pylorus so as to produce a kink,
the normal peristalsis of the stomach may be interfered with, leading
to dilatation -and stasis so extreme that stenosis of the pylorus may
be suspected. If slight, the adhesions may be separated and the
right free border of the omentum may be interposed between the
pylorus and its abnormal attachments so as to prevent close
adhesions re-forming ; but if the adhesions are extensive, a gastro-
enterostomy will be found to be the more satisfactory operation
and to give excellent results. If adhesions form on the anterior
wall of the stomach, fixing it to the abdominal parietes, normal
peristalsis will be interfered with and the patient's sufferings after
meals or on exertion may be considerable; the condition may give
rise to irregular dilatation or to hour-glass deformity and to stasis
of the stomach contents.
The adhesions must be detached, but are apt to re-form if at all
extensive, unless the raw surfaces can be covered by sliding the
omentum or grafting the peritoneum over them.
Simple gastrolysis, or detaching adhesions, is practically un-
attended by risk, and in many cases I have seen excellent results
by this simple operation, but in several cases relief has been
followed by relapse, necessitating a short-circuiting operation.
Posterior gastro-enterostomy should, under such circumstances, be
performed where feasible, but in case of adhesions being very
extensive, and involving the posterior wall of the stomach, an
anterior Roux's operation will probably be found to be the best
procedure to adopt.
A. W. MAYO-ROBSON.
337
HYPERTROPHIC STENOSIS OF THE PYLORUS.
HYPERTROPHY or hyperplasia of the pylorus, mainly of the
circular muscle fibres, can exist without symptoms. Gradual con-
traction of the muscle produces pyloric obstruction and secondary
dilatation of the stomach. In deciding on the best mode of
treatment, pyloric spasm must be differentiated from pyloric
hypertrophy. The two conditions may co-exist, the spasm bein^r
grafted on the hypertrophy and increasing the obstruction due to
the gradual contraction of the circular muscle fibres or even pro-
ducing acute symptoms, or either may occur independently.
Another view is that the hypertrophy is secondary to spasm and
that all cases can be cured by treatment directed to the relief of
spasm. Anti-spasmodic drugs are, however, useless. Almost all
infants with conclusive evidence of pyloric hypertrophy have
succumbed when treated by medical remedies only. A mild degree
of hyperplasia may produce no definite symptoms unless a further
factor, generally spasm or gastric catarrh, completes the obstruc-
tion. Not only is accurate diagnosis essential, but it is also
necessary to estimate the relative degree of hyperplasia and of the
secondary causes of obstruction.
Patients suffering from these conditions are almost invari-
ably infants under three months of age. The symptoms usually
begin in the third week of life, sometimes earlier. Cases of marked
hypertrophy in childhood, and at all ages, support the view that
the hypertrophic stenosis of later life is due to the persistence
of a mild degree of the infantile condition and that operative
treatment of the affection in infants is not always essential.
Pyloric Spasm gives rise to repeated and severe vomiting.
The meals are usually returned at once, but sometimes more than
one is kept down for a time. The spasm may begin shortly after
birth or not for some weeks or months, or may occur at any age.
In infants it is generally started by erroneous feeding, and possibly
depends on a local erosion or hyperaesthesia of the pyloric mucosa.
There is no reliable evidence that it is due to hyperacidity. It
induces constipation and emaciation. Slight dilatation of the
stomach and a little gastric peristalsis may be present. In fatal
cases no pyloric obstruction or hypertrophy is found after death.
A simple diet of breast milk, ass's milk, whey, albumin water, or
S.T. VOL. II. 22
338 Hypertrophic Stenosis of the Pylorus.
Allenbury No. 1 food, in small quantities every two hours, is suffi-
cient to cure most patients. In addition cocaine (y^ gr.) in water
(1 drachm) should be given hourly. Other remedies are tr. opii (| to
min.) every hour or two ; and drachm doses, every 2 to 4 hours, of
bismuth carb. 1 drachm, pulv. acacise 1 drachm, glycerine
2 drachms, aquam ad 2 oz. Such doses are suitable at six months
of age. A boy, seven months old, recovered after being fed on raw
meat juice every fifteen minutes for two days, in addition to the
cocaine.
Should there be no improvement the next step is lavage of the
stomach once or twice daily with a weak alkaline solution (sod.
bicarb. 1 drachm, water, I pint).
Infantile Hypertrophic Stenosis gives rise to the symptoms of
pyloric obstruction and definite signs of hypertrophy, viz., marked
peristalsis of the stomach, gastric dilatation, and a pyloric tumour
the size of a filbert or the last joint of the little finger. Vomiting
is characteristic. After two or three feeds have been taken the
whole lot is ejected violently without any of the usual signs of
nausea. The child may take food greedily immediately afterwards.
In mild cases nothing may be found save an indefinite tumour in
the pyloric region, and vomiting may be trivial or absent. The
child, however, progressively wastes. In marked cases the stools
are devoid of faecal material, like meconium in consistence, and
like darkish red-brown or green paint. They are composed of
cholesterin, mucus and epithelial debris. An absolutely positive
diagnosis is impossible in the early stages before obstruction
has existed long enough to cause marked peristalsis and gastric-
dilatation.
At first, and in all doubtful cases, the condition should be treated
as one of simple pyloric spasm. The stomach must be washed out
once or twice a day, and the amount of food retained and the
amount of faecal matter in the stools noted. Lavage washes away
irritating products of the decomposition of food long retained in
the stomach. It may prove curative in those cases of mild hyper-
plasia in which the obstruction is due to secondary spasm or gastric
catarrh. It has the further advantage of reducing over-distension
of the stomach, provided that it is done twice daily and only small
feeds are given in the intervening periods. In this way it may
prevent vomiting. By reducing the dilatation the muscular power
of the stomach is increased and may then prove sufficient to drive
.a suitable food through the pylorus, if it is not excessively con-
stricted. Probably a dilated stomach increases the obstruction by
dragging on the pylorus and causing a certain amount of kinking.
Hypertrophic Stenosis of the Pylorus. 339
Lavage undoubtedly assists in the cure of gastric catarrh and of
acid dyspepsia, either of which may be present. It is difficult to
believe that it can have the least effect on the hypertrophied
pylorus. By preventing vomiting it may lead to an unduly favour-
able view of the progress of the case.
Drug treatment is similar to that recommended for pyloric
spasm. Treatment by diet, drugs and lavage, may be continued
for days or weeks if the child does not lose ground and there is
faBcal matter in the stools. It is foolish to persevere with it until
the child is so emaciated that the chance of recovery from the
shock of operation is infinitesimal ; although it has been asserted
that after a stage of progressive emaciation the almost moribund
child suddenly turns the corner, because, forsooth, the spasm then
relaxes. My experience is totally opposed to such a termination.
With one doubtful exception, cases treated on these lines have
proved fatal. Even when the food passed through the pylorus in
moderate quantities and vomiting was slight or absent, the infants
became marasmic and died.
It is not uncommon for parents to decline operative treatment in
the early stages, when good results can be obtained, and to demand
it in late stages when the outlook is almost hopeless. Under
medical treatment a child may progress favourably for days or
weeks, perhaps longer, and then comes a time when the vomiting
gets severe and emaciation is rapid. Kecovery after an operation
done as a forlorn hope is extremely rare ; indeed, the prognosis of
operative treatment, omitting the risks incidental to the operation,
depends on the degree of marasmus. The greater the emaciation
and gastric dilatation, the smaller is the chance of recovery. Even
if recovery is possible under medical treatment, it is certain that,
except in mild hyperplasia, the prolonged illness far exceeds in risk
the dangers of operation before marasmus has developed.
Surgical Measures. The choice lies between pyloroplasty,
Loreta's stretching operation and posterior gastro-enterostomy. A
skilled anesthetist is necessary. The operation must be done quickly
and every measure taken to minimise shock. Pyloroplasty is in my
opinion the most scientific method, for afterwards the contrac-
tion of the pyloric muscle will enlarge rather than constrict the
lumen, and there is no fear of recurrence. Out of twelve cases treated
by this method nine recovered, two dying subsequently from enteritis.
Loreta's stretching operation is analogous to the forcible rupture
of a urethral stricture, a surgical proceeding now discountenanced.
It involves gastrotomy and rupture of some or all of the circular
muscular fibres. The peritoneal coat is liable to be ruptured as
22-2
34 Hypertrophic Stenosis of the Pylorus.
well, and must be sewn up or fatal peritonitis may ensue. It takes
just as long as pyloroplasty, but has proved perfectly successful in
many cases. Occasionally it has been followed by relapse, through
subsequent contracture of imperfectly ruptured muscle fibres, and
a further operation has been needed.
Some surgeons prefer posterior gastro-enterostomy on the
grounds tbat it is a simpler, easier and more rapid operation, and
satisfactory as regards the nutrition of the patient. Many success-
ful cases are on record. Its effect on the state of the pylorus is
interesting as an argument against the hypothesis that the hyper-
trophy is due to spasm. Morse reported a case treated by this
method. The child died at eight months of age, more than six
months after operation, and the pylorus was found to be in the
same state as at the time of operation.
After-treatment. Except for the wound the treatment after
operation should be entrusted to the physician, not to the surgeon, for
it is the treatment of the gastric condition and the marasmus.
Immediately after operation, a rectal feed of peptonised milk and
water (aa 1 oz.), and brandy (10 to 20 min.) should be given. This
must be repeated every four hours for two days, every six hours for
two days, and every twelve hours for two days, a rectal wash being
given once daily. Recurrence of the vomiting may necessitate a
temporary return to rectal feeding. In one case even better results
were obtained by means of regular saline injections instead of
peptonised milk. The brandy can generally be omitted in twenty-
four hours. For the first twelve hours a teaspoonful of plain hot
water by mouth every fifteen minutes should be given if the child is
awake. After that whey in similar quantities should be substituted.
Then in two days whey, 2 drachms every fifteen minutes ; next day
\ oz. every half hour ; on the fourth day, 1 oz. hourly and then
2 oz. every two hours. Next the quality of the food should be
improved by the addition of cream (\ to 1 drachm) to each feed.
Such a diet, increased in quantity if necessary, can be continued
for some weeks, or it may be replaced slowly by peptonised milk
and water, and then by ordinary milk and water. The main in-
dication for increasing the whey by mouth in the early stages is the
passage of food through the pylorus, faecal matter being usually
found in the stools on the third day. Vomiting often persists for
two to six days, and altered blood may be brought up a few hours
after operation. It is of the utmost importance not to overfeed
these infants in the early stages of convalescence. They are very
liable to enteritis, for the intestinal mucosa appears to undergo
nutritional changes, from disuse in marasmic infants, and the
Hypertrophic Stenosis of the Pylorus. 341
operation allows food to pass rapidly from the stomach into the
intestines. Evil results are most liable to occur in those infants in
whom operation has been long delayed.
In older children and adults treatment is carried out on similar
lines. If daily lavage is insufficient to maintain health and reduce
the gastric dilatation, operative treatment will be required.
EDMUND CAUTLEY.
SURGICAL TREATMENT OF HYPERTROPHIC
PYLORIC STENOSIS.
FROM being one of the curiosities of medicine, having little more
than pathological interest, congenital hypertrophic pyloric stenosis
has become a recognised clinical entity. From the number of cases
recorded, it is evidently far from uncommon, and it is extremely
probable that many of the children dying from " marasmus,"
vomiting, or intestinal obstruction have really been its victims.
According to Mormiee, 80 per cent, of cases die unless treated
surgically.
In the earlier stages of the disease, before the vomiting has become
incessant, much good may be done by careful washing of the
stomach and feeding in small quantities through an indiarubber
catheter.
In feeding it is better to pass an indiarubber catheter and gently
to wash out the stomach with a little sterile salt solution before
introducing the food. The best food is diluted and sweetened cow's
milk. It should be given in small quantities of 2 drachms or slightly
more, and be gradually increased as experience may sanction. The
catheter may be passed through the nose, and the sucking action,
which is the starting of the peristaltic wave, thereby avoided. If all
goes well for eight or ten days, an attempt may be made to feed the
child by the mouth, either by a teat or with the spoon. If the
food is quietly retained, the nasal feeding may be gradually aban-
doned.
Despite the fact that recovery from this condition under medical
treatment, on the plan just described, is possible, there will doubt-
less remain .a proportion of cases that can only be dealt with
satisfactorily by surgical measures.
The operations which have been performed are Loreta's operation
(dilatation of the pylorus), pyloroplasty, gastro-enterostomy, and
pylorectomy. The last is obviously unsuited to the tender age and
the prostrate condition of the infant, and, as equally effective
methods of overcoming the mechanical obstruction exist, it is not
worthy of further thought.
Loreta's operation consists in opening the stomach by a small
incision near the pylorus, and through this incision introducing a
small pair of forceps through the stenosed pyloric orifice. The
Hypertrophic Pyloric Stenosis. 343
blades of the forceps are then gently separated and the tissues
around them stretched as widely as is possible without rupturing
the serous coat.
Mr. Burghard prefers this operation on account of its ease, the
rapidity with which it can be performed and the absence of shock.
He employs Hegar's dilators. In one case a rupture of the peri-
toneal coat was produced. The disadvantage of the operation would
appear to be the likelihood of a recurrence of symptoms after the
paralysis of the pyloric sphincter has passed away. Experience has
shown that when the sphincter ani, for example, is stretched, to
its utmost limit, a fair degree of control is established by the third
or fourth day. But it must be admitted that in all the patients who
have recovered from the pyloric operation the after-results seem to
have been most satisfactory.
Pyloroplasty has been practised, and especially advocated, by
Mr. Clinton Dent. He believes that pyloroplasty is preferable to
dilatation, for the following reasons :
(1) It can be done at least as quickly.
(2) It is a more definite proceeding and allows more range, as
the length of incision can be graduated according to the condition
found.
(3) The lumen of the tube can be examined, and, if thought
desirable, the longitudinal fold of mucous membrane can be
removed.
(4) The exact amount of injury done to the "parts is known.
Gastro-enterostomy , which was first performed in congenital pyloric
stenosis by W. Abel, consists of an anastomosis between the stomach
and the jejunum which may be made upon the anterior or the
posterior surface, though posterior gastro-enterostomy is the
operation most frequently selected. Its disadvantages are said to
be the greater length of time required for its performance and the
greater exposure of viscera. Neither of these objections, however,
is sound. A considerable experience of the operation entitles one
to say that no more than half an hour need be expended in the
operation, whilst in desperate cases twenty minutes will be
adequate. During the operation there need be no exposure of the
viscera except those parts of the stomach and jejunum which are
to be united. The soiling of the peritoneum is certainly less in
gastro-enterostomy than in either pyloroplasty or in Loreta's
operation, and there is no blood lost from cut vessels of the
stomach. It is, however, necessary in the early stages of the
operation of gastro-enterostomy to handle the stomach and to
prepare it for the application of the clamp, if clamps are employed,
344 Hypertrophic Pyloric Stenosis.
whereas in pyloroplasty the stomach need hardly be touched and
the intestines are not seen.
Congenital Atresia of the Pylorus, in which there is no com-
munication between the stomach and duodenum, is extremely rare,
and has hitherto pursued a rapidly fatal course in all recorded
cases. If diagnosed early, it should prove amenable to treatment
in the shape of gastro-enterostomy.
A. W. MAYO-ROBSON.
345
INFLAMMATIONS OF THE STOMACH.
ACUTE GASTRITIS.
General Treatment. The prevention of acute gastritis in
persons who are predisposed to the disorder is a matter of
much importance. In the case of young children an attack
is usually precipitated by exposure to cold or fog or by the
ingestion of substances which are either in a state of incipient
putrefaction, or are unsuitable to the peculiar digestive powers of
the individual. However pure the milk may appear to be it is
always advisable to sterilise it, and drinking water should always
be boiled ; while if the latter contains an excess of lime salts,
Salutaris, Malvern water or that obtained from some natural spring
should be substituted for the local supply. One of the reasons
why so many persons suffer from acute gastritis or " biliousness "
when they reside at certain seaside places is that the drinking
water is exceptionally hard or chalky. The epidemic forms of acute
gastro-enteritis are almost invariably due to the presence of patho-
genic organisms in the milk or water. Excessive indulgence in
food and overloading the stomach with sweets, fruit and cakes are
apt to lead to gastrectasis in persons who have already suffered
from attacks of inflammation of the stomach and thus to pre-
dispose to frequent recurrences of the complaint. In such cases it
is advisable that the meals should be taken at regular intervals
and be composed of substances that are least liable to undergo
fermentation in the stomach. Care must always be taken to
protect the surface of the body from rapid changes of temperature,
and with this object woollen underclothing and warm stockings
should be worn all the year round, with a flannel or chamois
leather belt next the skin. Cold baths should be prohibited even
in summer. The fact that unusual excitability and buoyancy of
spirits often precede an attack of gastritis in a child, constitutes an
indication for preventive treatment in the form of a dose of calomel
and a saline purge ; while in those cases where excitement or
fatigue provoke the disorder the amount of outdoor exercise must
be restricted, and parties or other forms of entertainment be
prohibited for a few years.
Diet. An inflamed organ requires physiological rest, and an
inflamed stomach is the best illustration of this elementary law.
346 Acute Gastritis.
Starvation is essential to the rapid cure of acute gastritis, and no
food should be administered by the mouth for twenty-four hours
or even longer. In the case of an adult this abstinence produces
no ill-effects, but in young or debilitated children deprivation of
nourishment is apt to increase the exhaustion produced by retching
and vomiting, and it may, therefore, sometimes be necessary to
administer nutrient enemata composed of peptonised milk with a
few drops of brandy. When thirst is excessive small pieces of ice
may be sucked at intervals or the patient may be encouraged to
drink large quantities of hot water with the view of inducing
vomiting, and thus of cleansing the stomach from its mucous
contents. It is usually held that cessation of sickness and return
of appetite are indications for the administration of food, but it
must be borne in mind that profound exhaustion is itself productive
of anorexia as well as of nausea, and that the latter symptom will
often disappear if the patient is encouraged to take food. As a
rule, feeding may safely be commenced within forty-eight hours of
the commencement of an attack, but should emesis occur recourse
must be had to rectal alimentation. In such cases from 8 to 15 oz.
of peptonised milk are slowly introduced into the bowel every six
hours by means of a rubber catheter and funnel, about forty-five
minutes being required for the due performance of the operation.
A rectal douche of normal saline solution night and morning
prevents irritation of the lower bowel and promotes retention and
absorption of the milk (see p. 326). As soon as the stomach is able
to retain food, iced milk, diluted with an equal quantity of lime-
water, may be allowed in tablespoonful doses every hour for six
hours, after which time, if vomiting has not recurred, the dose
may be increased to 6 oz. or more, and the proportion of lime-
water gradually diminished. In severe cases egg-albumin water,
followed by iced whey, should be substituted for milk. As soon as
the nourishment is retained with comfort, the diet may be increased
by the addition of clear soups, bovril, beef-tea, Benger's food,
toast and milk, lightly boiled or poached eggs ; and subsequently
by fish, chicken, sweetbreads, scraped raw meat, lean ham, etc.
Cooked meats and green vegetables should be prohibited for at
least a week, and the meals should be moderate in amount and be
taken at regular intervals.
Medicinal Treatment. Acute simple gastritis undergoes
spontaneous cure by the operation of two great natural factors,
namely, the evacuation of the irritant contents of the stomach by
vomiting and the period of physiological rest that is imposed upon
the organ by the suppression of appetite. The medicinal treatment
Acute Gastritis. 347
of the disease should therefore be conducted upon these lines. In
every case the first consideration should be the probable amount
of noxious material still retained in the stomach, as shown by
the vomit. Should emesis not yet have commenced, or if the
ejecta contain food, the obvious indication is to assist the stomach
fco rid itself of its irritant contents. With this object 20 gr.
of powdered ipecacuanha should be administered at once and
followed in a few minutes by a tumblerful of hot water, while in the
case of a child 10 to 15 min. [U.S.P. 13 to 20 min. fluid
extract] of the liquid extract or a dessertspoonful or more of
the wine may be employed. A dose of emetine or a hypodermic
injection of apomorphine finds favour with many practitioners,
but they prove unduly depressant to some individuals. Substances
like mustard, tartar emetic, sulphate of zinc and sulphate of copper,
which cause vomiting by direct irritation of the gastric mucosa,
should be avoided, as they tend to increase the existing inflamma-
tion. Even after all decomposing food has been evacuated, the
inner surface of the organ may still be irritated by the presence of
fermenting mucus, the expulsion of which is always a matter of
difficulty owing to its thick, tenacious character. Continental
writers consequently advise lavage of the stomach with warm water
containing a small proportion of bicarbonate of sodium whenever
emesis recurs at short intervals and the ejecta consist of mucus.
Washing out the viscus in this manner is an excellent remedy, and
will usually subdue the nausea and retching more quickly than
any other form of treatment ; but unfortunately many people
strenuously object to the passage of a tube, and will only submit
to its use when milder measures have failed. The stomach may
also be cleansed by the propulsion of its contents into the intes-
tine, and since the time of Hippocrates brisk purgation has always
been regarded as indispensable in acute gastritis. In infants and
young children a dose of castor oil or the administration of the
castor oil mixture every three hours will usually promote a rapid
cure in mild cases ; but if vomiting is a troublesome feature,
?} gr. of calomel given every two hours until free purgation has
been produced, will be found more efficacious. At a later period of
life the same treatment is equally successful, although preference
should be given to salines rather than to castor oil. As soon as
the stomach is free from food, from 2 to 4 gr. of calomel or a
mercurial pill may be administered, followed after three hours by
a dose of Carlsbad salts, sulphate of sodium or magnesium, or
phosphate of sodium. If emesis is excessive gr. of calomel
should be placed upon the tongue every half hour and the saline
348 Chronic Gastritis.
draught deferred for six hours. It rarely happens that vomiting
continues after the bowels have been thoroughly evacuated ; but
should nausea or retching still persist, a mixture containing
solution of bismuth, bicarbonate of sodium and dilute hydrocyanic
acid, with or without morphine, administered in an effervescent form,
will usually cause these symptoms to subside. A hypodermic
injection of morphine is seldom required. In the after-treatment
of the case it may be necessary to repeat the mercurial and salines
at intervals or to prescribe a mixture of bicarbonate of sodium
and rhubarb to be taken between meals. Tonics invariably disagree
with the subjects of gastritis, and the employment of these drugs
either causes a recrudescence of the former symptoms or induces a
subacute form of the disease. Alkaline remedies, on the other
hand, always agree, and if the case shows a tendency to relapse
they may be continued with advantage for several weeks.
ACUTE TOXIC GASTRITIS.
This variety of gastric inflammation is usually due to the indi-
gestion of metallic salts, corrosive acids or alkalies, so that actual
destruction of the tissues of the stomach frequently exists.
Vomiting rarely removes all the poison from the organ, and
consequently, whenever it is possible, steps should immediately
be taken to wash out the viscus. No tube should ever be passed
when there is reason to suppose that mineral acids, caustic alkalies,
or carbolic acid have been swallowed, or when excessive pain or
haemorrhage indicate that considerable damage has been inflicted
upon the oesophagus or stomach. As soon as the stage of collapse
has passed away, the case should be treated in the same manner
as a severe example of simple gastritis. As regards the consequences
of the disease, oesophageal stricture will require the use of a
Symonds' tube or the performance of gastrostomy and stenosis of
the pylorus, systematic lavage ; while general atrophy of the
stomach must be treated in the manner already described (p. 293).
CHRONIC GASTRITIS.
General Treatment. The various conditions which tend
to excite or to perpetuate inflammation of the stomach must
be carefully avoided, and such adverse influences as exposure
to extremes of temperature, insufficient mastication of food, abuse
of alcohol or tobacco, or constant indulgence in rich and indigestible
articles of food must be guarded against. Special attention must
also be paid to those organs of the body whose functional derange-
ment is apt to excite gastritis, and the treatment appropriate to
Chronic Gastritis. 349
diseases of the lungs, heart, liver, kidneys or of the blood should
be adopted as occasion requires. In all cases the patient should
endeavour to lead a rational existence and indulge in some regular
form of exercise which does not require over-exertion or pro-
duce undue fatigue. Walking, golf and horse-riding are usually
beneficial, and in many instances a cold or tepid sponge bath on
rising, followed by a calisthenic exercise for ten minutes, is a useful
adjunct to other methods of treatment. Lavage is indicated in all
chronic cases where there is either an excessive secretion of mucus
or stagnation of food. In the former case it is most advantageously
performed in the early morning. The secretion is extremely
tenacious and difficult to evacuate, and it is often necessary to
make the patient at first sit upright, then lie on his back, and
finally recline on his left side so as to ensure a complete washing
of the organ. Gentle massage of the stomach during lavage often
aids the expulsion of mucus ; while the addition of bicarbonate of
sodium to the water, in the proportion of one teaspoonful to the
quart, renders the slime more easy of removal. When lavage is
performed on account of the fermentation of stagnant food it may
be performed either before breakfast or three hours after a light
evening meal. The residual food is first evacuated and the organ
is subsequently washed out, one or other of the antiseptic solutions
being employed, if necessary, for the purpose (p. 813). If vomiting
is a feature of the case, lavage should be performed both morning and
evening for the first ten days. After the expiration of three weeks
or a month every alternate day is usually sufficient, and if the
patient continues to make satisfactory improvement, it is afterwards
gradually discontinued. In the majority of cases the good effects
of the washing out become apparent about the third day of the
treatment, when the appetite begins to return, and the nausea,
distension and other symptoms subside. When lavage is discon-
tinued a douche may often be employed with advantage, since
forcible spraying of the gastric mucosa stimulates secretion and also
increases the tone of the muscular coat. For this purpose a soft
tube provided with numerous small holes at its lower end should
be used, and the fluid injected under pressure by raising the funnel
or reservoir above the patient's head. Einhorn advocates an
ordinary spray apparatus, to the hard rubber branch of which a
soft stomach tube is attached. Within the latter is another soft
tube of small calibre, which conveys the fluid from the bottle to
the vulcanite nozzle. By this means the entire surface of the
organ may be subjected to a fine spray. When the coats of the
viscus require tone, water at a temperature of 65 F. is employed,
350 Chronic Gastritis.
but if the secretion is also deficient, the addition of .chloride of
sodium (90 gr. to the pint) is found to increase the production of
hydrochloric acid, while nitrate of silver (1 in 1,000) produces a
contrary effect. Chloroform water added to the douche exerts a
sedative action, and a douche of the infusion of hops or quassia is
stated to stimulate the appetite. In all cases where a medicated
solution is employed the fluid should not remain in the stomach
for more than one minute, and the organ should afterwards be
washed out with warm water. No food should be present when
the douche is given. Electricity is only of value in long-standing
cases of gastritis, where the muscular coat is markedly atonic and
secondary my asthenia has produced retention of food. In such
regular massage of the stomach combined with hydrotherapeutic
measures may be employed.
Diet. It is impossible to formulate a definite scheme of diet
applicable to all cases, since the powers of digestion and assimila-
tion vary considerably at different stages of the complaint and in
different individuals. The main object to be kept in view is to
order food of a quality and in such quantity as not to overtax
the enfeebled organ. When a case first comes under treatment,
and especially if there are any acute manifestations of the disease,
rest in bed for ten days or a fortnight and the administration
of some bland form of nourishment afford immediate relief to the
pain and vomiting, check emaciation and promote restful sleep.
As a rule, food should be administered every three hours, and the
fluid be restricted to ^ pint on each occasion. If milk agrees,
from 8 to 4 pints may be given in the twenty-four hours,
but if it produces discomfort it must be diluted with lime-water,
sterilised or peptonised. In some cases the sour milk prepared in
the manner recommended by Metchnikoff is an excellent adjunct to
the usual diet, but ten days usually elapse before its good effects
become apparent. Half a pint of the sour curds, well sprinkled
with sugar, nmy be given twice a day. Eggs, either poached or
lightly boiled, clear soups, meat essences and jellies, junket, custard,
cocoa made from the nibs, milk puddings, Benger's food, revalenta
arabica, Gerrard's peptones, with toast, rusks and butter should
constitute the remainder of the dietary. It is often stated that
proteids should be withheld whenever the gastric secretion is deficient,
but in cases of chronic gastritis the motor power of the stomach
is rarely impaired until the terminal stage of the disease, and any
diminution of proteid digestion in the organ is amply compensated
by an increased activity of the biliary and pancreatic secretions.
Carbohydrates may be allowed in moderation, but vegetables that
Chronic Gastritis. 351
contain a large amount of cellulose and all raw fruits must be
excluded. Fats are valuable, especially when the general nutrition
is much reduced, and for this purpose the patient should be
encouraged to take cream, butter or dripping with his meals.
After the lapse of a fortnight he is usually able to leave his bed
and to attempt a more extended dietary. If the milk and other
fluids agree they may be continued in lesser quantities, and the sour
milk be taken once or twice a day. The most digestible articles at
this period of the disease are as follows : Calf's brains and thymus,
boiled cod, whiting and plaice, oysters, scraped raw beef, tripe,
sweetbreads, mashed potato, cauliflower, asparagus, toast, rusks,
oatmeal, tapioca, sago, cornflour and rice, to which may be added
boiled chicken, partridge or pigeon, well-stewed beef, boiled ham,
calf's feet, sardines, spinach and stewed apple. If the case
continues to progress in a satisfactory manner, the diet is further
enlarged at the end of another month by the inclusion of such
articles as turkey, game of various kinds, underdone roast mutton
or sirloin of beef, lightly grilled chops or steaks, and plain puddings.
On the other hand, hard or coarse-fibred meats, pork, veal,
sausages, lobster, salmon, mackerel, carrots, salads, celery, cabbage,
cucumber, pickles, cheese, new bread, uncooked fruits and alcoholic
drinks should be prohibited until the health has been completely
restored.
Medicinal Treatment. Natural mineral waters have always
been held in high repute for the treatment of chronic inflammation
of the stomach, and much relief is sometimes obtained by a few weeks'
residence at a suitable watering-place. Before advising a " cure "
of this description, care should be taken that the general health is
sufficiently good to withstand the exertion and excitement of a long
journey and the somewhat debilitating effects of the treatment. In
this connection it is well to bear in mind that chronic gastritis is
often merely an expression of serious disease of some vital organ
of the body, and that to submit a person suffering from a fatal
affection of the heart, lungs, stomach or kidneys to the orthodox
treatment at a foreign watering-place merely because chronic
gastritis complicates the original complaint, is wholly unscientific
and frequently ends in disaster.
Alkaline waters are chiefly indicated in cases of secondary
gastritis, where the heart, lungs or kidneys are seriously affected
and much irritability of the stomach exists. Under these conditions
the warm springs of Vichy are particularly valuable, or if a milder
form of treatment is required the waters of Neuenahr may be pre-
ferred. The salt waters of Kissingen, Homburg and Wiesbaden
352 Chronic Gastritis.
exert a marked influence upon gastric subacidity and are chiefly
indicated during convalescence from primary chronic gastritis and
in that variety which ensues from long-standing myasthenia. In
England, Harrogate and Llandrindod possess somewhat similar
waters and have the advantage of a more bracing climate. The
springs that contain sulphate of sodium in addition to the chloride
and bicarbonate are chiefly of use in the gastritis which arises from
diseases of the liver, gall-bladder and pancreas, from habitual
over-indulgence in rich living or the abuse of alcohol. The best
waters of this kind are those of Carlsbad, Marienbad, Tarasp and
Brides-les-Bains. In all cases the water should possess a medium
temperature, as the inflamed stomach is intolerant of cold or unduly
hot fluids.
The indications for the administration of drugs are threefold :
(1) To allay the symptoms of gastric irritation and inhibit fermenta-
tion ; (2) to stimulate the appetite ; and (3) to correct constipation.
(1) The abdominal discomfort, distension, nausea and other
symptoms of the complaint are partly due to diminished secretion
and partly to direct irritation of the mucous membrane of the
stomach. Both these conditions tend to subside under daily
lavage and careful dieting, but they rarely disappear completely
without the use of drugs. The carbonate of bismuth is pre-
eminently valuable in these cases, and may advantageously be
combined with bicarbonate of sodium (15 gr. of each) and from
8 to 12 min. of the glycerine of carbolic acid. The further
addition of 1 drachm of pure glycerine to the mixture increases
its sedative and antiseptic properties. The medicine is given
between meals, and should nausea be troublesome, five drops of
dilute hydrocyanic acid may be added to it. In less severe cases
the solution of bismuth may be prescribed in similar combination.
Morphine is only indicated when acute gastritis, accompanied
by excessive vomiting, complicates the chronic complaint and is
contra-indicated when albumin is present in the urine. In
gastritis of alcoholic origin chloretone, in doses of 15 gr., or
1 drachm of the elixir in an alkaline mixture, is often of much
value. Salicylate of sodium and salicylic acid are much inferior
to carbolic acid. A drachm of the solution of perchloride of
mercury administered three times a day after meals is an excellent
remedy when the gastritis is associated with alcoholic cirrhosis
of the liver. If acidity is the chief cause of complaint, the com-
pound lozenges of bismuth, or capsules containing calcined magnesia
and bicarbonate of sodium, taken an hour after food, are of
service.
Chronic Gastritis. 353
(2) Lavage is the best stimulant to the appetite, but when this
procedure cannot be carried out recourse may be had to medicines.
In some instances a cupful of beef-tea or hot water taken a
quarter of an hour before a meal excites a certain amount of
relish for food, or 15 min. of dilute hydrochloric acid diluted
with 2 oz. of water, between meals, has a good effect. Condurango
has long enjoyed a reputation as a stomachic, and a teaspoonful
of the wine, or 30 min. of the liquid extract, with or without
hydrochloric acid, may be prescribed before each meal. Orexin
is too irritating to be borne by an inflamed stomach, while
nux vomica, iron, quinine and the various so-called gastric elixirs,
increase the inflammatory trouble. The fact that a deficiency
of the mineral acid is always accompanied by a diminution of
the peptic ferment has led to the introduction of pepsin, papain,
papayotin and the pancreatic preparations, as artificial aids to
digestion. Personally, I have never observed the slightest benefit
to ensue from their use, and even takadiastase, which theoretically
should be of value, is quite useless.
ALCOHOLIC GASTRITIS.
In every case of alcoholic gastritis, as well as in many of the
secondary forms of the complaint, the administration of a saline
each morning before breakfast is of the greatest value. As a rule,
a mixture in equal proportions of the dried sulphate and phosphate
of sodium answers best, but artificial Carlsbad salts, Kutnow's
powder, the sulphate and carbonate of magnesia, or the Rochelle
salts, may be prescribed. Enough should be taken to procure
two liquid motions each morning, and after a few weeks the
dose may gradually be diminished. The natural aperient waters
are of less value.
PHLEGMONOUS GASTRITIS.
The treatment is chiefly symptomatic, and is identical with
that of other acute inflammations of the stomach. No food is
allowed by the mouth, and the nutrition should be maintained
entirely by large rectal injections of peptonised milk. Opium
or other sedatives are usually required on account of the severe
pain which exists, preference being given to hypodermic injections
of morphine. Hot applications to the epigastrium usually afford
relief. In every instance full doses of the polyvalent antistrepto-
coccus serum should be tried, and also stock preparations of anti-
staphylococcus vaccines.
W. SOLTAU FENWICK.
S.T. VOL. II. 23
354
NERVOUS DISEASES OF THE STOMACH.
GASTRIC NEURASTHENIA (NERVOUS DYSPEPSIA).
THE measures usually recommended for general neurasthenia are
also indicated in cases of nervous dyspepsia. The patient should be
encouraged to pursue a definite line of treatment, and be constantly
reassured as to the non-existence of organic disease. In mild cases
he should be directed to pursue his usual vocation, provided it is
not of too arduous a nature, to devote adequate time to his
meals, to go to bed at a reasonable hour, and to avoid adventitious
forms of excitement and unnecessary fatigue. Sexual intercourse
is often harmful, and should be always restricted as far as possible.
Change of air seldom fails to afford relief if care is taken to
avoid humid and enervating localities. In most instances high
altitudes are beneficial, and a residence in Switzerland or Scotland
during the summer months tends to improve the appetite and
to remove the indigestion. When much physical enfeeblement
exists a voyage to Australia is of greater value. As a rule, the
southern and south-western parts of England do more harm than
good, and many persons who endeavour to regain their health
by a holiday at Bournemouth, Torquay, the Isle of Wight, or
in Devonshire, return home in a worse condition. Of the inland
health resorts, Malvern and Ilkley, in the north, and Hindhead, in
the south, are the best, and there is seldom any objection to
the east coast during the warmer months of the year. In
every case the patient must be impressed with the fact that
a complete rest is the main object of his enforced absence
from home, and he should consequently free himself entirely
from business worries, and remain away for at least two months.
Short holidays are quite useless and week-end visits only promote
exhaustion. Owing to the important influence of environment, the
patient should be surrounded by cheerful associates, and all news
of a depressing or irritating character be withheld from him as
far as possible.
In the severe form of the disease, accompanied by rapid
emaciation, it is advisable to confine the patient entirely to bed for
a month or six weeks and to try the effects of a milk diet
combined with general massage and, if necessary, electricity. The
prohibition of literature and the visits of friends are usually
Nervous Diseases of the Stomach. 355
harmful owing to the inherent tendency to melancholia, and
very often when an effort is made to procure complete isolation
the patient throws off all restraint and refuses to subject himself
to further treatment. In every instance the condition of the
generative organs requires special attention, and careful enquiries
should be made concerning masturbation, spermatorrhoea, and
venereal excesses, with the view of removing these potent causes
of nervous exhaustion. Electricity is often of value, both in
relieving the dyspepsia and in the treatment of the constipation.
For the stomach, a constant current of 3 to 5 niilliamperes
should be passed through the epigastrium for twenty minutes
daily, the negative electrode being applied over the lower dorsal
region and the positive one immediately below the left costal
margin. Einhorn and others prefer direct electrisation of the
organ by means of a metallic wire inserted into an ordinary
stomach tube, but the procedure is unpleasant to the patient
and tedious of application. When electricity is employed for
constipation, one pole is inserted into the rectum, and the other,
consisting of a large metal disc, is successively applied to the
surface of the abdomen at different points along the course
of the large intestine. The interrupted current is to be preferred
to the constant one, and each application should last for half
an hour. This electrical treatment may be combined with
massage of the colon, but the latter should be avoided if
symptoms of mucous colitis exist. If anorexia is a serious
symptom it may be necessary to resort to gavage (forcible
feeding).
Diet. The fact that the dyspeptic symptoms are only slightly
influenced by the nature of the food renders it inexpedient to
prescribe a fixed dietary. As a rule, an excess of innutritions
liquids, such as beef -tea, broths, tea and mineral waters, tends
to inflate the stomach and to increase the sense of discomfort ;
while green vegetables and fruits almost always disagree, and
are to be prohibited. The meals should be moderate in quantity,
composed of materials that are easily digested, and be taken
at intervals of three hours. If an excessive craving for food
occurs between the meals, egg and milk, hard-boiled eggs, or
a cup of milk cocoa may be allowed. The advisability of an
excess of milk must depend upon the state of the gastric secretion.
In the mild form of' the complaint, where the secretory and
motor powers of the stomach are usually unaffected, 5 pints of
warm milk each day in divided doses, either with or without lime-
water, form an excellent substitute for other forms of nourishment
232
356 Nervous Diseases of the Stomach.
and promote the formation of fat and muscle. In the severe
variety of the complaint, on the other hand, the failure of the
gastric secretion renders raw milk very liable to disagree, and
it must be given in restricted amount, and either peptonised
.or well diluted. Sometimes Horlick's malted milk is tolerated
when other forms produce discomfort. The sour milk is extremely
variable in its action, but should always be given a trial. In every
case mastication must be thoroughly performed, and no exercise
should be permitted for one hour after meals.
Medicinal Treatment. The choice of drugs depends upon the
state of the gastric secretion. When hyperacidity accompanies the
nervous disorder an alkaline mixture containing bicarbonate of
sodium, carbonate of bismuth and glycerine should be given after
each meal, or a compound bismuth lozenge sucked at intervals
during the course of digestion. As a rule, however, the severe form
of the complaint is accompanied by a marked deficiency of gastric
secretion, and it is in such cases that hydrochloric acid is of value.
In most instances it is sufficient to prescribe fifteen drops of the
dilute acid after each meal, but sometimes a wineglassful of a
2 or 3 per 1,000 solution of hydrochloric acid at the end of each
repast is more beneficial. The various digestives, such as papain,
pepsin, pancreatin and lactopeptin are rarely of any decided use,
nor does the administration of maltine or takadiastase appear to
relieve the symptoms of flatulence and distension. The treatment
of the constipation is always a matter of difficulty owing to the
severe exhaustion that is apt to follow the use of purgatives. In
the first instance a trial should be made of a tablespoonful of
glycerine by the mouth each morning before breakfast, or of a
small dose of mercury and chalk, cascara or euonymin combined
with rhubarb and hyocyamus every evening. Saline aperients and
the natural aperient waters should be avoided, as their administra-
tion always increases the symptoms of distress. In severe cases
reliance must be placed upon enemata, soap and water or warm
water containing glycerine or castor oil being used for the purpose.
Another useful method is to inject olive oil into the bowel at
atmospheric pressure. At first ^ pint is given each alternate
morning, but as the patient improves the injection need only be
employed every third or fourth day, and the amount of oil may
be gradually diminished. In all cases the general health must
receive attention. If hysteria exists, a course of bromides combined
with valerian often affords relief. Anaemia usually requires the
exhibition of some bland preparation of iron, with which arsenic
and nux vomica may be combined if necessary. Zambelleti's
Nervous Diseases of the Stomach. 357
injections of soluble arsenic and iron are of great value in some
cases. In young persons cod-liver oil and the compound syrup of
the hypophosphites constitute an admirable tonic.
NERVOUS ERUCTATION.
In this disorder there is apparently a constant eructation of
gas from the stomach accompanied by much noise. In almost
every instance, however, it may be shown that the condition
is due to the involuntary swallowing of air that passes up the
oesophagus at intervals in the form of bubbles which burst in
the mouth and excite a noisy vibration of the soft palate. The
complaint, when well established, is ' exceedingly difficult to cure.
The most effective treatment in recent cases consists of the passage
of a full-sized tube into the stomach and its maintenance in
position for twenty minutes on each occasion. In obstinate cases
it may be necessary to administer a constant electrical current by
means of a wire passed down the tube and to apply repeatedly
small blisters to the epigastrium. When the complaint develops in
adults without obvious cause, its violence may be allayed by the
insertion of a gag into the mouth, so as to keep the teeth apart, or
of an instrument to depress the tongue, but these expedients are only
of temporary value. Young women almost invariably require a
course of arsenic and iron, with perhaps the addition of bromides.
HABITUAL REGURGITATION.
This differs from rumination in being an acquired and not an
hereditary complaint, while the mouthfuls of food are usually
ejected from the mouth with disgust rather than swallowed. In
every case the patient should be made to eat slowly, to masticate
thoroughly and to avoid any form of pressure upon the abdomen.
Voluntary efforts to suppress the regurgitation are attended by a
certain degree of success and should be encouraged as much as
possible. Sometimes the swallowing of small pieces of ice reduces
the frequency of the regurgitation Electricity should be tried both
internally and externally, and strychnine may be prescribed. A
milk diet and massage often reduce the severity of the symptom,
but when the patient returns to his ordinary mode of life it usually
recurs.
CARDIOSPASM.
The treatment is primarily prophylactic. If the inner surface of
the oesophagus is unduly irritable and the spasm occurs after eating
or drinking, mastication must be thoroughly performed and only
358 Nervous Diseases of the Stomach.
foods and fluids of medium temperature should be taken. In most
instances a full-sized oesophageal tube passed night and morning
and maintained in position for ten minutes affords considerable
relief, the procedure being gradually discontinued as improvement
sets in. If the spasm is accompanied by pain, it is probable that
secondary erosions of the mucous membrane exist in the neighbour-
hood of the cardia.
In such cases a milk or pultaceous diet should be prescribed for
a few weeks, while in severe instances recourse should be had to
rectal alimentation. Internal electrisation is always worthy of
trial.
W, SOLTAU FENWICK.
359
PARASITES AND CONCRETIONS OF STOMACH.
IN addition to various worms, the stomach is occasionally infested
with the larvae of several varieties of insects and even by living
beetles. In most cases the insects' eggs gain an entrance to the
organ by the ingestion of impure water, contaminated milk, high
meats, game, mouldy biscuits or decaying vegetable matter, or the
minute larvae are swallowed alive in raspberries and other fruits.
Accidental parasitism would probably be prevented if sufficient
care were taken to preclude the access of flies to meat and other
articles of food during the summer months, and to avoid uncooked
vegetables, musty cakes and unboiled water. Muslin safes are
alone of any value in protecting meat from blow-flies. In mild
cases of internal myiasis a sharp purge is sufficient to rid the body
of the larvae and eggs, while in chronic cases the administration
of thymol, santonin, or other anthelmintics is often successful.
Beetles are, however, notoriously difficult to kill, and large doses of
turpentine are usually required to free a patient from these pests.
Slugs, leeches, frogs, lizards and other living creatures are often,
though erroneously, supposed, to exist in the human stomach for
a long period, and it is comforting to be able to assure the sufferers
from such unusual intruders that a few draughts of strong salt and
water will never fail to kill them.
Hair-balls, bezoars and gastroliths are very rarely met with, the
former being the least uncommon and practically confined to
women. When a history of hair-swallowing suggests the cause of
the intractable dyspepsia, but no abdominal tumour exists, the
cure of the habit combined with a daily saline purge will gradually
cause the elimination of the material, but when sufficient hair has
accumulated to create a palpable tumour, surgical interference is
always necessary.
W. SOLTA.U FENWICK.
3 6
SECRETORY DISORDERS OF THE STOMACH.
THIS class comprises three complaints. In the first, or hyper-
acidity, an excess of free hydrochloric acid is secreted as the result
of ingestion of food ; in the second, hypersecretion, gastric juice,
which usually contains an excess of the free mineral acid, is secreted
continuously, both when the organ contains food and when it is
empty ; while in the third variety, or achylia, the gastric secretion
is almost completely suppressed.
HYPERACIDITY.
General Treatment. The first indication is to avoid every-
thing which tends to over-excite the glandular activity of the
stomach. If the hyperacidity arises from mental exertion,
emotional excitement or physical overstrain, these conditions must
be obviated as far as possible. During an acute access of the
malady complete rest should be enforced, and the patient should
remain in bed or upon a sofa for a few days. Climate always
exercises an important influence upon the severity of the symptoms,
and in many cases exposure to cold or damp will invariably provoke
an attack. Residence in an enervating atmosphere increases the
disorder, and hence all low-lying districts as well as those situated
upon the south coast and in the south-western parts of England
are unsuitable for persons affected with chronic hyperacidity. As
a rule inland health resorts are preferable to those situated on
the coast, especially Hindhead, Malvern, Ilkley, the north of
Scotland and the elevated parts of Sussex and Bucks. In all
cases the patient should be advised to wear warm underclothing,
with a woollen or chamois-leather belt next the skin, and should
be warned against the use of cold baths in winter or prolonged
immersion in the sea.
Everything which tends to increase the production of hydro-
chloric acid is to be avoided, and if the teeth are in bad condition
they should receive immediate attention. Nuts, fruits, salads and
other substances difficult of solution by the gastric juice must be
prohibited, as well as such stimulating articles as salt, pepper,
mustard, vinegar, horseradish, alcoholic beverages and beer. Tea
always increases the acidity, and in most instances black coffee is
inadmissible. Moderate smoking need not be prohibited, but
Hyperacidity. 361
strong tobacco and cigars should be avoided, and inhalation should
not be practised. The spa treatment of hyperacidity is often dis-
appointing, and the particular watering-place selected should depend
upon the cause of the gastric complaint. Hyperacidity associated
with neurasthenia or gastroptosis is most benefited by a high and
bracing locality, and consequently a prolonged residence in Switzer-
land is often of the greatest value. When the disorder is associated
with biliary lithiasis, gastric ulcer, pancreatitis or gout, a course of
treatment at Carlsbad or Marienbad, Harrogate or Strathpeffer, is
sometimes invaluable, but when it appears as a sequela of disease
of the nervous system the warm waters of Vichy or Neuenahr are
of greater value.
Lavage is indicated only when gastrectasis complicates the
functional complaint. Some writers assert that internal galvanisa-
tion of the stomach reduces the secretion of hydrochloric acid and
is capable of curing the complaint. That the degree of acidity does
occasionally diminish under this method of treatment cannot be
doubted, but I have never met with a case where a genuine cure
had been effected by electricity. Hot-air baths have been recom-
mended as a means of controlling the secretion of acid, and
temporary relief is often experienced after copious perspiration has
been produced in this manner.
Diet. The chemistry of digestion in hyperacidity demonstrates
in an unmistakable manner that, while nitrogenous foods are
rapidly dissolved and passed into the intestine, starches and fats
lie stagnant in the stomach and undergo fermentation. Pawlow
has shown by experiment that different forms of proteid food excite
varying degrees of acidity, the most potent in this respect being
beef and mutton, while milk not only induces less secretion but also
fixes the greatest proportion of free hydrochloric acid. Clinical
experience also teaches that starchy substances give rise to more
discomfort than proteids, and milk to less than meat. In every
case, therefore, milk should constitute the staple diet during an
acute attack of the disorder, care being taken to administer it in
the form that proves most agreeable and beneficial to the patient.
At first 6 oz. of warm milk containing a tablespoonful of lime-
water should be given every two hours, and after a few days the
dose may be increased to ^ pint every two and a half hours.
Some persons prefer the milk to be mixed with Vichy or soda water,
while others find the addition of 15 gr. of citrate of sodium
to each ^ pint prevents the discomfort that ensues from its
rapid coagulation in the stomach. Peptonisation is of course super-
fluous, and milk curdled by means of lactobacilline never agrees.
362 Hyperacidity.
When the stomach is exceptionally irritable it may be necessary to
restrict the patient entirely to whey. Junket and koumiss answer
well in some cases. As soon as the acute symptoms have subsided
the milk may be thickened with fine oatmeal, sago or ground rice,
after which poached and boiled eggs, chicken-cream, boiled fish rubbed
through a sieve and cold bacon may be allowed. Wheaten bread
and toast almost always produce discomfort and should be replaced
by rusks or the Brusson-Jeune rolls. Sole, whiting, plaice and
cod usually agree better than the oily forms of fish, and should be
boiled, finely minced and served with plain sauce. Subsequently,
poultry, game and the various red meats, tongue, sweetbreads,
tripe and ham may be tried, with a small quantity of boiled or
mashed potato, cauliflower, seakale or asparagus. On the other
hand, cabbage, lettuce, peas, beans, celery, carrots and turnips
never agree, and no fruits should be allowed. Although starchy
foods appear to increase the secretion of hydrochloric acid, probably
by their stagnation in the stomach, the soluble sugars are free from
this defect, and according to some authorities a considerable amount
of dextrose in solution may be given each day without disturbance
of the digestion, provided that the motor power of the stomach is
intact. A moderate amount of fat may be included in the dietary,
especially in the form of butter or cream, but fried bacon is apt to
produce acidity. Olive oil is sometimes recommended on account
of its inhibitive influence upon gastric secretion, and may be taken
before meals or mixed with the food. Salt must be avoided as far
as possible.
The frequency of the meals should vary in different cases.
If the appetite is normal it is usually advisable only to allow
three full meals in the course of a day, so as to afford the stomach
definite periods of rest ; but when hunger is a marked feature of
the case, or the patient finds that his desire for food is easily
satisfied, it is better to administer a smaller quantity of food every
three hours.
A moderate amount of fluid may be taken at the end of
a meal, as it helps to dilute the acid secretion, and for this
purpose warm water, or water containing bicarbonate of potassium
in the proportion of 1 gr. to the ounce, is particularly valuable,
or one of the natural alkaline waters, such as those of Vichy, Ems,
Seltzer, or Contrex6ville, either alone or mixed with milk, may be
prescribed. Kefir sometimes agrees well, and some practitioners
advise cider, but as a rule acid fluids tend to increase the pain and
discomfort. Occasionally a glassful of fresh lemonade taken at night
prevents the occurrence of acidity in the early hours of the morning.
Hyperacidity. 363
Spirits and beers always augment the symptoms of indigestion, but
if alcohol is considered necessaiy, a light white wine well diluted
with water is probably the least harmful.
Medicinal Treatment. In mild cases or at the commencement
of an attack the patient should be directed to suck two or three com-
pound bismuth lozenges after meals or to swallow three of the 5-gr.
tablets of bicarbonate of sodium. As a rule, however, a more
active form of treatment is required in which the exhibition of
alkalies plays an important part. Most authorities prefer the
bicarbonate of sodium, either alone or in combination with calcined
magnesia or prepared chalk, to neutralise the excess of acid in the
stomach ; but whichever drug is used it should be given in full
doses about two hours after a meal. In severe cases a sedative is
always required, and 10 min. of the solution of morphine [U.S.P.
gr. ^ of morphine hydrochloride] or 1 grain of the phosphate of
codein may be added to the alkaline mixture. Belladonna has
been recommended on account of its supposed influence upon
the gastric secretion, but neither it nor atropine really diminish the
acidity and not infrequently produce vomiting.
When the pain is severe and only partially relieved by alkalies,
it is safe to assume that the symptom is due in great part to a
concomitant hyperresthesia of the gastric mucosa induced by long-
continued irritation by free hydrochloric acid, and under these
circumstances the salts of bismuth are invaluable. As a rule, the
carbonate, in doses of 15 or 20 gr., is the best preparation,
especially when combined with morphine and glycerine, but the
solution of bismuth prescribed with the elixir of chloretone finds
favour with some practitioners. In very obstinate cases nitrate of
silver has been recommended, either in the form of a pill or as a
gastric douche (1 in 1,000), but I have never seen a case where
permanent benefit was derived from the employment of this
salt.
The constipation which invariably accompanies hyperacidity
should be combated in the first instance by saline aperients
administered in the early morning. Phosphate of sodium (2
drachms), the artificial Carlsbad salts (2 to 4 drachms), sulphate of
sodium (2 drachms), or Eochelle salt (2 to 4 drachms), should be
dissolved in a tumblerful of hot water or such natural aperient
waters as those of Carlsbad, Friedrichshall, Hunyadi Janos, or
Apenta may be prescribed. As the case improves the quantity of
the aperient is gradually reduced, and finally the saline is omitted
in favour of an occasional dose of aloes and rhubarb, mercury and
colocynth, or other simple aperient.
364 Acute Hypersecretion.
HYPERSECRETION.
The Acute Hypersecretion. During an attack the patient
must be confined to bed. No food should be given by the mouth,
but a little ice may be sucked if the thirst is severe, or the mouth
rinsed out from time to time with hot water. If vomiting
persists for more than twenty-four hours, from 15 to 20 oz. of
warm peptonised milk should be slowly introduced into the rectum
through a tube every six hours and the bowel washed out with
normal saline solution each day. In this manner irritation of
the stomach by the ingestionof food is avoided, and the duration of
the attack is much curtailed. Some authorities, however, prefer to
administer milk diluted with Vichy or lime-water or white of egg
during the whole period.
The quickest method of relieving the pain and sickness is to
introduce a soft tube into the stomach, and, after evacuating the
acid contents of the organ, thoroughly to wash it out with a weak
solution of bicarbonate of sodium (2 gr. to the ounce). The use of
nitrate of silver (1 in 1,000) for the purposes of lavage never stops
the abnormal secretion and does more harm than good. As a rule,
the lavage should be repeated every six hours, but it rarely happens
that it is required more than four times. If the tube cannot be
employed, the patient should be encouraged to drink pint of
hot water at intervals and to induce vomiting by inserting his
fingers down the throat. In either case it is wise to administer 1
drachm of carbonate of bismuth suspended in 4 oz. of water at the
completion of lavage, or to prescribe an alkaline bismuth mixture
combined with morphine. As soon as vomiting has subsided, milk
diluted with lime-water, whey, or albumin water may be allowed in
small quantities at frequent intervals, and after a short time a more
substantial diet can be given.
In the meantime it is always advisable to administer a full
dose of a saline aperient, or ^ gr. of calomel every hour until
the bowels have been thoroughly evacuated. When the latter
has been accomplished the vomiting hardly ever recurs. Between
the attacks an effort should be made to remove the cause
of the complaint. If it can be shown by the incidence of the
disease that mental or physical overstrain is an important factor in
its causation, the patient must be advised to limit his labours and
to take moderate exercise in the fresh air. Excessive smoking
must be prohibited ; in severe cases the habit should be abandoned.
Alcohol can rarely be tolerated, and in many cases an attack may
be traced directly to indulgence in even a small quantity of wine
or spirits. It is highly probable that acute hypersecretion is
Chronic Hypersecretion. 365
merely an early expression of the chronic complaint, and depends,
like it, upon an organic lesion of the digestive organs. Sooner or
later, therefore, the question of surgical interference will have to be
considered.
Chronic Hypersecretion. Every case requires to be treated
upon its own merits, special attention being paid to the type of the
disease, the degree of gastrectasis and the presence of complica-
tions.
General Treatment. There is no remedy so efficient in relieving
the attacks of pain and sickness as methodical lavage, while in those
numerous examples of the complaint where the perversion of secretion
is associated with stenosis of the pylorus the performance of lavage is
essential to the maintenance of nutrition. In every case, therefore,
when vomiting occurs at night or food is found in the viscus in the
early morning, the stomach should be washed out once a day. The
time at which the operation is to be performed must be determined
by the peculiar requirements of each case. Thus, when sleep is
disturbed by indigestion or vomiting, it is most conveniently under-
taken when the patient retires to bed, but if much muscular
insufficiency exists it may be necessary to wash out the organ
again before breakfast. As a rule, warm water containing about
2 gr. of bicarbonate of sodium to the ounce is the rnqst suitable
medium for the purpose, but some writers recommend boric acid (10
in 1,000) or other antiseptics (see p. 313). Reichmann claims that
irrigation of the stomach with a weak solution of nitrate of silver
(1 in 1,000) exerts a direct inhibitive influence upon the secretion, but
this plan has not been attended by much success at the hands
of other observers and is apt to produce severe pain. It is a
convenient practice to administer a dose of a saline aperient through
the tube at the conclusion of the morning lavage.
The enlarged and dislocated stomach should always be supported
by means of a firm abdominal belt, which the patient can readjust
for himself night and morning. When duodenal ulcer or gall-
stones are the cause of the secretory disorder, treatment at Carlsbad
or Marienbad often affords considerable relief, but should the
stomach be much dilated mineral waters in large quantities must
be avoided. Massage should never be recommended, owing to the
frequent association of hypersecretion with an open ulcer of the
stomach or duodenum or with a diseased appendix, while rubbing
of the stomach itself in no way affects the excessive secretion.
Electricity is useless.
Diet. In the arrangement of a suitable dietary the principal
indication is to avoid those articles of food which stimulate the
366 Chronic Hypersecretion.
gastric secretion and which at the same time are difficult of solution.
This class includes all amylaceous substances that have not pre-
viously been digested, excess of fats, and cellulose. Few subjects
of chronic hypersecretion, whether the stomach is dilated or
not, are able to take bread and starches without experiencing an
access of discomfort. On the other hand, experience teaches that
the total exclusion of starch from a dietary usually increases the
tendency to emaciation and favours constipation, so that it
becomes necessary to devise a method by which a moderate
amount of carbohydrates may be given each day. The fact that
the presence of gastric juice in the organ at once inhibits ptyalin
digestion and favours the fermentation of sugar, suggests that the
viscus should be emptied of its acid contents before starch is given,
and that a suitable amount of diastase should be added to the meal
to aid the conversion of at least a portion of the amylacea into
sugar before the accumulation of hydrochloric acid puts a stop to
the process. With these objects in view it is customary to wash
out the stomach each morning with a weak alkaline fluid, and
immediately afterward to give a meal consisting of oatmeal, a
cereal soup, bread and milk, milk pudding, or some special form of
starchy food that has already been partially digested. Occasionally
a solution.of dextrose may be given with advantage, or a full dose
of maltine or takadiastase administered at the end of the meal.
Bread almost invariably increases the distension and flatulence
and should be omitted in favour of thin toast, rusks, starch-free
biscuits or that most useful and palatable preparation which has
recently been introduced, the Brusson-Jeune rolls. Green vege-
tables never agree, but well cooked asparagus, seakale, or stewed
celery may be allowed in moderation. All varieties of fruit
increase the gastric acidity, more especially strawberries, goose-
berries and plums. Apples, baked or stewed without sugar, and
oranges are the least harmful. The patient should be encouraged
to take a moderate amount of butter and cream with his meals, but
excess must be avoided, as they are apt to produce fat- vomiting in
the later stages of the complaint. Few subjects of hypersecretion
can take alcohol without discomfort, and very often an attack of
gastric intolerance can be traced to indulgence in wine or spirits.
Tea always disagrees, and in many instances coffee must also be
prohibited, but cocoa made from the nibs or husks and diluted with
milk, or the plasnion and peptonised cocoas, may usually be taken
with benefit. At the other meals one of the natural alkaline
mineral waters, milk and soda water and whey are the most suitable
drinks. Milk is invaluable, since it rapidly fixes free hydrochloric
Chronic Hypersecretion. 367
acid and is a comparatively slight stimulant to secretion. When
raw milk disagrees it is certain that the stomach contains a
large quantity of stagnant acid, and lavage will have to be
performed for several days before milk can be tolerated. As a rule,
from G to 10 oz. of milk, either raw or mixed with lime-water, may
be administered every two hours. In other cases it may be
necessary to employ fresh whey or Horlick's malted milk. Of
recent years curdled milk has been introduced on a large scale into
gastric practice, but according to my experience it never agrees
with any case in which the secretion of the stomach is abnormally
acid. It is only in those cases of " appendicular " hyper-secretion,
accompanied by gastric sub-acidity, that the use of sour milk is
sometimes attended by success. Unless the complaint depends
upon an ulcer of the stomach, animal food may also be allowed,
especially if it is finely minced and carefully masticated. Mutton,
lamb, veal, ham, cold bacon, poultry, fresh game, sweetbreads,
tripe, calf's head and feet, or sheep's brains, should be lightly
cooked and taken at the midday meal, while at other times fish,
clear soups, meat essences and jellies, custard, junket and eggs
may be allowed. When a craving for food develops soon after a
meal, it may usually be allayed by egg and milk or by albumin
water.
MfdiciiKil Treatment. Drugs are administered with the object of
allaying pain and vomiting, relieving constipation and restricting the
secretion of gastric juice. Pain usually demands the use of an
alkali to neutralise the excessive acidity. For this purpose full
doses of bicarbonate of sodium, solution of potash, carbonate of
magnesia, or of ammonio-magnesium phosphate, are given two
hours after a meal and repeated when necessary. When much
dilatation of the stomach exists the solution of potash is to be
preferred to the bicarbonates. Carbonate of bismuth is extremely
valuable as an antacid and gastric sedative, and may be combined
with a soluble alkali and a teaspoonful of glycerine. If flatulence
is also a troublesome symptom 10 min. of the glycerine of carbolic
acid may be added to the mixture. Sedatives are required when
pain is severe, in which case 10 to 15 min. of the solution of
morphine [U.S. P. gr. y\j to gr. ^ of morphine hydrochloride]
may be added to the prescription. Belladonna is occasionally
of service, but is apt to induce dry ness of the mouth and
aggravate the thirst. A saline administered in hot water before
breakfast each morning is the best remedy for the constipation, as
it not only procures a free action of the bowels but also sweeps into
the intestine the gastric juice which has accumulated during the
368 Achylia Gastrica.
night, and thus performs a kind of internal lavage. As a rule, a
mixture of the dried sulphate and phosphate of sodium in equal
parts is the most useful saline, but the artificial Carlsbad salts, the
carbonate and sulphate of magnesia or Kutnow's powder are some-
times preferred. The natural aperient waters are not so efficacious.
In very chronic cases an occasional dose of calomel or blue pill at
night improves the appetite and removes the feelings ascribed to
biliousness. Hypersecretion dependent upon latent disease of the
appendix is apt to be accompanied by a form of secondary gastritis
which is extremely intolerant of all medicines, and especially
of alkalies. The employment of opium, belladonna, atropine and
nitrate of silver, with the object of directly controlling the excessive
secretion of the stomach, is never attended by any permanent
benefit, owing to the existence of an organic cause of the complaint.
Sooner or later chronic hypersecretion has to be submitted to
surgical treatment. For the treatment of the various complications
of the disease see Haemorrhage ; Tetany ; Acute H^persecretion
or Gastric Intolerance ; Carcinoma, and Gastric Dilatation.
ACHYLIA GASTRICA.
Diminished secretion of the stomach occurs in many diseases
of that viscus and especially in atrophy of the mucous membrane.
The term "achylia," however, is limited to a peculiar nervous
affection of the stomach in which the production of hydrochloric
acid and the ferments is practically absent.
So long as the patient suffers no ill-effects from the absence of
gastric digestion, it is only necessary to arrange a form of diet
which shall not unduly distend or embarrass the organ and to
assist as far as possible the compensatory action of the intestines.
As a rule, the dietary should be of the mixed type and the meals be
taken every three hours. Milk, eggs, fish, sweetbreads, tripe and
sheep's brains are easily digested in the small intestine, while such
farinaceous substances as rice, sago, tapioca, macaroni and mashed
potato give rise to no difficulties of solution. Well-cooked spinach,
turnips and cabbage may be allowed in moderation, but salads,
tomatoes, raw vegetables and fruits are apt to disagree. If the
appetite is deficient the various artificial foods that have undergone
partial digestion may be given, and cod-liver oil and maltine are
sometimes useful. Inflammatory conditions of the overtaxed
intestines must be carefully treated, and the patient should take
special precautions against cold. Hydrochloric acid is the drug
usually employed, and may be given in doses of 15 min., well
Achylia Gastrica. 369
diluted, after each meal, or as a draught in the strength of 1 in 1,000.
Pepsin, pepsencia, lactopeptin, or the peptenzyme tablets, may also
be prescribed, but the pancreatic preparations, which from a
theoretical point of view appear to be especially indicated, are
rarely of any value. Metchnikoff's sour milk is always deserving
of a careful trial. When motor insufficiency of the stomach
develops, lavage with warm water should be performed each day,
and massage and electricity may be employed. Mineral waters
must be avoided.
W. SOLTAU FENWICK.
S.T. VOL. II. 24
370
SYMPTOMATIC TREATMENT OF DISORDERED
DIGESTION IN THE STOMACH.
Acidity. Regurgitations of an acid fluid into the throat or
mouth, known by the name of pyrosis or heartburn, accompany
many different diseases of the stomach. In the vast majority of
the cases the symptom depends upon an excess of hydrochloric
acid in the gastric secretion, and is therefore met with in all
varieties of hyperacidity and hypersecretion. It usually develops
between one and three hours after a meal, and is often more
severe after a light than after a heavy repast. In some individuals
it is accompanied by cardialgia, palpitation, dyspnea, tachycardia,
oppression at the chest, or a sense of impending death. Less
frequently the regurgitations arise from excessive fermentation
of the food, the acid products of which find their way into the
oesophagus or pharynx along with the eructated gases. This
phenomenon is consequently met with in many forms of chronic
gastritis, especially in the alcoholic variety, in stenosis of the
pylorus due to conditions which are not accompanied by an
excessive gastric secretion, such as carcinoma and sarcoma, peri-
toneal bands, adhesions to the gall-bladder or abdominal parietes,
or to mechanical displacements. Finally, pyrosis is often com-
plained of in nervous affections of the stomach and oesophagus,
such as hyperaesthesia and neurasthenia gastrica, in which the
secretion of the organ may be quite normal, but the increased
sensibility of the mucous surfaces that accompanies these disorders
renders it intolerant of even the normal degree of acidity.
Acidity due to hyperacidity requires to be treated in the manner
recommended for the cure of that complaint (p. 360). Substances
which stagnate in the stomach and excite secretion without under-
going digestion must be avoided, and accordingly green vegetables,
uncooked fruits, bread, pastry, cakes and sweets must be prohibited,
as well as those articles which unduly stimulate the stomach, such
as alcohol, malt liquors, wines, condiments, salt and tea. Milk
diminishes gastric irritation and also fixes the largest percentage
of free acid, so that it should always form the staple diet in severe
cases. It is most agreeable when taken warm, and may be mixed
with a moderate proportion of lime-water (a tablespoonful to
\ pint), Vichy water, or citrate of sodium (10 gr. to the pint)
Symptomatic Treatment of Disordered Digestion. 37 1
if it seems to disagree. As the symptom subsides the quantity of
milk may be diminished, but a tumblerful should always be taken
in the middle of the morning and at bedtime. Any kind of animal
food may be given in moderation, but those which possess much
grease or a coarse fibre, like veal and pork, are the least easily
digested. In like manner oily fish, such as herring, sardine,
pilchard and salmon, are apt to create acidity. Eggs may always
be allowed, but the amount of farinaceous substances taken in the
form of milk puddings or vegetables must be restricted. Fresh
orange or lemon juice diluted with soda water sometimes relieves
the symptom. In all cases a saline purge administered in
\ pint of hot water each morning is invaluable, but as a rule
mercurials should be avoided. The medicinal treatment of the
hyperacidity comprises the exhibition of the carbonate or solution
of bismuth, combined with an alkaline bicarbonate, prepared chalk,
calcined magnesia, carbonate of magnesia or the solution of potash,
according to the necessities of the case. In mild instances the
compound bismuth lozenges, or the tablets of soda mint, may be
sucked at intervals between the meals. The cure of the pyrosis
must depend upon its cause.
Acidity due to excessive gastric fermentation invariably requires
systematic lavage and a course of antiseptic treatment. In most
cases the stomach should be washed out with warm water, either
alone or combined with an antiseptic, each morning for a month,
after which it is gradually discontinued; but if sleep is much
disturbed, lavage should be performed at night as well. Vegetables,
fruits, sugars and amylaceous substances generally, must be reduced
to a minimum, and only those forms of animal food allowed which
are comparatively easy of digestion (see Dilatation). An alkaline
mixture containing glycerine and carbolic acid administered one
hour after meals seldom fails to afford relief, and a saline purge in
the early morning is usually a necessity.
The sensation of acidity that accompanies nervous affections of
the stomach must be treated in the manner appropriate to the
primary disease. As a rule, bromides combined with a sedative,
such as hydrocyanic acid, morphine or nepenthe, answer best;
but occasionally the use of arsenic, iron, or zinc valerianate is
required. Salines and all drastic purgatives should be avoided,
and large rectal douches should be employed if collapse ensues
after an evacuation. Massage, electricity and mountain air are
required in severe cases.
Flatulence. Inflation of the stomach by gases, small quantities
of which escape at intervals through the cardiac orifice, is
242
37 2 Symptomatic Treatment of Disordered Digestion.
usually attributed to abnormal fermentations in the organ, but
this conception of the cause of the symptom is not always correct.
In many instances much of the eructated gas is found to consist of
atmospheric air which has been swallowed, while not infrequently
regurgitation of the intestinal fluids increases the gaseous contents
of the stomach. Starches and sugars undergo abnormal fermenta-
tion in almost every disorder of the gastric functions, whether the
mineral acid be deficient or in excess, and consequently in both
hyperacidity and hypersecretion flatulence is a prominent and
troublesome symptom. The treatment of the condition varies,
therefore, according to its cause and the state of the gastric juice.
In cases of excessive acidity, farinaceous food should be limited as
far as possible, and toast, rusks, or Brusson-Jeune rolls substituted
for bread, and sugars prohibited. Animal food of any kind may be
allowed, and the fluids need not be restricted. Flatulence dependent
upon failure of the motor power of the viscus, which is usually
associated with diminished acidity, also requires strict limitation
of starches, but at the same time the food should be well masticated
so as to favour its thorough incorporation with the saliva, while
only the most easily digestible forms of meat and game should
be allowed and the quantity of fluid reduced to a minimum.
Flatulence due to chronic subacidity requires to be treated by a
dietary similar to that described in cases of chronic gastritis,
achylia, and atrophy of the stomach.
When hyperacidity exists alkalies are usually required, and in
this connection it is to be observed that calcined magnesia and the
solution of potash effect neutralisation without the production of
carbonic acid gas. It is sometimes advisable to combine the alkali
with spirits of cajuput or chloroform, aromatic spirit of ammonia,
essence of peppermint, or tincture of ginger, and, if much irritability
of the stomach exists, with one of the salts of bismuth. A saline
draught each morning is of great service. The flatulence of
myasthenia and other conditions, accompanied by diminished
gastric acidity, is best combated by dilute hydrochloric acid, com-
bined with pepsin, given after meals. The addition of a teaspoonful
of glycerine, with carbolic acid or other suitable antiseptic, usually
increases the value of the medicine. Takadiastase is also some-
times of value. Salines in this disorder tend to increase the
distension, and the various alkaline mineral waters also intensify
the symptoms. A dose of grey powder, mercurial pill, podophyllin,
euonymin, or other hepatic stimulant, two or three times a week, is
always advisable.
Nausea. A feeling of sickness at intervals usually precedes
SymptomaticTreatment of Disordered Digestion. 373
vomiting, and also occurs during the process of gastric digestion in
several nervous disorders of the stomach, in inflammatory affections
of the mucous membrane, in carcinoma, and in strictures of the
pylorus. Persistent nausea is frequently met with in alcoholic
and other forms of toxic and toxsemic gastritis and in gastroptosis.
As an intermittent symptom it usually subsides as soon as vomiting
has occurred ; but the persistent forms are extremely difficult to
treat. The administration of bromides, combined with alkalies and
dilute hydrocyanic acid, is sometimes of service, but as a rule nitro-
hydrochloric acid, combined with nux vomica and chloride of
ammonium, is of more value. If anaemia is a conspicuous feature
of the case, full doses of ammonio-citrate of iron often remove the
symptom within a few days. In other instances injections of
soluble arsenic and iron are more valuable. The nausea of gastro-
ptosis requires the use of a firm elastic belt to support the dislocated
organ, while in carcinoma of the body of the stomach 10 gr-
ot chloretone or 10 min. of nepenthe administered before food
often relieves both the sense of sickness and the abdominal pain.
Pain. This symptom arises from so many different causes
that concise directions as to its treatment are almost impossible.
Genuine pain developing within half an hour of a meal usually
indicates some form of gastric ulcer, and requires for its relief a
liquid or semi-solid diet, abstinence from green vegetables, fruit
and alcohol, and a course of sedatives combined with alkalies.
When pain is deferred for two or three hours it is usually due to
hypersecretion of the gastric juice, secondary to ulcer of the
duodenum, gall-stones, or disease of the appendix, and must be
treated by a milk diet, alkalies, and sedatives, while the per-
sistent pain of carcinoma demands the administration of morphine.
The gastric discomfort that ensues from gaseous distension of the
organ must be treated on the lines laid down for that disorder.
Vomiting. This symptom usually ensues from one or other
of the following conditions : (1) Stricture of the cardiac orifice
from cancer or simple ulcer (regurgitation) ; (2) inflammation of
the stomach, acute and chronic ; (3) ulceration of the stomach or
duodenum, simple, cancerous or syphilitic ; (4) irritation of the
organ by hair-balls, bezoars, or other foreign bodies ; (5) strictures
of the pylorus or duodenum from carcinoma, simple ulcer, pyloro-
spasm due to hyperacidity, kinking, adhesions, or from central
constriction (hour-glass) ; (6) diseases of the brain and spinal cord,
such as meningitis, cerebral tumour, ataxia, etc. ; (7) reflex irrita-
tion, from peritonitis and other serous inflammations, irritation of
the gall-bladder, kidneys, ovaries, uterus )ti and intestinal canal in
374 SymptomaticTreatment of Disordered Digestion.
children ; (8) mechanical causes, such as violent cough in pulmonary
tuberculosis, irritation of pharynx, etc. The treatment of emesis
must depend upon its cause. Stenosis of the outlet requires a liquid
diet, systematic lavage and gastric sedatives, combined with bismuth
and antiseptics. The rejection of food that ensues from inflamma-
tions of the stomach is usually relieved by rectal alimentation in
the acute cases, and lavage, with whey or other form of liquid
food in the more chronic conditions. Cerebral and reflex emesis
requires the exhibition of sedatives, while ulceration of the organ
necessitates the special treatment for that complaint.
Waterbrash. This term is confined to the occasional eructa-
tion of a small quantity of neutral or alkaline fluid, which is usually
preceded by a cramping pain in the epigastrium. The fluid con-
sists for the most part of saliva which has been swallowed, mixed
with a neutral secretion of the stomach, and peptones. It is a
common symptom in certain cases of hyperacidity, in gastric
neurasthenia, and in the mixed gastric neurosis that occurs in
women about the climacteric. The most effective treatment consists
in the administration of bromides and a sedative in an alkaline
mixture, before meals, but in obstinate cases 5 gr. of compound
kino powder [U.S. P. 1^. Pulveris Kino, gr. 4 ; Pulveris Opii, gr. 5- ;
Pulveris Cinnamomi, gr. 1] with 10 gr. of carbonate of bismuth in
the form of a cachet answers well. When a strong neurotic
element exists, assafoetida, valerian, or valerianate of zinc are
usually prescribed between meals. Counter-irritation of the skin
of the epigastrium is often of use.
W. SOLTAU FENWICK.
375
ULCER OF THE STOMACH AND DUODENUM.
Prophylaxis. So many simple chronic ulcers of the stomach
commence in the acute manner that the utmost care should be
taken to promote healing of the disease at the earliest possible
moment. Excessive caution is therefore to be preferred to any
suggestion of negligence, and if doubt exists as to the presence
of an acute erosion or an open ulcer it is always advisable that the
patient should be treated as if he were the subject of the more
serious complaint. Chlorotic girls are especially liable to develop
the chronic form of the disease from comparatively slight abrasions
of the gastric mucous membrane, since anaemia is one of the prin-
cipal obstacles to the repair of the injured tissue, and every effort
should be made to improve the state of the blood as soon as the
gastric disease is recognised. The subjects of malaria are also unduly
prone to gastric ulcer, and a peculiar and obstinate form of the
disease not infrequently develops as the result of tertiary syphilis.
Continued pressure upon the epigastrium, such as results from
the use of ill-fitting corsets or belts or from occupations in which
a hard substance is constantly applied to the abdomen, may prove
the exciting cause of ulcer, while the frequent tasting and swallow-
ing of hot foods by cooks should be avoided as far as possible. A
severe blow upon the stomach not infrequently induces haemorrhage
into its mucous and submucous tissues, followed by necrosis, and
under these conditions precautionary measures in the form of rest
and diet not only tend to limit the damage, but also aid the pro-
cesses of repair.
General Treatment. Rest is essential to the cure of an ulcer
whether this is situated externally or in the stomach, and the impor-
tance of this curative measure cannot be too strongly insisted upon.
As a rule, a fortnight in bed should form a part of the systematic
treatment of the disease, while in cases where excessive pain or
vomiting suggest acute inflammation of the ulcer or the existence
of peritonitis at its base, the period of complete rest should be pro-
longed for three weeks or a month. Some authorities regard the
application of moist heat to the region of the stomach as an impor-
tant procedure, and either employ frequent fomentations or poultices
to the epigastrium, or use an oval tin receptacle for hot water which
is fixed in position by a belt. In chronic cases the frequent
376 Ulcer of the Stomach and Duodenum.
application of a small blister over the site of maximum tenderness
certainly produces a beneficial effect upon the symptoms, which
may be further enhanced by dusting the raw surface daily with
\ gr. of acetate of morphine. Occasionally excessive tender-
ness of the epigastrium rapidly yields to cupping or after the
application of a couple of leeches. Lavage is only employed when
the ulcer has produced stenosis of the pylorus or when concomitant
hypersecretion is associated with pylorospasm. Massage should
never be permitted, owing to the danger of perforation and
haemorrhage, and electricity is useless and usually gives rise to
pain.
Diet. Functional rest is of vital importance to an ulcerated
stomach, as no repair can take place unless its secretory activity
and its restless peristalsis are kept under control ; and since both
secretion and motility receive their greatest stimulus by the inges-
tion of food, the selection of an appropriate dietary is a matter of
the greatest moment. Complete rest can only be obtained by pro-
hibiting food by the mouth and maintaining the nutrition by means
of nutrient enemata. This procedure is particularly indicated when
severe pain is experienced, in cases where vomiting ensues after
meals or when haemorrhage has occurred. It is also advisable to
feed the patient entirely by the bowel during the period of physical
rest at the commencement of a systematic cure. In most instances
nutritive enemata solely are employed for eight or ten days, during
which time the patient is encouraged to wash out his mouth fre-
quently with an antiseptic solution and to suck a rubber teat with
the view of stimulating the secretion of saliva. If there is much
thirst he may suck a little ice from time to time or sip hot water.
Opinions concerning the relative value of various enemata vary
considerably, but there can be no doubt that the administration of
15 oz. to a pint of fluid every six hours is infinitely more valuable
than the old-fashioned injection of 2 oz. every three hours. The
method of injection has already been discussed (p. 326). As a rule,
simple peptonised milk answers every purpose, but some authorities
recommend peptonised milk-gruel, beef-tea mixed with raw eggs
and a little brandy, or milk containing pure glucose, powdered
peptones (somatose), or powdered casein (sanatogen, plasnion,
nutron). The latter ingredients should not be used in a concentra-
tion greater than 10 per cent. The following are examples of such
enemata : (1) Somatose, 300 gr. ; glucose, 300 gr. ; common salt,
16 gr. ; water, 7 fluid ounces. (2) The yolks of two eggs, 400 gr. of
pure glucose, 8 gr. of salt, and 10 fluid ounces of peptonised milk.
To supplement rectal feeding the subcutaneous injection of pure
Ulcer of the Stomach and Duodenum. 377
sterilised olive oil has been recommended, ^ oz. of which is
introduced beneath the skin night and morning. A sterilised
solution of pure glucose has also been used in a similar manner.
At the termination of the period of rectal alimentation, feeding
by the mouth is commenced. For at least a fortnight milk alone
should be employed, if possible, the quantity of which must vary
according to the requirements of each case. The value of milk in
cases of chronic gastric ulcer is of a threefold kind : it does not cause
mechanical irritation of the sore, it induces the least secretion of
gastric juice of any proteid food, and it fixes a large proportion of
the free acid. In these various ways it serves to relieve the sym-
ptoms of pain and acidity and also aids the repair of the ulcer. At
first from 2 to 4 oz. may be given every two hours, and subsequently
3 to 4 pints in the course of each twenty-four hours. The
majority of patients prefer the milk to be warmed to a temperature
of 70 F. Extremes of temperature must be avoided. If milk
produces a sensation of fulness, or if it be followed by acidity, it
is advisable to dilute it with lime-water or barley-water (a table-
spoonful to \ pint), or to add citrate of sodium in the pro-
portion of 2 gr. to the ounce. By these means the curd is rendered
flocculent and more easy of digestion. Both sterilised and boiled
milk are more readily digested than raw milk. In some cases it is
necessary to remove a portion of the casein before it can be tolerated,
either by humanisation or by the process of Gartner (fat-milk).
Buttermilk is preferred by some patients, but it is less nourishing
owing to its inferior percentage of fat and sugar. Whey is chiefly
of value when vomiting is troublesome. Koumiss and kefir find
many advocates, but they are somewhat difficult to obtain. Sour
milk prepared in the manner recommended by Metchnikoff rarely
agrees, owing to the frequent existence of hyperchlorhydria. Con-
densed milk and Horlick's malted milk occasionally agree when
every other variety gives rise to discomfort. When milk cannot be
tolerated in any form, the various meat essences and juices must
be employed, the most useful of which are freshly expressed meat-
juice, beef-tea, concentrated chicken, veal or mutton broth, Liebig's
beef extract, Valentine's meat juice, Brand's essence of meat, the
meat solution of Leube and Kosenthal or Fleiner's meat jelly, pre-
pared by boiling chicken or beef with calf's feet. About the tenth
day it is often possible to strengthen the diet by the addition of
eggs and farinaceous materials. Wheaten flour boiled with milk
is usually very acceptable, while tapioca, rice, grated biscuit, toast,
and bread and milk are easily digested. Sanatogen, somatose,
nutrose, plasmon, and such semi-digested foods as those of Nestle,
378 Ulcer of the Stomach and Duodenum.
Savory and Moore, or Benger, may also be allowed. At the begin-
ning of the third week of the treatment, the diet is further increased
by the addition of boiled calf's brains, boiled thy m us, boiled and
finely-minced chicken or pigeon, scraped raw beef, boiled calf's feet
and oatmeal. At the end of six weeks the patient is permitted to
take minced broiled beef, raw ham, white fish which has been passed
through a sieve, mashed potato, cauliflower and bread that has been
twice baked, while after the expiration of three months the dietary
may include broiled chicken, pigeon, venison, underdone roast beef,
sweetbreads, tripe, soups, souffles, etc. Uncooked vegetables, fruits,
pastry and alcoholic liquors must be prohibited for many months.
Lenhartz has suggested a concentrated egg-albumin diet which
has received considerable support. On the first day of the treat-
ment the patient is given 7 to 10 oz. of iced milk in spoonful doses
and three or four beaten eggs. The amount of milk is increased
each day by about 3 oz. and the number of eggs by one, so that at
the end of the first week the patient receives about 30 oz. of milk
and eight eggs each day. These are continued in the same
daily amounts for another week. On the sixth day 1 oz. of raw
minced meat is also usually allowed, the quantity being doubled the
following day and subsequently gradually increased. In the third
week of the treatment a mixed diet is resumed.
Medicinal Treatment. At the present time there is no drug
which can be regarded as a specific for ulcer of the stomach or duo-
denum. It is true that in the somewhat rare examples of syphilitic
ulceration, a prolonged course of iodides and mercury not only
relieves the severe pain and other symptoms but also appears to cure
the disease, while in those that are associated with chronic malaria,
injections of arseniate of sodium sometimes appear to produce an
equally satisfactory result ; but with these exceptions the treatment
of ulcer of the stomach or duodenum is almost entirely sympto-
matic. The administration of horse serum by the mouth in doses
of 25 cc. each day has recently been advocated as a cure of the
disease, and there can be no doubt that the serum, like other
albuminous fluids, does in some measure relieve the pain ; but in
several cases that have come under my notice, in which the disease
was reputed to have been cured by this method, no indication of
healing was discovered at subsequent operation. It is usually
held that repair of an ulcer is aided by reduction of the gastric acidity
and the protection of the surface of the sore. The hyperchlorhydria
which usually accompanies a chronic ulcer may be allayed by
various drugs which neutralise an excess of free acid, of which
the most reliable are the alkaline bicarbonates, prepared chalk,
Ulcer of the Stomach and Duodenum. 379
the salts of magnesia, and the solution of potash. The best
method, however, is to reduce the gastric secretion by methodical
depletion of the portal system by saline purgatives. In suitable
cases a course of waters at Carlsbad, Neuenahr, Marienbad, or
Vichy, is often followed by excellent results, but when a visit to
these watering-places cannot be undertaken artificial Carlsbad salts
of the following composition are a good substitute : Chloride of
sodium, 1 part ; bicarbonate of sodium, 2 parts ; sulphate of
sodium, 5 parts. A mixture of equal parts of phosphate of sodium
and the dried sulphate of sodium, of which a dessertspoonful or
more dissolved in a tumblerful of hot water is taken each morning
before breakfast, is more palatable than the former and equally
efficient. The saline should be continued for six weeks at least,
one or two liquid evacuations being procured each day. The salts
of bismuth have long enjoyed a great reputation for the treatment
of irritable conditions of the stomach, and in cases of ulcer they are
of special benefit, since the deposition of the salt upon the raw
surface forms a protective coating and not only allays pain but
promotes the processes of repair. Opinions are divided as to the
best preparation to employ, but personally I am greatly in favour
of the carbonate by reason of its antacid properties and its com-
patibility with alkaline bicarbonates. When it is desired to
protect the ulcer, much larger doses may be given than are usually
prescribed, and the drug should be administered in the following
manner. After the stomach has been thoroughly cleansed by
lavage, from 60 to 120 gr. of the carbonate or subnitrate of bismuth
are suspended in 6 oz. of warm water and the mixture poured
through the tube and washed down by 5 oz. of water. The
patient reclines upon his back for ten minutes after the completion
of the operation in order to allow the salt to be deposited upon the
inner surface of the stomach, and the excess of water is then
siphoned off. This treatment is repeated every morning for three
weeks, and subsequently each alternate day for another month.
When the passage of a tube is not considered advisable, the patient
may be instructed to drink a tumblerful of warm water containing
2 drachms or more of the bismuth salt in suspension each morning
before breakfast. These large doses of bismuth rarely induce
constipation, and no toxic symptoms ever ensue. Nitrate of silver
is an old remedy for gastric ulcer, which is much lauded by some
writers and condemned by others. In many cases it undoubtedly
relieves the pain, but its effects are uncertain and cannot be
predicted. It is most advantageously administered in solution,
^ gr. dissolved in 1 oz. of distilled water being given three
380 Ulcer of the Stomach and Duodenum.
times a day before meals, with the patient in the recumbent
posture. Subsequently the dose is gradually increased to 1 gr.
Every three weeks the drug is omitted for a week. It is less
useful in the form of a pill, each of which contains i gr.
Argyria is stated to be very rarely encountered. Three other
remedies, which are credited with direct healing powers, require
brief mention. Chloroform given in doses of 10 to 15 ruin., well
diluted with water, four times a day, has been recommended, and
the decoction of condurango bark is also regarded as a curative
agent, although this is extremely doubtful. Lastly, iodide of
potassium, especially when combined with mercury, is very
efficacious in that intractable and painful variety of ulcer which
develops as the result of syphilis.
Treatment of Symptoms and Complications. (1) Pain. In
most instances rest in bed, combined with local applications to
the epigastrium and a liquid diet, suffices to relieve the pain,
but if this symptom persists recourse must be had to sedatives.
Of these the most valuable is opium, the various preparations
of which have always been held in high repute. The drug is
often given in the form of the tincture, 5 to 10 min. [U.S.P. 3 to
6 min.] of which may be combined with an alkaline bismuth mix-
ture, but some practitioners prefer the solid extract (i gr.) adminis-
tered as a pill three times a day after food. If these preparations
produce nausea or loss of appetite, they should be omitted in favour
of the solution of morphia, nepenthe, or codeine. If the pain is
excessive, hypodermic injections of morphine may be necessary.
Among the other preparations of opium which are of service in par-
ticular cases are the compound ipecacuanha and kino powders, the
astringent properties of the latter being sometimes considered of
special service. Should it be desirable to conceal from the patient
the fact that he is taking opium the compound soap pill may be
prescribed. Among other sedatives that are sometimes employed
are cannabis indica, belladonna, cocain, hyoscyamus, bromide of
potassium, chloric ether and chloretone. Whichever drug is
employed it is always necessary to add an alkali to it in order to
neutralise the excessive acidity of the gastric juice which is such an
important factor in the production of pain.
(2) Vomiting. This symptom usually subsides after a few
days' rest in bed combined with a liquid diet and local applications.
Should it persist, an alkaline mixture containing carbonate of
bismuth, hydrocyanic acid, solution of morphine and 1 drachm of
glycerine may be given two or three times a day before food.
(8) Constipation. The bowels are usually regulated by the
Ulcer of the Stomach and Duodenum. 381
administration of Carlsbad or other salines previously described.
Drastic purgatives should never be prescribed.
(4) Tetaini. This rare complication of gastric ulcer is exceed-
ingly dangerous, since the attacks tend to recur at short intervals
and usually prove fatal. The passage of a tube, palpation of the
abdomen and even the use of a catheter is apt to induce a seizure.
Pending the performance of gastro-jejunostomy, it is advisable to
prohibit all food by the mouth and to feed the patient entirely by
the bowel.
The treatment of the other complications of ulcer, such as
haemorrhage, perforation, hypersecretion, cancer, has either already
been dealt with or is discussed under the surgical aspect of the
disease.
W. SOLTAU FENWICK.
3 82
THE SURGICAL TREATMENT OF ULCER OF THE
STOMACH.
FBOM the point of view of treatment, ulcers may be conveniently
divided into two classes, acute and chronic.
In acute ulcer the treatment should at first be medical, and above
all things it should be thorough ; but if after a month or six weeks
in bed on milk diet, followed by a further similar period of from two
to three months (in which only soft food, chiefly milk, is taken),
the patient is not free from digestive troubles, or if after a period
of freedom from symptoms relapse occurs, the question of surgical
treatment should be seriously considered. .
In chronic or relapsing ulcer, if medical treatment has not had
a fair trial, a rigid course of diet and rest as in acute ulcer should be
tried ; but in case of non-relief, or of relapse after temporary free-
dom from symptoms, surgical treatment should be urged.
Before surgical treatment is recommended it must be ascertained,
as far as possible, that the symptoms clearly and definitely point
to ulcer, and to this end a chemical as well as a clinical investigation
should be made, since operation is, as a rule, contra-indicated in
purely functional cases, and when carried out not only gives no
satisfaction, but tends to bring discredit on operative treatment.
Gastric ulcer is a much more serious disease than it is ordinarily
thought to be, and the profession has generally considered it more
amenable to medical treatment than the facts warrant.
The accuracy of the observations of Leube, who states that one-
half or three-fourths of all cases of ulcer will be cured by four or
five weeks of treatment, but if not cured in that time they will not
be cured by medical treatment alone, has been more than borne out
by the careful investigations undertaken by Dr. Bulstrode, at the
instigation of Mr. Mansell Moullin, in 500 cases of ulcer occurring
in the London Hospital from 1897 to 1902. He showed that 18 per
cent, died while under medical treatment, and these did not include
any of those patients admitted suffering from the serious complica-
tions of ulcer, such as pyloric stenosis, hour-glass contraction,
gastric dilatation, etc.
Of the 82 per cent, discharged as cured, Dr. Bulstrode calculated
that in at least two-fifths relapse would occur, for out of the 500
Surgical Treatment of Ulcer of the Stomach. 383
cases no less than 211 had suffered and been under treatment for
ulcer from one to four or more times previously.
The more recent observations made by Mr. Paterson and Dr.
Rhodes at the London Temperance Hospital on 158 consecutive
cases under the care of Dr. Soltau Fenwick and Dr. Parkinson are
still more striking, showing that the proportion of real cures in cases
of gastric ulcer, even after prolonged treatment by diet and rest in
hospital, is under 25 per cent.
Private patients amid more favourable surroundings, who can
rest longer and are more willing to bear restriction of diet over a
lengthened period, suffer less from relapses, though probably not
less from the dangers of the serious complications, haemorrhage and
perforation, occurring in the acute ulcer.
We may thus on ample evidence accept the fact that at least one-
lihird of all cases of ulcer of the stomach treated medically ultimately
succumb to the disease or to one of its many complications, and
that one-half or two-thirds of the cases that recover relapse. How
does surgical treatment compare with this ?
As surgeons we only see the worst cases that have failed to yield
to medical treatment, or cases suffering from relapsing or chronic
nicer ; yet, arguing from my own experience alone in over 500
operations of various kinds, such as pylorectomy, excision of the
ulcerated area, gastro-enterostomy, ligature of bleeding gastric
vessels, pyloroplasty, gastrolysis, etc., undertaken for ulcer or its
complications (excluding peritonitis after perforation), usually in
patients at the time very seriously ill, the total mortality has
been only a little over 3 per cent. ; but the actual risk of posterior
gastro-enterostomy in my private practice, the most frequent
operation in this class of cases, has only been 1*7 per cent., and the
patients completely relieved have been over 90 per cent.
Surgical treatment may be direct or indirect. By direct
treatment excision of the ulcer or of the ulcer-bearing area is
referred to ; by indirect treatment is meant gastro-enterostomy or
one or other of the modifications of pyloroplasty, operations the
aim of which is to relieve obstruction and to secure physiological
rest to the stomach.
Excision of the ulcer has been practised since 1881, when
Bydigier excised a large ulcer from the posterior wall of the
stomach, but his results and the experience of other surgeons
appear to show that the direct operation is more dangerous than
gastro-enterostomy. Moreover, gastric ulcers are frequently
multiple, and the excision of one ulcer will not cure the remaining
ones ; hence, as might be expected in practice, excision of ulcer has
384 Surgical Treatment of Ulcer of the Stomach.
been frequently followed by relapse. My own experience shows
that the dangers with modern technique need not deter us from
FIG. 1. Three stages of the operation of pyloroplasty.
excision if it is the better operation ; but as excision alone has
been followed by relapse in 20 per cent, of cases, it is advisable at
the same time to perform posterior gastro-enterostomy, in order to
Surgical Treatment of Ulcer of the Stomach. 385
secure physiological rest for the cure of any other ulcers that may
he present, and to prevent tension on the sutured area.
The operation of excising the ulcer-bearing area with the per-
formance of an independent gastro-enterostomy, as suggested by
Dr. Rodman, will probably in. the future be more frequently per-
formed, for, as I reported in my Bradshaw Lecture at the Royal
College of Surgeons, no less than 59'3 per cent, of cases of cancer of
the stomach on which I had operated gave a history of chronic ulcer.
Dr. Graham states that a pre-cancerous history of ulcer was
obtained in 36 per cent, of cases of cancer operated on in the
Rochester clinic, and a clear evidence of cancer development on
ulcer in 30 per cent, of the last forty partial gastrectomies. This
affords the most potent argument for the radical operation.
The indirect operations are pyloroplasty and gastro-jejunostomy.
Pyloroplasty, invented by Heinecke in 1886, and improved by
Mikulicz in 1887, although excellent in principle and safe and
simple in practice, has been followed in a large proportion of cases
by relapse. Although the symptoms may be relieved for months
or possibly years, the tying up of the pylorus by adhesions or the
subsequent contraction -of the cicatrix has ultimately in about a
quarter of all the cases led to relapse and the necessity of a
further operation. I have personally performed twenty-eight
pyloroplasties, with immediate success in all except one ; that died
a fortnight later from perforation. But of the twenty- seven that
recovered and remained well for various periods, in only sixteen
have the results been perfect, the patients being well from four to
eleven years later ; eight have required a subsequent operation ;
one was quite well for nine months, relapsed and died of acute
tetany some time later ; and two are said to have developed cancer
after six years and eighteen months respectively of good health.
Dr. W. J- Mayo, out of twenty-one cases, had seven that required
a secondary operation, and Mr. Rutherford Morison had four
relapses out of twenty-eight cases.
The modification of pyloroplasty, invented by Dr. Finney and
improved by Dr. Gould, of Boston, which gives a very wide
opening from the stomach into the duodenum, is a severe operation
when the pylorus and duodenum have to be extensively freed from
adhesions. Out of fifty-eight cases operated on by Drs. W. J. and
C. Mayo the mortality was 7 per cent., and of 112 cases collected by
Dr. Finney it was 9 per cent.
Dr. Munro, of Boston, says that the operation has not given him
good results and he has abandoned it, and Dr. W. J. Mayo thinks
it only available in certain selected cases.
S.T.- VOL. n. 25
386 Surgical Treatment of Ulcer of the Stomach.
Gastro-enterostomy, first performed by Wolfler, at the sug-
gestion of Nicoladini in 1881, in a case of obstruction of the
pylorus due to cancer, was first employed for the treatment of
ulcer by Doyen in 1893, and in the same year by Talma, who
independently came to the conclusion that spasmodic stenosis of
the pylorus was the chief factor in maintaining the hyperacidity
and unrest which prevent the healing of gastric ulcers.
It acts by affording a free outlet from the stomach, thus over-
coming stasis, relieving hyperchlorhydria, securing rest, and pre-
venting the tension induced by spasm of pylorus.
The after-results of the operation in ulcer of the stomach and
duodenum are usually really remarkable. The pain vanishes, food
can be readily taken and retained, vomiting ceases, in a little time
the anaemia improves, and as a rule the patient rapidly puts on
weight.
The ill-effects said to follow the operation can usually be avoided
by correct technique. I well remember in the early cases of
gastro-enterostomy the fear that was entertained of regurgitant
vomiting the so-called vicious circle a complication that I have
not experienced in my work since adopting the posterior operation
without a loop ; neither have I seen a case of closure of the
anastomotic opening nor any of the forms of internal hernia,
either through a loop or through a slit in the niesocolon, after any
of my operations. Pneumonia and other chest complications are
seldom seen if the operating-room is properly warmed and the
patient enveloped in a gamgee suit at operation, and placed in the
semi-recumbent position subsequent to operation.
Death from asthenia, w r hich at one time was to be feared after
stomach operations, when starvation for some days was adopted in
already enfeebled patients, is no longer a danger as feeding can be
begun immediately.
The danger of primary haemorrhage is avoided by continuous
suture embracing the margins of the opening between the two
viscera, though it is not always possible to avoid the dangers of
secondary haemorrhage from pre-existing ulcers.
The only complication that perhaps is unavoidable is somewhat
rare peptic ulcer of the jejunum, which arises from an excessively
acid gastric juice passing directly into the jejunum. I think the
condition may be avoided by making the opening sufficiently large
so that there can be no possibility of stasis, and by taking pains
to carefully diet and treat the patient medically for some time
after operation, so as to cure the hyperchlorhydria. It has been
clearly proved that this complication occurs more frequently after
Surgical Treatment of Ulcer of the Stomach. 387
the anterior operation, where there has been a long jejunal loop,
but whether occurring after the anterior or posterior operation it
is very serious, as perforation is very liable to occur.
The operation is performed by an incision about 4 inches in
length, f inch to the right of the mid-line above the umbilicus.
The transverse colon and the great omentum are brought out of
the wound, exposing the under-surface of the mesocolon and the
commencement of the jejunum. A slit is made through a non-
vascular portion of the mesocolon close to the duodeno-j-ejunal
junction ; a portion of stomach is dragged through the opening
and seized by rubber-covered clamps applied vertically. The
jejunum close to its junction with the duodenum is then seized
and the stomach and jejunum are brought into apposition. A
suture of Pagenstecher's thread is applied to unite the serous
surface of the stomach and jejunum ^ inch beyond the point
at which it is intended to open the viscera.
The stomach and jejunum are then opened by an incision of
about 2 inches, and the cut margins are united by a chromic catgut
suture, beginning at the left and carried round until it meets the
starting-point, when it is knotted off. This suture takes up all the
coats, and thus acts as a haemostatic suture. The Pagenstecher's
thread is then picked up and continued round so as to approximate
the serous surfaces beyond the mucous suture, and when it reaches
the starting-point it is also knotted off. The clamps are then
removed and two or three sutures are applied to the edge of the
incision in the mesocolon, uniting it to the point of apposition of
the stomach and jejunum, thus closing the slit and preventing
hernia. The omentum and transverse colon are then brought
down in front of the small intestines, and the abdomen is closed in
the usual way. After the operation the patient is propped up in
bed in the semi-recumbent posture, and feeding is begun as soon as
the patient has come well round from the anaesthetic and feels that
he can take water or albumen water, which is given in J-oz. doses,
at first hourly or every half- hour, and within a few hours in 1-oz.
doses. On the second day chicken broth may be given and tea or
coffee, and on the third day milk, jelly and junket, after which
a gradual advance is made to pulpy foods.
This is the ordinary operation of gastro-enterostomy, which has
been modified in various ways.
In certain cases, where adhesions are so extensive as to prevent
the posterior wall of the stomach being reached, or where growth
has invaded the posterior wall, it may be desirable to perform the
anterior operation, in which case the jejunum is picked up and
25-2
388 Surgical Treatment of Ulcer of the Stomach.
clamped at a point 12 to 15 inches from the duodeno-jejunal
flexure. This clamped loop is brought round the colon and fixed
horizontally to the lowest point of the anterior wall of the stomach,
in a way similar to that described under posterior gastro-enterostomy.
As regurgitant vomiting was found at times to follow the anterior
operation it was found advantageous to short-circuit the long loop
or to perform Koux's operation, which consists in dividing the
jejunum at about 9 inches from the duodeno-jejunal flexure, the
distal jejunal opening being fixed to the wall of the stomach, and
the proximal opening of the divided loop being anastomosed into
the jejunum about 3 inches below the stomach.
A. W. MAYO-ROBSON.
3*9
PERFORATING ULCER OF THE STOMACH.
THIS complication, which is estimated by various authors to occur
in from 12 to 28 per cent, of all cases of gastric ulcer, is fatal, unless
surgically treated, in 95 per cent. There can, therefore, be no room
for any difference of opinion as to the wisdom of operation in this
serious accident. As shown by the statistics drawn from a very
large series of cases, every hour's delay adds to the danger ; hence
it is of the utmost importance that an early diagnosis and imme-
diate operation should be insisted on.
In cases operated on within twelve hours of rupture the mortality
has been 25 to 28 per cent., in from twelve to twenty-four hours
63 per cent., in from twenty -four to thirty-six hours 86 per cent.,
and after thirty-six hours the mortality has been so great (95 to 100
per cent.) that purely medical treatment would seem to give an
equal chance of recovery.
The results of operation in late cases will probably always be
unsatisfactory, but I believe that the cases seen within twelve hours
of rupture should give much better results than those yet attained ;
my feeling is that the mortality should be brought down to from
5 to 10 per cent.
Excision of the ulcer is not necessary to success, since folding
in of the edges of the rupture, the careful application of a continuous
serous suture, and, if possible, the use of an omental graft, give
good results. I prefer to wash out the abdomen with hot normal
saline solution, and to drain above the pubes with the patient well
propped up in bed ; but, as shown by a series of cases operated on
by Mr. Littlewood in which lavage was not adopted, washing out is
not always necessary to success.
My rule is that, where the effusion is general, lavage should be
adopted, but where it is local a mere wiping out of the soiled area
only is necessary.
The important point is the actual damage to the peritoneum ;
for, if it has not lost its polish, it is capable of absorbing any
amount of effusion ; but if the peritoneum has lost its polish it
must be assisted by artificial drainage. Seeing that in one-third
of all the fatal cases other ulcers have been found, that in 20 per
cent, of cases of ruptured ulcer the perforations are multiple
(Finney), and that in a large proportion of cases recovering from
operation the patients have subsequently had other gastric
symptoms or even a second perforation, the question of the
390 Perforating Ulcer of the Stomach.
desirability of gastro-enterostomy at the time of operating for the
perforation is well worthy of consideration.
Of fifteen cases traced by Mr. Crisp English four suffered subse-
quently from gastric trouble ; and of thirty-five traced by Mr.
Paterson, one died from perforation within two years, two required
subsequent gastro-enterostomy, nine had definite symptoms of
gastric ulcer, and five had gastric symptoms. In Mr. Moynihan's
cases seven out of twenty-four required an immediate or subsequent
gastro-enterostomy.
The chief argument against gastro-enterostomy is the prolonga-
tion of the time of operation in cases already very seriously ill from
the perforation, but in cases not too ill to bear it the following argu-
ments are decidedly in its favour :
(1) Other ulcers present at the time of perforation will probably
be cured by the operation, and in case of ulcer at the pylorus the
effects of cicatricial contraction will be averted.
(2) If a second ulcer is on the point of perforation, such perfora-
tion will probably be prevented, as tension and pressure on the
stomach wall will be avoided.
(3) After gastro-enterostomy more secure healing of the sutured
ulcer is likely to occur, and there will be less likelihood of the stitches
giving way.
(4) It diminishes the risk of haematemesis occurring after
operation.
(5) It enables saline aperients to be given shortly after operation,
and so secures more efficient drainage of the peritoneal cavity.
(6) It permits earlier feeding than would otherwise be the case
had no gastro-enterostomy been done.
On all these accounts, therefore, it is important that, where the
patient's condition will permit of it, the question of a gastro-
enterostomy should be considered at the same time that the
perforated gastric ulcer is closed.
Preventive Treatment. Although the symptoms of ulcer may
be latent in about 20 per cent, of cases and only slight in others, yet
in fully 50 pei - cent, or probably more there are serious symptoms
of ulcer which should lead to very thorough medical treatment, or
that failing, to curative surgical treatment, before the onset of
perforation. So that, besides advocating early operation in case of
perforation, I think we ought to urge quite as strongly preventive
treatment, in other words, the curative treatment of ulcer, so as to
avoid the serious sequelae of perforation and haemorrhage.
A. W. MAYO-ROBSON.
SURGICAL TREATMENT OF ULCER OF THE
DUODENUM.
IF duodenal ulcer could be diagnosed early and with certainty,
the importance of a thorough course of treatment by diet and rest
might be the means of bringing about a cure of the condition. But
the facts that the symptoms are often comparatively slight or even
absent in a certain proportion of cases at the inception of the
disease, and that it is frequently difficult to say at first that the case
is not one of simple gastro-duodenal catarrh, result in the trouble
being seldom treated seriously until the symptoms have persisted
off and on for a long time, sometimes for many years, or until some
more severe attack or one of the serious complications leads to a
diagnosis being made. Then, perhaps, the patient will submit to
restraint in diet and to a course of medical treatment, which is, as
a rule, left off as soon as he is relieved, to be resumed again in a
half-hearted manner at each recurrence of symptoms, until the time
comes that the disease can no longer be dallied with ; and if com-
plications do not prove it, the patient grasps the fact that he is
seriously ill and must have true remedial treatment. I have seen
so many cases that have been treated medically off and on for
years, and which ultimately had to submit to surgical treatment
either for the disease or for complications resulting from it, before
obtaining real relief, that I sometimes wonder whether a patient
with chronic duodenal ulcer is ever cured by medical treatment
alone.
Lapeyre says that very few completely cicatrised ulcers have been
observed, but Perry and Shaw found evidence of repair, more or
less complete, in 50 per cent, of cases coming to autopsy, and in
several the cicatrix had produced stricture of the duodenum.
Fortunately surgical treatment offers not only a means of relief,
but of cure, in this otherwise troublesome and dangerous disease.
Surgical treatment may be either direct or indirect. By direct
treatment I mean excision of the ulcer or an infolding of the
duodenal wall at the site of the disease. By indirect treatment
I mean a gastro-enterostomy with or without occlusion of the
pylorus.
Except in some of my very early cases in which a duodenal ulcer
was associated with ulceration and thickening of the pylorus, and in
392 Surgical Treatment of Ulcer of the Duodenum.
which I excised the ulcerated area, or while performing pyloroplasty
took the opportunity of excising the ulcer, I have not attempted the
direct treatment of duodenal ulcer ; moreover, in these cases,
though temporary relief was given, subsequent operative treatment
was required, so that my experience does not lead me to favour in
any way the direct treatment of this condition.
My results after the indirect method have been so satisfactory,
whether looked at from the immediate or ultimate issues, that I can
see no need to consider the direct operation further, especially as
there seems to be no evidence to prove that carcinoma develops
in the healed scars of duodenal ulcers, since cancer of the
duodenum is very uncommon, while ulcer is by no means rare.
My experience leads me to express a very decided opinion that
the operation of posterior gastro-enterostomy is the treatment for
duodenal ulcer. It acts by diverting the food from the ulcerated
region and so relieving the ulcer from the irritating effects of the
acid stomach contents ; the ulcer is thus enabled to heal smoothly,
and in addition the associated conditions of hyperchlorhydria,
spasm of the pylorus, and dilatation of the stomach are relieved.
The relief is immediate, and within a very short time the patient
can, as a rule, take his food without pain or discomfort, and without
the subsequent flatulency and other distressing symptoms usually
associated with duodenal ulcer.
Not only are the immediate results good, but the ultimate issue
is very satisfactory, as I know by the communications I have had
subsequently from my patients or from the medical men with whom
I have been associated in their cases. But my information of the
after-progress of some of these cases has been even more direct,
for in quite a number of cases the operations have been on
medical or other professional men whom I have had the oppor-
tunity of seeing subsequently and knowing in their ordinary social
life.
The method I always adopt in performing gastro-jejunostomy is
the posterior operation, in which the stomach is united to the jejunum
as near to the duodeno-jejunal flexure as can be conveniently
managed ; clamps are always used ; the opening is made sufficiently
large (about 2 inches), the margins of the opening are united by two
continuous sutures, an outer of Pagenstecher's thread taking up the
serous coats a little way from the margin, an inner of chromic catgut
taking up the whole thickness of the cut walls of the stomach and
intestine.
If the duodenum is free from adhesions and can be easily handled
there is an advantage in infolding the ulcerated area and occluding
Surgical Treatment of Ulcer of the Duodenum. 393
the pylorus. Frequently this is impracticable on account of adhe-
sions and from the position of the ulcer, and in such cases gastro-
enterostomy alone may be relied on.
Subsequent to operation the patient is always placed in bed well
propped up, in fact almost in the sitting posture, a position which I
have found by long experience is not only the most comfortable to
the patient, but is one that avoids chest complications. It assists
thoracic breathing, takes off pressure from the heart, assists drain-
age from the stomach into the jejunum, as a rule prevents vomiting
subsequently to operation, and by giving the patient a sense of well-
being it hastens convalescence, and enables him to be moved on to
the sofa within a fortnight of operation.
In peritonitis from ruptured duodenal ulcer this position serves
another purpose, that of draining septic fluids from the diaphrag-
matic area towards the pelvis, where they can be more easily drained
away, or if not removed, can be more safely disposed of by the
efforts of nature.
During operation the patient is enveloped in a cotton-wool suit
made by the nurse of gamgee tissue, thus preventing chilling of
the extremities and avoiding shock ; this suit is of use subsequently
by keeping the patient warm when propped up in a position in
which it is difficult to keep him covered by the bedclothes.
I think the value of this care to avoid chill during operation is
shown by the almost total absence of chest complications in my
cases as compared with their frequency in many of the Continental
clinics, in some of which, to my knowledge, the patient suffers much
exposure before and even during operation.
The administration of saline fluid per rectum subsequent to opera-
tion in large quantities is of great service in relieving thirst and in
supplying fluid to keep the blood-vessels full until the patient can
take sufficient fluid and food by the mouth. Feeding by the mouth
is begun as soon as the nauseating effect of the anaesthetic has
passed off, so that by the evening of the day of operation the patient
is taking 1 oz. of albumen water or other bland fluid every hour,
and on the day following 2 oz. at hourly intervals.
The administration of food at frequent intervals is advisable for
some time after operation in order to absorb and neutralise the
irritating acid of the gastric juice.
For some time only soft food is allowed, such as fish, mashed
potatoes and gravy, jellies, pounded meats, etc., and between each
meal I usually advise that some milk and lime-water should be
given to take up the excess of acid; this saves discomfort and
prevents harm should any of the stomach contents pass through
394 Surgical Treatment of Ulcer of the Duodenum
the pylorus. If the pulse is feeble during or after operation, sub-
cutaneous injections of solution of strychnine in 5-min. [U.S.?.
strychnine hydrochloride gr. ^V] doses are useful, and if needful
they are repeated every four or six hours for a time.
I have thus far spoken of gastro-enterostomy as an operation for
the relief and cure of uncomplicated duodenal ulcer, but the same
operation is the one indicated in many of its complications, such as
haemorrhage, obstruction from adhesions, or from contraction of the
lumen due to cicatrisation of ulcer, and for dilatation of the
stomach secondary to ulcer. It may also be called for as a primary
or secondary procedure in perforation of duodenal ulcer, and as a
secondary measure in abscess or in extensive adhesions following
on perforation.
A. W. MAYO-ROBSON.
395
PERFORATING ULCER OF THE DUODENUM.
IT is universally accepted that early operation is as desirable in
case of perforation of a duodenal as of a gastric ulcer, and that time
has more to do with success or failure than has any other element,
if ordinary skill is used. If the extravasation occurs through a
small leak, the peritoneal soiling will be localised to the right side
of the abdomen, and, as, at first, effusion is only slightly septic, a
vertical incision through the right rectus, about 1 inch to the right
of the mid-line, which will enable the right kidney pouch to be
cleansed and the opening in the duodenum to be sutured, is only
necessary. Drainage in such a favourable case is not abso-
lutely necessary, though personally I think it is safer to drain.
Irrigation of the peritoneal cavity under these circumstances is
undesirable, and excision of the ulcer is not called for. The edges
of the perforation should be turned inwards, and a Lembert con-
tinuous suture, or several interrupted peritoneal sutures, or a
purse-string suture according to the size of the opening, must be
applied, and, if possible, an adjoining piece of omentum should be
stitched lightly over the line of suture.
If the perforation is a large one and the abdomen has been
flooded with the stomach and duodenal contents, the incision over
the right rectus will still be called for to remedy the rupture ; but,
in addition, a small incision should be made over the pubes just
large enough to admit a tube that will reach to the bottom of
Douglas's pouch in the female, and to the bottom of the pouch
between the rectum and bladder in the male.
Now comes the question of irrigation with hot saline fluid.
Man}- surgeons do not advise it, and say that they get better results
without it. Murphy is very emphatic on this point. I must confess
that I have only seen good to result from saline irrigation if applied
judiciously in such cases, for, with the patient in the half-sitting
posture, all the fluid gravitates to the pelvis and escapes through
the tube, bringing with it any foreign matter that has entered the
peritoneum. The viscera should not be handled, and any rough
swabbing or wiping out of the abdomen should on no account be
done.
If the patient is in fair condition at the time of operation, and
the peritoneum has not lost its polish, the prognosis is good.
396 Perforating Ulcer of the Duodenum.
If the endotheliurn of the peritoneal sac has been damaged, and
the intestines are distended from paralysis of the muscular coat, the
duodenal opening should be rapidly repaired, irrigation with hot
normal saline solution be thoroughly but quickly performed, and
free pelvic drainage adopted.
In exceptional cases seen late, after distension has supervened, it
may be advisable to bring out a loop of distended small gut and
incise it transversely so as to get rid of flatus and fluid faces in
order to relieve the distension, afterwards suturing and returning it ;
and while the patient is under the anesthetic the stomach tube
should be passed and gastric lavage effected.
The patient must afterwards be well propped up in bed so as to
favour drainage, and must have saline fluid administered by the
rectum in large quantity after the manner recommended by Murphy.
Although the prognosis in such a late case is not good it is not
hopeless ; the danger will have been due to the delay and to the
absorption of toxins, and if the patient can be kept going for a time
until the poison is washed out of the blood he may recover.
In case of perforation leading to localised suppuration it is
important not to delay operation lest the abscess burst secondarily
into the peritoneum, or if extending upwards burst into the pleura
or pericardium.
In such cases the abscess must be opened and drained, but it is
neither necessary nor wise to look for the perforation, which is often
very small and may give no further trouble ; moreover, to search
for a perforation under such conditions would involve danger of
separating adhesions and spreading infection.
The question of performing gastro-enterostomy in perforated
duodenal ulcer is important, and not always easy to decide. In
some cases, when the patient is seen shortly after perforation and
is in good condition, a gastro-enterostomy will lead to a more rapid
repair of the ulcer, and may not seriously add to the shock ; but as
a rule the added shock of an extended operation is not advisable,
and I prefer to do the gastro-enterostomy as a subsequent operation
if necessary. In abscess following on perforation I think this course
ought always to be followed, and in my experience this has proved
satisfactory.
Dr. W. J. Mayo in speaking of the subject says : " In three out of
ten cases of acute perforation we made a gastro-jejunostomy at the
same time, but generally speaking it is safer to do this as a second
operation if necessary." Out of the ten cases four died.
During the past two or three years a considerable number of
cases of operation for perforated duodenal ulcers have been recorded
Perforating Ulcer of the Duodenum. 397
by individual surgeons, but owing to the limited number of cases
coming under the notice of any one surgeon a statistical estimate is
almost useless unless a considerable number of cases from various
sources can be collected and analysed together.
Out of 155 operations for acute perforating duodenal ulcer (of which
fifty-two recovered and 103 died, a mortality of 66 per cent.), sixty -one
were operated on within twenty-four hours of rupture, with thirty-
eight recoveries and twenty-three deaths (a mortality of 37'7 per
cent.), whereas of sixty-three cases operated on later than twenty-four
hours after rupture there were eleven recoveries and fifty-two deaths,
(a mortality of 82'5 per cent.). Of the remaining thirty-one cases,
in which the time of operation was not stated, but in which the
time of operation was probably over twenty-four hours after
rupture, three recovered and twenty-eight died (a mortality of 90*3
per cent.).
One point is clearly brought out on analysis, and this is the
fact that the earlier operation is performed after rupture the better
the result.
A. W. MAYO-ROBSON.
398
SEA-SICKNESS.
A LIGHT diet should be taken before embarking. Fresh air is a
powerful element in the prevention of the nausea and vomiting,
and the voyager should remain on deck if possible, the temperature
of the body being maintained by wrapping in shawls and the use
of a hot bottle applied to the feet. The face may be bathed with
eau-de-Cologne and water, and the vapour of ammonia or smelling
salts inhaled through the nose. An effervescent mixture contain-
ing an alkali, valerian and chloroform water finds favour with
many people, and may be given every two hours, while others
prefer the solution of bismuth and hydrocyanic acid. In bad cases,
ice should be sucked at intervals and iced champagne be given when
symptoms of collapse develop. If such patients are tolerant of
opium, 15 min. of the solution of morphine [U.S.P. gr. -j^ of
morphine hydrochloride] or a hypodermic injection will some-
times stop the incessant retching. Among other remedies,
hydrochlorate of cocaine, antifebrin, nitro-glycerine and chloral,
have been advocated. Of recent years chloretone has been used
with great success and appears to control sea-sickness in about
80 per cent, of all cases. Ten grains enclosed in gelatine capsules
are taken when the traveller goes on board, and are repeated at the
end of two hours. Should nausea ensue at any time, another dose
may be given. The general dietary to be observed should include
soups, broths, toast, fish, chicken, and milk puddings, but alcoholic
liquors, cheese, pickles, oily sauces and greasy meats must be
avoided. A saline purge each morning, with an occasional dose of
grey powder or mercurial pill at night, is invaluable.
W. SOLTAU FENWICK.
399
TETANY OF THE STOMACH.
To make a distinction between the severe and fatal form of
gastric tetany and the tetanoid spasms associated with gastric
dilatation is purely arbitrary, and it seems more rational to include
all cases of tetany and tetanoid spasms dependent on stomach
diseases under the term of " gastric tetany."
Moreover, to conclude that gastric tetany is almost necessarily
fatal, as is insisted on in certain medical works, is to my mind a
great mistake, as an extensive experience of the disease, both of
the mild and severe varieties, has convinced me that under efficient
surgical treatment hardly any case is hopeless.
The treatment of gastric tetany is essentially surgical, as I had
the privilege of first pointing out in a paper in the Lancet on
November 26th, 1898, when several cases were given as examples of
successful surgical treatment. Since that time my experience has
increased, and out of a large number of cases in which I have operated
I can state definitely that in no single case has drainage of the stomach
by gastro-enterostomy failed to give relief. Moreover, at the same
time that relief to the tetany is secured, a cure of the disease producing
it is accomplished, as in almost all cases there is a grave mechanical
obstacle to the onward passage of the food. It is this obstacle which
causes dilatation and hypertrophy, to be later followed by stasis and
fermentation of the contents of the stomach. To relieve this
obstruction and to do away with the stagnation of the stomach
contents surgical measures are necessary. In simple cases gastro-
enterostomy will be the method of choice, in malignant cases a
partial gastrectomy or gastro-enterostomy as circumstances dictate.
In hour-glass stomach, gastro-gastrostorny, combined with gastro-
enterostomy performed in the distal pouch, will as a rule be the
suitable operation.
A. W. MAYO-ROBSON.
400
BENIGN TUMOURS OF THE STOMACH.
THOUGH simple tumours of the stomach adenoma, lymph-
adenoma, lipoma, lipo-myoma, myoma, nbro-inyoma, and cysts
are rare, they are clinically important, in that they may simulate
cancer or sarcoma, and may produce pyloric stenosis or may assume
importance from their volume, which is at times considerable.
The first stage of any operation for the treatment of a simple
tumour inside the stomach will be exploratory gastrotomy. If the
tumour is attached by a pedicle it must be divided and the base
ligatured. If the attachment is sessile it will be advisable to
excise that portion of the stomach wall. The incision must be
well beyond the growth, and the healthy edges of the gap must be
brought together in such a way as to avoid leaving a stenosis.
If the growth is at the pylorus it may be necessary to perform
pylorectomy, then to close the open ends of the stomach and
duodenum respectively, afterwards completing the operation by the
performance of gastro-enterostomy.
Pedunculated tumours of large size usually myomas or fibro-
myomas may hang as pendulous masses from the stomach and
may be removed by simple ligature of the pedicle without opening
the stomach cavity.
Cysts of various sizes both simple and multilocular have been
found in the gastric wall; they may be treated by tapping or
drainage, or by excision, according to their size or situation.
A. W. MAYO-ROBSON.
VOLVULUS OF THE STOMACH.
VOLVULUS of the stomach is a rare condition that can only occur
when there is gastroptosis.
The treatment consists in immediate laparotomy with untwisting
of the volvulus, and in order to prevent a recurrence of the
condition the performance of Beyear's or Eve's operation (see
p. 824).
A. W. MAYO-ROBSON.
401
DISEASES AND AFFECTIONS OF THE
INTESTINES.
APPENDICITIS.
INDICATIONS FOR OPERATION.
THE treatment of appendicitis is entirely a surgical problem,
and in the great majority of cases operation is the only rational
procedure. In this article the general principles of treatment will
be discussed, but individual cases vary so considerably that each
must be carefully judged on its merits.
Personally I believe that every case of appendicitis should be
treated by operation, unless there is some strong reason to the
contrary ; that acute cases should be operated upon as soon as
possible after the diagnosis has been made, unless the symptoms
are obviously subsiding ; and that the appendix should be removed
in all cases in which there is evidence of past or of chronic
inflammation, unless there is some condition in the patient's general
health which contra-indicates operation. An unbiassed study of
available statistics will show that expectant treatment is associated
with a higher mortality than the policy of immediate operation,
and that the mortality of appendicitis is a mortality <>j ' <l<-lay. A. study
of the work in any large hospital where cases of appendicitis in all
stages are constantly being admitted will certainly lead to the same
conclusions. Nearly all of the patients who die of this disease might
have been saved if operation had been performed earlier, and a
large proportion of them have had previous attacks and could have
had their appendices removed in the quiescent interval without
incurring any risk.
Indications for treatment must be based as far as possible upon
ascertainable facts, and the following series of cases collected by
my late house surgeon, Mr. Gilbert Humphry, illustrates certain
points in the frequency and mortality of the various forms of
appendicitis. It must be remembered that appendicitis as seen in
hospital practice is a more severe - disease than that met with
amongst better-class patients, for, in hospital, mild cases seldom
come under notice, and a large proportion of those admitted have
already been ill for several days.
S.T. VOL. ii. 26
402
Appendicitis.
One thousand Consecutive Cases admitted into the Surgical Wards
of St. George's Hospital bettveen 1905 and 1910.
1905 (November and December)
1906
1907
1908
1909
1910
28 cases
167
158
213
206
228
1 death
15 deaths
14
Total
1,000
70
Analysis of Cases.
Mortality.
Per cent.
Acute without Abscess ....
272
10
3-6
Acute with Abscess : Appendix removed .
209
18
8-6
Acute with Abscess : Appendix not removed
80
11
13 7
Acute with General Peritonitis
35
24
65-6
Sub-acute .......
86
Chronic and Quiescent ....
246
1
4
No operation ......
72
6
8-3
1,000
70
The difference between the mortality in cases of abscess in which
the appendix was removed, and in those in which the appendix was
not removed, is mainly explained by the fact that the latter class
included a larger proportion of serious cases. Of the cases not
submitted to operation, the non-fatal ones were practically all
sub-acute or quiescent cases, in which operation was not considered
necessary or was refused : in the fatal cases the patients were too
ill for operation, and all but one of them died shortly after
admission.
In discussing the indications for operation in detail, it is most
convenient to divide the cases into the groups in which they are
met with clinically.
(1) Acute Cases seen within Twenty-four Hours of the Onset
of Symptoms. There is no shadow of doubt that the ideal time
for operation is during the first twenty-four hours of the attack,
and when the condition is diagnosed during this period and
operation can be arranged, the appendix should be removed at
once. This advice applies especially to patients under twenty
years of age.
The reasons for urging operation at this stage are the
following :
Appendicitis. 403
(//) It is the safest course for the patient. This is obviously the
strongest argument. All statistics show that the mortality of
operation^ ]'rf< inin'iJ on the first daii in eery *>tt<i!/, mnl considerably
less titan of those performed at any later time during the attack : at
this stage the inflammatory mischief will have involved the
peritoneum but very little, and complications will not have occurred.
In the St. George's Hospital series, twenty-eight patients were
operated upon on the first day of the attack, and twenty-seven of
these recovered.
Prognosis is impossible in appendicitis : even those who have
had extensive experience cannot tell by the clinical symptoms what
the condition of the appendix is, or whether the attack is likely to
be a mild or severe one. At the onset of symptoms there may
already be perforation or gangrene : cases which are apparently
mild may at any moment suddenly develop signs of widespread
infection.
(b) A comparatively small incision is adequate, and drainage is
often unnecessary, so that the abdominal wall is not weakened.
(c) The shortest convalescence follows this procedure, and the
patient is spared the pain and discomforts of the days of waiting
and the long illness which so often follows a late operation.
(d) The need for a subsequent operation for removal of the
appendix, for ventral hernia, or for adhesions and their results, is
obviated.
Some writers point out that it is seldom possible to operate as
early as this ; but as the importance of early operation is recognised
by the profession and the public, it will become a practicable
proceeding in an increasing number of cases. Most cases of
perforated gastric ulcer are operated upon within twenty-four hours
of perforation, and there is no reason why it should not be possible
to treat appendicitis in the same way. The practitioner should be
prepared to have a case of appendicitis operated upon within a few
hours at any time when such a case arises in his practice, and a
surgeon should have his arrangements so planned that no delay
occurs when he is summoned to such a case.
(2) Acute Cases seen after the First Twenty-four Hours of
the Attack. Each case calls for the most careful judgment. In
the great majority of cases immediate operation is indicated, and
operation should not be postponed without very definite reasons.
The medical attendant should ask himself " irhat reasons are there
to justify delay ! " realising that to countenance delay is to assume
a great responsibility, and that this course frequently leads to
difficulties, and is responsible for most fatal results. As stated
26-2
404 Appendicitis.
above, the mortality of appendicitis is a mortality of delay, and
those who advocate expectant treatment will inevitably meet with
cases in which they will regret it. A critical study of published
statistics shows indisputably that the risk of acute appendicitis
increases with each day of delay.
The morbidity of the disease must also be considered ; late
operations involve prolonged illnesses, grave complications, and
unnecessary weakening of the abdominal wall. Moreover, when
large abscesses are allowed to form, it may be expedient to
drain the abscess without removing the appendix, so that the patient
is faced with the risk of further trouble from the appendix, or the
inconvenience of a second operation.
Any one of the following symptoms is a definite indication for imme-
diate operation : Pain which is severe or of increasing severity, or
which is spreading ; pain on micturition or defaeeation ; a rigor ;
persistent vomiting ; any increase in the pulse-rate; a fall of tempera-
ture unaccompanied by a corresponding fall in the pulse-rate ;
distension.
If the symptoms are obviously subsiding when the surgeon first
sees the patient, delay is usually justifiable ; but these cases must be
watched most carefully, and unless the improvement is continuous
and rapid, operation is the wisest course. The cases which are
most likely to mislead are those in which a temporary improve-
ment occurs after the first two or three days of the attack, and
is followed by a secondary rise of temperature denoting abscess
formation.
(3) Cases in which the Symptoms and Signs point to the
Presence of Abscess. In all of these cases I feel strongly that
operation should be performed at once, and this opinion accords
with the general principle that any abscess should be opened as soon
as it is diagnosed.
Some recommend delay in order that the abscess cavity may
become more firmly shut off by adhesions, or may become adherent
to the abdominal wall, and so the risk of infecting the general peri-
toneal cavity by earlier operation may be avoided. This risk, how-
ever, is a very small one, if the general cavity is carefully protected
with gauze packing, and if the abscess cavity is properly opened
and drained. The risk is decidedly smaller than that of leaving pus
inside the abdomen ; moreover, experience shows that the longer
an abscess has lasted the greater are the difficulties and dangers in
the management of the case, removal of the appendix becomes
more difficult each day, and it may become the wisest course to
leave it.
Appendicitis. 405
If an appendix abscess is allowed to remain unopened, the
following risks are incurred : (a) Rupture of the abscess into the
general peritoneal cavity ; (b) steady enlargement of the abscess
towards the pelvis a process which may occur without causing
external signs, and which considerably adds to the seriousness of
the case ; (c) rupture into the bladder ; (d) infective thrombosis
of the mesenteric, iliac, or portal veins ; (e) portal pyaemia, liver
abscess, septicaemia ; (/) sudden exacerbation of symptoms with
Spread of the peritonitis, in which case hurried operation becomes
necessary under far less favourable conditions.
(4) " Fulminating " Cases. These cases are marked by sudden
onset, very acute symptoms, severe pain and quick pulse ; they are
quickly fatal unless they are operated upon at once. Such cases,
therefore, obviously demand operation at the earliest possible
moment, provided that the patient's condition allows it. Special
attention should be directed to the fact that the temperature is often
normal or subnormal in these cases.
(5) Cases with Symptoms of General Peritonitis. For
practical purposes, the only hope for these cases is immediate
operation. It is true that cases of apparent general peritonitis
have recovered under expectant treatment, or have improved to the
point that signs have localised, and a later local operation has been
successful ; such cases are rare, and should not influence the
surgeon to postpone operation.
(6) Desperate Cases. When the surgeon first sees the patient
his condition may appear almost hopeless. This unfortunate state
of affairs is met with most often in children, and in those who
have been treated with morphia and purgatives. Every effort should
be made to produce some improvement in the general condition,
so that rapid opening of the abdomen may be possible. A large
rectal injection of saline and brandy should be given, and the
body temperature should be raised by hot-water bottles and warm
blankets. The condition of the pulse should be carefully watched,
and if improvement occurs, an incision is made, preferably under
local anaesthesia, through the lower part of the right rectus muscle,
and free drainage is instituted. Under this treatment cases will
occasionally be saved which are otherwise quite hopeless.
(7) Acute Cases in Children. It should, be an invariable
rule to operate as soon as the diagnosis has been made.
Acute appendicitis in children is a very severe disease, with a
high mortality ; the large amount of lymphoid tissue in a child's
appendix, the poor development of the ornentuin, and the lower
resistance to infection, are factors which account for this high
406 Appendicitis.
mortality. The condition is often unrecognised during the first
three or four days of the attack, and complications such as sub-
phrenic abscess and empyema are much more frequent than in
adults.
Statistics show very clearly that the mortality is small when cases
are operated upon during the first twenty-four hours of the attack,
and that it rises rapidly with each day of delay.
Cases of Appendicitis in Children, ten years of age and under,
at St. George's Hospital, 1904 to 1910.
Total number of cases . . .88
Males 61
Females 27
Youngest patient . . . . .14 months
Acute cases 79
Deaths ....... 15
Mortality in acute cases . . .19 per cent.
Two cases were not operated upon, one being moribund when
admitted.
(8) Appendicitis in Elderly Patients. Appendicitis in elderly
patients is usually insidious in onset, and the clinical symptoms
are relatively mild : the rise in temperature may be quite moderate.
As a result, operative treatment is often considerably delayed, and
the mortality of these cases is high. In the St. George's Hospital
series there were twenty-six patients over fifty years of age ; twenty-
two of the cases were acute and seven died, a mortality of 31 '8 per
cent.
Operation, therefore, should be performed as early as possible,
before the occurrence of complications, unless there is some
co-existing disease which strongly centra-indicates operation.
(9) Appendicitis and Pregnancy. Appendicitis during preg-
nancy involves great risk to the mother, and frequently causes
abortion. As Kelly says : " The danger involves two lives and the
entire happiness of a family."
Acute cases demand immediate operation, for the mortality is
high, and increases with each day of delay. Cases in which an
abscess has formed are especially serious, for abortion usually occurs,
and the contraction of the uterus, which often forms part of the
abscess wall, causes widespread diffusion of the infective material.
On the other hand, prompt operation usually saves the patient and
leaves the pregnancy undisturbed. The risk of miscarriage is small,
if care is taken that the necessary manipulations are as gentle as
Appendicitis. 407
possible, that the uterus is not touched or dragged upon, and that
drainage tubes and gauze do not pass down to its neighbourhood.
Sub-acute cases may usually be treated expectantly : the inflam-
mation generally subsides without influencing the course of the
pregnancy. In most cases it is wiser to remove the appendix soon
after the subsidence of a sub-acute attack, rather than to incur the
risk of a more severe attack during the later months of pregnancy.
If appendicectomy is decided upon, the best time for its performance
is between the fourth and seventh months, preferably in the latter
part of the fourth month. If operation is carefully carried out, the
risk of miscarriage is slight.
A patient who has had appendicitis and who is likely to become
pregnant should most certainly be advised to have her appendix
removed whilst it is still quiescent, owing to the grave risk which
she will run if an attack should occur during pregnancy. On the
other hand, if she is already pregnant when advice is asked, opera-
tion is not, as a rule, to be recommended, unless there are definite
signs that the trouble is not quite quiescent. Such a patient must
be kept under careful observation, and should be instructed to send
for her medical attendant at once if she should feel pain in the right
side of the abdomen (s<v also Medical Diseases in Pregnancy,
Vol. IV.).
(10) Sub-acute Cases. Very great caution is needed in these
cases. There are undoubtedly many cases of appendicitis which,
though definite, are so mild that immediate operation is obviously
not called for ; cases in which the temperature does not reach 100,
and the pulse-rate does not exceed 90, and in which the physical
signs are slight and localised. Most of these cases may be treated
expectant^, but they require very careful watching ; if decided
improvement has not occurred within forty-eight hours, operation
should be performed at once.
As a corollary to this, all cases in which the temperature exceeds
100, or in which the pulse-rate reaches 100, should be regarded as
acute.
(11) The Quiescent Appendix. Patients who have had one
definite attack of appendicitis should be advised to have their
appendix removed, unless there is some centra-indication in the
general condition. It is now known that recurrent attacks occur
in the majority of cases, and any one of these attacks may be fatal ;
moreover, it is indisputable that a large proportion of patients who
die of appendicitis have had previous attacks, and would have lived
if their appendices had been removed in the quiescent stage.
Operation in the quiescent stage is very safe. Many surgeons
408 Appendicitis.
are able to record long series of cases without a fatality. At St.
George's Hospital between the years 1900 and 1910 over 500 cases
of sub-acute, quiescent and chronic appendicitis were operated upon,
and there was only one death, the mortality thus being less than
'2 per cent. The operation itself is, as a rule, quite simple ; a com-
paratively small incision is usually sufficient, little inconvenience
follows, a weak scar is exceedingly rare, and the period of convales-
cence is short.
Any healthy patient, therefore, who has had one definite attack
should be strongly recommended to have his appendix removed in the
quiescent stage, and this applies particularly to those who are going
abroad and to others who may be far removed from surgical aid.
Children who have had appendix trouble should always be
operated upon ; the great majority of them will otherwise get
further attacks, and these attacks are twice as dangerous as those
in adults. Boys with doubtful appendices should never be allowed
to return to boarding schools without operation, for circumstances
at school are such that appendicitis is easily mistaken for ordinary
" stomach-ache," and there have been many instances in which fatal
delay has occurred before operation. In elderly subjects, and in
those with serious visceral disease, it is usually wise to leave the
appendix in the hope that it will remain quiescent.
Date of Operation when the Attack has been Severe. As a rule at
least three weeks should elapse before operation. If operation is
performed earlier it may be found that the inflammatory trouble
has not fully subsided, that there is still a small pocket of pus
which will complicate the operation of removal : it is probable that
virulent organisms lurk in the neighbourhood of the appendix for
many days after an acute attack. When practicable, therefore, the
patient should take a holiday before having the operation. In the
meantime he should attend to the regular action of the bowels, and
especially avoid anything in his diet which might excite intestinal
disturbance.
Should the Appendix be removed after Recovery from the Operation
of Incision and Drainage of an Appendicular Abscess? Reliable
statistics are needed as to the subsequent history of cases in which
an appendicular abscess has been treated without removal of the
appendix. Those which we possess at present are contradictory.
It is estimated by some authorities that 85 to 90 per cent, of the
cases under discussion heal satisfactorily and have no further trouble,
and that only 10 to 15 per cent, suffer from further symptoms, such
is a persistent sinus, fsecal fistula, and recurrent attacks of inflam-
matory trouble in the appendix. Within the last few years, how-
Appendicitis. 409
ever, evidence has been accumulating to show that recurrent troubles
and even fatal attacks are more common than was formerly supposed.
G. H. Makins, in Burghard's " System of Operative Surgery," states
that in iifty-nine cases of localised suppuration fifty-two recovered,
and that of those in which the future course has been able to be
followed, twenty-three (or 39*9 per cent.) are known to have suffered
from recurrences, and in seventeen of these the recurrence was
accompanied by suppuration. Personally, I believe that in most
cases the surgeon should advise subsequent removal of the appendix.
This, of course, is the only plan which will guarantee the patient
against further trouble, and the operation involves but trifling risk.
Amongst the cases of this nature operated upon at St. George's
Hospital there has been no fatality.
Each case, however, must be considered on its merits, and in
making a decision the following points should be borne in mind :
(a) Suppuration about an appendix does not lead to its destruc-
tion ; further attacks may occur and may terminate fatally. In
most cases, however, these recurrent attacks are less severe than
first attacks. The presence of adhesions makes the process more
localised, and the inflammation is less intense owing to the thicken-
ing of the appendix and of the surrounding peritoneum.
(b) The longer the abscess had lasted before it was opened the
less the risk of subsequent attacks.
(c) Further trouble is more likely in those under twenty years
of age than in those over forty. In children the appendix should
always be removed subsequently.
(d) It is clear that if, after the opening of an abscess, satis-
factory healing does not occur, the appendix should be removed ;
sinuses, persistent pain, or induration are indications for opera-
tion.
(e) The appendix may have come away as a slough after the
opening of an abscess.
These secondary operations are usually simple if a sufficient
interval is allowed to elapse after the primary operation ; in most
cases the best time for their performance is about two months after
the healing of the abscess. Complete removal of the appendix
rarely presents any special difficulty, except in retro-caecal cases,
and the opportunity may be used to repair the damaged abdominal
wall.
(12) Chronic Appendicitis and Appendix Dyspepsia.
Chronic appendicitis is undoubtedly a common disease, and often
exists without any clinical evidence of the occurrence of an
acute attack.
4io Appendicitis.
The term " appendix dyspepsia " has been applied to the
symptoms which occur in certain cases of chronic appendicitis.
These cases fall into two groups : (1) Cases in which chronic
appendicitis actually causes dyspepsia; some authorities also
believe that chronic lesions of the appendix may even act as
infective foci and originate ulcers of the stomach and duodenum ;
(2) cases in which the symptoms of chronic appendicitis have been
attributed to dyspepsia, their real nature being overlooked.
The most important aspect of these cases is their diagnosis, and
the possibility of chronic appendicitis must always be remembered
when investigating disturbances of the digestive functions.
The only treatment is appendicectomy, and it may be again
pointed out that the operative mortality in this group of cases is
practically nil.
(13) Removal during Laparotomy for Conditions other than
Appendicitis. When the abdomen is opened for some condition
other than appendicitis, and it is found that the appendix is
adherent, thickened or in any way abnormal, it should be removed,
unless the circumstances of the original operation contra-indicate
this proceeding. It is now recognised that chronic appendicitis
may simulate many other abdominal diseases, and the differential
diagnosis is a matter of great difficulty. In doubtful cases, there-
fore, the appendix should always be examined, and this applies
particularly to operations for affections of the stomach, duodenum,
gall-bladder and pelvic organs.
When a median sub-umbilical incision has been made, it is
usually possible by good retraction of the wound to remove the
appendix ; but if there is difficulty owing to adhesions or to the
retro-csecal position of the appendix, a second incision should be
made.
It is generally agreed that if a normal appendix is exposed during
the course of a laparatomy for some other condition, it is not
justifiable to remove it unless the patient has previously expressed
a strong wish for its removal.
(14) The Appendix in a Hernial Sac. Acute appendicitis may
occur in a hernial sac, and, as a rule, is the result of strangulation
of the appendix, the part above the constriction being quite healthy.
Careful judgment is required in these cases, for the inflammation is
limited to the hernial sac, and when an abscess has formed it is
usually advisable to be content with its drainage, leaving removal of
the appendix for a later date.
Whenever the appendix is found during the course of a radical
operation for hernia it should be removed, for it is rarely normal.
Appendicitis. 411
(15) The Appendix and Tuberculous Peritonitis. Appen-
dicectomy is not advisable in these cases unless the symptoms of
appendicitis are very definite. The disease in the appendix is
usually secondary to the more extensive trouble, and not much
good can be expected from its removal. If operation is performed,
especial care is needed in the separation of adhesions and in
covering the stump, for otherwise fistulas are apt to develop.
(16) Appendicitis and Typhoid Fever. The diagnosis of
appendicitis as a complication of enteric fever is obviously
difficult. If the symptoms are sudden and acute, it will be
impossible to eliminate perforation of an enteric ulcer, and
operation will be performed if the patient's condition allows
it. In other cases it is best to treat the case expectantly,
and if an abscess forms to deal with it by simple incision and
drainage.
(17) Malignant Disease of the Appendix. This affection is not
recognisable clinically, and therefore the question of its treatment
is of little importance. There are two groups of cases : (a) Those
in which the disease is discovered when the appendix is examined
macroscopically and microscopically, after an operation for appendi-
citis : the prognosis in these cases is usually excellent ; (6) those in
which there is a palpable tumour for which the abdomen is opened,
and which is usually too advanced for radical operation. The point
of practical importance is that all appendices should be carefully
examined after removal ; otherwise the existence of a malignant
growth will often be overlooked.
REMOVAL OF THE APPENDIX IN THE QUIESCENT STAGE.
Surgeons vary considerably as to the exact details of the
operation for removal of the appendix. The methods described
below are simple and efficient.
The Incision. Of the many incisions devised for this operation
two are in common use, and their position is shown in Figs. 1
and 2.
(1) McBurney's Muscle -splitting or Gridiron Incision. An oblique
incision is made which crosses the line between the anterior superior
spine and the umbilicus at a point 1^ inches internal to the
spinous process, corresponding as accurately as possible in direction
to the fibres of the external oblique aponeurosis. These fibres are
now exposed and are separated throughout the length of the
incision ; the underlying fibres of the internal oblique and trans-
versalis muscles are next separated with a blunt dissector and are
well retracted. A quadrilateral opening results, the floor of which is
412
Appendicitis.
formed by the trans versalis fascia and the peritoneum ; these struc-
tures are picked up with a pair of dissecting forceps and are
carefully incised. There is no bleeding except from small vessels
in the skin, and no muscle nerves are divided.
(2) Battle's Incision through the Outer Part of the Rectus Sheath,
with Temporary Displacement of the Rectus Muscle. A slightly
oblique incision is made over the outer part of the right rectus
muscle, midway between the anterior superior spine and the
umbilicus. The anterior layer of the sheath is divided and the
underlying fibres of the muscle are freed from the outer margin of
FIG. 1. Appendicectomy : muscle-splitting incision.
the sheath and are displaced inwards ; the posterior sheath and the
peritoneum are then divided obliquely to avoid injury to the dorsal
nerves. Care must also be taken to avoid haemorrhage from the
deep epigastric vessels and their branches, for such haemorrhage is
apt to cause annoying delay. The outer margin of the wound is
well retracted, and good access to the right iliac fossa is obtained.
The Choice of Incision depends on the circumstances of the case.
When the patient is comparatively thin and the diagnosis is clear,
the muscle-splitting incision is best ; if there is any doubt as to the
diagnosis, and especially if the pelvic organs require careful exami-
nation, Battle's incision is to be preferred. The operator should
accustom himself to the use of either incision.
Appendicitis.
413
The Length of the Incixioii must vary with the thickness of the
abdominal wall and the ease with which the appendix can be
brought to the surface. In simple cases in which the abdominal
wall is thin, it is usually possible to perform the operation through
an incision 1^ to 1| inches long. As a rule, the primary incision
should be 1^ to 2 inches long, and may be enlarged subsequently if
necessary. In general, the shorter the incision the better ; but
shortness of the incision should never so increase the difficulty as
Fi<;. L>. Appendicectomy : incision through sheath of rectus: muscle.
to cause any increased risk to the patient, or to involve possibility
of overlooking disease of surrounding structures.
As soon as the peritoneal cavity has been opened, a finger is
inserted and the parts are explored. The operator then decides
whether he can remove the appendix through the opening made, or
whether special difficulties, such as dense adhesions, necessitate
enlargement of the wound.
Isolation of the Appendix. The appendix may be quite easily
found, unfettered by adhesions and sometimes at once presenting
through the peritoneal opening ; on the other hand, its isolation
may involve the hardest task that can be set to a surgeon, and this
is especially liable to occur when there has been an abscess
around it.
Usually there is no difficulty in detecting the appendix with the
414 Appendicitis.
finger. If, however, it cannot be felt and brought up to the wound,
it is usually best to pull up the caecum, for its anterior longitudinal
band will lead to the base of the appendix. When there is trouble
in finding it, it is usually lying behind the caecum, or is buried in a
mass of adhesions close to the bowel. Soft adhesions may be
gently broken down with the finger or with a pad of gauze ; strong
fibrous adhesions require careful division and ligature.
When the appendix has been isolated, it should be carefully
inspected. Even if it appears normal on its outer aspect, it should
be removed, for it not infrequently happens that there is ulceration
or a stricture in its interior which presents no external sign ; but
before removal, a thorough examination must be made of the
surrounding structures.
Removal of the Appendix. The appendix and the adjacent
1cm. across flat
Dart of blade
FlG. 3. Crushing clamp.
portion of the caecum are brought out of the wound ; the opening
through the wound and the edges of the wound itself are packed off
with gauze, to avoid any accidental contamination during the
removal of the appendix, and the operation now becomes extra-
abdominal.
The meso-appendix is tied off as a whole, or in sections according
to its arrangement, especial care being taken to secure the vessels
in the angle between the appendix and caecum.
The proximal end of the appendix is then crushed with a special
crushing clamp (Fig. 3), or with stout artery forceps ; the clamp is
left on for twenty to thirty seconds, and is then removed. The thin
transparent segment which results is shown in Fig. 4 ; a fine silk
ligature is applied to its proximal portion. The appendix is then
removed, a pair of forceps having been placed just beyond the point
of section to prevent any leakage from its interior. The application
of pure carbolic acid to the stump is quite unnecessary.
Appendicitis.
415
A purse-string suture is then inserted into the caecum around the
stump, which is seized by the assistant with a pair of dissecting
forceps and inverted into the caecum, whilst the purse-string suture
is tightened and tied ; the appearance of the parts at this stage is
shown in Fig. 5. The cut surface of the mesentery is covered in
with a fine silk suture, and any other surfaces denuded of peritoneum
are similarly covered.
Some surgeons have suggested that inversion of the stump into
FIG. 4. Appendicectoiny :
base of appendix crushed ;
applied.
purse-string suture
the caecum is unnecessary, simple ligature being sufficient. Cases,
however, have occurred in which this proceeding has been followed
by untoward results, such as adhesions, intestinal obstruction, and
slipping of the ligature, and there can be no doubt that inversion of
the stump is an additional safeguard.
The structures in the neighbourhood of the appendix should
always be examined, for co-existing diseases are easily overlooked.
One or more fingers should be passed to the pelvis, to ascertain the
condition of the right tube and ovary and of the uterus ; a finger
is passed along the ureter up to the right kidney, which is examined
416
Appendicitis.
especially as regards its mobility, and the gall-bladder is palpated if
possible for the presence of gall-stones. Adhesions of omentum or
intestine are searched for ; the peritoneum and mesenteric glands
are examined for tuberculosis, especially in children.
Closure of the Wound. When the muscle-splitting incision
has been used, the wound is closed as follows : The peritoneum is
sutured with fine catgut; the muscular fibres of the internal oblique
and transversalis are allowed to fall together, and are kept in apposi-
tion by two or three interrupted catgut sutures ; the external
FIG. 5. Appendicectomy : inversion of stump.
oblique aponeurosis is sutured with chromicised catgut or with two
interrupted fine silk sutures ; and the skin edges are united by a
sub-cuticular stitch of catgut, or by interrupted silkworm-gut
sufcures.
For the rectus sheath incision, Mr. Battle recommends closure in
the following way : The posterior layer of the sheath and the peri-
toneum are sutured with a continuous suture of silk (00) or fine
sterilised catgut in the case of females; whilst in the male, owing to
the more fixed character of the peritoneum, it is frequently necessary
to use silk or catgut of a larger size and interrupted sutures. The
Appendicitis. 417
rectus is then permitted to fall back into its usual position ; the
anterior layer of the sheath is closed with three to six interrupted
silk sutures, and the skin edges and the superficial wound are then
united.
Special Difficulties. (1) When the distal portion of the
appendix is situated deeply or is hidden in adhesions, it is some-
times best to deal with the caecal end first ; the appendix is
amputated from the caecum, and the distal half is then followed
up and isolated. This plan is especially useful when the appendix
lies behind the caecum in a mass of adhesions.
(2) If the appendix is buried in very dense, firm adhesions and
lies close to the bowel, its separation in the ordinary way may
involve grave risk of tearing the bowel, and the plan recommended
by Dr. Howard Kelly should then be adopted. An incision is made
through the peritoneal and on to the muscular coats of the appendix ;
the entire serosa and a portion of the circular muscular coat are
then stripped out ; the cavity left is cleansed, and closed with a
continuous suture of fine silk or catgut.
(3) If the appendix is adherent to or is wrapped in omentum, it
is best to excise it with the attached omentum, for separation of
the omentum may unseal a perforation or open a small encapsuled
abscess.
(4) If the appendix is distended with fluid, great care is needed
in dealing with it, for the fluid may be infected. Manipulations
should be very gentle : a free incision and a good light are essential.
(5) Thickening about the base of the appendix and the adjacent
part of the caecum may make it difficult to deal satisfactorily with
the stump. The crushing clamp, if used in these cases, is liable to
cut right through the brittle tissues, and the sutures used in
ordinary cases to invaginate the stump do not hold well. Under
these circumstances the circular-flap method of amputation is
usually best. The knife is carried round the appendix about inch
above the caecum, and a cuff composed of the peritoneum and
the superficial muscular layer is reflected ; the appendix is then
ligatured at its junction with the caecum and is removed ; the cuff
is closed over the stump by a fine silk ligature.
A mistake which is often made is to leave a stump of appendix
J to f inch long ; it is particularly easy to do this in the method of
amputation by a peritoneal flap or collar. This stump is capable
of reproducing all the symptoms of ordinary appendicitis, and there
have been several cases in which a fatal peritonitis has originated
in a stump of this nature months or even years after the operation.
The after-treatment of these cases is described in detail
S.T. VOL. II. 27
418 Appendicitis.
elsewhere. The bowels are opened by an olive-oil enema on
the third day, and a purgative is given on the fifth day. The
wound is dressed and the stitches are removed on the sixth or
seventh day ; the patient gets up between the tenth and fourteenth
day, according to the size of the incision and the condition of the
abdominal wall. No belt is required.
OPERATION IN ACUTE CASES.
Whilst preparations are being made for the operation, the patient
should be kept as quiet as possible. The skin is shaved and
prepared in the usual way, or the iodine method of preparation
may be used. A catheter is passed if the bladder is full and the
patient is unable to empty it. Great care must be exercised in the
removal of the patient to the operating table, for much harm may
be done by want of gentleness.
The choice of incision depends upon the circumstances of the case.
In early cases the oblique incision is usually preferable, as it is
nearer to the periphery of the general peritoneal cavity, and gives
better access to the appendix. The rectus sheath incision is better
when the swelling is placed towards the pelvis or is nearer than
usual to the middle line, when there is any doubt as to whether the
appendix or the right tube is the cause of the trouble, and when the
peritonitis is diffuse.
The peritoneum is divided carefully, for bowel may be adherent
to it. If the general peritoneal cavity is not shut off by adhesions,
it is protected by systematically packing it off with sterilised gauze ;
a long strip of broad ribbon gauze is passed first towards the pelvis,
then towards the middle line, and then upwards along the ascend-
ing colon, so that coils of small intestine are kept out of the opera-
tion area.
The parts about the appendix are then explored with the finger,
the longitudinal band on the exposed surface of the caecum serving
as a guide to the position of the appendix. The utmost gentleness
is necessary in order to avoid the sudden opening of an abscess or
the rupture of a tightly distended appendix ; if pus is present it is
important that it should be let out gradually, the best plan being to
control its flow and to mop it away with a series of swabs, so that
the amount of soiling is limited as far as possible. Irrigation
should never be employed. As soon as the pus has been thoroughly
mopped up, the appendix is isolated ; if it is lying behind the caecum,
the caecum is displaced upwards and inwards, and adhesions are
gently separated.
The meso-appendix is then secured with one or more pressure
Appendicitis. 419
forceps, and the distal portion is divided so that the appendix is
freed. The base of the appendix is then thoroughly crushed with a
stout pair of artery forceps or with the special crushing clamp, and
a fine ligature is applied at its junction with the caecum ; the
appendix is then amputated, a pair of forceps having been placed
just beyond the point of section to prevent any escape from its
interior. The stump is sterilised by the application of liquefied
carbolic acid on a probe, and is sunk into the caecum by a purse-
string suture.
The details of the operation vary considerably in different cases.
The appendix may be so deeply placed and its condition so friable
that formal amputation is out of the question, and in such cases the
operator may have to be content with securing the stump with a
single ligature tied firmly, but not sufficiently tightly to cut through.
Inflammatory thickening about the caecum may make crushing of
the base of the appendix undesirable, and in such cases removal by
turning back a cuff of peritoneum and muscular fibres is usually
the best plan. When the appendix runs up behind the ascending
colon and cannot be brought to the surface easily, the most satis-
factory plan is to amputate it from the caecum before enucleating it
from the retro-colic tissues.
Drainage is necessary in the majority of cases ; it may, however,
be dispensed with in many of the cases which are operated upon
within the first thirty-six hours of the attack. Drainage is effected
by the insertion of one or more tubes : a tube passes directly into
the iliac fossa, and it is often well to pass a second tube towards or
into the pelvis. A gauze drain is placed by the side of the tube ;
these drains should be of ribbon gauze, so that removal is effected
easily, and they should be packed in lightly, for otherwise they prevent
the escape of discharge. When slight drainage only is required, a
strand of ribbon gauze may be placed inside a split drainage tube,
no other gauze drainage being used.
The wound is then sewn up with through-and-through sutures of
silkworm-gut.
Full details of the after-treatment will be found elsewhere.
Operation in Cases in which Abscess is Present. The
incision should be made slightly to the outer side of the most pro-
minent part of the swelling. The abscess may be adherent to the
anterior abdominal wall ; this is usually indicated by the inflam-
matory infiltration of the deeper layers, which may cause some
difficulty in the recognition of the peritoneum : a blunt dissector
should then be used, and the opening should be made well to the
outer side of the swelling.
272
42O Appendicitis.
Often, however, it is necessary to open the general peritoneal
cavity before the abscess is reached ; if this is so, a free incision is
necessary so that the operator has a good view of the parts, and it
is essential that the general peritoneal cavity should be systematic-
ally packed off with gauze ; if this is properly done the risk of
infecting the general cavity is remote. In fact, some surgeons
recommend that even when the abscess is adherent to the anterior
abdominal wall, the general peritoneal cavity should be opened and
the abscess dealt with from its intra-peritoneal aspect, after careful
gauze packing. It is claimed that by this procedure the appendix can
be removed in almost all cases of abscess, without additional risk.
If the abscess is large and tense, great care must be exercised in
opening it ; any undue pressure must be avoided, for it may cause
rupture internally. Pus should be let out gradually, and its flow
should be controlled by a series of swabs, which mop it away as fast
as it comes. As soon as the main bulk of pus has been evacuated,
the abscess cavity is thoroughly opened up and explored with the
finger. The position of the appendix is made out if possible, and
any loose stercolith is removed. Tracks running towards the pelvis
should be looked for, and if there is a collection of pus in the pelvis
it should be made to drain freely into the main cavity. There is
sometimes a large pelvic abscess communicating with the cavity
about the appendix by a small opening which is easily overlooked ;
attention is usually called to the existence of this pelvic abscess, either
by pelvic examination before operation, or by the fact that as the
primary abscess cavity is emptied more pus wells into it from below.
Free drainage is essential : unsatisfactory results in most of these
cases are due to inefficient drainage. A large tube should be used,
and gauze drains are lightly packed in by its side.
Counter-drainage. Drainage through the loin is indicated in
some cases of abscess lying to the outer side of or behind the colon,
and sometimes it is justifiable to completely close the anterior
wound. Lumbar drainage must be free to be efficient. A large tube
should be inserted, so that it just projects into the abscess cavity,
and especial care should be taken to see that the tube is not com-
pressed or kinked by the lumbar muscles ; this kinking explains
the unsatisfactory drainage which is often obtained through loin
incisions.
Large pelvic abscesses resulting from appendicitis may be
efficiently drained through the vagina or the rectum. A drainage
tube may be used for a vaginal opening, but should not be employed
for openings in the rectum. In the latter case the opening is kept
patent, if necessary, by the occasional passage of the finger. The
Appendicitis. 421
patient is well propped up during convalescence, and quick healing
usually follows.
Should the Appendix be Removed when an Abscess is
Present ? Considerable divergence of opinion exists at the present
time upon this point. Some advise that a determined attempt should
be made in every case to remove the appendix, others content them-
selves with simple drainage in the bulk of cases, and others open
the abscess and remove the appendix a few days later. In 289
cases of acute appendicitis with abscess admitted into St. George's
Hospital between 1905 and 1910, the appendix was removed at the
primary operation in 209 cases, or 72 per cent. ; in cases in which
the appendix was removed, the mortality was 8'6 per cent., and in
those in which it was not removed, the mortality was 13*7 per cent. ;
but it has been pointed out that the latter group includes a larger
proportion of serious cases, and also many cases in which a pro-
longed attempt to find the appendix proved unsuccessful.
It is obvious that if the appendix can be removed at the time
without involving additional risk, this is the most satisfactory
course. Convalescence is likely to be shorter, complications are
uncommon, there is no risk of further trouble from the appendix,
and the patient and his relatives are naturally more satisfied than
if the appendix has to be left behind.
It must be remembered, however, that the object of the operator
must be to secure the greatest safety for the patient, and there are
certain cases in which the wisest course is to empty and drain the
abscess cavity, making no attempt to remove the appendix at the
time. This course should be usually adopted under the following
circumstances :
(1) Large abscesses.
(2) Abscesses of several days' standing.
(8) Cases in which it is found that the appendix is firmly
embedded in inflammatory tissues, so that complete removal would
be a matter of great difficulty.
(4) Cases in which the appendix points inwards and upwards
towards the general peritoneal cavity.
(5) Cases in which the operator's experience is limited, and in
which the surroundings are unfavourable for surgery, as, for
instance, when operation has to be performed in a small farmhouse
without adequate assistance.
(6) Cases in which the patient is too ill to stand a prolonged
operation.
Attempts to remove the appendix in these cases usually involve
risk of spreading infection, and of setting up general peritonitis.
422 Appendicitis.
Other disadvantages are that removal of the appendix is often
incomplete, and that an unduly large opening through the abdominal
wall is necessary. On the other hand, there is no doubt that when
the appendix has been left behind, complications such as pleurisy,
empyema and secondary abscesses are much commoner than when
the appendix has been removed.
In Cases of Diffuse and General Peritonitis a free incision
should be made through the outer part of the right rectus muscle,
and a second incision in the hypogastrium or right loin may be
necessary. Whenever the patient's condition allows it, the
appendix should be removed : cleansing should be effected by
swabbing, and not, as a rule, by irrigation. Eapid operating and
the institution of free drainage are the essential points.
Irrigation is occasionally indicated in diffuse peritonitis of
appendical origin ; for instance, in cases in which there are large
quantities of purulent fluid without adhesions of intestines and
pocketing of pus, a condition sometimes found in young subjects.
Irrigation should then concern tbe right lower quadrant of the
abdomen only, and attempts should never be made to wash out
the whole peritoneal cavity. Magnesium sulphate may be injected
into the caecum or ileum, when intestinal paresis is present and a
prompt action of the bowels is desired. An ounce of a 1 in 2
solution of the salt is injected into the bowels with a large
" exploring " syringe, the needle of which is passed obliquely
through the wall of the bowel to prevent leakage. In the after-
treatment of cases of diffused or general peritonitis the most
important measure is the continuous infusion of saline into the
rectum (proctoclysis). There is no doubt that this form of treat-
ment has saved many cases of extensive peritonitis, and it should
be employed in all severe cases of appendicitis. (See Treatment of
General Peritonitis.)
Intussusception of the Appendix must be dealt with according
to circumstances. In most cases an incision into the caecum is
necessary : it may be possible to reduce the invagination, in
which case the wound in the caecum is closed, and the appendix is
removed in the ordinary way ; in some cases the appendix may be
excised from within the caecum, and in a few cases it is advisable to
resect the appendix and the neighbouring part of the caecum in one
mass.
THE NON-OPERATIVE TREATMENT OF APPENDICITIS.
This section will deal with the treatment of those cases in which,
for one reason or another, immediate operation is not performed.
Appendicitis. 423
These cases are : (1) Sub-acute cases : (2) acute cases in which
the inflammation is obviously subsiding when first seen by the
surgeon : (3) cases in which the patient refuses operation :
(4) -cases in which some co-existing disease makes it desirable to
avoid operation, if possible.
The Management of Sub-acute Cases, and Acute Cases in
which the Inflammation is Obviously Subsiding. It has
already been pointed out that great caution must be exercised in
classing a case as sub-acute, and that in the majority of
apparently sub-acute cases the safest treatment is immediate
operation.
If, however, it is decided that the symptoms are not sufficiently
acute or definite to demand immediate operation, or if the attack is
obviously subsiding when the patient is first seen, the following
treatment should be adopted.
The patient is kept in bed, and is not allowed to leave bed for
any purpose whatever. The services of a nurse should be obtained
at once. Nothing is given by the mouth except small quantities
of plain water with the chill taken off it, or albumen-water ;
neither milk nor any more solid foods are allowed until recovery is
assured.
The bowels are cleared by small injections of olive oil carefully
given ; large enemata are dangerous, as they increase the disturb-
ance about the appendix ; and if there is a perforation, some of the
injected fluid may find its way through it into the peritoneal
cavity.
Purgatives should not be given under any circumstances until
the symptoms have completely subsided. Urgent symptoms in
these cases frequently date from a few hours after the adminis-
tration of a purgative, especially in children. The active peristalsis
set up by a purgative causes the rapid passage of a large amount of
material past the caecum ; it hinders the formation of protective
adhesions, aggravates the local inflammatory conditions, and may
actually cause an ulcerated area to become perforated.
Pain, if slight, requires no special treatment : if severe, it may
be relieved by the administration of 10 gr. of aspirin or phenacetin,
and by hot fomentations or an ice-bag locally. An ice-bag has the
special advantage of keeping the patient absolutely quiet. Poultices
should not be applied, as they make the skin septic, and interfere
with the local examination, which has to be made frequently.
Morphia should not be given under any circumstances ; the pain is
rarely severe enough to call for its use, and if it is so, immediate
operation is usually indicated.
424 Appendicitis.
The Pulse-rate and Temperature should be recorded every two
hours, unless the patient is sleeping : the pulse-rate is by far the
more important observation, and the surgeon should be informed
at once of any increase.
The Abdomen should be regularly examined, especial attention
being paid to the movement of the abdominal wall on respiration,
and to the condition of the muscles overlying the appendix area.
As the tenderness and rigidity in the iliac fossa disappear, it often
happens that definite thickening about the appendix becomes pal-
pable ; this observation is of importance, for it confirms the
diagnosis and gives information as to the position and extent of the
inflammation.
In these sub- acute cases, immediate operation should be advised
if there is not regular and steady improvement and if the local
signs persist. It must be remembered that a fall of the tempera-
ture is not a favourable sign, unless it is accompanied by a
corresponding fall in the pulse-rate.
The patient should be kept in bed until the temperature and
pulse-rate are normal, until the tongue is clean, and all abnormal
signs in the right iliac fossa have disappeared.
In acute cases in which operation is refused by the patient, treat-
ment should be conducted on similar principles. Symptomatic
treatment is dealt with in the article on the Treatment of Patients
after Abdominal Operations, p. 262.
Prophylactic Treatment. The only satisfactory prophylaxis
against recurrence of appendicitis is removal of the appendix. The
question of prophylaxis may, however, arise in the case of those
who are unwilling to undergo operation, or in whom operation is
inadvisable. The medical man may also be consulted by persons
in whose family several cases of appendicitis have occurred, and
who fear that they themselves may be affected by the disease.
Comparatively little is known of the determining causes of
appendicitis. It is generally admitted, however, that attacks of the
disease are frequently preceded by digestive disorders, such as
constipation, acute attacks of indigestion and diarrhoea. It is
obviously important, therefore, to regulate the functions of the
alimentary canal. Especial attention should be devoted to the
teeth. Dyspepsia, if present, should be treated and general directions
should be given as to diet, although special dieting should be
avoided unless there is some definite reason for it : the import-
ance of regular daily action of the bowels should be emphasised.
Injury and certain forms of exercise, such as bicycling, are said
by some authors to be responsible for a certain number of cases of
Appendicitis. 425
appendicitis. Mr. Battle and Mr. Corner state that of the various
forms of exercise, motor-bicycling seems especially liable to
originate an attack in persons who have latent appendicitis.
Those who fear appendicitis, and yet present no evidence of past
or present inflammation of the appendix, should be firmly reassured,
for it is of great importance to their general welfare that they
should not be allowed to become introspective as regards this
subject.
T. CRISP ENGLISH.
426
CCELIAC DISEASE.
IT is to Professor Herter l that the recognition of coeliac disease
as one of the important wasting diseases of childhood is largely
due, though it was originally described by Gee 2 so long ago as 1888.
Herter considers that the disease is produced by the development
in the intestine of an abnormal bacillary growth, and he finds that
the predominant organisms are gram-positive instead of gram-
negative, as is ordinarily the case. Coeliac disease has been
defined by Hutchison 3 as " a chronic wasting disease of childhood
characterised by chronic diarrhoea with large pale and offensive
stools, running a prolonged course with a great tendency to relapses,
exhibiting often certain nervous complications, such as weakness
of the legs and tetany, and ending either in death or in complete
recovery, or in partial recovery with great impairment of growth
and development (infantilism)."
The symptoms usually manifest themselves in the second or
third year of life.
In the treatment of coeliac disease the diet must be so arranged
as to meet as far as possible the inability of the patient to digest
fats and starches. For this purpose the most important article
of diet is raw meat juice or raw minced meat, of which 8 to 14 oz.
should be given daily according to the age of the child. To this
may be added whey, skimmed milk, and rusks or malted bread.
If there is definite improvement the scope of the diet may be
increased in from four to six weeks, such articles as Benger's
f ood, Horlick's malted milk and boiled rice being gradually added.
Drugs are of but little service in the majority of cases. If
the diarrhoea is excessive astringents may be employed, such as
bismuth salicylate (10 gr. thrice daily), or silver nitrate (^ gr. in
piU form) ; but opium is often more efficacious for this purpose
(Tr. opii 2 min. three times a day for a child of two years).
It is possible that sometimes there may be some impairment of
the pancreatic function, and, in cases where the stools contain
very much unaltered fat, Hutchison advises the use of pancreatic
preparations, such as pancreon sugar tablets or holadin, after
each meal.
Particular attention must be directed to the avoidance of chill
and cold, and it must be remembered that these children are
Cceliac Disease. 427
especially liable to suffer from cold extremities, a condition which
must be corrected by suitable clothing.
JAMES TORRENS.
EEFERENCES.
1 Herter, C. A., " On Infantilism from Chronic Intestinal Infection," New
York, 1908.
2 Gee, S. J., St. Bartholomew's Hospital Reports, 1888, XXIV., p. 17.
8 Hutchison, E., " Cooliac Disease," Practitioner, 1911, LXXXVII.,
pp. 147 152.
COLIC IN CHILDREN.
COLIC is a frequent and troublesome symptom in infants, more
especially during the earliest months of life. The accompanying
pain is manifested by screaming, restlessness, sleeplessness, an
anxious expression of the face, and the drawing up of the lower
limbs. In predisposed subjects colic may even induce convulsions.
The part of the bowel affected is usually the colon, but any part of
the intestine may be the seat of disturbance and pain. The local
changes associated with colic are two in number : (1) paresis or
paralysis of a portion of the bowel from over-distension or obstruc-
tion, and (2) irregular and severe muscular contractions in the
bowel immediately above. The temporary weakening of the bowel
wall is usually due to over-distension from flatulence, or from
irritation of the bowel contents, or from an accumulation in the
bowel.
There are various forms of colic which must be differentiated.
The most common type is that associated with intestinal dis-
turbance from some dietetic error. Another variety is associated
with definite intestinal obstruction, e.g., from intussusception or
strangulated hernia. In a third class of case there is no real colic,
but the pain experienced is produced in some organ other than the
bowel, e.g., renal colic.
An acute attack of colic in an infant calls for immediate relief
of the urgent symptoms, and this must be followed by a careful
inquiry into the dietetic and other habits, so as to ascertain and
remove the cause of the trouble. The abdomen is usually distended
and hard from the presence of much flatus in the bowel and rigidity
of the abdominal muscles. At times, if the abdominal wall relaxes,
it is possible to feel the bowel wall standing out firmly in parts as
strong muscular contractions take place. It is our aim under such
conditions to dispel the flatus and check the excessive peristalsis.
With this object an enema of from 10 to 15 oz. of hot water
should be slowly administered. The warmth tends to allay
the spasm, and a considerable amount of flatus will often be passed,
giving great relief. If the bowels have not acted for some time,
soap may be added to the enema, so as to produce an evacuation
more certainly than plain water will. The application of fomenta-
tions to the abdomen will also tend to check spasm. Flannel
Colic in Children. 429
cloths, wrung out of boiling water, should be applied as hot as they
can be borne over the whole surface of the abdomen, back and
front, and changed every quarter of an hour, until the skin is
thoroughly reddened. In addition it will be advisable to stop all
feeding for from three to six hours so as to give the bowel a much-
needed rest, and to give a dose of castor oil (1 to 2 drachms) to
clear out any irritating material that may remain. A carminative
mixture may be ordered, such as the following : fy Tincturae
Belladonnas, r\\ 2 ; Spiritus Ammonias Aromatici, w[ 2 ; Sodii Bicar-
bonatis, gr. 5 ; Aquam Cinnamomi, ad 5]. Sig. : One drachm every
six hours (for an infant of six months). If the pain is not speedily
relieved, a more powerful carminative may be added, such as \ drop
of laudanum or 5 drops of paregoric.
The next stage in the treatment is to find out the cause of the
colic. It will often be found that previous to the acute attack
there had been numerous mild attacks, which had been treated in
the domestic circle. The diagnosis had been "wind," and the
treatment dill-water. When the baby cried it was thought to be
hungry, and more food had been given. The first points to be
attended to are regularity in the meals and a sufficiently long
interval between feeds. The amount of food must also be inquired
into. It is not uncommon to find that infants of three months old
are taking from 25 to 30 oz. of cows' milk in the twenty-four
hours. This can be indulged in for a time, but sooner or later
a breakdown in the intestinal functions occurs, and colic is the
result. Gulping down the food rapidly and swallowing air at the
same time are other conditions which may require correction. The
careless feeding with long-tube bottles, when the infant often gets
nothing but air to draw, is a specially common cause of colic in
infants. In bottle-fed babies the protein element, from its indi-
gestible nature, is apt to cause fermentation, flatulence and colic.
This must be remedied by dilution of the milk, and by adding
citrate of soda /(I gr. for each 1 oz. of milk) to the feeds.
Milk which has become soured from contamination is a frequent
cause of flatulence and colic in infants. Another possible cause of
similar disturbances is the addition of excessive amounts of sugar
(usually cane sugar) to the milk. In the present day the abuse of
starchy food, which is given to an extent quite beyond the require-
ments or even the digestive powers of an infant, is frequently
manifested by colic. From the earliest months prepared barley, or
the whole barley boiled down in water to a jelly, is often added to
the milk, or large quantities of some patent (starchy) food are
given. Barley- water, if properly prepared, is a bland and innocuous
430 Colic in Children.
fluid containing about 1 per cent, of starch. The infantile stomach
does not tolerate comfortably any but the smallest quantities of
starch, and even when converted, as in many patent foods, the
starchy element must be strictly limited in amount during the first
nine months. It is scarcely necessary to add that gross errors in
infant feeding, such as the giving of sausages, potatoes, stew, or " a
bit of what is going," are very frequently followed by severe colic.
The correction of a faulty diet will be found the most effective
factor in the prevention and cure of colicky attacks.
Many infants are liable to colic through exposure to cold and
chilling of some part of the body, such as the feet, or the thighs, or
the abdomen. Warm socks and a hot bottle when necessary should
always be available. The abdomen should be well protected from
cold by flannel. Not infrequently one finds that while the rest of
the body is well covered the knees and thighs are much less so, and
are in consequence often distinctly chilled. All these forms of
surface chilling are apt to induce attacks of colic.
A physical examination of the abdomen may reveal the presence
of a faecal accumulation in the colon. This must be treated by
enemata of soap and water, castor oil, etc. A condition of chronic
constipation may be present, leading to irregular contractions of the
bowel wall, and must be corrected (see Constipation in Children,
p. 432). If a persistent distension of the bowel wall is present, a
condition of atonic dilatation, it is advisable to employ abdominal
massage once or twice daily, which will not only dispel the flatus
but will tone up the bowel wall.
The pain of colic may be due to a serious lesion as well as to a
passing disturbance. In young infants intussusception is usually
accompanied at the onset by severe pain and screaming, which
are very similar to the conditions present in simple colic. No
case should be lightly passed over without an examination for
any signs of intussusception, hernia, tuberculous peritonitis, or
other forms of obstruction. A special form of colic is associated
with Henoch's purpura, in which haemorrhage takes place into
the bowel wall, producing temporary paralysis and spasm of the
adjoining part of the intestine. In cases of angio-neurotic oedema
similar symptoms are produced by serous effusion into the bowel
wall. With a little care such conditions can be distinguished from
simple colic, and, of course, call for very different treatment.
The third class of case to which reference has been made is that
in which colicky pains are produced in some other organ than the
bowel, but may be referred to the intestinal region. We may
find, even in the youngest infants, severe colic -like pains, usually
Colic in Children. 431
referred to the umbilical region, which are due to the irritation
of the urinary passages by crystals of uric acid or oxalate of
lime. The seat of irritation is usually in the kidney, and an
examination of the urine will demonstrate the cause. In older
children a renal calculus may be present. Any form of acute
peritonitis may be characterised at the onset by severe pains, not
unlike colic.
In the case of older children the food factor is all-important
in the production of colic. The young schoolboy is apt to let
himself go at times in the matter of diet ; he often covets the
forbidden fruit, and a hasty, surreptitious and sumptuous feast ma} 7
be followed by a severe attack of colic. -Vomiting may, of course,
anticipate this result, but if the pylorus does not prevent the
passage of the food downwards, the bowel will probably resent the
presence of an undigested meal, and pain of a colicky nature
will follow. We cannot improve on the old-fashioned treatment
by means of a good dose (^ oz.) of castor oil, of which the
physical and moral benefits are undoubted. This is to be followed
by a few days of low feeding, of plenty of plain water to drink, and
if necessary for the pain, 5-drop doses of chlorodyne or laudanum
[U.S.P. iri3] two or three times a day.
G. A. SUTHERLAND.
432
CONSTIPATION IN CHILDREN.
IN order to secure the proper evacuation of the bowels
a certain regular habit must be acquired. This ought to be
established in the earliest months of life, and if it were so
established, and if the infant were properly fed, there would
not be much necessity for medical advice as to the treatment
of constipation. As it is, however, constipation in infants and
children is one of the commonest conditions we are called on to
treat. An infant will not make any voluntary effort to empty the
bowel unless the rectal reflex is very active, and as it easily becomes
dulled the bo\vel soon becomes overloaded. It is easy for the
mother to give a dose of medicine and empty the bowel, but the
same course of events is quickly repeated. Thus a vicious habit is
established which may seriously impair the healthy development of
the bowel and intestinal functions generally.
Preventive Treatment. In order to prevent the development
of constipation in an infant, a habit of soliciting an action of
the bow r els should be begun at the age of one or two months.
After the morning bath and thorough general friction the child
should be placed on the chamber. At first there may be
no result as the bowels may have been acting, quite normally
for the age, at irregular intervals three or four times a
day. If there has not been an action for twelve hours then a
small piece of soap or the little finger dipped in glycerine may be
introduced through the anus. This will probably start the rectal
reflex, and an action will follow : at the same time a mental
impression is conveyed to the child, which simply requires repetition
to become a habit. On no account should it be regarded as a
healthy state of affairs for a young infant to pass one, two, or three
days without an evacuation. Just as certainly as the response to
the rectal reflex in the form of an action of the bowels becomes a
habit, so the dulling of the rectal reflex will become chronic if the
rectum is allowed to retain faecal matter for a day or two. While a
young infant will usually pass several motions a day, the fact
that one motion only is passed must not be regarded as a sign of
constipation. It is the bulk of the matter passed which is
important. Several small motions a day may be passed without
there being any thorough evacuation of the bowel, and a condition
Cqnstipation in Children. 433
of constipation is being developed. On the other hand, one full
motion in the day may represent a normal and healthy action of
the bowel.
All babies do not start life with the same ease and regularity in
emptying the bowels. For those who have any difficulty simple
measures are often sufficient to prevent the development of con-
stipation. Care must be taken first of all as regards the food and
the feeding. Errors in this respect are responsible for most of the
cases of constipation in early life. In the case of breast-fed infants,
the habits of the mother must be carefully regulated, and if she is
herself healthy and feeds her child regularly, the tendency to con-
stipation in the infant will not be great. This constipation of
breast-fed children is seen much more amongst the poorer classes,
and in them the quality of the milk, the state of the mother's
health, and irregularity in the feeding are probably chiefly
responsible for the condition of the baby. As regards bottle-fed
children it is equally necessary that proper food at proper intervals
should be given if constipation is to be avoided (see article on
Infant Feeding).
Some infants show a tendency to constipation from birth, which
is not necessarily a pathological condition, for it can often be
remedied by a slight alteration in the diet. Thus a few ounces of
plain or barley water in the day, given between feeds, may suffice
to maintain a regular action. Orange-juice or grape-juice may be
given with benefit and safety to the youngest infant for the same
purpose, to 1 oz., diluted with water, and given between
feeds. In other cases the milk may be so thoroughly digested
and absorbed that little residue is left in the bowel. Without some
residue to act on it is difficult for the bowel to exert its peristaltic
action effectively. In such cases we may allow a small amount,
three or four teaspoonfuls daily, of a starchy food, either uncon-
verted or partially converted, which is sufficient to act as a
stimulus without acting as an irritant to the bowel. Again, a
tendency to constipation may be induced by frequent doses of
castor oil given in early infancy. It cannot be too strongly
impressed on mothers that castor oil is not the drug to give for
constipation. It finds its true use in connection with diarrhoea and
intestinal irritation. The action of castor oil as a purgative is
usually followed by a period in which constipation results, so that
no permanent progress is made. The habit of drugging young
infants with castor oil, as if it were an essential part of healthy
babyhood, is one of those nursery customs which is responsible for
much constipation.
S.T. VOL. ii. 28
434 Constipation in Children.
Another factor which sometimes leads to constipation is the
habit of depriving infants of facilities for the free exercise of their
limbs. A healthy child is a very active person, but if the limb
muscles are hampered by tight and heavy garments or by heavy
bedclothes, those natural movements are much curtailed. It should
be the daily practice to let an infant be on the bed or some warm
protected place where it can indulge in its natural muscular move-
ments with perfect freedom. At the same time the abdominal
muscles will be strengthened, and their action has an important
influence in securing natural evacuations. It is the custom
amongst many primitive races for the mothers to carry their
infants slung over the back or on the hip. The result is a con-
siderable amount of shaking, which acts on the liver and induces a
flow of bile, just as riding exercise does. Perhaps it is impossible
to introduce such a custom amongst the advanced races here, but
it is quite easy to give the baby some exercise in the nursery which
will serve the same purpose, such as jumping it up and down. If
the period after the morning bath is utilised in this way it will
often be found that an action of the bowels follows.
After an infant has cut some teeth the prolonged use of a soft,
pappy diet and the custom of using pre-digested foods are apt to be
followed by constipation. Intestinal peristalsis is weakened when
there is no solid residue in the bowel to call it into action. Hence it
will be found advisable to employ those foods which contain some
irritating and non-digestible materials, such as porridge, whole-
meal bread, figs, etc., and in the case of older children, salads,
green vegetables, tomatoes and raw apples. At the same time care
must be taken that these substances are not given in excess of the
age and requirements, as the result may be impairment of the
digestive powers and diarrhoea. A sufficient amount of fatty
material must also be part of the diet. Fats and oils have a
lubricant effect on the bowel contents, and prevent the inspissation
of the faeces which sometimes leads to constipation. In suet
puddings, cod-liver oil or olive oil, cream and butter, one finds the
necessary fatty elements. In the case of children of school age the
same principles apply, and the best diet for the prevention of con-
stipation is a mixed one, in which all the essential elements are
represented, care being taken that a sufficient amount of water is
drunk both at and apart from meals.
LOCAL CAUSES OF CONSTIPATION.
In cases of constipation an abdominal examination should always
be carried out, and frequently a rectal examination is also called
Constipation in Children. 435
for. By the omission of such measures one will be liable to
overlook cases of serious abdominal disease and local conditions
bearing directly on the cause of the constipation. Amongst the
local causes there may be : (1) Atonic dilatation of the bowel ; (2)
overloading of the sigrnoid flexure with faeces ; (3) anal fissure or
tenderness ; and (4) a spasmodic contraction of the anus.
(1) The chief cause of atonic dilatation of the bowel in young
children is rickets. At the same time a prolonged course of over-
feeding or improper feeding is apt to be followed in young persons
by atonic dilatation, quite irrespective of rickets. The abdomen is
distended by the dilated bowel, which is incapable of driving on its
contents properly. The first and most important part of the
treatment is to put the patient on a spare and digestible diet so as
to restore the muscular tone of the bowel wall. For the same
object massage of the abdominal wall may be carried out twice
daily. The muscles of the abdominal wall should be well pounded,
and pressure exerted from the right iliac region along the course of
the colon to the sigmoid flexure. A firm flannel binder should be
applied round the abdomen. During this period of toning-up the
bowel wall it may be necessary to use regularly a mild aperient,
such as the following : 1^ Tincturae Nucis Vomicae, nt 2 ; Tincturae
Belladonnas, 111 3 ; Tinctures Aloes, n\_ 3 ; Glycerini, TTJ. 10 ;
Aquam, ad 5J. [U.S. P. 1^ Tincturao Nucis Vomicse, rr|.4 ; Tincturse
Belladonnae, HT,4 ; Tincturae Aloes, rn,l ; Glycerini, ntlO; Aquam,
adsj.]. T.d.s.
(2) An overloaded condition of the sigmoid does not
necessarily manifest itself by constipation. On enquiry one may
be told that the bowels act daily, but on examination it will be
found that the motions are usually small and lumpy. There is
never a complete evacuation of the bowel. Irregular attacks of
abdominal pain, of vomiting, and of diarrhoea are common mani-
festations of this condition. The loaded bowel can be palpated
easily in the left iliac region. Sometimes the accumulation is
enormous and extends into the rectum, as well as throughout the
whole of the colon, in the form of hard masses. In extreme cases
the rectal accumulation is so hard that it must be mechanically
broken down. In less severe cases it is advisable to give an enema
of 2 or 3 oz. of olive oil at night, to be retained, and to
follow this with a soap-and-water enema in the morning. This
procedure should be repeated for three days, or longer if the bowel
has not been cleared. When the lower bowel has been emptied, a
dose of 2 drachms of castor oil should be administered on con-
secutive nights, so as to empty thoroughly the parts of the colon
28-2
436 Constipation in Children.
beyond the reach of enemata. One has then to give a course of
mild aperients to prevent the recurrence of such a condition. This
form of constipation is often the result of want of regularity in
soliciting an action of the bowel on the part of the child. It may
have been as the result of difficult and painful defecation or of
neglect of the calls of nature that the rectal reflex has become
blunted and then lost. In many schools, and not only those for
the poorer classes, this is too often neglected, and much preventable
constipation, both in boys and girls, is brought about. Full
facilities should be provided at schools for the performance of these
natural functions, and both meals and work should be so arranged
that no boy or girl can plead want of time.
(3) A small anal fissure or abrasion may be the result of hard
and inspissated motions. The presence of blood in the fseces even
in the youngest infants is quite common, and is due to the irritation
of hard scybala in the rectum. Whenever a movement of the bowels
becomes painful a child will instinctively try to avoid an action, and
constipation follows. If small, a fissure will usually heal under the
local use of boracic ointment ; if at all deep, it must be divided
freely. At the same time the action of the bowels should be ren-
dered easy by the daily use of olive-oil enemata, (4 to 6 oz.). The
enema should be retained for five or ten minutes, and the action
following will cause little pain.
(4) In some cases of constipation, on making a rectal examination
one may find a spasmodic contraction of the sphincter ani, which
resists the entrance of the finger. Such a condition of spasm in the
sphincter is usually accompanied by imperfect emptying of the
rectum. This spasm may exist quite apart from fissure or other
local irritation, and is sometimes very difficult to cure. In such
cases we may employ locally the injection of hot water for its seda-
tive effect, and also try the effect of bromides and belladonna, given
by the mouth, for their anti-spasmodic action.
In the case of children the treatment of constipation by means
of enemata and drugs ought to occupy a very secondary place. Bad
habits have not become fixed, and the errors of youth have not had
time to impair the normal working of the bowel. Nevertheless, a
medical man will often be consulted after constipation has existed
for some time, and until it is cured there must be an interval during
which drugs or enemata must be employed to maintain a healthy
state of the intestinal functions, and through them of the system
generally. It is well to remember that strong aperient medicines
should not be used in the treatment of constipation, but reserved for
occasional use only. When mild aperients are used for constipation
Constipation in Children. 437
they are much more efficacious when given in divided doses, three
times daily, rather than as one dose at night. As regards the
dosage, children require much larger amounts of such drugs as
senna and cascara than would be considered necessary from a com-
parison of their body-weight with that of adults. Some parents
will stuff their children with porridge, prunes, bananas, apples, etc.,
in order to relieve constipation, but will object to a dose of senna or
cascara because it is a medicine, and in their opinion weakening to
the bowel. As a matter of fact, there is no such difference of nature
or action, and a healthy tone of the bowel wall and healthy intes-
tinal secretions can be secured much more quickly and effectively
by cascara than by prunes.
Enemata are called for in those cases in which the motions are
hard or there is a chronic difficulty in emptying the rectum the
condition to which Dr. Hertz has given the name dyschezia. The
choice lies between plain water (which is not efficient unless given
in considerable amount), soap and water, olive or other simple oil,
and glycerine. Glycerine suppositories are so slow and uncertain
in their action that plain glycerine is to be preferred : 1 drachm
of glycerine is sufficient to produce a speedy action. If any pain
follows it may be avoided in future by giving equal parts of glycerine
and water. When the rectal wall seems to require a gentle stimulus
to provoke the dulled reflex, plain warm water up to pint may be
employed. When the rectum is overloaded with faeces soap and
water may be used, with or without a preliminary injection of olive
oil. When the motions have been hard and the evacuations incom-
plete an enema of from 4 to 6 oz. of olive oil will procure an easy
evacuation. In giving enemata only soft rubber should be used for
introduction into the bowel, as any hard substance is apt to cause
abrasions about the anus.
Amongst the mild aperients cascara and senna are specially suit-
able for children. Cascara may be given in the form of the fluid
extract or " cascara evacuant," the latter being more palatable and
equally effective. An ordinary dose for a child of five years is from
5 to 15 drops three times daily. The best preparation of senna
is a fresh infusion of the pods, made by pouring 3 oz. of boiling
water over four or six pods, and standing for twelve hours. Of this
1 oz. can be given three times a day. A fresh infusion of the pods
may be prescribed, to be made of the strength of one in six, flavoured
and preserved with chloroform, and of this drachm may be
given thrice daily. This preparation should be made fresh twice a
week. Senna is also the active ingredient in syrup of figs (
drachm thrice daily) -and of " laxative fruit pastilles " (one thrice
438 Constipation in Children.
daily). In prescribing senna or cascara it will often be found useful
to meet certain indications by the addition of other substances.
Thus if the hepatic action seems to be defective we add tincture of
rhubarb iri.5 to irtlO [U.S.P. in.3 to Tri5],if spasm of the bowel
and colic are present we add tincture of belladonna TTi.5 to nilO
[U.S.P. 111 6 to nil2], and when the muscular tone of the bowel is
weak we add tincture of nuxvomica Tri2 to nt4 [U.S.P. Tit4 to nt8].
The use of an aperient may have to be continued for from one to
six weeks, according to the length of time the constipation has lasted.
The best plan is to begin with doses sufficiently large to produce
complete evacuation of the bowels, without looseness, and gradually
to diminish the amount of the dose as the normal action of the
intestine becomes re-established.
G. A. SUTHERLAND.
439
CONSTIPATION IN ADULTS.
FOR the rational treatment of constipation it is necessary to
distinguish between the two great classes of cases : (1) That in
which the passage through the intestines is delayed, whilst
defecation is normal intestinal constipation ; and (2) that in
which there is no delay in the arrival of faeces in the pelvic colon,
but their final excretion is not adequately performed pelvi-rectal
constipation or dyschczia.
THE HYGIENE OF THE BOWELS.
Neglect of the hygiene of the bowels is not only often the sole
cause of dyschezia, but it is also an important factor in the majority
of cases of constipation of every variety. When there is delay in
the passage of faeces through the intestines, the resulting constipa-
tion is frequently aggravated by neglecting to make a proper effort
to evacuate the dry faeces collected in the bowel below the splenic
flexure. Consequently this part of the intestine is never completely
emptied, and an increasing degree of faecal obstruction is produced,
which materially increases the difficulty the intestine has in
adequately performing its excretory functions.
Instruction in the hygiene of the bowels how to defaecate most
efficiently is an essential part of the treatment of the majority of
constipated individuals, whatever be the cause of their constipation.
In some cases of slight constipation attention to the hygiene of the
bowels may be all that is necessary in order to relieve the condition.
An attempt should be made every day at the same hour to open
the bowels. The best time is immediately after breakfast, as under
normal conditions most of the contents of the alimentary canal are
then collected in the pelvic colon, and food taken into a completely
empty stomach is such a powerful stimulus to intestinal activity that
some of the contents of the pelvic colon are propelled into the rectum,
where they give rise to the " call to defsecation." The muscular
activity involved in getting up and dressing, in some people a cold
bath and a glass of cold water drunk before breakfast, and in others
a cup of coffee and a pipe or cigar, help to make the early morning
the most suitable time for the daily action of the bowels. Even
when the natural stimuli have produced no call to defsecation, the
patient should make an attempt, as the increased intra-abdominal
440 Constipation in Adults.
pressure produced by the voluntary contraction of the abdominal
muscles and diaphragm may force faeces into the rectum, and so
produce the desire to defaeeate.
In addition to the attempt to defaecate in the early morning,
a call to defaecation felt at any other time in the day should be
obeyed at once. Otherwise it soon disappears, although the fasces
which give rise to the sensation remain in the rectum, the sensi-
bility of which becomes impaired, and the first step is taken towards
the loss of the defaecation reflex. It is particularly important to
impress upon girls that no feeling of shyness should prevent prompt
obedience to the call to defaecation, at whatever inconvenient time
it may occur. Sufficient time should always be spent over the act
of defaecation, as it is rare for a single effort to be sufficient to
evacuate all the accumulated faeces. One or more additional
attempts to defaecate should be made after a short pause, whatever
the result of the first effort ; by this means any faeces left behind
after the first evacuation may be expelled. The activity of the
defaecation reflex varies in different individuals : the active rectum
works without delay, but the lethargic rectum requires solicitation.
For the latter it is often advisable to pay two visits to the closet at
short intervals, perhaps before and after breakfast.
In order to prevent the temptation to hurry over defecation the
closet should be clean, devoid of smell, well lit and properly warmed
in winter. There should, moreover, be a sufficient number of closets
in every house, as a single one is quite inadequate for a family of
four or five individuals, particularly if several of them have to hurry
away to business or to school immediately after breakfast. The
hour of rising and of breakfast should be regulated, so as to allow
sufficient time for the evacuation of the bowels to be efficiently
carried out before the business of the day begins.
In all cases of dyschezia, and whenever the sluggish passage of
faeces through the intestines has caused them to become so hard
and dry that a special effort is required in order to expel them
completely, it is most important that a proper position should be
assumed for performing the act of defaecation. This is quite
impossible with the high seat of the majority of water-closets. A
wooden footstool 9 inches lower than the seat should therefore be
provided, or a bed-pan raised slightly above the floor should be used.
Bed-ridden patients should, whenever possible, be allowed to sit erect
on a bed-pan, or, better still, be moved on to a commode placed at
the side of the bed, as the constipation, from which they are likely
to suffer for various reasons, is certain to be increased if they are
compelled to defaecate whilst lying down.
Constipation in Adults. 441
PYSCHOTHERAPY.
Psychical treatment consists primarily in the eradication of two
ideas which inhibit intestinal action and defaecation. One of
these is the conviction that constipation will inevitably result if no
artificial means are taken to produce the regular action of the
bowels, so that the habit is established of using purgatives or
enemata, although they are not really required. In such cases an
attempt should be made to persuade the patient that his constipa-
tion is merely a faulty habit, which can be readily and completely
overcome without recourse to purgatives or enemata by attention
to the hygiene of the bowels and by some slight changes in
diet.
The second idea which must be eradicated is that the attempt to
defecate will prove ineffectual. The patient is so frightened that
he will not get his bowels opened that by the violence of his efforts
he inhibits the involuntary reflex part of the act. The patient's
fears should be allayed, and he should be instructed to make less
strenuous efforts, and perhaps to divert his attention from the act
by reading.
After the patient has been thoroughly examined, he should, if
no organic disease is found, be told that with perseverance in
treatment he will get well, but that much depends on his own
co-operation. Throughout the period of treatment the patient
should be encouraged, and the most should be made of any
improvement. If he is disappointed that his improvement is not
faster, he should be reminded of his condition before the treatment
was begun, so that he may realise that he is already a little better,
and can hope to obtain finally complete relief by steady per-
severance.
Much treatment applied locally to the intestines, such as
enemata, electricity especially when intra-rectal and massage,
tends to confirm the hypochondriacal tendencies of neurotic
patients. Such patients should be encouraged to think as little as
possible about their illness, and be forbidden to make minute daily
examinations of their excreta. I have often found that X-ray and
sigmoidoscopic examinations are of value for their mental effect in
demonstrating the absence of any organic obstruction, the dread of
which is frequently a source of great worry to hypochondriacal
patients.
DIETETIC TREATMENT.
Errors of diet are among the commonest of all the causes of con-
stipation, and frequent!} 7 complete relief can be obtained by a
442 Constipation in Adults.
change in diet without any other treatment. In all cases, in which
the motor activity of the intestines is deficient or the constipation
is a result of the faeces being too dry, considerable improvement
results from dietetic treatment. In dyschezia a change in diet is
oftgn of value, even when the motor activity of the intestines is
normal, as it hastens the passage of the intestinal contents to the
rectum, which they reach in a comparatively soft condition, so that
the force required to expel them is diminished.
In the first place it is important to see that sufficient food is
taken, as constipation is often, especially in nervous patients, as
much due to the insufficient quantity as to the unsuitable quality
of the food.
The principles upon which a suitable dietary for constipation
should be framed can be readily gathered from a consideration of
the normal stimuli to intestinal activity. The mechanical stimula-
tion of the intestinal movements depends on the direct irritant
action of cellulose, and on the distension produced by the food ; the
latter is mainly due to the indigestibility of cellulose, which also
diminishes the digestion of vegetable proteins and starch, and so
adds to the bulk of the intestinal contents. The intestinal juice
and bacteria, both of which are increased by vegetable food,
further increase the distension of the intestines. The chief
mechanical stimulants of intestinal activity are sugars, the organic
acids and salts of vegetable food, fats, the extractives of meat, and
the products of the digestion and bacterial decomposition of
carbohydrates, fats and to a less extent of proteins.
Thus the main consideration in choosing a diet for constipation
is to increase the quantity of vegetable foods, especially those
which contain much cellulose, organic acids and sugar, and of fat.
The following is a list of the articles of diet which are of most value
in the treatment of constipation :
Diet for Constipation. Wholemeal bread. Porridge, made
with coarse oatmeal ; oatcake. Vegetables twice a day, especially
green vegetables, of which spinach and cabbage are best ; asparagus
and onions ; carrots, parsnips, turnips and artichokes ; tomatoes,
watercress and lettuce ; olives. Fruit, except bananas and bil-
berries, three times a day, raw or cooked ; especially fresh plums,
greengages and peaches ; raspberries, currants, gooseberries,
strawberries and figs ; pears, apples, oranges, grapes and melons.
Dried figs, raisins, prunes, dates and ginger. Jam and marmalade
with bread and puddings ; honey ; treacle. Butter with bread and
vegetables ; oil in salad ; cream with porridge and stewed fruits ;
bacon fat ; suet pudding ; cod-liver oil. Lemonade, cider, beer.
Constipation in Adults. 443
No claret or port. Tea, preferably China, only allowed if freshly
prepared and drunk with cream or milk, and not more than three
cups a day. It may be replaced by an equivalent amount of
cafe au lait, but black coffee is not allowed.
Although there are no solid foods which have a directly consti-
pating action, it is advisable to prohibit certain articles of diet on
account of their extreme digestibility, which deprives them of all
mechanically stimulating properties and is not compensated for by
the presence of any chemically stimulating constituents. Rice,
tapioca, sago, semolina, vermicelli and macaroni contain only
traces of cellulose, and are quite without effect on the intestinal
movements. The same is true of white bread and brown bread,
from which the bran has been removed, blancmange and mashed
potatoes. It is, therefore, advisable to replace these articles of diet
by others of a more stimulating character. Stewed fruit with
cream should replace rice and similar puddings, wholemeal bread
should replace white bread, and green vegetables potatoes. In mild
cases milk puddings and blancmange need not be prohibited, but
they should only be eaten with stewed fruit or with jam.
It is important that sufficient fluid should be drunk. In addition
to that taken with or immediately after meals, a glass of cold
water, which has a more powerful effect on intestinal peristalsis
than hot water, should be drunk before breakfast, another half
an hour before dinner, and a third just before retiring to bed.
Hard water has often been stated to be constipating, but it is
scarcely conceivable that the minute quantity of lime it contains,
amounting only to 0'002 per cent, can have any effect on intestinal
activity.
Sour milk has a slightly stimulating action on the bowels owing
to the lactic acid it contains. Its inhibitory influence on the
development of intestinal organisms is indisputable, so that in
cases of colitis associated with constipation, especially when the
stools are alkaline and offensive, sour milk should be given.
A non-irritating diet is generally recommended for spastic con-
stipation and muco-membranous colitis. It may indeed relieve
pain, but it tends to aggravate the constipation, and at the same
time to increase still further the malnutrition which is often
present. The most satisfactory diet for the majority of patients is
exactly the same as that given for other forms of constipation.
The accumulation of faeces in the colon having been removed,
retention of further quantities is prevented by the efficient stimula-
tion of peristalsis afforded by this diet, so that the exciting cause of
the spasm is removed.
444 Constipation in Adults.
MEDICINAL TREATMENT.
The majority of cases of constipation can be cured without drugs
if proper treatment is instituted at a sufficiently early stage. In
dyschezia purgatives are either absolutely useless or they only
have an effect when fluid stools are produced, a considerable
quantity of fluid and nutritive material being thereby wasted.
In mild cases of constipation, which require nothing more than
increased attention to the hygiene of the bowels, and perhaps some
slight change in diet, the patient generally thinks the matter is of
such slight importance that he treats himself with purgatives on his
own initiative. It is only when increasing doses fail to produce a
satisfactory result that he seeks medical advice, and then, the
underlying condition being more advanced, treatment by simple
hygienic measures and diet is less likely to be successful ; moreover,
the constant irritation of the intestinal mucous membrane so
greatly diminishes its excitability that treatment both by diet and
by drugs becomes comparatively ineffective.
Although the indiscriminate use of purgatives may have serious
results, their dangers have been exaggerated by some authorities,
who recommend that drugs should only be given as a last resource,
when all other methods have failed. It is indeed doubtful whether
more harm does not result from the excessively irritating diet
sometimes recommended than from properly regulated doses of
aperients.
INDICATIONS FOR PURGATIVES.
It is most unwise to give purgatives to every patient who
complains of constipation. The cause and nature of the constipa-
tion should first be ascertained, and drugs should only be given
for certain definite indications.
1. Symptomatic Constipation When constipation occurs as a
symptom of an acute illness, an occasional purge is useful and
does no harm, as with convalescence the normal condition of the
bowels returns spontaneously. In incurable diseases, such as
inoperable cancer, in which the expectation of life is short, con-
stipation is also best treated by purgatives. In chronic diseases of
the kidneys, in diabetes and in insanity, which are aggravated by
the constipation which is commonly present, purgatives should be
regularly given. When constipation is a symptom of a curable con-
dition, such as chlorosis, upon which it exerts a directly injurious
action, aperients should be ordered in the early stage of treatment,
in addition to the drugs and other therapeutic measures directed to
the cure of the primary disease. Finally, purgatives are useful for
Constipation in Adults. 445
making the stools soft, when defecation is painful as a result of
inflamed haemorrhoids, anal ulcer, or diseases of the pelvic organs,
and when straining at stool is accompanied by danger, as in
patients liable to cerebral haemorrhage.
2. Constitutional and Senile Constipation. The regular use
of purgatives for prolonged periods is most permissible in the cases
which appear to depend on a congenital hypoplasia or an acquired
atrophy of the intestinal musculature, the former being probably
the cause of some cases of hereditary and so-called constitutional
constipation, and the latter of senile constipation.
3. Intractable Constipation. In the comparatively small num-
ber of cases of constipation in which non-medical treatment proves
insufficient, purgatives must be used, but an effort should always
be made to dispense with drugs at the earliest possible moment.
4. Cumulative Constipation. Many individuals, particularly if
they lead a sedentary life and eat excessively, are in the habit of
taking a purge once a week or at other regular intervals, even if
they are not obviously constipated. The undoubted benefit they
derive from this practice suggests that they are really suffering from
cumulative constipation, although their bowels may be opened
daily, and that the purging gets rid of the excess of faeces accumu-
lated during the week. They would, of course, be in a more
healthy condition, and would no longer require their weekly purge,
if they ate more wisely and took more exercise; but it is often
impossible to persuade such individuals to make any radical
alteration in their mode of life.
CHOICE AND DOSAGE OF PURGATIVES,
The stool produced by an aperient should be normal in size and
consistence, and should not deprive the body of any water, salt or
nutritive material, which ought to be absorbed. The dose should be
so regulated that one stool is passed every day, and the desire to
defalcate is felt immediately after breakfast and not at an inconve-
nient time, which would interrupt the day's occupations or disturb the
night's rest. This is usually accomplished by giving a single dose
of the drug in the evening or on rising, according to the rapidity of
its action. But it is really more rational to divide the dose into
three parts, to be taken before or after meals ; the stimulating action
of the purgative is equally effective, and, being spread through the
whole day, it is less violent and therefore less liable to cause colic or
catarrh. The aperient should cause no pain or discomfort and should
not irritate the intestinal mucous membrane sufficiently to produce
any inflammatory changes. It should exert no harmful action on the
446 Constipation in Adults.
stomach, kidneys or other organs. If it is probable that the purga-
tive will be required permanently, one should be chosen which
experience has shown can in favourable cases maintain its good
effect without requiring any increase in the dosage.
From time to time attempts should be made to reduce the dose.
If the constipation does not improve and the drug begins to lose its
effect, it is advisable to try some other aperient before increasing
the dose. It is often found that no addition to the doses is
required if two drugs are given alternately for periods of a week
each.
1. Alkaloids : (a) XHX Vomica, Strychnine. Strychnine in-
creases the reflex excitability of the peripheral as well as the
central nervous system. The tone of the intestines, which probably
depends to a great extent on the constant slight stimulation of
Auerbach's plexus (the peripheral nerve-centre situated in the
muscular coat), isiherefore increased by strychnine. At the same
time the increased excitability of Auerbach's plexus causes the action
of a stimulating diet and of those purgatives, which act by means
of a peripheral reflex, to be more effective. Hence in the forms
of constipation, which depend on depression of the central and peri-
pheral nervous system, strychnine and nux vomica are of great
value, whether given alone or in combination with vegetable or
saline aperients.
(ft) Belladonna, Atropine. Atropine paralyses the nerve-endings
of the vagus and pelvic nerves in involuntary muscles. Hence its
action on the intestinal musculature is to diminish its tone and
contractile force, and to regulate the intestinal movements if they
were previously irregular. It is therefore of use in cases of spastic
constipation, as it diminishes the excessive excitability of the peri-
pheral nerve-centres, and so permits orderly intestinal contractions
to return.
The constipation associated with lead colic results from irrita-
tion of the vagus ; it is therefore sometimes relieved by the
partial paralysis of the vagal nerve-endings produced by atropine.
More frequently, however, atropine relieves the colic without open-
ing the bowels. It should then be given with a purgative, such
as magnesium sulphate or castor oil, which by itself generally
increases the colic without producing a thorough aperient action.
Most vegetable purgatives give rise to more or less griping. This
can often be entirely overcome by combining the drug with a small
dose of belladonna.
(y) Opium, Morphia, Codeine. Opium is of value in those
cases of constipation which are associated with pain, especially
Constipation in Adults. 447
when it results from disease of the pelvic or abdominal viscera.
The analgesic effect of opium, and its paralysing action on the
central nervous system, which leads to a diminution in the reflex
activity of the inhibitory nerves to the intestines, may result in the
bowels being opened. In spastic constipation opium is at first
even more effective than atropine, but as the condition is often
chronic or recurrent it is advisable to employ it as little as
possible.
Opium and its alkaloids should only be used in acute or incurable
cases, as in chronic conditions the morphia habit may develop.
Moreover, the initial good effects are generally replaced before long
by the ordinary constipating action ; this is less marked with
codeine than with opium or morphia.
Opium, morphia and codeine may therefore be used in acute
painful conditions associated with constipation, such as biliary
and renal colic, and in rapidly curable forms of intestinal colic,
such as that due to lead poisoning. They are generally most
effective when given in combination with a saline purgative.
2. Vegetable Purgatives. Vegetable purgatives irritate the
intestinal mucous membrane and thereby give rise to a local reflex
in Auerbach's plexus, which results in increased motor activity.
This diminishes the time during which absorption of fluids taken
by mouth or secreted into the alimentary canal can take place ; there
is no evidence to show that vegetable purgatives stimulate the secre-
tion of the digestive juices. Those most commonly used do not
irritate the stomach, as some, such as aloes, only act after they
have become dissolved in the bile, and others, such as castor oil,
after they have been split into active substances by the pancreatic
ferments.
(a) Anthracene Purgatives. Aloes, cascara sagrada, senna and
rhubarb owe their purgative action to certain irritant com-
pounds of anthracene. A considerable quantity of tannic acid is
present in rhubarb, so that its aperient action is generally
followed by constipation ; for this reason it is not suitable for regular
use.
(i.) Aloes can in many cases be taken regularly for years with-
out producing any bad result and without losing its efficacy. It
acts more slowly than any other aperient, requiring, as a rule, ten
or twelve hours to produce a result, it is commonly supposed to
irritate the rectum, but the evidence that it does so is not conclusive,
though perhaps it is best to avoid it when haemorrhoids are present.
The action of aloes is said to be increased by the addition of iron
salts ; it is therefore often prescribed with ferrous sulphate. It is,
448 Constipation in Adults.
however, not clear that the iron is really of value except in the con-
stipation of chlorosis, when it acts upon the cause of the constipa-
tion. It has already been explained how the efficacy of vegetable
purgatives can be increased by the addition of nux vomica and
belladonna ; one of the best pills for use in chronic constipation is
composed of J gr. of extract of nux vomica and \ gr. of extract of
belladonna, with from ^ to 2 gr. of aloin. This pill may be given
three times a day, or, in mild cases, only after the evening meal ;
the exact dose should be carefully adjusted so as to produce a single
formed stool each morning.
(ii.) Cascara Sagrada closely resembles aloes in its action ;
the dose of the extract is from 1 to 5 gr., and it is best given in a pill
or tabloid with nux vomica and belladonna. When it is necessary
for a purgative to be taken regularly for long periods, it is a good
plan to give a cascara and an aloes pill alternately for a week at
a time.
(iii.) Senna. Although the official preparations of senna are
made from the leaves of cassia, the pods contain an equal quantity
of cathartic acid, which is the active principle. Amongst the
former are the compound powder of liquorice and confection of senna,
which are mild laxatives, particularly suitable for children. Senna
contains a resinous substance, which tends to cause griping and
nausea. As this is insoluble in water, an aqueous extract is the
best preparation. The requisite number of senna pods are
allowed to stand in cold water for six hours, and the infusion is
drunk last thing at night, or some senna leaves contained in a
muslin bag may" be stewed with prunes without spoiling their
flavour. Senna pods have the great advantage over other
vegetable aperients in the ease with which the dose can be
regulated from day to day. A patient may start with six pods
each evening ; he can rapidly increase or diminish the number
until a satisfactory result is obtained, after which he should
gradually reduce the dose by one pod at a time as improve-
ment in his condition occurs.
3. Castor Oil. On account of its mild but certain action, and
the absence of gastric irritation and of griping, castor oil is
perhaps the most valuable of all purgatives for occa-
sional use, a dose of ^ or 1 oz. being generally required. The
regular administration of or 1 dr. at night, or night and
morning, is one of the best methods of treating senile constipation,
and it is often the only purgative which is effective in spastic
constipation and in muco-membranous colitis, especially when
opium or belladonna is given simultaneously.
Constipation in Adults. 449
The great disadvantage of castor oil is its nastiness, which,
however, is comparatively slight in the best preparations.
4. Synthesised Purgatives. Numerous synthesised purga-
tives have been introduced, but the only one that has proved of
much value is phenoiphthaleiti, which has been sold under
various names, such as purgen, purgatol and laxine. It appears
to stimulate both peristalis and secretion in the intestine without
producing pain, and it has no action on any other organs. The
dose varies between 1 and 15 gr. It is best taken alone in tablet
form or in capsules. Large doses are said to give rise to catarrhal
colitis, but in moderate doses it is a safe and efficient aperient.
5. Saline Purgatives. We have recently, proved that the
commonly accepted theory of the physical action of saline purga-
tives is erroneous. They act after absorption from the small
intestine by stimulating the motor and secretory activity of the
colon. They should be taken before breakfast, because the
stomach is then empty, and they are consequently rapidly
absorbed. When a dose of a saline purgative, sufficient to produce
a single copious and semi-liquid stool, is given, the whole of the
large intestine from the caecum to the rectum is completely
emptied. Salts are therefore particularly indicated when it is
desired to produce a complete evacuation of the colon without
interfering with digestion in the small intestine. They have the
advantage in such cases over many vegetable purgatives, such as
cascara sagrada and castor oil, in that they produce none of the
acceleration in the passage of chyme through the small intestine,
which leads to diminished digestion by the pancreatic and intes-
tinal juices.
Many individuals find salts the most pleasant form of aperient,
their action being, as a rule, very reliable and unaccompanied by
disagreeable symptoms. They tend, however, to produce depres-
sion in nervous individuals, owing to the loss of a considerable
amount of fluid, for they differ from vegetable purgatives in
increasing the secretory as well as the motor activity of the large
intestine. The softness of the stools, which result from the use of
saline purgatives, renders them particularly useful for patients
with hcernorrhoids, anal ulcer and painful pelvic conditions.
The xnli)lt<(1< '.s <>i xoila. <tn<] iiiajinesia are equally reliable, but
the latter has the disadvantage of possessing an unpleasant
bitter taste. Sodium sulphate is best taken either by itself, or
mixed with sodium bicarbonate and tartaric and citric acids as
the pharmacopoeial effervescent salt, in a tumbler of cold water,
which should be slowly drunk whilst dressing. One drachm is
S.T. VOL. ii. 29
450 Constipation in Adults. .
generally the best dose to begin with, but the quantity requires
regulating until the desired effect is produced. Sodium sulphate
can also be given three times a day, in doses varying between
20 gr. and 2 drachms. Its efficacy can then be greatly increased
by the addition of 5 min. of liquor strychninae [U.S.P. strychnin,
hydrochlor. gr. ^] to each dose. When a purgative is required
in cases of chlorosis, sodium sulphate can be added to an iron and
arsenic mixture.
6. Mercurial Purgatives. Large doses of mercurial salts
produce congestion, necrosis and ulceration of the intestinal mucous
membrane, especially in the colon ; watery, blood-stained stools are
passed, and intense pain and tenesmus are present. In small doses
the irritation leads merely to a slight increase in the motor and
secretory activity of the intestine, a soft stool being produced
without pain.
Mercurial purgatives were formerly believed to act by increasing
the flow of bile, but observations on animals and on men with
biliary fistulse have shown conclusively that they have no action on
the liver.
Only the insoluble preparations of mercury are used as purgatives,
as the others are absorbed to too great an extent. The former are
partly dissolved in the intestines, and then exert their action on the
mucous membrane. Calomel is the mercurial most commonly used
at the present day, but metallic mercury in the form of blue pill
[U.S.P. mass of mercury] or grey powder is still often given.
Mercurial purgatives are very valuable for occasional use,
particularly in so-called " biliousness," in which the furred tongue,
anorexia, general malaise, headache, discoloured conjunctivas and
constipation result really from gastro-intestinal disorder and not
from any hepatic condition. They are also valuable in diarrhoea
resulting from excessive putrefaction, in which they act mainly as
evacuants, but to some extent as intestinal antiseptics.
Mercurial purgatives should never be employed in the treatment
of chronic constipation, as they produce too much irritation of the
intestinal mucous membrane, and their constant use is likely to
result in symptoms of mecurial poisoning.
7. Substances which Increase the Bulk of the Faeces. It
might be supposed that the form of constipation, which is due to
absorption by the intestine being so active that very little faeces
remain to be excreted, required no treatment. But the occurrence
of symptoms in severe cases makes it probable that the small
quantity of faeces formed remains so long in the intestines before
sufficient accumulates in the pelvic colon to produce an effective
Constipation in Adults. 451
stimulus to defaecation that an abnormally large proportion of the
poisonous constituents of the faeces is absorbed. It is therefore
advisable to attempt to obtain an evacuation at least every other
day. This can best be done by increasing the bulk of the faeces by
the administration of some substance, such as agar-agar or paraffin,
which passes through the intestines without undergoing decomposi-
tion or absorption.
(i.) Ayar-agaria prepared from certain East Indian seaweeds, and
consists mainly of hemi-cellulose, which is unaffected by the
digestive juices and is for the most part unabsorbed. It readily
takes up about four times its weight of water, so that a compara-
tively small quantity taken by mouth yields a considerable volume
of material for excretion. Pure agar-agar can be obtained as an
almost tasteless powder and in shreds. It should be taken two or
three times a day in porridge, mashed potatoes, puddings, stewed
apples or other food. The patient may begin with doses of one
teaspoonful, and the amount should be increased or diminished to
suit each case. Many patients can after a time dispense with it
entirely, others have to use it permanently. The agar-agar can be
added to the food by the patient himself, or it can be incorporated
with it in the cooking. In the latter case it should be soaked in
water at from 100 to 150 F. until quite soft, after which as much
of the water as possible should be drained away; it can then be
mixed with the other ingredients of the various articles of diet
already mentioned, or with gelatine in the preparation of jellies.
The addition of a small quantity of an aqueous extract of cascara
sagrada has been recommended in order to replace the stimulating
decomposition products of the food, which are present in these
cases in abnormally small amount. The dose of cascara is quite
insufficient by itself to produce any purgative action. The com-
bination of agar-agar with cascara is sold under the name of
re; i a I in. It has the disadvantage of possessing an unpleasant
bitter taste. The addition of 1 gr. of phenolphthalein to each
drachm of agar-agar is equally effective, and does not alter the
tasteless character of the latter.
(ii.) Liquid Paraffin, is non-irritating, and is not absorbed in the
alimentary canal. It is particularly valuable when the fasces are
very hard and dry, and is therefore useful in certain other forms of
constipation besides that due to a greedy colon, as, for example, in
diabetes. In dyschezia also the soft stools which result from its
use are expelled with less difficulty than ordinary faeces. From
1 dr. to \ oz. should be taken with two or three meals every day.
It occasionally gives rise to nausea, but on the whole I have found
29-2
452 Constipation in Adults.
it much more useful than agar-agar, which not infrequently causes
disturbances in gastric digestion.
ENEMATA AND SUPPOSITORIES. REMOVAL OF IMPACTED
FAECES.
Enemata are used in the treatment of constipation with the
object of (1) producing an immediate evacuation of the large
intestine, and (2) softening hard accumulations of faeces, so that
they may subsequently be more easily evacuated.
Enemata as Evacuants. Enemata empty more or less of
the large intestine by stimulating its movements (a) mechanically,
(b) thermally, and (c) chemically.
(a) Mechanical Stimulation. The distension of the intestine
with fluid acts as a powerful stimulus to contraction, the strength
of which depends on the volume of fluid injected and the method
of injection, the latter being the more important factor. If no
obstruction is present, two pints of water can be run into the colon
under low pressure without stimulating its movements at all, as,
most of the large intestine being normally almost empty, the bulk
of its contents can be greatly increased without distending it.
When, on the other hand, an enema is given with a syringe, the
rapid intermittent increase in pressure in the lowest part of the
intestine stimulates it to contract.
(b) Thermal Stimulation. The stimulating action of enemata
can be considerably increased by using fluid which is not at the
body temperature. As water at a temperature more than a few
degrees above that of the body is injurious to mucous membranes,
the effect of the hottest enema which can be safely given differs little
from that of one which is thermally indifferent, and indeed there
is some evidence to show that it exerts a slight sedative influence.
On the other hand, water at a temperature of as much as 60 F.
below that of the body does not injure the intestinal mucous
membrane. As the application of cold stimulates peristalsis, the
efficacy of enemata can be greatly increased by using cold instead
of hot water. The stimulation produced by water between 60 and
70 F. is, however, generally sufficient, as colder water is liable to
produce such violent contractions that severe colic results and the
enema is at once rejected.
In spastic constipation and in muco-membranous colitis, injections
at the body temperature or slightly above it help to relieve the
spasm in addition to emptying the colon. On the other hand, cold
enemata increase the spasm and may cause considerable pain.
(c) Chemical Stimulation. Water and normal saline solution
Constipation in Adults. 453
do not produce any chemical stimulation of the intestines. The
presence of soap in enemata is supposed to increase the efficacy
of enemata to a slight extent by mildly stimulating the intestinal
mucous membrane.
Owing to its power of abstracting water from tissues, glycerine
acts as an irritant to mucous membranes. The injection of 1 or
2 drachms of glycerine into the rectum acts as a powerful
stimulus, which gives rise to a defecation reflex, often sufficiently
strong to cause the bowels to be at once thoroughly opened. As a
rule its action is painless, but it often causes some tenesmus, which
can be prevented by mixing the glycerine with an equal quantity of
water.
Glycerine Suppositories are as effective as glycerine enemata,
and have the advantage that they can be very easily introduced
by the patient himself. They rapidly dissolve in the rectum, and
generally act within a few minutes. One or 2-drachm supposi-
tories can be used for adults, and J or ^-drachm for children. The
solid suppository produces a mechanical stimulus in addition to
the chemical stimulus of the glycerine, and the stimulus it
exerts is often so strong that an action is obtained before
sufficient time has elapsed for more than a small part to
dissolve.
On account of their irritant action glycerine enemata and supposi-
tories should not be used by patients with haemorrhoids. It is also
unwise to use them regularly for long periods, as they are likely
to give rise to catarrhal proctitis. But they are very valuable for
occasional use, when fceces have become impacted in the rectum
and an attempt to open the bowels naturally has failed. A glycerine
suppository will then often produce a single evacuation without
delay, the stool being of normal consistence, so that no nutrient
material or excess of fluid is lost. Under such circumstances they
are more convenient than either purgatives or enemata. They are
very useful before parturition, as they are more cleanly and more
sure of action than the enemata usually employed.
Cases of dyschezia, in which the defecation reflex is impaired,
can often be cured by a course of treatment with glycerine enemata
or suppositories. An effort to defalcate having proved unsuccessful or
the result insufficient, the glycerine is at once introduced. In the
case of enemata the treatment should begin with pure anhydrous
glycerine ; every day the strength is slightly reduced by replacing
an increasing proportion of glycerine by water. Finally the injec-
tion is so dilute that it no longer exerts any chemical stimulus, the
result being due simply to the slight mechanical stimulation
454 Constipation in Adults.
produced by the introduction of the syringe and the injection of
2 drachms of an indifferent fluid. If suppositories are used, a series
should be employed containing respectively 95, 75, 60, 50, 40, 30
and 15 per cent, of glycerine.
As vegetable purgatives act by directly stimulating the intes-
tinal mucous membrane, their addition to an enema increases its
efficacy. Castor oil, however, has no action on the intestines until
it is split into glycerine and ricinoleic acid ; when given as an
enema it is generally retained too short a time for this to occur, so
that it has no more effect than a non-purgative oil, such as olive
oil.
Bile stimulates the motor activity of the colon, but not of the
small intestine ; it has, therefore, a mild purgative action if added
to an enema, and a small quantity of undiluted bile gives rise to a
defecation reflex, which, however, is much feebler than that pro-
duced by glycerine.
Turpentine stimulates peristalsis ; when added to enemata it is
supposed to be specially efficacious in causing the expulsion of
flatus from the rectum, but why the contractions it gives rise to
should act particularly on the gaseous rather than the solid con-
tents of the intestines has never been explained.
Varieties of Enemata depending on Method of Administra-
tion and Amount of Fluid Used. According to the method of
administration and the amount of fluid used, enemata may act
on (1) the whole colon, (2) the pelvic colon and rectum, or (3) the
rectum alone.
(1) High Enemata. If fluid is run under a constant pressure
of not more than 3 feet of water from a funnel or douche-can
through an indiarubber tube into the intestine, it reaches the
caecum without difficulty. It is quite unnecessary to assume any
of the special positions or series of positions which have often
been recommended, as the fluid runs in equally easily when the
patient lies on his back or on either side.
When a large injection under low pressure has to be made,
difficulty is sometimes experienced in introducing the fluid beyond
the pelvi-rectal flexure ; this can generally be overcome by
increasing the pressure for a moment. It is useless to introduce
the tube more than 3 inches, as when it reaches the pelvi-
rectal flexure its end turns backwards towards the anus, from
which it may finally project.
If between 1^ and 3 pints of water are introduced into the
colon in this way, the whole of it is slightly distended. If
a desire to defecate is not felt at once, the fluid should be
Constipation in Adults. 455
retained for a quarter of an hour. An effort should then be made
to defaecate ; the increased intra-abdominal pressure, acting
on the filled large intestine, stimulates it to such an extent
that strong contractions occur throughout its length, and the water
is expelled, carrying with it most of the contents of the colon. On
the rare occasions in which all the water is retained, a further
quantity should be injected, when a second effort to defaecate will
almost certainly be successful. There is no danger of over-dis-
tending the gut so long as the fluid is introduced at a low
pressure.
It is important that a proper position should be assumed during
defecation after the administration of an enema. The full benefit
of treatment with euemata is sometimes not obtained owing to
the common practice, especially in hospitals, of letting the patient
lie or half-sit on a bed-pan, so that it is quite impossible for him
to make a proper effort to defaecate, instead of allowing him to get
out of bed and use the water-closet.
(2) Low Enemata. When an enema is administered in the
ordinary way by means of Higgiuson's syringe the rectum and
pelvic colon are stimulated to contract so quickly that it is
generally difficult to inject more than a pint of fluid, and not
much of this gets beyond the pelvic colon. This is, therefore,
an effective method of emptying the rectum and pelvic colon,
except in severe cases of dyschezia, in which the atonic rectum
and pelvic colon do not respond to the mechanical stimulation,
but simply become over-distended by the fluid, the atonic dilata-
tion being thereby aggravated.
(3) Rectal Enemata. When not more than 4 oz. of fluid are
injected they do not, as a rule, reach beyond the rectum. As
their mechanical effect is very small, they must either be cold, so
as to produce a thermal stimulus, or contain some chemical
stimulant, such as glycerine, ox-gall or aloin. In either case the
stimulus may give rise reflexly to defaecation.
Enemata as Solvents. The force required to propel hard
faeces along the last part of the large intestine and to expel them
in the act of defaecation is sometimes so great that it becomes
necessary to soften them before any other treatment can be
effective.
Enemata of olive oil and bile have been most commonly
used for this purpose, but I have proved experimentally that
they have very little softening action on faeces. On the other
hand, I found that contact with water at the body temperature
for four hours caused the hardest scybala to crumble completely
456 Constipation in Adults.
away when shaken. Considerable softening of the whole mass
occurred already in half an hour, and even in a quarter of an
hour a greater effect was achieved than oil could produce in
twelve hours.
Water is too rapidly absorbed from the rectum for a single
injection to have much effect in softening faeces. It is, therefore,
best to give a series of injections at short intervals, each being
retained, if possible, for twenty minutes or half an hour. The
water should be at the body temperature, and the amount
regulated according to whether the faecal mass is in the rectum
only, in the rectum and pelvic colon, or in the proximal parts
of the colon. It should be injected at a pressure not exceeding
3 feet. The number of injections required varies ; but, as a
rule, an effort to defaecate after the second or third injection is
successful.
Although the softening action of oil on faeces is negligible, it
detaches scybala from the intestinal walls and lubricates the
mucous membrane, so that the expulsion of the fasces is facili-
tated. It is only absorbed from the colon to a very small
extent; consequently its injection in the evening prevents the
absorption of water from the fasces collected in the pelvic colon,
with the result that no increase in their hardness occurs during
the night. Oil has also a soothing effect upon the mucous mem-
brane when catarrh is present, and it diminishes the tendency to
spasm of the intestines and the sphincter ani in spastic constipa-
tion. Lastly, if oil is retained in the intestine for some hours, it
is partly decomposed into glycerine, fatty acid and soap, which act
as mild stimulants to the motor activity of the pelvic colon and
rectum. Oil enemata are therefore specially indicated in spastic
constipation and in muco-membranous and other forms of colitis,
which are secondary to constipation.
Injections of olive oil are best given at night, and they should
be retained until the morning. About 5 oz. should be used on
the first occasion. If the treatment has to be repeated, the amount
should be gradually increased to 10 or 15 oz. The oil, which
must be absolutely pure, is warmed to 100 F. and is then
slowly introduced into the colon from a funnel or douche- can
suspended 2 or 3 feet above the level of the body. A little
cotton-wool should be placed between the buttocks during the
night in case a few drops escape from the anus. In the
morning the bowels are sometimes satisfactorily opened without
further assistance, but often the injection of a high enema of
water is required.
Constipation in Adults. 457
GENERAL INDICATIONS FOR THE USE OF ENEMATA.
(1) In Intestinal Constipation. The majority of cases of
moderately severe constipation are more or less cumulative, excess
of faeces being always present in the large intestine. It is therefore
necessary that the colon should be completely evacuated before
other methods of treatment are adopted.
It is generally possible to empty the bowels completely by
means of a dose of castor oil or calomel, followed, if necessary, by
a saline purge. In severe cases, however, especially if the consti-
pation is of long standing, it is necessary to remove the
accumulation of faeces from the large intestine by enemata before
other treatment is attempted. When the improvement is slow, it
is often advisable to give occasional enemata for some weeks. A
good rule to follow is that an enema should be used whenever a
really satisfactory stool has not been procured for two consecutive
days in spite of the regular application of other methods of
treatment. In cases of this sort a high enema of 1 or 2 pints of
warm water should be used. An attempt should be made to
retain it for J or J hour in order that it may have time to soften
the faeces. It is often advisable to give a second similar injection
immediately after the first has been expelled. It need not be
retained for more than a couple of minutes, and its stimulating
action can be increased by giving it cold.
When a satisfactory result is not obtained by the two enemata
owing to the hardness of the faeces, a series should be given in
the manner already described, or, if there is any catarrh or spasm
of the colon, an olive-oil injection should be given the previous
evening and retained during the night. It is often necessary to
repeat the treatment for two, three or more consecutive days before
the colon is completely evacuated.
The occasional enemata given after the regular treatment has
been begun can be of the same sort ; but a smaller quantity of
fluid, injected with a Higginson's syringe, is often effective if
used before any considerable amount of faeces has had time to
re-accumulate.
When the constipation is accompanied by much flatulence, 1 oz.
of turpentine may be added to each pint of the enema.
(2) In Dyschezia. The most important part of the treatment of
dyschezia is to keep the rectum and pelvic colon empty, so that
they may in time regain their normal tone and contractile power.
This can only be accomplished by the regular use of enemata or
suppositories.
The belief that the regular use of enemata is always harmful is
458 Constipation in Adults.
erroneous, and in many cases of dyschezia it is the only treatment
which can lead to complete recovery. Even in the most obstinate
cases the ultimate result of the treatment is often very satisfactory,
although the enemata may have to be given regularly for a year or
longer before the rectum and pelvic colon return to their normal
condition. In very exceptional cases the- atony and paralysis of
the rectum are so complete that recovery is impossible ; in such
cases treatment by enemata, though it does not cure, is the only
way in which a regular evacuation can be obtained.
The use of enemata should be discontinued as soon as the power
to empty the bowels completely without artificial aid has returned.
The exact moment when this occurs can only be recognised by
instructing the patient to make an attempt to defecate every day
before he has an enema, even if he never experiences a desire to do
so. If the attempt is completely unsuccessful, or if only a small
proportion of the faeces in the rectum is evacuated, an enema must
be given.
In slight cases, in which the contractile power of the
rectum and pelvic colon is not greatly impaired, stimulation
of the anal mucous membrane is generally sufficient to produce
reflexly an efficient defecation. For this purpose a glycerine
enema or the more convenient glycerine suppository should be used,
the strength of the glycerine being regulated in the manner already
described. When glycerine fails to act, the muscle can often still
be caused to contract by the mechanical stimulus produced by the
injection of about 1 pint of water by means of a Higginson's
syringe. If plain warm water is ineffective, the stimulus can be
increased by using cold water, or by the addition of soap or senna
to it.
In the severest cases the muscular power of the pelvic colon and
rectum is so feeble that it can never contract in response to any
stimulus with sufficient force to expel all its contents. Under these
circumstances a high enema should be given at very low pressure ;
on then making an effort to defecate, the large intestine above the
pelvic colon, being normal, contracts on the fluid it contains with
sufficient force to expel the greater part through the anus, the
water carrying with it most of the faeces collected in the pelvic colon
and rectum.
Some nervous patients complain of exhaustion or abdominal
pain after an enema has been administered. This drawback can be
avoided by giving the enema just before the patient retires to bed
instead of in the morning, or by the introduction of a belladonna
suppository half an hour before the enema is injected.
Constipation in Adults. 459
Removal of Impacted Faeces. It is generally unwise to
give purgatives when faeces have become impacted in the intestines,
as the colic, which is usually present, indicates that the intestinal
musculature is already contracting very actively, and that it is
unlikely that any additional stimulation will result in a sufficient
increase in the force of the contractions to overcome the obstruc-
tion.
The rational treatment of faecal impaction is by means of enemata.
Occasionally, however, they fail to act, and it becomes necessary to
remove the faeces piecemeal by a finger introduced into the rectum.
This is much more effective and much less likely to injure the
rectal mucous membrane than removal by means of a metal scoop
or the handle of a spoon. When digital evacuation is required it
is generally necessary to give an anaesthetic, as the dilatation of
the sphincter and the manipulation, which is often very prolonged,
are always painful. The evacuation is much facilitated by simul-
taneously irrigating the intestine with water through a tube
inserted into the rectum by the side of the finger. In this way
small fragments of faeces are washed out while the large masses
are being broken by the finger. When the accumulation is not
confined to the rectum it is sometimes possible, by a hand placed
on the abdomen, to press the faeces from the pelvic colon into the
rectum after the latter has been evacuated.
HYDROTHERAPY.
Cold applied to any part of the skin, but particularly to the abdo-
men, reflexly stimulates the muscular coat of the entire alimentary
canal. Hence a cold bath taken every morning is a very valuable
addition to the series of stimuli which lead to the morning evacua-
tion. If a hydrotherapeutic institute is available, a trial may be
made of the Scotch douche, in which hot and cold water are alter-
nately played on the abdomen from a distance for ten seconds each,
the pressure being gradually increased if the patient is able to
tolerate it.
The spasm in spastic constipation is often benefited by a hot
bath or by a hot compress applied to the abdomen. When con-
stipation is due to some painful pelvic condition, the latter and
the associated spasm of the sphincter ani may be relieved by the
use of a hot sitz-bath.
EXERCISE AND SWEDISH GYMNASTICS.
Regular exercise is one of the most important means of prevent-
ing constipation, especially in individuals who follow a sedentary
460 Constipation in Adults.
occupation. It increases the appetite, it strengthens the voluntary
muscles of defecation, and it stimulates the intestinal movements by
producing rapid changes in the intra-abdominal pressure. Moreover,
it has a most important mental effect, as it takes the thoughts away
from business cares and household worries, the depressing influence
of which on the nervous system is an important factor in the pro-
duction of many cases of constipation.
It is necessary, however, to avoid taking too much exercise, as
the harm produced by great fatigue more than outweighs the good
done by the exercise which causes it. People who are unac-
customed to exercise and are advised to take it for constipation
should therefore begin with a mild form for periods of short
duration. Rest rather than exercise is required when constipation
is due to reflex inhibition of the intestinal movements by disease of
some abdominal or pelvic organ, as the latter may be aggravated
by exercise and the inhibition consequently strengthened.
Walking on the level may improve the appetite, but it is too mild
an exertion to have much effect on the intra-abdominal pressure,
and it does not do much to strengthen any of the muscles con-
cerned in defaecation. Bicycling is very little better. Climbing, on
the other hand, is most valuable, as the diaphragm and abdominal
muscles are brought into great activity, and the thighs inter-
mittently exert considerable pressure on the abdomen. Walking in
a hilly neighbourhood, quite apart from actual climbing, is much
more useful than walking on the level. No forms of exercise are
more valuable for all the muscles of the body than rowing, skipping,
and swimming, and the latter has the additional advantage of afford-
ing a thermal stimulus to intestinal activity. For those who require
some less strenuous exertion, riding is of value for the diaphragm
and abdominal muscles, and the constant bending in gardening
and when playing bowls makes these recreations useful for the
abdominal muscles. Gymnastics have the serious disadvantage
that they must be done indoors, as one of the most important
effects of exercise is the stimulating influence it has on the appetite,
and this is most marked when it is taken in the open air.
Swedish Gymnastics. When any of the voluntary muscles of
defaecation are weak, considerable benefit can be gained by the
regular performance of Swedish exercises. At first each move-
ment may be repeated six times morning and evening, the number
being gradually increased as the muscles become stronger ; but the
exact time to spend over the exercises varies in each case and
depends upon the amount of fatigue produced, for the patient
should always stop before he feels very tired. It is generally
Constipation in Adults. 461
necessary to continue the exercises for several months, but after a
time the number done can be slowly diminished.
The abdominal muscles are those which most frequently require
strengthening, and it is important to remember that exercises are
just as essential for the transversalis, internal and external oblique
muscles as for the recti. The following list gives the most
generally useful exercises, but they require modification to suit
individual cases.
(1) Lying. (a) Slowly sit up with the arms stretched forwards
until the finger-tips touch the feet, then slowly lie down again.
When the muscles are very weak it may be necessary at first to
have the shoulders supported at the commencement of the
movement.
(b) Clasp the hands together behind the neck ; raise the extended
legs as high as possible, and slowly let them fall ; raise them again
before they reach the ground. Here again it is often necessary
at first to have the legs supported.
(c) Sharply draw in the abdomen, let it out again, and then push
it out by contracting the diaphragm.
(d) With one foot laid over the other raise the pelvis as high as
possible. This may be done against the opposition of an attendant,
who presses downwards with his hands on the crests of the ileum.
(2) Standing. (a) Extend the arms above the head and keep the
legs stiffly extended ; bend the trunk forwards and try to touch the
toes with the finger-tips.
(b) Hang the arms by the side and keep the thighs and legs
stiffly extended ; bend first to one side and then to the other,
trying to touch the foot with the hand of the same side.
(c) With the hands on the hips, twist the body round as far as
possible, first in one direction and then in the other.
(d) With the hands on the hips, lean back as far as possible, and
slowly move the body round the fixed pelvis, so that the head
describes a large circle.
(e) Raise the legs alternately as high as possible, so as to com-
press the abdomen with the thighs. This exercise can be replaced
by going slowly upstairs two steps at a time.
(f) With the hands on the hips, stand on the toes and slowly
bend the knees outwards with the body bent forwards, so as to
assume a squatting position, with the buttocks touching the heels,
and the thighs pressing on the abdomen ; then slowly rise again.
Patients in whom injury to the pelvic floor has led to dyschezia
should be instructed to make the movement they would do were
they trying to restrain a commencing defalcation ; by this means
462 Constipation in Adults.
the levator ani muscles are contracted. They should be alternately
contracted and relaxed thirty times every morning and evening.
Abdominal Supports. Dyschezia is most often associated with
visceroptosis, both being due to weakness of the abdominal muscles.
In such cases a proper support is of the greatest value. It has
sometimes been taught that a support should only be worn when the
abdominal muscles are so weak that their recovery is deemed
unlikely, as it is supposed to cause disuse-atrophy of the muscles.
This view is, however, erroneous ; by supporting the viscera a
well-fitting belt or " visceroptosis truss " prevents the abdominal
muscles from being stretched ; it consequently becomes possible
for them to regain some of their former strength.
MASSAGE.
Whenever constipation is due to want of activity of the intestinal
musculature, the condition of the latter may be improved by
abdominal massage, which exerts a directly stimulating action
upon it. In dyschezia the atonic and paretic pelvic colon and
rectum cannot be influenced by massage owing to their situation in
the pelvis, but massage is beneficial in the numerous cases which
result from weakness of the abdominal muscles.
Massage has sometimes been recommended with the object of
directly forcing faeces along the colon. Not only do X-ray observa-
tions show that this can only rarely be done, but if much force is
used there is considerable danger of injuring the intestinal wall in
the attempt. It is, however, possible to soften faecal masses in the
descending and iliac colon by pressure, so that their subsequent
removal by enemata is greatly facilitated.
Massage should never be employed if there is any evidence of
inflammatory complications, and spastic constipation is generally
made worse rather than better by this treatment.
The bladder should be emptied immediately before the massage ;
the patient should be recumbent and his knees raised by a pillow
in order to relax the abdominal muscles as much as possible. The
massage should be repeated daily, and should be continued regularly
for several weeks at least. The best time is before breakfast, as
the stomach is then empty, and the massage, being added to the
natural morning stimuli to defalcation, may at once result in a
normal evacuation. Only when there is insufficient time in the
morning should the massage be done on retiring for the night. Its
duration should at first not exceed five minutes, but it can be
gradually increased up to half an hour. If it causes much fatigue
the time spent in the treatment should be diminished, and it may
Constipation in Adults. 463
be necessary to limit it to three times a week. It is also advisable
to discontinue the massage during the menstrual periods. Abdo-
minal massage should not cause any pain ; the production of pain
is an indication that the massage is not being done skilfully, or
that the condition is one which should not be treated in this
way.
When it is desired to act directly on the bowel, it is usual to begin
with massage of the csecum and pass along the colon, finishing
immediately above the pubes, although it is generally impossible
to manipulate the pelvic colon. A preliminary examination with
the X-rays is of great value, as it shows the exact position of the
colon and also the part in which the sluggishness is most marked.
In cases of dyschezia due to weakness of the abdominal muscles,
the whole surface of the abdomen should be massaged without
regard to the probable position of the colon, as the superficial
muscles and not the intestinal musculature require treatment.
In mild cases good results may be obtained when the patient
massages himself. This has the great advantage of costing nothing
and causing very little trouble, so that the treatment is more
likely to be thoroughly carried out for a sufficient period than if
massage by a professional masseur is advised. " Auto-massage "
is best done by means of a cannon-ball, weighing from 3 Ib. to 10 Ib.
and covered with chamois-leather or flannel ; it is rolled by the
patient over the abdomen along the course of the colon, the same
precautions being taken and the duration of treatment being the
same as when the treatment is given by hand.
If a professional masseur or masseuse is employed, it is important
to give definite instructions as to whether direct stimulation of the
colon is required, in addition to the more superficial massage
suitable for the abdominal muscles, and the situation of the colon
and the part in which delay is most marked should be indicated.
When possible the masseur should give the first treatment with his
hands under the fluorescent screen after a bismuth meal has
rendered the colon visible. By this means he learns how he can
best manipulate the colon, as he can watch it move under his
fingers.
The results obtained with vibratory massage applied by means
of a more or less elaborate electrical apparatus hardly warrant the
trouble and expense involved in carrying out the treatment, as it is
not clear that it can do anything which simple massage by the
hand cannot accomplish. Moreover, it is possible to combine a
certain amount of vibration with the other manipulations when the
massage is done by hand.
464 Constipation in Adults.
ELECTRICAL TREATMENT.
I have found by experiments on animals that galvanism has
much more effect than faradism on intestinal movements. When
the kathode is placed on the back, the passage of the anode over
the course of the colon causes a wave of contraction to occur. If
one electrode is introduced into the rectum, the rectum can also be
caused to contract. Faradism has no effect except to cause the
abdominal muscles to contract, and, when the abdominal wall is
thick, even galvanism probably exerts no action on the intestines
unless a stronger current is used than can comfortably be borne.
The good results sometimes obtained with electricity are probably
due to a large extent to suggestion, the patient being persuaded
that electricity is certain to do him good.
(1) Intestinal Constipation. In severe cases of this kind
electricity may be tried in addition to other treatment, when
the latter proves insufficient alone. The large kathode is placed
on the back, and the smaller anode is moved slowly along
the colon, starting at the caecum ; the electrode should be kept
longest and be pressed most deeply over that part of the large
intestine where the delay is greatest. As strong a current as the
patient can bear with comfort should be used, and the treatment
may be given for a quarter of an hour every morning.
(2) Dyschezia. When the tone and contractile power of the
rectum and pelvic colon are so impaired that spontaneous evacua-
tions do not return after some months of treatment with enemata,
intra-rectal galvanism should be tried. A thick wire electrode,
insulated by a soft indiarubber tube except at its olive-shaped
end, is introduced 3 or 4 inches into the rectum. The other
electrode, which should be large and flat, is placed on the lower part
of the abdomen. The treatment should be given daily for from five
to twenty minutes shortly after breakfast. In favourable cases it
produces a desire to defaecate, which is likely to be most effective
if it occurs at the natural time. In other cases the patient is able
to defaecate shortly afterwards, or the improvement is only noticed
after some days. Unfortunately, however, many of the worst cases
derive no benefit whatever from the treatment.
Great care is required in treating constipation by intra-rectal
galvanism, owing to the danger of injuring the rectal mucous
membrane by electrolysis, where the bare metal of the electrode is
in contact with it. The danger can be greatly diminished by
introducing through the tube containing the electrode a pint of
normal saline solution, which is retained during the treatment.
The electrode is then generally not in contact with the mucous
Constipation in Adults. 465
membrane, and the current is diffused over a considerable area by
the water, which acts as a large electrode. The danger of electro-
lysis can be further diminished by frequently reversing the current.
Its strength is slowly increased to a maximum of 30 or 40 milli-
amperes, according to the sensation it produces, and then slowly
diminished to zero. After reversing the direction of the current it
is again slowly increased.
(3) Dyschezia with Weak Abdominal Muscles. When the
abdominal muscles are weak they undoubtedly derive benefit from
the active contractions produced by faradism or labile kathodal
galvanism. As exercises and massage are equally efficacious and
are generally more convenient, electrical treatment should only be
recommended when special facilities for its employment are at
hand. A large electrode is placed over the lumbar spine ; a smaller
one is moved slowly over the abdomen. Either faradism or
galvanism may be used, and the current should be as strong as the
patient can bear without discomfort.
(4) Neurasthenic Constipation. When constipation is secon-
dary to neurasthenia, static electricity, which may be given for half
an hour three times a week, is often of value.
SPA TREATMENT.
Many patients, who are unwilling to undergo any systematic
treatment for constipation at home, are very willing to devote
a few weeks in the year to a " cure " in some popular health resort.
The removal from business and household worries, daily exercise
in the open air, regular hours and the change from rich food to
a suitable diet are of much more importance than the drinking of
waters, which could be done equally well at home if they were
really needed. In most of the resorts which are regarded as
suitable for constipated patients, excellent arrangements are at
hand for hydrotherapy, massage and electrical treatment, which
can rarely be applied satisfactorily at home from lack of time and
the requisite apparatus and skilled attendants. Lastly, better
results are obtained from intestinal lavage in such places as
Harrogate than is generally possible at home.
When constipation is associated with definite neurasthenia,
complete rest from the ordinary occupations is essential. In mild
cases the patient should leave home and spend a quiet time in the
country or by the seaside. In winter nothing gives such good
results as a visit to the Swiss mountains. In other cases some
English or foreign spa may be visited, where general hydrothera-
peutic and perhaps electrical treatment may hasten the recovery.
S.T. VOL. II. 30
466 Constipation in Adults.
In severe cases, especially when anorexia and emaciation are
present, improvement may only begin when the patient is removed
from his home surroundings and remains in bed for a few weeks,
as in the Weir-Mitchell treatment. At the same time, the patient
is made to eat an increased quantity of suitable food. This often
results in a rapid recovery from the constipation without any local
treatment at all, but hydrotherapy, massage and electricity often
hasten the improvement.
As the natural aperient waters and the intestinal lavage may be
regarded as the special features of spa treatment, these must be
described in greater detail.
(1) Natural Aperient Waters. Sodium sulphate is the chief
ingredient of the hot Karlsbad and the cold Elster, Marienbad,
Franzenbad and Tarasp waters ; it is associated with magnesium
sulphate in the much weaker Cheltenham water and in the strong
imported bitter-waters, such as Franz -Joseph, ^sculap, Hunyadi-
Janos, Friedrichshall, Rubinat, Apenta and Seidlitz. 1
There is no evidence to show that these natural waters have
any advantage over a simple solution of sodium sulphate or over
artificial Karlsbad salts, although it is conceivable that waters taken
at the source have some unknown specific action which is of value.
It is, indeed, a common experience to find that drinking the waters
at one of the popular Continental health resorts produces nothing
more than temporary improvement, which lasts no longer than
the period of the " cure." An attempt has, however, recently
been made to put the spa treatment of constipation on a more
scientific basis. In the old-fashioned four weeks' " cure" sufficient
water was drunk to give the largest possible stool every day. The
treatment is now divided into three periods. In the first the dose
is varied until the minimum quantity required to produce one
normal stool every morning is discovered. During the second
period the patient is taught to accustom himself to obtain with this
dose a satisfactory evacuation every morning at the same hour.
When he no longer experiences any difficulty, the third period is
begun, in which the dose of saline aperient is gradually diminished
by substituting a weaker water and finally ordinary water for the
strong water first used. It is often necessary to continue this
third period for some weeks or even months after the patient has
returned home. The waters should always be taken on an empty
stomach in the early morning.
1 Artificial seidlitz powders bear no resemblance to the genuine Seidlitz
water, as they depend for their activity on sodium tartrate instead of magnesium
sulphate.
Constipation in Adults. 467
(2) Intestinal Lavage. Until recently lavage was only practised
at Plombieres and Chatel-Guyon, but since 1905 the same treat-
ment has been efficiently carried out at Harrogate Bath and
Llandrindod Wells. There is probably no specific action in either
the simple thermal water of Plombieres or the alkaline sulphur
water of Harrogate, the mechanical removal of fseces and mucus
being all that is required. But the systematic and skilful perform-
ance of intestinal lavage combined with the accessory treatment
obtainable in these health resorts gives very good results in many
cases of constipation associated with faecal retention, especially
when it has become complicated with muco-membranous colitis.
Between 1 and 2 pints of the natural water at a temperature
of 100 F. are introduced into the colon through a long india-
rubber tube from a douche-can, suspended at a height of 1 or
2 feet above the couch on which the patient lies. The water is
retained for ten or fifteen minutes, after which the patient gets up
and evacuates it, together with scybala and mucus. The proceeding
is then repeated, a smaller quantity of fasces but more membranes
(in cases of muco-membranous colitis) than after the first injection
being generally expelled. The irrigation is followed by a bath at
100 F., and a douche at 110 F. is played through the cooler
water of the bath on to the abdomen with a finely-perforated nozzle.
The treatment is continued for about three weeks.
OPERATIVE TREATMENT.
When constipation is the result of definite organic obstruction
of the intestine, operative treatment is plainly indicated. Various
operations have recently been introduced for the relief of severe
constipation in the absence of any such clear indications, but the
results hitherto obtained have not been sufficiently good to warrant
surgical interference except under most exceptional conditions.
(1) Division of Adhesions. In the belief that peritoneal
adhesions, especially at the hepatic flexure, are a frequent cause as
well as a result of constipation, the effect of dividing adhesions in
constipated patients has been tried, but the results obtained were
unsatisfactory. This is due to the fact that the adhesions are not
as a rule either a cause or a result of constipation ; moreover, it is
always exceedingly difficult to prevent the re-formation of adhesions
after they have been divided.
(2) Short-circuiting Operations. In the very exceptional cases
of severe constipation associated with pain or well-marked con-
stitutional symptoms, which are unrelieved by all other means,
and which are not the result of dyschezia, a short-circuiting
302
468 Constipation in Adults.
operation may be required. Before resorting to surgery, however,
a thorough skiagraphic investigation should be made, in order to
exclude dyschezia and to discover in what part of the large
intestine the delay takes place, so that only the part of the colon in
which stasis is occurring should be short-circuited instead of the
whole of the colon, as in ileo-siginoidostomy.
(3) Exclusion of the Colon. After the failure to relieve
constipation by division of peritoneal adhesions, the effect of
exclusion of the colon by division of the end of the ileum, which
was implanted into the pelvic colon or rectum, was tried. But
trouble was often caused by the collection of faecal material in the
blind end of the colon, owing to the accumulation of the secretion
of the large intestine, which is insufficient in bulk and in irritating
constituents to stimulate the caecum and colon to empty themselves
without the aid of the contents of the ileum.
(4) Colectomy. The more radical operation of colectomy has
therefore been performed on a large number of constipated patients
during the last few }'ears. But the mortality is high, even in the
hands of the most experienced surgeons. Moreover, the principle
of the operation is wrong, as it is assumed that the whole of the
large intestine is not performing its functions normally. My
X-ray observations have proved that in a large number of the
severest cases of constipation there is no delay in the passage of
faeces through the colon at all, but that dyschezia is present, the
act of defaeeation being inefficient, largely owing to abnormal
conditions of the pelvic colon and rectum. When colectomy is
performed in such cases, a normal colon is removed, and an
abnormal rectum and often an abnormal pelvic colon are left
behind. The cases in which constipation has remained after
colectomy were probably of this nature. In severe cases of con-
stipation not due to dyschezia, the delay is generally confined to
a single segment of the colon, such as the splenic flexure, in
the case of which an unoffending caecum and ascending colon
would be removed by the operation. It is therefore much
wiser to perform the safer and more rational operation of lateral
anastomosis, in order to short-circuit the part affected and that
part alone, as already suggested, than to perform an operation
which, even in the most skilful hands, has a high mortality, and in
which the prospects of complete relief are by no means certain.
(5) Appendicostomy. Appendicostorny has recently been
recommended as a method of treating chronic constipation ; the
patient is taught to pour a saline purgative or cascara, dissolved
in a pint of hot water, through a catheter introduced by way of
Constipation in Adults. 469
the appendix into the caecum. By this means it is said that a
painless action of the bowels can be readily obtained. This opera-
tion has more to be said in its favour than colectomy, as it is
comparatively simple and does not appear ever to have been
fatal. It is, moreover, reasonable to expect that the colon can be
more effectively washed out from above than below. But when it is
remembered that fecal accumulations occur much more frequently
in the distal than in the proximal part of the colon and in cases of
dyschezia in the rectum and pelvic colon alone, it is clear that
water has less distance to traverse in order to reach the accumu-
lations when introduced through the anus than when introduced
through the appendix. Moreover, faeces often stick so tenaciously
to the mucous membrane that it is difficult to clear the colon even
with a really strong current of water. Lastly, it is not clear what
advantage can be gained by giving a saline purgative or cascara by
the appendix instead of by the mouth, particularly as it has now
been demonstrated that the former acts only after absorption into
the blood.
ARTHUR F. HERTZ.
REFERENCES.
Discussion on " The Treatment of Constipation " in the Medical Section of
the British Medical Association, July, 1910. Brit. Med. Journ., 1910, II.,
pp. 104146.
Hertz, A. F., "Constipation and Allied Intestinal Disorders," London, 1909.
Froussard, " Le Traitement de la Constipation," Paris, 1903.
Goodhart, Sir J. F. ; Lancet, 1902, II., p. 1244.
470
THE OPERATIVE TREATMENT OF CHRONIC CON-
STIPATION DUE TO DISEASE OR ABNORMALI-
TIES OF THE COLON.
THE cases which require operation are those in which the patient
is becoming seriously ill from auto-intoxication, and in which the
bowels cannot be made to act regularly either by enemata, aperients
or massage. Here an operation is certainly the best treatment, and
is quite justified.
Three methods have been advised, viz. : (1) To perform appendi-
costomy in order that the colon may be washed out daily and the
accumulation of faecal material within it thereby prevented ; (2) to
short-circuit the colon by performing ileo-sigmoidostomy ; (3) to
resect the entire colon.
Appendicostomy. It is obvious that the material which is
retained in the colon causes the auto-intoxication. If we can
prevent this retention we shall be able to stop the chronic poison-
ing from which the patient suffers. If an appendicostomy is
performed the patient is able to wash out the colon daily and so
prevent accumulation. The results have in most cases been
extremely encouraging, and the daily irrigation has caused rapid
and marked improvement in the patient's general condition.
Further, in several cases after irrigation has been carried out
continuously for some time, there have been signs that the colon
was recovering its lost functions, the bowels having begun to act
regularly without the irrigation. Appendicostomy has an advantage
over the other two operations mentioned, in that it is practically
unattended by any risk to life, and that it does not in any way
mutilate the patient or leave a condition which may at some later
period cause trouble.
Ileo-sigmoidostomy. In October, 1900, Mr. Mansell Moullin
published a case in which he had performed this operation for
chronic constipation, and Mr. Arbuthnot Lane published a paper
advocating it in 1904.
Mr. Lane, who has performed a number of these operations,
found that the results were satisfactory, but that the partially
excluded colon was a source of danger, and this has led him to
advocate complete resection of the colon, the ileum being
implanted into the sigmoid flexure or rectum.
P. LOCKHART MUMMERY.
DIARRHCEAL DISEASES IN CHILDREN*
ONE of the commonest symptoms of intestinal disturbance in
early life is diarrhoea, which may result from many different causes.
In some cases it is led up to by constitutional disease, such as
rickets ; or it may be due to irritation from the bowel contents,
for example, a mass of indigestible food ; or it may be due to a
lesion of the bowel wall, such as ulceration ; or it may be
the result of excessive peristalsis of nervous origin, as in lienteric
diarrhoea. In the most marked and fatal form, known as acute
summer diarrhoea of infants, we have a definite diarrhoeal disease
clearly due to an acute infective inflammation of the alimentary
tract. In the case of a symptom with such a multiplicity of causes
it is essential for successful treatment that a careful examination
should be made as to the diet, the condition of the abdomen, and
the presence or absence of constitutional disease or symptoms, in
order to determine the etiological factor or factors.
A large number of cases of diarrhoea, both in infancy and in
childhood, will be found to be associated with improper feeding.
The chief faults are over-feeding, too frequent feeding, bad food, and
unsuitable food. The diarrhoea may be acute and occasional, or
chronic and persistent. It may be accompanied by vomiting, by
colicky pains, and by the passage of blood and mucus. The
stools are often green, offensive, and contain undigested particles
of food. The affection may be apyrexial in the milder cases, but
in the more severe the temperature may be raised for some time, due
to active inflammation of the bowel or to the absorption of toxins.
The immediate treatment of such cases of diarrhoea consists in
diminishing the amount of food taken, in seeing that it is fresh
and sound, and in clearing out any irritating material left in the
bowel. In the milder cases the amount of milk taken may be
safely diminished by one-half, while in the more severe cases it is
advisable to give only some weak veal or chicken broth. If
vomiting is at all marked it is a good rule to stop the milk for
a time and to wash out the stomach with warm saline solution.
The great essential, rest to the bowel, cannot be secured unless the
amount of food is severely curtailed, while the essential needs of the
infant can be met by giving it freely plain water or barley-water to
drink.
47 2 Diarrhoeal Diseases in Children.
The bowels should be cleared by repeated small doses of castor oil
( 1)1 10 to irtl5) every four hours or of magnesium sulphate (5 gr. to
10 gr.) every four hours, for a few days. In cases accompanied by
pain and vomiting one may substitute a mercurial preparation,
such as the following : 1^ Hydrargyri cum Greta, gr. \ ; Pulveris
Ipecacuanhas Compositi, gr. \\ Pulveris Cretae Aromatic!, gr. 1.
[U.S.P. ! Hydrargyri cum Greta, gr. \\ Pulveris Ipecacuanhas
et opii, gr. \ ; Pulveris Aromatici, gr. T ^ ; Pulveris Cretae Compositi,
gr. 1.]. Sig. : One powder every six hours. When the diarrhoea is
definitely lessened, and appetite is present, the amount of food may
be increased. Equal parts of milk and lime-water or, in the case of
infants over nine months, Benger's food and milk may be given,
but the feeds should be small and the intervals between feeding at
least two-and-a-half hours. Such attacks of food diarrhoea in older
children are best treated by a full initial dose of calomel (2 gr. to
3 gr.), or castor oil (5J to 5ij), so as to ensure the removal of any
irritating masses in the bowel. A similar course of low feeding for
a few days is ordered, and a mixture containing sodium bicarbonate
5 gr., sodium sulphocarbolate 5 gr., and infusion of gentian is to
be ordered. In some cases where the irritation seems to persist,
after the bowels have been thoroughly emptied, bismuth in full
doses (10 gr. to 15 gr.) may be given every four hours.
In the preventive treatment of infantile diarrhoea special
attention must be directed to the purity and freshness of the milk.
Whatever views one may hold as to the relative advantages of
boiled and unboiled milk, it may safely be asserted that in hot
weather all cows' milk for children's use should be boiled for two
or three minutes and then kept on ice in a closed or covered vessel.
The greatest cleanliness should be observed in connection with the
feeding bottles, and no " dummy " soothers should be allowed in
the infant's mouth. A mild attack of diarrhoea in summer pre-
disposes to the more grave infective forms. The tendency to give
young infants some fruit, which is so common with nurses in the
fruit season, should be severely discouraged as very dangerous.
As chilling of the surface of the trunk or limbs often directly
induces diarrhoea, care must be taken that the child is sufficiently
clothed and is not exposed to chills. In hot weather the danger
often lies not in too few but in too many clothes. If a child is at
all delicate or subject to " colds," it is customary to overload it with
clothing in summer, with the result that the skin is constantly
damp from sweating, and chilling of the surface of the body can
scarcely be avoided. Such a chill lowers the resisting powers of
the tissues generally, and of the alimentary canal more especially
Diarrhoeal Diseases in Children. 473
so that an attack of diarrhoea often follows. The clothing should
be light and loose, and a flannel binder ought always to be worn.
These precautions are specially necessary in the case of rickety
infants.
In no disease of early life will the therapeutic resources of the
practitioner be tested more fully than in the case of acute summer
diarrhoea of infants. As the name implies, it is a disease of hot
weather, and interesting observations have been made as to its
association with a certain temperature of the soil as the summer
heat increases. The essential point, however, is that the disease is
due to contaminated food, and more especially milk. If an infant
is entirely breast-fed and does not get the poison introduced into
its mouth by such means as infected " comforters " or toys, there
is no risk of the development of this disease. The exact organism
causing this form of disease is at present unknown, although
several have been described, and Gaertner's bacillus has been found
in many cases of the disease. A large mass of evidence has now
been brought forward in support of the view that contamination of
the food is chiefly brought about through the agency of the
common house-fly. Bearing infection from some polluted source,
the house-fly settles on the milk supply of the infant and infects it
with the particular organism, which seems to flourish abundantly
in all forms of milk. Having this in mind, a wise householder
will be particularly careful in summer to keep his house and
neighbourhood free from all breeding and feeding places for flies,
and to prevent any possibility of flies reaching the milk supply.
All rubbish, such as bones, stale vegetables or fruit, will attract
flies, and should therefore be burned at once or kept in a closed
dustbin. All food in the house should be kept covered up and
protected from flies. More especially does this apply to milk,
and it is not sufficient security to boil the milk, for boiled milk
will be contaminated as quickly as that which is unboiled. The
experience of institutions has shown that the disease may spread
rapidly amongst young infants. Each case, therefore, should be
treated as a possible source of infection, and special feeding vessels
should l>e reserved for each individual patient, while all the stools,
diapers, etc., should be thoroughly disinfected as in the case of
typhoid fever.
The onset of an attack of acute summer diarrhoea is usually
sudden, although there may have been slight gastro-intestinal
disturbance for a few days beforehand. Vomiting occurs, the
temperature rises rapidly, and the motions become loose, the
emptying of the bowel being often accompanied by the pain of colic.
474 Diarrhoeal Diseases in Children.
The condition rapidly becomes worse within a few hours. The
motions, at first loose but with yellow matter in them, become more
watery. Some grey or green material may be present, but the
chief constituent is mucus or blood-stained mucus. Great con-
stitutional weakness comes on ; the pulse is feeble and rapid, the
extremities are blue and cold, and the whole of the tissues seem to
be shrivelling up.
As regards the treatment, the disease is so acute in its course,
and presents so many and such diverse symptoms, that no one line
of treatment can be laid down as suitable for all cases. In the
present day the form of treatment which is most generally adopted
may be described as evacuant and eliminative. The first object is
to remove the poison from the seat of its active production, namely,
the gastro-intestinal tract, and to eliminate from the blood and
tissues the organisms and toxins which have found an entrance.
At the same time one must prevent the introduction into the body
of further doses of the poison, or of food materials which ma}' prove
a suitable medium for the growth of these organisms.
Diet. The use of milk in any form must be stopped at once. It is
especially dangerous in this disease, as it adds fuel to the fire which is
already going on in the intestinal tract. We have therefore to find
some temporary substitute during the time that an effort is being
made to obtain a thorough clearing out of the bowel. In very acute
cases the best plan is to stop all food entirely, and to give only
boiled water or barley-water or rice-water for twenty-four or forty-
eight hours. As thirst is usually a marked symptom, this water
should be administered frequently, every hour or two hours, but in
small quantities (2 to 3 oz.), so that vomiting should not be
induced. If vomiting is a severe symptom, it may be necessary to
give only one or two teaspoonfuls of water at intervals of fifteen or
twenty minutes. A little brandy will be found beneficial if given
well diluted, a teaspoonful in J pint of water during the day,
and the same amount during the night. At the end of thirty-six or
forty-eight hours, or when sufficient time has been allowed for the
aperient medicines to act, a beginning should be made with feeding
in the shape of albumin- water, or weak veal, mutton or chicken
soup. Here the rule must be to proceed very slowly and gradually,
watching the effect. Albumin-water may be made at first of the
strength of oz. of white of egg to \ pint of water, and
this may be rendered more palatable by the addition of
'2 drachms of extract of malt. Similarly, 1 oz. of ordinary soup
may be diluted with 5 oz. of water. This modified diet, with
small feeds at intervals of two or three hours, may be carried on for
Diarrhceal Diseases in Children. 475
one or two days, until the diarrhcea is somewhat lessened, and the
motions are not of a purely mucous or watery character. The third
stage is reached when we commence tentatively a return to milk
food. A trial of milk in one or other form should be made by
alternating it with a feed of soup or albumin-water. Of the various
forms in which milk may be used at this time the following repre-
sents a scale of digestibility : (1) peptogenised milk, made with
peptogenic milk powders ; (2) whey ; (3) condensed milk, diluted
with twenty-four parts of water ; and (4) citrated milk, containing
2 grains of citrate of soda in each ounce of milk. It is not necessary
to take every infant through these four stages, and the experience
of the doctor and the condition of the patient must decide which
form is to be used. If milk in any form provokes a recurrence of
vomiting or diarrhoea, its use must be suspended fora time. Tolera-
tion will not readily be established, and in no case must an attempt
be made to feed up the patient rapidly. The chief points about the
dietetic treatment are : (1) to give no food until the stomach can
retain and digest it ; (2) to begin with very weak foods, and very
small meals ; and (3) to let the patient have as much water as he can
retain, so as to compensate for the great loss of fluid from the
tissues and to wash out the bowel.
The first part of the medicinal treatment consists in the thorough
cleansing of the intestinal tract as quickly as possible. The best
drug is castor oil, which is more effective if given in small repeated
doses. From 5 to 10 drops of oleum ricini may be given every
four hours for a day and a-half , and then less frequently. It is usually
well tolerated by infants ; but if there is much gastric disturbance
and vomiting, it may be necessary to wash out the stomach first
Instead of castor oil small doses of mercury may be given, especially
if the vomiting is severe. Grey powder (in J-gr. doses)
or calomel (in ^-gr. doses) may be given every two hours
until six doses have been taken. When the acute symptoms are
subsiding and the motions are becoming less frequent, a sedative
and astringent mixture may be given as follows : fy . Acidi Sulphurici
Aromatici, in2 ; Tr. Camph. Co., nt.4 ; Tr. Chlorof. Co., ni2 ; Tr.
Goto, irt3 ; Syr. Aurantii Floris, 1118; Aq. Menth. Pip., ad 33.
Sig. : One drachm every six hours. fy. Or, Sp. Aminon. Arorn.,
in 4 ; Tr. Catechu, 111 3 ; Tr. Cardam. Co., in.3; Tr. Opii, rrt^ ;
Mist. Gretas, ad 5] [U.S.P. 1^. Sp. Ammon. Arom., n\_4 ; Tr.
Gambir. Co., in.12; Tr. Cardam. Co., in.3 ; Tr. Opii, irt|; Mist.
Cretae, 5ss; Aquam, ad 5j]. Sig. : One drachm every six hours.
Various symptoms may be present which call for special treatment.
When vomiting is severe the stomach should be washed out with a
weak solution of Coudy's fluid, or of bicarbonate of soda (gr. 10 to
476 Diarrhoeal Diseases in Children.
1 pint). Until this has been done it is often impossible to adopt
any effective treatment. The substitution of rectal feeding for
stomach feeding is useless, as the bowel is not in a condition to
retain or absorb anything. The sedative effect of washing out the
stomach will be increased by the application of hot fomentations to
the abdomen. When severe colicky pain is present, associated with
tenesmus, 4 or 5 minims of paregoric may be given to secure
relief. The use of opium in this affection is not without danger,
and it should not be given if the patient is in a collapsed or semi-
conscious condition. Opium should not be given in a solid form, as
in Dover's powder, as it probably will not be absorbed. If opium is
contra-indicated, pain may be relieved by giving the tincture
of belladonna in doses of 2 or 3 minims every four hours.
Washing out the lower bowel with hot water will also tend to relieve
the straining pain, and will at the same time clear out a consider-
able amount of irritating matter. The water should flow from a
fountain syringe at a height of 2 feet, and should enter through
a soft rubber catheter introduced as high as possible into the bowel.
The motions are sometimes so offensive as to render the air of
the room most unpleasant. The addition of 1 or 2 gr. of salol
to the castor-oil mixture will help materially in reducing the offen-
siveness of the motions. By its use also the stools will be rendered
less acrid and irritating to the anus and buttocks. The restlessness
and sleeplessness of the acute stage will be greatly relieved by the
use of hot baths or hot packs. The effect of the bath may lc
increased by the addition of 1 or 2 drachms of mustard. The
value of hot baths in this affection cannot be over-estimated. In
addition to calming the nervous system, and thereby inducing
much-needed sleep, they are stimulating, and by their action on the
skin help to eliminate the poison from the system. The great loss
of fluid produced by the diarrhoea often leads to a condition of
collapse, of shrivelling up of the tissues, and of cardiac weakness.
This condition is best treated by the subcutaneous injection of
normal saline fluid. From 6 to 8 oz. may be injected at a time
into the loose tissues of the axilla or the abdominal wall, and
the warm fluid should be allowed to enter slowly, so as to avoid the
risks of sloughing or haemorrhage. The benefit thus obtained may
be increased by giving small doses of brandy, nux vomica, or strych-
nine. Injections of saline fluid serve a further beneficial purpose
in aiding the elimination of the toxins from the blood and tissues,
and should be repeated as often as necessary to reinforce the fluids
of the body. Strychnine is of undoubted advantage in collapse
from cardiac weakness, and is best administered hypoderinically in
Diarrhceal Diseases in Children. 477
doses of ^ minim of the liquor strychninae [U.S.P. strychnin,
hydrochlor. gr. ^Jn] every four hours. The reaction of
infants to strychnine in the toxic condition present is very
much less than in healthy subjects, and full doses may safely
be given. The value of brandy as a stimulant is undoubted
if given in small doses, but it is very questionable if large doses are
beneficial in this affection. For an infant of six months suffering
from summer diarrho?a \ oz. of brandy daily is a maximum
amount. If the beneficial effect of brandy is not clearly evident,
it is better to limit the amount to 1 or 2 drachms a day. After
the subsidence of the attack, a prolonged period of convalescence
follows, characterised by impaired nutrition and intestinal weakness.
The feeding must be very carefully regulated, and a change to the
country or seaside is advisable in the case of town-dwellers.
The astringent treatment of summer diarrhtea has its advocates,
but is not to be recommended during the acute stage. Such drugs
as catechu, coto, tannigen, chalk, etc., will be found useful in some
cases after the bowel has been thoroughly emptied and the diarrhoea
is lessening. The antiseptic treatment has also failed to prove a
specific for this disease. Carbolic acid, creosote and perchloride of
mercury have been tried as a means of destroying the organisms in
the alimentary canal, but without definite success. Both serum
and vaccine treatment are at present on trial. These cannot be
expected to prove practical methods of cure until the organism
which is the etiological factor has been isolated and cultivated. So
far Shiga's bacillus, Gaertner's bacillus and Morgan's bacillus have
all been claimed as the causa causans, but the serums produced
have not fulfilled the hopes of the discoverers. It is probably on
this line of investigation, however, that one may look for a specific
curative treatment.
The Lienteric Form of Diarrhoea is characterised by a chronic
looseness of the bowels or frequency of action. The immediate
stimulus is the taking of food, fluid or solid, into the stomach, and
there is probably a reflex passing from the stomach to the lower
bowel in which the nervous control is unstable. This quick action
on the taking of food leads to the common description " that the
food passes right through him." In such cases it is not necessary
to put the child on a milk or sloppy diet, for digestion is usually
quite normal. If on physical examination the abdominal condition
calls for no special treatment, the patient may be put on an ordinary
plain mixed diet, care being taken that there is no overloading of
the stomach. The sufferers are usually nervous little subjects, so
that a quiet life should be ordered. Much benefit will usually
478 Diarrhoeal Diseases in Children.
follow from a course of arsenic and bromide. Two drops of
Fowler's solution and 5 gr. of potassium bromide may be
given three times a day after meals. If this fails to check the
trouble, 2 or 3 drops of liquor opii sedativus may be added to
the mixture. Eelapses are not uncommon, but may be met by
another course of treatment, as described above. The nervine
tonics, nux vomica and iron, may be given with advantage after
the special treatment is ended.
G. A. SUTHERLAND.
479
ENTERITIS (ACUTE AND CHRONIC) IN ADULTS.
THIS condition is recognised clinically as diarrhoea, and if we
restrict enteritis to inflammation of the small intestine the
diarrhoea is characterised by the presence of bile or particles of
food and the absence of mucus. It may be either acute or
chronic.
Treatment of Acute Diarrhoea. This may be directed to three
objects : (1) To remove the cause ; (2) to heal the anatomical lesion ;
and (3) to remove or alleviate symptoms.
Under the first of these headings we have to consider the very
large number of causes to which acute enteritis may be due. There
are the primary causes, including improper food, such as uncooked
fruit and vegetables, imperfectly converted starch, as well as seed
husks and bran ; the various organic poisons in decomposing milk,
meat or fruit ; inorganic poisons, such as antimony ; the action of
specific organisms taken with the food but not killed by the action
of the gastric juice; changes of temperature, and perhaps nervous
influences giving rise to the acute diarrhoea from which recruits in
battle or candidates at examinations sometimes suffer.
Then there are the numerous secondary causes, including the
various infectious diseases in which enteritis is symptomatic, such
as typhoid fever and septicaemia ; inflammation extending from
neighbouring parts and that depending upon circulatory disturb-
ances ; congestion of the portal system from liver, lung or heart
disease ; various cachectic conditions, such as Bright's disease and
diabetes ; and, lastly, the catarrh that may be set up by intestinal
parasites, e.g., tape worms or round worms.
Obviously all these conditions require appropriate treatment and
this presupposes accurate diagnosis. It would be outside the pur-
pose of the present writer to pursue this subject further ; it must
suffice to say that the cause in each case must be sought for and
where possible removed.
The second object of treatment is to heal the anatomical lesion.
In acute diarrhoea we endeavour to do this by keeping the parts at
rest, and this we seek to effect by sending the patient to bed. Food
should be withheld which may cause irritation either by its
mechanical condition or its chemical properties ; only bland liquid
or semi-liquid diet, such as milk and lime-water, should be allowed ;
480 Enteritis (Acute and Chronic) in Adults.
a hot poultice or a hot fomentation or a Priessnitz compress should
be applied over the abdomen ; the last is a towel folded lengthways
and wrung out of hot water, wrapped round the abdomen and
covered with a double layer of thick flannel to prevent the escape of
heat.
Lastly, the removal or alleviation of symptoms is ensured best by
opium or by one of its preparations combined with carminatives ;
by this means pain is allayed, and by checking peristalsis the
frequency of the stools is diminished. A mixture of milk and
lime-water in equal parts should be prescribed ; 1 oz. every
hour. This quantity may be increased to 2 oz. if desired,
should it be retained and cause no pain or discomfort. In hot
weather it may be iced. To relieve thirst it is better not to increase
the amount of milk but to give a lemonade containing dilute
sulphuric acid: R. Tr. Limonis, Jss ; Ac. Sulph. Aromat.,
5ss ; Aq., ad Oj. [U.S.P. 1^. Tr. Limonis, 5vj ; Acid. Sulph.
Aromat., iri.20 ; Aq., ad. Oj.]. Sig. : To be taken freely.
The following anodyne and astringent mixture may be given
every four hours: 1^. Bismuthi Carb., Sodii Bicarb., aa gr. 10;
Tr. Opii, irilO; Muc. Tragacanth., rn.10 ; Sp. Chloroformi,
iri,15; Aq., ad jj [U.S.P. 1^. Bismuth. Carb., Sodii Bicarb., aa
gr. 10; Tr. Opii, 111,6; Muc. Tragacanth, ir[2 ; Sp. Chloroformi,
tril2; Aq., ad jj].
Where there is vomiting nothing should be given by the mouth,
but Inject. Morphinae Hypoderm., gr. , administered, or enema
opii, gij, given by the rectum.
Diarrhoea caused by mushroom poisoning should be treated by
belladonna or atropine : 1^. Tr. Belladonnse, ir|.15 ; Sp. Chloroformi,
m20; Aq., ad jj [U.S.P. 3. Tr. Belladonna, in.20; Sp.
Chloroformi, ni!6 ; Aq., ad 31]. Inj. : Atropinee Hypoderm., wi4
[U.S.P. Atropin Sulph., gr. ^J. A dose every hour until dryness
of the throat or dilatation of the pupils comes on.
Treatment of Chronic Diarrhoea. The objects of treatment
are the same as in acute diarrhoea though the causes may differ,
but the principle holds good that these must be sought for and
removed wherever possible. Secondly, the anatomical conditions
are usually less amenable to treatment, or show less tendency to
recover spontaneously, but depend upon more or less permanent
conditions and are associated with gross anatomical alterations,
where it is useless to expect a restitutio ad intcgrum. The most that
can be hoped for is by avoiding irritation to diminish congestion and
restrain exudation or, by checking abnormal fermentations and the
growth of pathogenic microbes, to determine healthier action in the
Enteritis (Acute and Chronic) in Adults. 481
structures concerned, to promote the healing of ulcers, and to restore
the lining of the bowel so far as possible to its former healthy state.
The chief place in this treatment must be assigned to diet, but we
have to recognise that a patient may suffer from chronic diarrhoea
for weeks, months, or even years, and that his diet must be so
arranged that it will supply all the needs of his body and enable
him to perform his daily duties as far as possible. Such a diet
will exclude all superfluous and indigestible articles, and those that
are mainly useful as affording bulk, e.g., vegetables containing
cellulose. This substance is of great value in promoting intestinal
peristalsis, and its absence is regarded by many as responsible for the
constipation which is the common affection of civilised peoples ; but
in the condition we are considering there is no need to stimulate
peristalsis, so that cellulose must be carefully excluded. The
vegetables which contain it most abundantly are : green vegetables,
leeks, radishes, carrots, turnips, parsnips, celery and kidney beans ;
it is also present in nuts and in most fruits. The vegetables that
contain least cellulose are cauliflowers, young spinach, cucumber,
vegetable marrow, potato, artichoke, onion, green peas. Of fruits
grapes and apples may be mentioned. The permitted vegetables
should be given in the form of purees, that is, strained to remove all but
a fine semi-liquid paste. Apples may be eaten reduced to a pulp in
the form usually served as apple sauce ; boiled rice may often take
the place of a vegetable, as it is free from cellulose. All articles
containing bran, such as brown bread and oatmeal, must be for-
bidden ; all starchy food must be well cooked, a condition which
excludes pastry. Meats must be finely divided and their fibre
should be easily digestible, so that we must prohibit smoked and
salted meats and fish, pork and veal, duck and goose, salmon,
mackerel and eel, lobster and crab.
It is best to prescribe a stringent diet at first in order to get
the disease under control ; this may be exclusively milk or
milk thickened with flour, a tablespoonful to a pint, or under-
done minced or scraped meat, three meals a day each of 4 oz.,
the meat being freed from fat, cooked lightly and eaten with-
out condiments, bread or vegetables, each meal to be followed two
hours later by pint of hot water. But on this diet the amount of
nourishment given is so small that the patient should be kept as
much as possible at rest. When the tongue is clean and the stools
are better formed the diet should be modified. The change should be
gradual, at first involving only one meal and one article of food, so that
if the result is unfavourable the cause may be detected and it is easy
to retrace our steps. In making changes it should be remembered
S.T. VOL. II. 31
482 Enteritis (Acute and Chronic) in Adults.
that food is likely to be well borne in something like the following
order : Animal food, including milk, eggs and meat ; starchy food,
including the pure starches, fine flours and sugar ; lastly, well-
cooked vegetables or fruits. The last should be selected from those
which contain the minimum of cellulose. It is generally necessary
to give patients positive dietaries as well as lists of articles of food
to be avoided. Sour milk made with the lactic acid bacillus is
valuable in some cases of chronic diarrhoea ; about a pint should be
taken daily. It may be started with the well-known cultures and
then inseminated from day to day with a spoonful of that which has
been made, being kept at a suitable temperature in a thermos flask.
The most useful drugs are opium and its alkaloids, arsenic, the
biniodide and bichloride of mercury, bismuth, vegetable astringents
containing tannin and carminatives such as the essential oils : 1^ .
Bismuthi Garb., Sodii Bicarb., aa gr. 10; Tr. Catechu, 5 ss. ; Muc.
Tragacanth., ir[10; Aq. Cinnamomi, ad j [U.S.P. J^. Bismuthi
Carb., Sodii Bicarb., aa gr. 10 ; Tr. Gambir. Co. 5ij ; Muc. Traga-
canth. ,ii| 2; Aq. Cinnamomi, ad j]. Sig.: Two tablespoonfuls before
each meal. This mixture may be strengthened by adding 10 min. of
tincture of opium or Collis Browne's chlorodyne to each dose, and
after the diarrhoea has been checked this can be left out and the
original mixture continued as long as necessary : 1^. Liq. Hydrarg.
Bichlor., 5 ss. ; Liq. Arsenicalis, iTj.5 ; Pot. lodidi, gr. 2 ss. ; Inf.
Gent. Co., ad j [U.S.P. I. Hydrarg. Chlor. Corrosiv., gr. g 1 ^ ; Liq.
Potass. Arsenitis, iri5 ; Pot. lodidi, gr. 2 ss. ; Inf. Gent. Co., ad 33'].
Sig. : Two tablespoonfuls three times a day after meals.
ROBERT SAUNDBY.
FISTUIJE OF THE INTESTINES.
FISTULA of the intestine may be external or internal ; the former
open upon the surface of the skin, whilst the latter are bi-mucous
and open into another abdominal viscus. Further, the external
fistulae are of two degrees of completeness ; in one, the simple fistula,
the main channel of the gut is not diverted by the fistula, but there
is a mere leakage of faecal material through it ; in the other the
faecal stream pours out at the fistula itself, and the latter is known
as an artificial anus. One of two conditions must be present in
order to divert the faeces through an abnormal opening in the
intestinal wall, either the presence of a spur of bowel dividing the
orifice of the fistula into afferent and efferent channels, or else the
existence of obstruction of the bowel beyond the fistula. This
distinction between fistulae which are mere faecal leaks and those
which are functionating as an anus is of cardinal importance in
treatment, because in the latter case the condition cannot be cured
until the gut below is quite patent and functional.
SIMPLE EXTERNAL FISTULA.
These may be caused by many different factors, inflammation,
trauma and congenital defects being the chief. (1) Inflammation :
(a) Simple : Appendicitis, pericolitis, peritonitis, hernia ; (b) Specific :
tuberculosis, actinomycosis, cancer; (2) trauma, injury, opera-
tions, extrusion of foreign bodies ; (3) congenital (see Affections
of the Umbilicus ). Of these appendicitis and tuberculosis account
for the great majority.
In some cases the bowel is attached directly to the skin or
parietes and the fistula is direct. This is the case in the majority
of operative or traumatic origin. In others a more or less extensive
and complicated abscess cavity intervenes between the bowel and
the surface and the fistula is indirect.
The urgency of these conditions for treatment depends upon their
size, position in the intestine, and the amount of suppuration occur-
ring in an accompanying abscess. A widely open fistula of the small
intestine or caecum, such as is left after operations done for the
relief of urgent obstruction, will constantly discharge large quantities
of irritating faeces so that the patient's life becomes an intolerable
burden ; whereas a fistula of the appendix or colon may merely
31 2
484 Fistulae of the Intestines.
cause discomfort by its intermittent leaking. If any doubt exists
as to the part of bowel with which the fistula communicates, there
are several methods at our disposal of determining this point, for it
must be borne in mind that the situation of the external opening
of the fistula may be widely distant from the intestinal. For
example, cscal fistulae of appendical origin may open behind the
right loin, at the umbilicus or at the left inguinal region. The
faecal discharge from the small intestine is usually copious, fluid
and continuous, and it has little or no odour, whereas that from
the caecum or appendix has a characteristic odour and that from
the colon is less fluid and more intermittent. If carmine is given
by mouth in the form of a 5-gr. pill, the time of its first
appearance in the fistulous discharge will be some indication of the
position of the intestinal lesion. Thus, its discharge from the
caecum will be within about four hours, and a less period than this
will indicate a small bowel leak, whilst the longer period denotes a
colic fistula. Further, a supplementary investigation may be made
by injecting colouring matter by the anus, after the lower bowel has
been well cleared out by enemata. If a rectal injection leaks
readily from the fistula it is probably in the large intestine, but in
some cases there is no doubt that the fluid may pass the ileo-caecal
valve and escape through a fistula of the ileum.
Non-operative Treatment. This will be suitable for those
cases of merely leaking fistulae, such as are so often left after opera-
tions for acute appendicitis. The patient is kept in bed on a light
fluid diet. The fistula is washed out with solutions of peroxide of
hydrogen and lightly packed with iodoform gauze. When there is
much pus and but little fasces coming from the fistula the use of
Biers' cupping glass will be most helpful, and indeed this device if
used early enough will often prevent the formation of a chronic
fistula. A glass cup, about 2 inches in diameter, with a good rubber
ball attached, is applied over the wound after smearing its rim with
sterile liquid vaseline and squeezing the ball. Every five minutes
the suction is released for one minute and an intelligent patient
will readily carry this out for himself. The application should be
for about one hour night and morning. If healing does not take
place within a few weeks the fistula should be touched with the
actual cautery after packing it with gauze soaked in cocaine solution
(10 per cent.). This should of course be done with due regard to
the length and relations of the fistula. I have found that in some
cases a small Kelly's tube (illuminated at the distal end, as made
by the American Electro- Surgical Instrument Co.) is very useful in
this connection. The fistula is dried as much as possible and the
Fistulae of the Intestines. 485
tube then passed. In favourable cases it is possible to see the
opening into the intestine, which often has everted edges of mucous
membrane. These can then be accurately destroyed by the electro-
cautery.
Another non-operative plan which is of great value consists
in immersing the patient in a bath. The best plan, which is
specially suited to emaciated patients with a copious thin fsecal
discharge, is to allow the patient to remain altogether in the bath,
the water of which is constantly circulating at a temperature of
about 100 F. In addition to the cleansing and healing action of
the water, the fact that the patient's weight when immersed up to
the neck in water is reduced to a few pounds greatly relieves the
back from pressure. But in ordinary cases where this arrangement
cannot be made, the patient is immersed one or two hours daily
and then rubbed down and given a hot meal. The procedure is a
very comfortable one and will often greatly expedite the spontaneous
cure of a fsecal fistula.
Probably about 70 to 80 per cent, of fistulae, apart from those due to
specific diseases, such as tuberculosis, actinornycosis or cancer, will
close in response to these non-operative procedures, though in some
cases this result may take several months for its accomplishment.
Operations for Abscesses connected with Fistulse. When the
fistula is an indirect one, opening into a large and irregular abscess
cavity, the treatment must be primarily directed to the cure of
the abscess. Such conditions may be found in connection with
appendicitis where an abscess has spontaneous^ burst or been
opened without removal of the appendix, also with subphrenic
abscesses connected with the duodenum or tuberculous abscesses
anywhere in the abdomen. The amount of pus in these cases is
out of proportion to that of the faeces discharged from the fistula,
and a probe can be made to enter a large irregular cavity in
various directions. Such a condition will, if not soon cured, lead
to septic absorption or an extension of the peritoneal inflammation.
The opening in the parietes must be enlarged as freely as
possible, multiple orifices being thrown into one and the abscess
cavity exposed in all its recesses. In cases of some standing this is
by no means an easy proceeding or one devoid of risk, because
various sinuous tracks which invite exploration may be surrounded
by very friable adherent intestine. This is notably the case with
fistulae of tuberculous origin and the attempt to close one
fistula may lead to the creation of many more. Therefore an
enlargement of the external orifice with a very gentle swabbing of
the main abscess cavity, followed by careful packing, should be all
486 Fistulae of the Intestines.
that is done in the majority of cases. When the condition has
resulted from appendicitis and there is any doubt as to the appendix
having been completely removed, it should be searched for and
removed. The tip of the finger is sufficient to separate the adhesions
round the end of the caecum and the root of the appendix is sought
for at the point where the colic taenia meet. Sometimes the
appendix lies completely separated from the caecum. It is only in
exceptional cases that the intestinal leak can be so freely exposed
as to admit of satisfactory suture. If, however, the abscess cavity
has been freely opened and drained, the probability is that the
fistula will undergo spontaneous cure.
Plastic Operations for the Cure of Fistulae. Theoretically, this
is the ideal method of dealing with fistulae, but practically, it is very
difficult of successful execution ; in fact, it is only in the case of
the direct fistula left as the result of enterostomy that it can be
regarded as at all satisfactory. The reason for this is that in all
other cases the fistula is surrounded by adherent coils of intestine
which make it impossible to excise it adequately. The closure of
enterostomy or colotomy fistulas will be described in the section on
artificial anus, and the present paragraph will deal only with the
more difficult cases of the more indirect fistulas where between the
bowel and parietes there intervenes a channel formed of scar tissue
lined by granulations and surrounded by adhesions. It is to be
presumed that this has refused to heal in response to the non-
operative treatment, including the use of the actual cautery detailed
above. This will be due to one of two conditions, either the specific
infection of the track by tubercle, actinornycosis or cancer, or to
the bowel opening being large and held open by the adhesions. In
the case of a specific infection any plastic operation is utterly
useless and will probably make matters worse. In other cases
plastic repair may succeed. An incision is made round the mouth
of the fistula through the skin and the matted layers of the parietes.
This is most conveniently done in the shape of two converging
crescentic lines. When the peritoneum is reached this is found
adherent to underlying coils of bowel. By means of the finger and
cautious blunt dissection the adhesions are broken down round the
fistula and the latter is isolated as a sort of test tube of fibrous
tissue. If this can be carried out right down to the bowel with
which it communicates, it is then cut off about ^ inch from
the gut and its edges inverted or sewn together after destruction
of its lining by the actual cautery. The wound is closed after
inserting a small rubber drain. If in the course of the operation
it is found that the tough scar tissue of the fistula is so densely
Fistulae of the Intestines. 487
adherent to the surrounding coils of bowel that it cannot safely be
separated from them, it is necessary to desist from further efforts
in this direction and be content with a thorough cauterisation of
the fistula.
Anastomosis Operations. In those fistulae which refuse to
close by the non-operative methods it is in reality a far safer and
more satisfactory proceeding to short-circuit the piece of gut
involved by the fistula than to attempt plastic operations. It is
necessary of course to know exactly where the intestinal lesion is
situated and to be able to get at the bowel above and below it. In
fistulae communicating with the ileo-caecal region the operation of
ileo-sigmoidostomy is very satisfactory.
An incision is made in the mid-line between the umbilicus and
pubes. The terminal part of the ileum is identified by its relation
to the mesentery, and it is completely divided by the actual cautery
between clamps as near as convenient to the adherent mass in the
caecal region. Both ends are closed by double purse-string sutures.
A lateral anastomosis is then made between the proximal portion
of the ileum and the highest convenient piece of the iliac or pelvic
colon. When the patient has recovered from this operation the
fistula will either close spontaneously or be amenable (in the case
of direct fistulae) to plastic repair. I have described a very typical
case of this treatment successfully performed after numerous
failures of direct primary operations 1 and shown how perfectly the
nutrition is carried out after this unilateral exclusion of the greater
part of the colon. The details of this operative procedure may be
varied in many ways, e.g., the ileum may be implanted into the
transverse colon, an end-to-side anastomosis may be made instead
of a side-to-side, and so on, but the principle is applicable to the
majority of fistulae which occur in the end of the small or begin-
ning of the large gut. It is essential, however, that the ileum
be divided completely, otherwise faecal material will continue to
be passed by the fistula. In the case of an intractable fistula
of the small intestine, the exact relations of which are not known,
anastomotie operations will be seldom required. If such fistulas are
of traumatic origin (e.g., after a strangulated hernia) they usually
heal spontaneously, and if they do not they are best treated by
excision of the involved part of the bowel. If they are associated
with an inflammatory condition which mats together many coils
of bowel, any anastomotie operation will be fraught with the
greatest difficulty. It is difficult to get near enough to the affected
coil to short-circuit its two ends, and it is still more difficult to
identify the afferent and efferent loops which are connected with
Fistulae of the Intestines.
the whole mass. Such fistulae are usually of tuberculous origin,
and these are particularly unsuitable for operative manipulations,
because the adhesions are so dense and the bowel so friable.
ARTIFICIAL ANUS.
The existence of an artificial anus nearly always implies that a
previous condition of intestinal obstruction has been relieved either
by an operation or by the bursting of a faecal abscess ; therefore
the first condition necessary before the closure of such an artificial
anus can be contemplated is that the obstruction below the anus
should be permanently cured.
If it is the small intestine which is involved, the condition is one
of some urgency, because not only does the constant stream of
fluid faeces cause great discomfort and excoriation, but serious
failure of nutrition will rapidly result. This may be temporarily
mitigated by the injection of saline solution by rectum or into the
distal limb of the bowel at the artificial anus. Mr. Bruce Clarke
has described a most interesting case where the jejunum was
involved and in which life was sustained by collecting the material
which escaped from the proximal end of the gut and injecting it
into the distal. But such expedients can only be for a matter of
days or a week or two at most, and the continuity of the bowel
must then be restored. If the stoma involves only the lateral
wall of the gut, it will be best to separate it from the skin and
then sew it together temporarily in order to avoid soiling the
wound. The peritoneal cavity is then cautiously opened by enlarging
the incision which encircles the artificial anus, and the continuity of
the bowel is restored by infolding the stoma in a direction trans-
verse to the lumen of the bowel, or if this is not possible without
much kinking, the affected segment is cut out and a fresh anasto-
mosis made. This latter procedure will also be necessary if the
bowel has originally been cut right across in the formation of the
artificial anus. In cases where the obstruction of the bowel is
irremediable (e.g., an inoperable cancer of the caecum), and where
the patient has recovered well from the acute obstruction for which
the enterostomy was performed, the only procedure available will
be an ileo-colotomy, the incision for which can be made through a
clean area of skin.
If the case is one of colotomy in which there is no spur, the
opening will usually close spontaneously if it affects the gut at or
below the transverse colon, provided that the cause of the original
obstruction has been quite removed. But this closure may be
so tedious that an operation is required for its expedition. This
Fistulae of the Intestines.
489
will consist in the following procedure. The bowel having been
thoroughly emptied by purgatives and injections, the mucous edges
of the stoma are separated from the skin and the external muscle
aponeurosis. The edges of the bowel wall are then brought
together by two rows of interrupted Lembert sutures placed in
close sequence. The muscle and skin are separately sewn up with
iSc
FIG. 1. Dupuytren's enterotome.
catgut sutures. It is almost invariable for a little faecal leaking to
occur after this operation, but this very quickly heals. The essential
characteristic of this operation is that the peritoneal cavity is not
opened.
If the colotomy is provided with a good spur which separates
the proximal from the distal loop of gut, its spontaneous closure
will be very unlikely to take place. There are two alternative ways
of treating this condition. The older and perhaps the safer way is
to destroy the spur by a clamp forceps. The original instrument
introduced by Dupuytren and figured in most of the text-books is
quite efficient, but several
others of essentially the same
principle, but of somewhat
lighter construction, have been
introduced. That of Miculicz
is quite good, being provided
with sharp points to prevent
it slipping out. I have devised
an enterotome which is worked FIG. 2. Hey Groves' enterotome with key.
by a screw and key, the great
advantage of which is the avoidance of the long handles projecting
from the abdomen and dragging upon the bowel. Whichever instru-
ment is used, one blade is introduced into the proximal and the
other into the distal limb of the colon and then screwed up as
tightly as possible. Every day the screw is given a further turn,
and usually from the sixth to the eighth day the instrument will
come away, having produced a pressure necrosis in the bowel wall,
490 Fistulae of the Intestines.
the two limbs of which have become adherent. After this the
stoma must be treated as described above.
The more modern and more rapid way of closing this type of
colotomy is by opening the abdomen and excising the affected
part of the bowel, restoring its continuity by some method of
anastomosis. As a preliminary to this the edges of the colotomy
are tightly sewn together and touched with the actual cautery, in
order to prevent peritoneal infection.
In choosing between these two methods various facts must be
taken into consideration. The enterotome procedure is best suited
for very stout patients and for those in poor general condition. If
the colon is known to be loaded with fat, its accurate anastomosis
will be a matter of some difficulty. And in cases where a con-
siderable length of gut has already been removed (e.g., after the
excision of cancer of the pelvic colon) there may not be enough
bowel to allow of resection and anastomosis. Where, however,
none of these conditions exist, the latter operation is the one to be
chosen.
BI-MUCOUS OR INTERNAL FISTULA.
Fistulous communications may take place as the result of any
inflammatory process between various parts of the intestinal canal
and other hollow viscera. But these conditions are all very rare,
even as pathological events, and still rarer as clinical manifestations.
They have been recorded in connection with the pleura, the gall-
bladder, stomach, kidney, ureter, urinary bladder, Fallopian tube,
uterus and vagina. Of these the majority either cause no symptoms
or else are only a part of some extensive disease which will require
special treatment. But a few words may be said about gastro-
colic, vesico-intestinal and vagino-intestinal fistulse.
Gastro-colic Fistulae usually arise from the extension of an
ulcer, either simple or malignant, from the stomach into the trans-
verse colon. They are characterised by the two symptoms of
true faecal vomiting and lienteric diarrhoaa. The fact that the
whole of the small intestine is short-circuited explains the rapid
marasmus, especially if there is also any pyloric obstruction.
Unless the condition arises as a complication of inoperable
cancer of the stomach, it will require operative treatment without
delay. The diagnosis may be confirmed by noting that carmine
or charcoal given by mouth appear in the faeces within less than an
hour, that air can be injected into the stomach from the rectum,
and by the examination by means of radiography after bismuth
feeding. The operation will consist in opening the abdomen in the
Fistulae of the Intestines. 491
mid-line and excising the diseased portions of both stomach and
colon with appropriate suture.
Fistulae between the Bladder and Intestine. These are usually
connected with the rectum, and the colon comes next in frequency.
The ileum or more than one part of the bowel is occasionally
involved. Gas and faecal matter are passed in the urine, more rarely
urine may be passed in the faeces and septic infection of the kidneys
soon occurs. The recto-vesical fistulae may result from the injury
produced by foreign bodies, from tubercle, cancer, or an abscess
bursting into both viscera. Unless the fistula arises in the course
of inoperable malignant disease, it must be treated by an inguinal
colotomy at once before irremediable infection of the urinary tract
has taken place. The operation must be performed with a good
spur, so that complete diversion of the faeces is effected, and the
distal limb of the colon is then used for copious daily irrigation of
the rectum, under which treatment the fistula will close and the
colotomy can be subsequently dispensed with. The vesico-colic
fistulae are generally due to some inflammatory affection of the
colon, which js often of the nature of peri-diverticulitis. Out
of 63 cases collected by Harrison Cripps 45 were due to
inflammatory causes and only 9 to malignant disease. The
treatment consists in laparotomy, which will reveal the nature
and extent of the disease and the portion of bowel affected. Unless
the parts are densely matted together by adhesions, the affected
portions of bladder and bowel are drawn up into the wound and
separated and then sutured. The diseased part of the colon will
often require to be resected. If this procedure is impossible then
a colotomy will terminate the operation. Faecal fistulae connected
with the bladder not infrequently arise in the course of appendicitis.
This may be due to a long appendix becoming actually adherent to
the bladder and then rupturing into it. In this case a foreign body,
such as a pin or worm, may be passed per urethram. 2 Much more
frequently, however, it is a pelvic abscess which communicates
with the bowel on the one hand and the bladder on the other.
Gas and faeces may be passed by the urethra or, if the case has
been operated upon, urine may escape by the wound. These cases
usually undergo spontaneous recovery if the abscess has been
freely opened and drained. It will very seldom be possible to
subject them to any direct operative treatment. Probably an
ileo-colotorny would be the safest and easiest procedure if direct
interference is demanded.
Fistulae between the Intestine and Female Generative
Organs. These may involve the rectum, pelvic colon, transverse
492 Fistulae of the Intestines.
colon or ileuin on the one hand, and the vagina, uterus or
Fallopian tube on the other. The subject of recto-vaginal fistulee
is dealt with in another section of this work. The other conditions
which usually result from operations, pelvic peritonitis, tuberculosis,
or cancer, present in simple cases a fair prospect of spontaneous
recovery under expectant treatment by vaginal douches, which
should be persevered with for a long time. If this fails and the
case is not due to tuberculosis or cancer, the abdomen is opened and
the involved part of the intestine separated from the uterus or
vagina and sutured or excised.
ERNEST W. HEY GROVES.
REFERENCES.
1 Groves, E. W. Hey, Proc. Boy. Soc. Med., 1909, II. (Surg. Sect.),
pp. 121133.
2 Kelly and Hurdon, "The Vermiform Appendix and its Diseases," Philad.
and Lond., 1905, p. 319.
493
FOREIGN BODIES IN THE INTESTINES.
FOKEIGN BODIES of almost every conceivable size and variety may
be swallowed or passed into the rectum, particularly in the case of
insane patients. Certain concretions may be formed in the intes-
tines or gall-bladder and act as foreign bodies in the intestine.
Very rarely they may be introduced through the abdominal parietes,
either as the result of a penetrating wound or by a process of
ulceration from the peritoneal cavity, where they have been
accidentally left (gauze swabs, drainage tubes or forceps). It
would be quite beyond the scope of this article to discuss any
further the variety of the foreign bodies which thus find their way
into the intestinal tract, but it will be sufficient for the purposes of
clinical diagnosis and treatment if we divide all these cases intp
three categories according to the predominating character of the
associated symptoms, viz. : (1) Those with no symptoms ; (2) those
with inflammatory symptoms ; (3) those with obstructive sym-
ptoms. A few preliminary remarks may be made on the subject of
diagnosis.
The history of the case may throw some light upon its nature,
but it is perhaps the exception for this to happen. Mothers often
bring children for advice who are stated to have swallowed various
objects, such as coins and whistles, but these are usually the cases
which require no treatment. Hysterical and insane persons who
devour the most extraordinary articles usually conceal their past
acts. A history of previous abdominal attacks of pain with jaundice
may suggest gallstones, or a person who has been in the habit of
taking large quantities of medicine, e.g., magnesia or bismuth, may
be likely to have developed an enterolith. Kadiography will be by
far the most valuable aid in diagnosis, for in the case of all metal,
glass, and earthenware articles it will clearly demonstrate both
their presence and position. Unfortunately, however, gallstones,
the commonest foreign bodies to cause obstruction, do not cast
a definite shadow, for they are almost as transparent to the X-rays
as the soft tissues themselves.
Cases without any Definite Symptoms. Considering that
every kind of solid article swallowed, teeth-plates, pins, coins,
clasp knives, etc., has passed by the anus after a longer or shorter
stay in the alimentary tract and that the majority of indigestible
494 Foreign Bodies in the Intestines.
articles do so pass, there is always a presumption in favour of this
simple ending of the case. When the article is round and small,
e.g., a coin or marble, there need be no apprehension about it. An
anxious parent may be satisfied by the frequent examination of her
child by means of a fluorescent screen, which shows the foreign
body in a different position on each examination until it reaches
the pelvic colon, usually within twenty-four hours, and then is
expelled. Supposing, however, that the foreign body is known to
be of a sharp or angular nature, e.g., a tooth plate or shawl pin,
experience teaches that if such a body has negotiated the oaso-
phagus and pylorus successfully, it is not likely to cause trouble in
the intestine. The patient should be kept under observation, and
if any signs of pain or local tenderness arise, or if the X-rays show
that the object has become stationary (in either case this will
probably be near the ileo-caecal region), then will be time enough
to open the abdomen and remove the foreign body. No drugs
should be given either to hasten or retard the intestinal stream.
Any violent or unnatural peristalsis will be much more likely to do
harm than good, and opiates which produce stasis will merely
postpone the natural cure of the case. A simple enema may
be useful in aiding the expulsion of a foreign body which has
reached the pelvic colon and in helping in its recognition when
it is passed. The diet should consist of food which leaves a bulky
residue, e.g., vegetables and fats. Brown bread, porridge, green
vegetables and cream, should be the staple food.
Cases Causing Inflammatory Symptoms. The cases in this
group are usually caused by small, sharp, irritating objects, e.g.,
pins, pieces of straw, or fish-bones, and in the majority of them
there is no history at all of their having been swallowed. When
we think of the great variety of indigestible things which are
swallowed by most people every day, the marvel is that the condi-
tions we are considering are not very much commoner than is
the case. Pins, which are sometimes swallowed in large numbers
by the insane, frequently perforate the intestine and travel to the
most remote parts of the body without causing any symptoms what-
ever. An angular body may become impacted in the duodenum, the
ileo-caecal region, or in one of the pouches or false diverticula of the
colon. It will then produce ulceration with inflammatory adhesions
or a local abscess, or general peritonitis from perforation. A
certain proportion (probably not more than 1 per cent.) of cases of
acute appendicitis are caused in this way. Pins, bullets, fish-bones,
and worms are found extruding through an inflamed and perforated
appendix. An exactly similar train of events may happen with
Foreign Bodies in the Intestines. 495
a diverticulurn of the pelvic colon. The treatment of all these
inflammatory manifestations will consist in opening the abdomen
and dealing with the inflammatory focus by drainage, removal of
the appendix, or diverticulum, and so forth. Very frequently it is
only subsequent examination of the tissue removed that reveals its
relation to a foreign body.
Sometimes ulceration and adhesion may result in fistula, either
external or internal. Through these the foreign body may be
extruded. For example, a spoon has escaped from a fistula of the
caecum and the femur of a rabbit by a fistula into the bladder.
When sharp foreign bodies, such as fish-bones, become impacted
just above the anus they will almost certainly cause rectal fistulas
or abscess. They should therefore be most carefully removed
under an anaesthetic, with the aid of a good speculum, immediately
their presence is ascertained.
The ulceration, stenosis, or inflammatory adhesions left by the
injuries due to foreign bodies will, of course, have to be treated
according to the general principles applicable to these several
conditions.
Cases associated with Obstructive Symptoms. Foreign
bodies which cause blocking of the intestinal lumen are usually
gallstones which have ulcerated their way into the duodenum from
the gall-bladder, or the condition may be due to concretions formed
/// xitu, either of medicinal substances (e.g., various magnesia salts),
indigestible residue from the food, or veritable stercoliths formed
by a deposit of mineral salts round a foreign body. And, lastly,
a substance swallowed may cause obstruction, but this is extremely
improbable, because the lumen of the gullet is less than that of the
narrowest part of the intestine. Swallowed foreign bodies which
give rise to obstruction generally do so either by long-continued
iinpaction with subsequent ulceration, adhesions or kinking, or by
the accumulation of large quantities of small articles.
The question of the treatment of these cases of obstruction by
gallstones has been warmly debated in the past, but in modern
times, provided that the existence of obstruction is clear, there
ought to be no room for a difference of opinion. The facts which
have given rise to discussion are : (1) That in a fairly large propor-
tion of the cases (50 per cent, according to Naunyn) the stone is
passed spontaneously and the patient recovers without operation ;
(2) that the mortality of operations on these cases has been very
high. Passage of the stone by the anus has been recorded at
varying intervals of four to twenty days from the beginning of the
symptoms. There has been no recorded surgical success in cases
496 Foreign Bodies in the Intestines.
operated upon as late as the seventh day of illness. But no modern
surgeon would dream of allowing any case of intestinal obstruction
to remain untreated for a whole week, and we may confidently
assume that if these cases are operated upon within forty-eight hours
of the occurrence of obstructive symptoms the mortality will be as
low or much lower than other cases of acute obstruction. In obstruc-
tion by gallstones the operation is a simple and short one and the
intestine is rarely seriously injured. There is blocking of the lumen
of the gut but no strangulation or obstruction of the circulation. If
the patient refuses to be operated upon, the expectant treatment
consists in withholding food by mouth, giving nutrient and aperient
enemas, and administering small doses of morphia and atropine to
diminish the spasm of the intestine round the foreign body.
Operation will, however, be the method of choice and should
be performed as soon as possible. The stomach is thoroughly
washed out to prevent regurgitant vomiting and the abdomen
opened in the mid-line. Very rarely the foreign body will form
a palpable tumour, in which case the incision may be placed
over it. Otherwise it is best to open the abdomen below the
navel. The terminal part of the ileum is identified by its connec-
tion with the caecum and the empty gut passed rapidly through the
ringers until the obstructing mass is reached. If this is in a part
of the ileum or jejunum the coil can be brought outside the
abdomen whilst the rest of the intestine is replaced. In one case
it was found possible by Glutton to push the stone onwards through
the ileo-caBcal valve into the large gut, from which it was passed
naturally a few days later. But generally it will be unwise to
attempt any manipulation of the stone, as this is much more likely
to damage the bowel than to effect any good purpose. An incision
of an appropriate length is made into the bowel above the foreign
body after the gut has been clamped on either side of it. The mass
is removed and the incision closed by a double row of continuous
sutures. If the operation has been done without undue delay it
will be rare for there to be any damage of the bowel requiring
resection, or such distension of the intestines as will need drainage.
But in those cases where the operation is late both these procedures
may be necessary. If the patient's general condition is very bad
the following technique will be the best to follow. The damaged
bowel is freely resected and the bleeding vessels tied. The two
ends of gut are then sewn together by a through and through con-
tinuous stitch for about two-thirds of their circumference, including
the mesenteric border. There is still left an open gap, and into this
is tied a Paul's tube with long rubber attachment. The clamps
Foreign Bodies in the Intestines. 497
are removed and the parietes closed, leaving the sutured area of gut
in the wound. This permits of a thorough evacuation of the
intestines by the tube, and when the latter comes 'away, about the
third day, the fistula can readily be sewn up or dealt with at a later
date. A hypodermic injection of pituitary gland extract is of
great value in restoring the tone to the distended and paralysed
bowel above the stricture (see also Gallstones and Intestinal
Obstruction).
ERNEST W. HEY GROVES.
3.T. VOL. II. 32
49 8
HERNIA.
GENERAL CONSIDERATIONS.
THE treatment of hernia will vary according to circumstances.
It depends on the age of the patient, whether an infant or child,
an adult, or one advanced in years ; it depends on the sex, on the
general health, and on the surroundings of the patient, whether he
is in easy circumstances or not, living in out-of-the-way places or in
the haunts of civilisation. It will vary as to whether the hernia is
reducible, irreducible, or partly reducible, whether it is obstructed or
strangulated; whether it is an enterocele, all intestine; an epiplocele,
all omenturn ; or an entero-epiplocele, both intestine and omentum ;
and whether the sac contains such rare contents as the urinary
bladder, ovary, Fallopian tube, or appendix vermiformis ; whether,
too, the testis is descended or undescended, and when the latter,
whether it is properly or ill developed.
Treatment may be palliative by trusses, radical by operation, and
to a certain extent preventive.
Palliative Treatment (by Trusses) was in the past almost the
only method, and had to be employed even after successful operations
for strangulation. Nowadays, at the best a makeshift, it should
be the exception rather than the rule. About this in the young
and vigorous there can be no doubt, but even in the old and
comparatively feeble, modern surgery has made much that in the
past was impracticable and impossible, possible, advisable and even
urgent. To condemn a ruptured person to truss life, with its
inconveniences, difficulties and dangers, is more risky than for him
to undergo an efficient operation performed by a skilled surgeon.
Operative Treatment. In the early days of so-called 'radical
cures many of the operations were inefficient, many of the operators
unskilled and inexperienced, many of the results lamentable. To-
day the mortality is practically nil, and the operations that have
survived the test of time give exceptionally good results with
an exceedingly small percentage of recurrence. Even secondary
operations after recurrence hold out more than a hope of a permanent
cure. In the writer's experience it is more common if a second
hernia appears after operation for it to show itself on the opposite
side of the body, or in some part away from that first operated
on. This is not to be wondered at when the general lack
of development, patency of rings, and laxity of tissues of the
Hernia. 499
ruptured are taken into consideration. The operative treatment of
hernia sliould not as a rule require to be followed l>y the wearing of
a truss. It says little for the operator's confidence in his so-called
radical cure if he thinks this necessary, save in exceptional cases.
It may, however, in certain large herniae, be a physical impossibility
to perform an ideal operation, and all the surgeon can hope for
may be to enable by operation his patient to wear a truss and
subsequently to lead a careful life, avoiding any undue strain or
over-exertion.
Femoral and perhaps umbilical hernias will require mechanical
support after operation much more often than will inguinal hernias.
The operation for femoral hernia is less adequate and complete tha,n
that for the inguinal variety. That for an umbilical hernia is often
complicated both by the size of the rupture and the size of the
patient.
Preventive Treatment. The preventive treatment of hernia
resolves itself into removing, as far as possible, the exciting causes
in those congenitally predisposed to this condition, e.g., to cir-
cumcise the phimosed child when the phimosis is a bar to proper
micturition, to treat early and efficiently all causes of undue
straining, such as stricture of the urethra, stone in the bladder,
enlargement of the prostate, constipation, or stricture of the rectum,
to allay the cough of chronic bronchitis, to deprecate the wearing of
tight belts which throw excessive strain on the lower abdomen,
especially during gymnastics or athletic exercises, to caution those
with weak abdomen and patent rings against the danger of rupture,
to let them wear a truss as a precautionary measure, and to impress
on them the necessity of early and efficient treatment if their
potential hernia should ever become actual.
The treatment of hernia will to a certain extent vary according
to the age of the patient. In very young children palliative truss
treatment is usually indicated until they are older, easier to operate
upon, and better able to stand operation. Yet even here if the
hernia is unmanageable, rapidly increasing in size, practically
impossible to reduce and to keep reduced, an operation may be
safely undertaken.
The very old and feeble or those with visceral disease must be
treated with caution and discretion. That which is imperative for
the working man may only be desirable for one of the leisured
classes. That which is advisable and urgent for a man with years
of active life before him is not advisable for an old man of sedentary
and inactive habits. The latter should only be subjected to
operation if there is some local condition of the hernia in itself
322
500 Inguinal Hernia.
a danger to life, e.g., irreducibility, constantly threatening
obstruction, or even strangulation. The question of operation in
the old often resolves itself into the question of an anaesthetic. If this
can be safely given, if there is no chronic lung or cardiac trouble to
forbid it, operation may be advised with confidence.
The old, as was pointed out years ago by Sir George Humphrey,
heal well, though they are bad at making up loss of blood, and the
shock of the operation is perhaps less felt by them than by very
young children, who, however, rapidly make good the ill-effects of
haemorrhage. Kenal inadequacy and disease, although to be taken
into due consideration, are of less importance than in former days ;
l^it little stress is thrown on the excretory organs after an aseptic
operation, the wound of which should heal by first intention.
A man with hernia may take the risk of truss life if he lives
within reach of adequate surgical assistance in case of need ; he
certainly should not do so if his life has to be spent in remote
or out-of-the-way places.
The very real dangers of strangulation, even when treated in a
large hospital by men accustomed to operate daily, may be realised
by the statistics of St. George's Hospital for thirteen years :
Of 155 cases of strangulated inguinal hernia 24 died,
125 femoral 20
25 ,, ,, umbilical ,, 13
that is to say, 15*5 per cent, of strangulated inguinal hernias,
16'7 per cent, of strangulated femoral hernias, and 52 per cent, of
strangulated umbilical herniae have died after operation.
Operative treatment will be first considered, afterwards the
palliative treatment of those unfit for the radical cure of their
hernias. Operation should be the ordinary, the truss the extra-
ordinary, treatment of rupture.
INGUINAL HERNIA.
Modification of Bassini's Operation. The operation, whether
for bubonocele or the complete variety, the direct or indirect, is
much the same. In very large hernias it may be necessary in making
the incision to trench on the scrotal tissues (a thing, if possible, to
be avoided), especially if there is any adhesion of omentum or
other sac contents-to its lower part.
Preliminary sterilisation of the skin and shaving of the pubes
are, of course, necessary. Bassini's operation of laying open the
inguinal canal, removal of the sac, and suture of the conjoined tendon
to Poupart's ligament, thus obliterating the inguinal canal, is the
model of most of the modern successful operations. The operation
Inguinal Hernia.
FIG. 1. Operation for inguinal
hernia. External incision
avoiding the scrotal tissues.
about to be described is a modification of Bassini's, and has been
employed in many hundreds of cases with good results. The incision
is made more or less parallel with Pou-
part's ligament and 1 inch or 1^ inch
above it, commencing at the inner side
of the external abdominal ring and
running upwards and outwards for the
required extent.
In exposing the external ring and
aponeurosis of the external oblique,
some small cutaneous vessels, the super-
ficial epigastric, will be divided, and
should at once be clipped to make the
operation as bloodless as possible, a
point very important in dealing with
children or where the sac is very thin
and perhaps difficult to find ; again,
too, in recurrences where the anatomy has already been inter-
fered with in some unknown way by another operator, it is
very essential not-to have the parts obscured by bleeding, howsoever
trifling. The external ob-
lique is divided by a small
incision about 1 inch exter-
nal to the external abdo-
minal ring; the edges of
this puncture are clipped
by Spencer Wells's forceps,
which subsequently are
used as retractors. A direc-
tor introduced and passed
downwards and inwards
allows of further division
of the external oblique
aponeurosis, the inter-
columnar fibres and ex-
ternal spermatic fascia.
The divided aponeurosis of
the external oblique is next
separated from the con-
joined tendon above, and
from the cord and sac covered by the cremaster muscle below. In this
way Poupart's ligament is defined and ready for subsequent suturing.
The cremaster muscle and fascia are then divided and separated from
FIG. 2. Division of aponeurosis of external
oblique. The clips to be used subsequently
as retractors are placed wider apart than in
illustration.
502
Inguinal Hernia.
FIG. 3. Separation of external oblique apoaeu-
rosis from the conjoined tendon and definition
of Poupart's ligament.
the subjacent cord and
sac. If any vessel bleeds
it should, for reasons
already given, be secured
at once. In separating
the cremasteric fascia
from the sac and cord,
sponging is of the greatest
assistance. The sac in
old hernise is self-evident,
but in bubonoceles and
in the so-called con-
genital variety its finding
and separation may be
attended with some diffi-
culty. The white line of
its edge is very helpful
in its separation from
the vas deferens and vessels of the cord. Some loose connective
tissue may require division by the knife ; such division should be
parellel to the course of the vas spermatic vessels and veins. Even
in the congenital variety the peritoneal covering can with care be
separated from the subjacent cord. Sometimes there is a marked
protrusion of subperitoneal fat, which might at first sight be taken
for an omental hernia, and
in some rare cases the
muscular coat of a pro-
truding urinary bladder
might be mistaken for
some portion of the
cremaster muscle. The
writer has met two such
cases. The sac and sac
alone is isolated and
separated from both cord
and testis; any diverticula
of the sac are, of course,
dissected away and re-
moved. The testis in
these manipulations may
accidentally or unavoid-
ably be pulled up from FlG - 4. Separation of sac from the cord and
enveloping tissues up to the internal abdominal
the scrotum. It should be ring.
Inguinal Hernia.
503
FIG. 5. The sac of a direct inguinal hernia.
Note pedunculated process of subperitoneal fat
near internal abdominal ring.
handled as little as pos-
sible, and care should be
taken that in its replace-
ment there is no torsion of
the cord. Much has been
written as to the treat-
ment of the sac, whether
it should be twisted,
whether it should be
entirely removed and
whether it should be in-
vaginated. In the writer's
opinion the only necessary
thing is to pull it down
as far as possible and to
remove it, and in ligature
of its neck to take care
that nothing else is in-
cluded. To ensure this it is well to put the finger in the empty
sac, and to tie the neck on the finger which is removed as the
catgut is tightened. In a large number of cases a tight white
fibrous ring is found about the neck. This is the usual seat of
strangulation. The sac of a bubonocele has often a digital
process below this fibrous ring extending right to the bottom of the
scrotum down which no hernia has yet descended, but into which
some sudden strain may
cause the bowel to enter
and symptoms of strangu-
lation to supervene. The
emptying of the sac of
its contents is usually
easy. Omentum when
adherent must be sepa-
rated and may have to
be removed. Whenever
possible, all of it should
be returned into the abdo-
men without any inter-
ference, as the stump
of divided or removed
ornentum might give sub-
sequently rise to intestinal
FIG. I). Method of ligature of sac. Taken from u
actual operation on a direct hernia. obstruction.
504
Inguinal Hernia.
Adhesion of bowel to sac is luckily rare. If very firm and extensive,
a portion of the adherent peritoneum may be cut away from the rest
of the sac and returned with the bowel into the abdomen. As a
rule the adhesion of sac to bowel, or, as is more commonly the
case, to oinenturn, is easily separated. It should be remembered
that these adhesions are very frequently due to the improper
wearing of a truss over a descended hernia. In certain cases,
although there are no adhesions, it is very difficult to reduce the
bowel. In very large herniae so much of the abdominal contents
tf
have for so long a time lain outside the proper abdominal cavity
that the capacity of the latter seems seriously diminished, or, again,
the parts within the sac may after descent have become swollen,
congested and so per-
manently enlarged that
it is well nigh impossible
to return them through
the opening down which
they originally travelled.
This is especially the case
when the large intestine
is in question. The sac
having been emptied, liga-
tured and removed, suture
of the conjoined tendon
to Poupart's ligament is
next proceeded with. This
maybe done either behind
or, as the writer prefers,
in front of the cord. There
is less handling of the
latter if the suturing is in front of it. Poupart's ligament should
be picked up by a slightly curved needle on a handle armed with
silkworm-gut or kangaroo tendon, first of all where it is connected
with the os pubis ; care should be taken that the end of the suture
subsequently to be passed through the conjoined tendon is easily
recognised. Both ends of the suture may be clipped by Spencer
Wells's forceps with the one subsequently required near the
handles. Three, four, or more sutures are passed through
Poupart's ligament and clipped in this distinguishing way.
Traction on the one passed last will readily bring up the ligament
from the subjacent structures for the next suture. To avoid any
splitting of the aponeurosis a different thickness should be taken
by each suture. This is especially necessary in very young children
FIG. 7. Method of suture of conjoined tendon to
Poupart's ligament.
Inguinal Hernia.
505
where the aponeurosis has a great tendency to split obliquely in
the direction of its fibres. The conjoined tendon, which varies very
considerably in its muscularity, is now perforated by a McEwen's
needle and thus picked up in two places; the needle eye is threaded
by the kangaroo tendon or a piece of silkworm-gut already passed
through Poupart's ligament, and the needle withdrawn to allow the
subsequent approximation of the two structures. When these
deep stitches, some three or four in number, are tied and completed
the cut aponeurosis of the external oblique is sutured by a con-
tinuous catgut suture, and the edges of the superficial skin wound
brought together by silk. No drainage tube is required. The
question as to the best ma-
terial for these deep sutures
is still unsettled. Silk in
the writer's opinion is not
good, wire is distinctly bad.
Kangaroo tendon, silkworm
gut, and chromic catgut
have been much used. It
is contended by some that
non-absorbable sutures can-
not hold living structures
together for any length of
time. The points to re-
member in performing tliis
operation are that the
scrotal tissues as far as
possible are to be avoided, Fl - S.-Suture of conjoined tendon to-
Poupart s ligament completed. The knots
all superficial blood-vessels are not sufficiently shown.
are to be secured, and the
operation throughout conducted as bloodlessly as possible. The
external abdominal ring and the external oblique aponeurosis
is to be freely divided as high as the position of the internal
abdominal ring, the sac to be carefully defined and separated, sac
and sac alone, from the cord ; to ensure during its removal and
ligature that no abdominal contents are in danger it should be
ligatured upon the finger, the suture of the conjoined tendon to
Poupart's ligament should be complete and firm ; such suture is
perhaps best anterior to the cord. The cord itself should be handled
as little as possible ; if there is a varicocele the superfluous veins
should be removed, otherwise it is undesirable to interfere with
them. The stitching up of the external oblique should include a
definite amount of that membrane, especially if it is thin and
5o6
Inguinal Hernia.
weak, so that its last state shall be stronger, not weaker than its
first.
If any hydroccle of the tunica vaginalis is present it should be
dealt with at the same time as the hernia by free removal of the
parietal layer. Cysts along the course of the cord or near the
testis should also, when present, be removed.
It matters little whether a hernia is of the congenital, infantile or
adult variety if all the sac is removed right up to the internal ring.
The congenital variety is the most difficult to deal with, but with
care the serous covering can be separated from the cord and vas,
and the communication
with the abdomen closed
either by a catgut ligature
or a purse-string suture.
When an undescended
testis is present, if it is in
the way, ill-developed, and
if the patient is an adult,
it is best removed. In the
child when separated from
the hernial sac it may be
brought down into and
stitched, to the scrotum. It
has been recommended to
separate the globus minor
and body of the epididyiais
from the testis proper to
effect this. The writer is
not in favour of this proceeding, but prefers to return the testis
into the abdomen when the cord is too short to allow of scrotal
stitching.' The argument that this abdominal position is dangerous
in the event of orchitis or malignant disease in later life may
perhaps be disregarded.
In women the sac of an inguinal hernia is not so pyriform
as in men, the neck of it not so narrow, and accompanying
the hernia there may be some anatomical irregularities. Cysts in
connection with the round ligament are not uncommon, and when
present should be removed.
The dressings may be varied to suit the taste of the operator. In
children, in whom there is greater danger of soiling by urine, gauze
and collodion may be indicated, and protection may be afforded by
jaconet or thin mackintosh. The after-treatment is simple : rest in
the horizontal position for some three weeks in adults, somewhat
FIG. 9. Continuous catgut suture of aponeu-
rosis of external oblique.
Inguinal Hernia. 507
longer in children who cannot be trusted to avoid any over-exertion
or strain on first going back to normal life. For at least six
months after operation no great strain should be thrown on the
lower abdomen.
Operations Other than Modifications of Bassini's Method.
In his early operations Kocher, after torsion of the sac, passed it by
imagination through the external oblique and fixed it by suture.
Sloughing of this displaced sac was not unusual, so that after lateral
transposition it has been found better to remove it. It is claimed
for this that " the peritoneum is stretched in a lateral direction,
and any descent of the sac in the direction of the cord rendered
impossible." His last operation is transposition of the unopened sac
by invagination into the abdominal cavity. It is then made to pro-
ject external to the internal abdominal ring and an incision is made
through the abdominal muscles and through the parietal peritoneum
on to it. The sac is pulled out and the base crushed with pressure
forceps. It is then transfixed with silk, tied, and cut off and
the stump pushed back. A row of deep sutures, including the
external oblique aponeurosis and the internal oblique, is inserted
to strengthen the inguinal canal in its whole length.
In McE wen's operation the sac is thoroughly separated and
reduced into the abdominal cavity, forming a bulwark pad " to
shed the intestinal waves away," it being contended that if the
sac is merely tied there remains a funnel-shaped puckering on the
peritoneal aspect. The operation consists in exposing the external
ring. The sac is then separated from the cord in the inguinal canal
and for half an inch round the abdominal aspect of the internal
abdominal ring, folded on itself and perforated by a stitching which
is made to penetrate the abdominal wall 1 inch above the internal
abdominal ring. The skin during this manoeuvre is pulled up
and is not included in the suture. The inguinal canal is closed
by stitching the conjoined tendon to Poupart's ligament, and the
pillars of the external abdominal ring are brought together. In
congenital hernia the sac is divided transversely and the upper
part dealt with in the manner above described.
In Halsted's operation the spermatic veins are tied as high as
possible above and below the external ring ; the intervening mass is
excised. Care is taken not to touch or move the vas lest throm-
bosis of its veins occur. The neck of the sac is transfixed and
tied. The ends of the ligature are threaded into long curved
needles, passed deep to the internal oblique and transversalis
above and outside the internal abdominal ring and tied, displac-
ing the neck of the sac outwards. The lower flap of the divided
508 Inguinal Hernia.
cremasteric fascia is drawn up deep to the conjoined tendon and
sutured. The internal oblique and conjoined tendon are joined
to the top surface of Poupart's ligament by interrupted sutures.
The rectus sheath is incised vertically if the conjoined tendon is
narrow or atrophied. A flap of it may thus be sutured to the top
surface of Poupart's ligament, or the sheath slit up and the rectus
itself sutured to that structure.
Professor Nicoll, if Poupart's ligament is weak and movable,
sutures the conjoined tendon to the horizontal ramus of the pubes
in the same manner as in his operation for femoral hernia.
Direct Inguinal Hernia. The operative treatment of direct
inguinal hernia is much the same as has been already described.
Variations in the anatomy of the conjoined tendon and of the
sac have to be dealt with on ordinary surgical principles, and the
altered relation of the epigastric artery remembered. The neck of
the sac is often broad and not well defined, and the conjoined
tendon may be pushed aside or penetrated by the hernia, requiring
sutures after its reduction.
Other structures than bowel or omentum may be found within
the sac, e.g., the urinary bladder, or the latter itself may be mis-
taken for a direct hernial sac and inadvertently opened. Suture of
such accidental wound should not include the mucous membrane.
In two such cases which have come under the writer's cognisance
no harm resulted from this accident.
The appendix vermiformis, if in the sac, had better be removed ;
so, too, an ill-developed ovary or Fallopian tube.
Interstitial Hernia occurs in front of or behind the external
oblique, or in front of the peritoneum behind the abdominal muscles.
The latter variety does not lend itself to operation, is often un-
recognised, or is only discovered when " reduction en masse " has
been effected.
The interstitial diverticulum running either behind or in front of
the external oblique, if not of excessive size, should be dissected out,
together with any scrotal or labial sac, the abdominal aperture
closed, and the undescended testis, if present, treated according to
its position and development.
In some of the larger varieties complete operation may be impos-
sible ; and in cases of strangulation the internal opening and the
seat of strangulation may be exceedingly difficult to find.
If "reduction en masse" has taken place, the strangulated reduced
intestine must be followed up and relieved by appropriate incision ;
the treatment of the bowel will have to be varied according to its
condition, as is described under the heading of Strangulated Hernia.
Femoral Hernia. 509
In the varieties of reducible interstitial hernia where no operation
is performed, the patient will have to wear an interstitial pad as a
truss.
FEMORAL HERNIA.
The treatment of this variety by operation is attended with diffi-
culty, and the results are not nearly so good as those that follow
operations on inguinal hernia. After the sac has been removed,
the parts to be brought together are more or less unyielding, abso-
lutely fixed to the pubic bone and in the immediate neighbourhood
of a large vein (the femoral), any pressure on which cannot for
obvious reasons be allowed. The operation usually includes the
dissection of part of the fascia from the surface of the pectineus
muscle and its suture above to the margins of the femoral ring,
which is closed by kangaroo tendon, silk, catgut or fishing gut.
This pectineal fascia varies in thickness, but is usually thin and
but poor stuff for the purpose.
Operation. The superficial incision should be over the hernia,
and may either be transverse or vertical, according to the operator's
taste ; the vertical, perhaps, is the better. Any superficial blood-
vessels, such as the superficial external pudic, should be clipped or
tied, and the internal saphenous vein must be respected. The
femoral sac, with its coverings, very often resembles an onion, and
in dissecting through its concentric layers it is occasionally with
difficulty that the sac itself is recognised. Arborescent vessels, as
a guide to finding it, are not to be depended upon. When, how-
ever, it has been unmistakably defined, it should be separated right
up to the opening of the femoral canal, and its contents reduced, if
possible, into the abdominal cavity. To effect this, and to remove
the sac thoroughly, the external oblique aponeurosis should be
divided above Poupart's ligament, so that the femoral ring may be
accessible.
Adherent omentum is common, adherent bowel rare ; such adhe-
sions, when they do exist, are usually due to the previous wearing
of a truss over a descended hernia.
Adherent omentum must be dealt with by ligation and removal,
and in ligaturing it the usual precautions must be taken against
subsequent intra-abdominal haemorrhage ; in other words, the liga-
tures must be made to interlock, and must be firmly tied. Stout
catgut or sterilised silk are required for this. In ligaturing the
neck of the sac, care must be taken that it is completely empty ;
and the suggestion of ligaturing on a finger, in this case the little
one, given in the description of the operation for inguinal hernia,
Femoral Hernia.
may here also be usefully followed ; in many cases the neck of the
sac is too small to admit of this manoeuvre.
Other methods of treating the sac are as follows :
It may be invaginated, passed through a small opening of the
abdominal wall above Poupart's ligament, and there fixed by suture.
It may be transfixed, tied and invaginated.
It may be ligatured, the body of the sac cut away, and the ligature
ends left long passed
through the external
oblique aponeurosis and
tied.
The best method of
getting at the sac,
and dealing with it
thoroughly, is to make
an incision through the
external oblique, to pull
it upwards through the
femoral canal, and so
tie it in this way high
up. Some surgeons re-
commend the disloca-
tion of the sac and fixing
it as a pad above the
femoral ring.
When the sac has been
dealt with, the opening
of the ring has to be
FIG. 10. Operation for femoral hernia. Diagram of
parts concerned. The front of the.femoral sheath
has been removed to show the relation of the
vessels to the femoral canal. 1, Flap of pectineal
fascia which is dissected up and stitched to mar-
gins of femoral canal. The saphenous vein dis-
placed outwards. 2, Incision through external
oblique aponeurosis to allow of invagination and
thorough removal of sac ; also, if necessary , suture
of conjoined tendon to parts below.
closed by sutures (three
in number), which pass
through Poupart's
ligament down into
Cowper's ligament
below, taking up and including a flap of the fascia from the surface
of the pectineus muscle. In some cases this will be the only
structure that the surgeon can suture to the upper margin of the
ring. The operator must constantly bear in mind the propinquity
of the femoral vein, and on no account do anything likely to
endanger its safety.
To close the femoral canal Bassini passes three ligatures through
Poupart's ligament and the pectineal fascia, which are left untied
until three or more uniting the falciform ligament to the pectineal
fascia are passed and tied. Some surgeons recommend a
Umbilical Hernia. 511
purse-string suture of kangaroo tendon which takes up the edge of
Poupart's ligament, the pectineal fascia and muscle, the fibrous
septum covering the inner side of the femoral vein, and then
Poupart's ligament again. This is a quick method, and may be
done in cases of strangulation.
Lotheissen's operation is a complete and thorough one. An
incision is made above and parallel to the inner half of Poupart's
ligament, the edges retracted, the neck of the femoral sac exposed
and isolated below the conjoined tendon, above the femoral ring.
The sac is drawn upwards. If this is not possible it is dealt
with from the femoral aspect. Closure of upper end of femoral
canal is effected by suture of the conjoined tendon to Cowper's
ligament by means of sutures on very curved needles ; the opening
in the aponeurosis of the external oblique is then closed.
Professor Nieoll's operation is ingenious, but difficult to perform
and requires special instruments. The sac is bisected longitudinally,
one-half is pierced and the other half drawn through the opening so
made, so that the neck of the sac is closed without ligature. It is
then pushed up to the abdominal aspect of the femoral ring. The
pectineus muscle and fascia is joined to Poupart's ligament by
interrupted catgut sutures. The horizontal ramus of the pubes
is exposed and drilled. Catgut sutures passed by the aid of a
special probe through the drill holes in the bone are then made to
take up Poupart's ligament, and so tie it down to the pubes.
Eoux drives a metal staple through Poupart's ligament and the
femoral canal into the horizontal ramus of the pubes.
Superficial inguinal glands may have to be removed before the
sac of the hernia can be properly defined, and, as a consequence, a
cavity may be left on which it is well to make firm pressure by
dressing after the operation, or even, if need be, to drain for forty-
eight hours. The superficial wound can be united by any of the
usual sutures. The patient should rest in bed for some three weeks,
and perhaps it is as well if a truss is subsequently worn.
UMBILICAL HERNIA.
Small herniae in adults in the neighbourhood of the umbilicus in
the linea alba are protrusions of subperitoneal fat, but occasionally
possess a definite peritoneal sac and even bowel. As a rule,
they are above the umbilicus and are easily dealt with by operation.
They attain but small size and may exist for some time without
being recognised, and rarely give rise to any symptoms other than
those usually attributed to indigestion.
Operation for umbilical hernia is rarely necessary in children.
512 Umbilical Hernia.
In adults these herniae often attain a large size, and frequently a
large portion of their contents is irreducible. The omentum in
them commonly forms a definite lining sac, containing loculi in
which intestine is often adherent. The patients, as a rule, are fat
elderly women with fatty hearts and often chronic . bronchitis,
making them bad subjects even for a necessary operation. If the
hernia becomes obstructed or threatens strangulation, in spite of
the attendant risks operation must be undertaken. If the
hernia is reducible and small, the operation is easy, the risk
slight. In most cases the condition of the patient is so unbearable,
her danger from the hernia so great, that the safest thing is to
operate. Careful preparation and the treatment of any intertrigo,
excoriation or ulceration of the skin that may be present, is
imperative.
Operation. The incision may be transverse or a straight vertical
one, long enough to give plenty of room. "Where the integuments,
as is so frequently the case, are thin and perhaps ulcerated on the
surface, an excision of an elliptical portion of skin may be the best
procedure. The latter should also be practised when there is
any great redundancy of skin, apart from any thinness that may be
present. When the sac is opened, the adherent omentum, if the
adhesion is small in quantity, should be separated ; if, however,
this adhesion is extensive, it is better, quicker and safer to remove
sac and omentum together. To do this it is necessary to get at the
omentum as it comes through the umbilical aperture and to see
that there is no portion of intestine imbedded or mixed up with the
part to be removed. Small intestine can usually be easily reduced ;
it is the large which more often gives trouble by its omental
adhesions. The ligature and removal of the omentum demands all
the cautions given already in the description of the operation for
Inguinal Hernia. Sometimes not only is it adherent to the interior
of the sac, but all round the abdominal aspect of the umbilical
aperture. The sac being cleared of its contents is removed by
careful dissection right down to the abdominal aponeurosis ; its neck
should then be closed, if the aperture is large, by definite catgut
suture, if small by ligature. The aponeurotic margins of the opening
into the abdomen must now be dealt with, and it is held by some sur-
geons that a better result is given by teasing out the rectus muscle on
each side, cutting through the edge of the aponeurosis horizontally to
effect this. This is not nearly so easy a proceeding as it sounds.
If, however, it is possible to do it and to suture the two layers of the
aponeurosis and the muscle between them in three separate layers,
or by overlapping layers, a better and more permanent closure will
Umbilical Hernia. 513
be effected than by simply bringing together the aponeurotic edges
of the opening. If the latter is very small it maybe closed by silkworm
gut. In using this suture it is necessary to cut the knots short,
to leave as far as possible no projecting ends, and not at any time
to use it as a subcutaneous suture. The skin wound, any redun-
dancy bej[ng removed, can be united in the ordinary way and the
ordinary dressings applied.
The operation, when there is any adherent bowel or adherent
omentum, is often difficult and may be dangerous. The separation
of such adherent bowel may take time and cause shock in subjects
who can ill bear it. When the hernia is strangulated, and when, in
consequence, the condition of the bowel is seriously modified for the
worse, when, too, there may be septic discharges in the sac, the opera-
tion becomes one of the most dangerous in surgery. It requires in
the separation of bowel the utmost gentleness, and may well test
the experience and skill of the operator in forming a correct judg-
ment as to how a damaged bowel is to be most efficiently and safely
treated.
Mayo's operation is one of the best and most complete. A trans-
verse elliptical incision exposes the aponeurosis for 2 or 3 inches
around the hernial aperture. The fibrous and peritoneal coverings
are divided all round the neck of the rupture. The contents of the
sac are examined, any adherent intestine dealt with, and omentum
ligatured at the hernial orifice. The sac, adherent coverings and
omental contents are removed in one mass. The margins of the
hernial orifice are easily approximated by traction above'and below
on its edges. The aponeurosis ring may be widened by two incisions
1 inch or more outwards from the lateral poles. The peritoneum
being separated from the deep surface of upper flap, the lower flap is
drawn up behind and secured by mattress sutures, and at the edges
also. The peritoneum itself is closed by continuous suture.
The implantation of silver wire netting or filigree may, from its
presence as a foreign body, involve suppuration, sinus formation,
and perhaps a further weakening of an already weak abdominal
wall.
In the after-treatment, looking to the class of patient usually
affected, the sitting posture is to be recommended. Anything like
abdominal distension must, as far as possible, be combated, as such
distension adds seriously and mechanically to heart and lung
trouble already existing. Shock must be treated by warmth,
stimulants, strychnine and the subcutaneous or intra-rectal injec-
tion of saline solution ; flatulence" by the rectal tube and turpentine
enemata.
S.T. VOL. II. 33
514 Rare Forms of Hernia.
After a successful operation it is well that the patient should, as
a precaution against recurrence, wear an umbilical or abdominal
belt.
THE RARER FORMS OF HERNIA.
Obturator Hernia. The operation for this variety^ is more
often one for intestinal obstruction by an abdominal incision than
a deliberate operation on the thigh. Both of the cases the writer
has had to deal with were regarded as intra-abdominal obstruction,
and were relieved by pulling the involved bowel out of the obturator
foramen from the abdominal surface. It may, however, happen
that an obturator hernia can be definitely diagnosed as forming a
swelling in the upper part of the thigh, and can be felt close to the
origin of the adductor longus muscle. Direct operation would mean
the exposure of the sac passing out to the inner side, as a rule, of
the obturator vessels and nerve under the pectineus and superficial
to the obturator externus. The hernia reduced, the sac should be
invaginated, removed, and the ring closed. If strangulation should
be present, the incision to relieve this should avoid the vessels and
nerve, and should be made downwards and inwards rather than
outwards. Some form of truss would be indicated after such an
operation.
Gluteal and Sciatic Herniae. These present in the buttock
passing out of the pelvis either above or below the pyriformis
muscle, sometimes attaining a large size with the ordinary symptoms
of hernia. The operation to attempt cure would involve cutting
down over the upper part of the swelling, reduction of its contents,
removal of the sac, ligature of its neck, and the suturing of the
aperture out of which it had passed, taking, it is needless to say,
care not to interfere with the sciatic nerves or any of the important
vascular or nervous structures in the neighbourhood.
If small and strangulated, the condition, as in strangulated
obturator hernia, might easily be overlooked, and only revealed by
a laparotomy for intestinal obstruction.
Ventral Hernia. This variety when acquired usually follows
operations on the abdominal walls, and should be guarded against
by the surgeon, suturing peritoneum to peritoneum, aponeurosis to
aponeurosis, and skin to skin. If this form of suture is used,
hernia will be less frequent than when all the layers are included in
one suture. When ventral hernia is spontaneous it is found at the
points of junction and splitting of the aponeurosis, the lineaalba,
or much more rarely the linea semilunaris.
Some modification of Mayo's operation, described under the
Obstructed Hernia. 515
heading of Umbilical Hernia, is indicated when the hernia gives real
trouble and annoyance, the less severe varieties may be disregarded,
or require truss or belt treatment.
The exposure and removal of the protruding peritoneum may be
a difficult matter, and not devoid of danger, if there is not only
protrusion, but also adhesion of the bowel. The bringing together
and union of the aponeurotic edges of the hernial opening by suture
may be practically impossible. Such cases may be suitable for the
implantation of silver wire netting or filigree.
Lumbar Hernia very rarely requires treatment, and whether
traumatic, i.e., occurring at an operation or abscess scar, or spon-
taneous, i.e., occurring at Petit's triangle, will demand truss or
operation, according to the inconvenience it causes.
Diaphragmatic Hernia, when due to congenital defect, very
rarely calls for treatment, as, when present, its existence is over-
looked until revealed at a post-mortem examination.
When acquired and strangulated, if diagnosed, an early
laparotomy might save the patient.
Perineal Hernia, due to protrusion of the recto-vesical pouch of
peritoneum, may show itself as a perineal or even an ischio-rectal
swelling. Reduction of the hernial contents and removal of the
protruding sac may be tried if the inconvenience is sufficient to
justify operation.
Vaginal Hernia is probably best treated by the wearing of a
supporting pessary.
INFLAMED HERNIA.
The condition of inflammation of a hernia is nearly always
caused by an ill-fitting truss, external injury or forcible taxis, and
requires, as a rule, little more than warm boracic fomentations.
If later there should be signs of suppuration, incision is indicated,
and it may be necessary in rare cases to open the sac, to evacuate pus
or the fluid of a tense " hydrocele of the sac." Strangulation, if
neglected, leads to inflammation of the hernia, requiring prompt
immediate operation. In out-of-the-way cases it may happen that
tubercle or some other growth causes a chronic inflammation of
the hernial sac.
Umbilical and femoral herniae are more often inflamed than
inguinal.
OBSTRUCTED HERNIA.
Differing as it does from strangulation in causing little if any
collapse, little if any vomiting, little if any tenderness, with a
332
516 Strangulated Hernia.
constipation that may not be complete, the hernia still possessing
an impulse on coughing although it is irreducible, being a swelling
larger than usual, but which perhaps lacks the tension and the
suddenness of onset of strangulation, obstructed hernia can be
dealt with more vigorously and with less fear than a strangulated
one ; in other words, taxis may be employed, enemata and even
purgatives given, and operation, although in the writer's opinion
indicated, is not of such urgent necessity as in the more grave
conditions when the vascular circulation through the bowel is also
stopped. In cases, then, of old people, perhaps fat with fatty
hearts, bad subjects for a general anaesthetic, where the hernia is
umbilical, it may be advisable to delay, and, if posssible, put off
altogether operation. In the young, healthy, vigorous, and those
desiring to lead an active life, obstruction- should be met by
operation, and may be a blessing in disguise in inducing the patient,
who otherwise would not have thought of it, to submit to radical cure.
The amelioration of chronically obstructed inguinal hernia may
occasionally be assisted by the elevation of the lower part of the
patient's bed, and matutinal purgation with gentian and magnesia
mixture.
STRANGULATED HERNIA.
The treatment of a strangulated hernia should be nearly always
by immediate operation. The only other treatment is by taxis, and
taxis is sp of ten dangerous, so often unsuccessful, that its employment
should be reserved for selected cases. Much injury has in the past
been done by indiscriminate taxis. The bowel may be bruised, may
be lacerated, may be burst, the mesentery may be torn, the
superficial coverings of the hernia may be bruised, damaged and
become inflamed; the whole hernia may be reduced en masse,
the septic contents of the hernia sac may be returned into a
peritoneal cavity as yet uninflamed, and may perhaps produce a
general septic fatal peritonitis. Again, too, a gangrenous or
permanently damaged bowel, incapable of renewing its functions,
may by taxis be most unfortunately reduced into the abdomen.
The writer has never met with such a case when actual gangrene
was present, and is of opinion that, if the constriction has been so
severe and so prolonged as to have caused this condition, taxis could
hardly procure reduction without causing a rupture of the friable
gangrenous intestine.
The return of a seriously damaged bowel not yet absolutely
gangrenous is a very dangerous thing, and is said to account for
more than half the deaths after herniotomy.
Strangulated Hernia. 517
Operation by opening the sac, which in the writer's opinion
should always be done, enables the exact condition of the strangu-
lated parts to be observed, the nipped portion of the bowel or
omentuni to be investigated, the septic contents of the sac to be
got rid of, the constricting bands to be divided, and usually a
radical cure of the hernia to be effected. Against immediate
operation it may be urged that the dangers of a general anaesthetic
are sometimes real to a patient collapsed, aged or perhaps organically
diseased ; that the division of the constriction (e.g., femoral hernia
where Gimbernat's ligament is divided) may leave the patient, if he
recovers, a much larger aperture of exit from the abdomen outwards.
Local anaesthesia may in certain rare cases be advisable ; modern
surgery, by the use of intra-spinal injection of stovaine or eucaine
locally, can do much in this way that formerly was impossible.
The dangers of sepsis and subsequent septic implication of the
peritoneum have again, too, been urged against operation ; but, on
the whole, looking at the undoubted dangers of taxis, of the
frequency when it is inadmissible, it is far better to make it a rule
to operate on strangulated hernia than to treat it in any other way.
Taxis is inadmissible when the bowel has been strangulated for any
length of time, and when consequently its resisting power is uncer-
tain, when it may be gangrenous or ulcerated at the seat of stricture,
or when there already is swelling, redness, oedema or other signs of
local inflammation present. If, too, the collapse of the patient is
great, operation should be performed without previous taxis. The
method of applying taxis when admissible, or if the patient or his
friends refuse operation, is to relax, as far as possible, the tension
of the rings ; in inguinal hernia to flex the leg on the thigh, the
thigh on the abdomen and to rotate the limb inwards, and then to
apply pressure in the proper direction, that is to say, towards the
internal opening of the hernial canal. The extent of that pressure
and the method of applying it must be left to the discretion,
judgment and experience of the surgeon. If the hernia should
suddenly disappear under such pressure without the usual
characteristic snap or gurgle of returning bowel, the surgeon must
remember the possibility of reduction en masse, or even of rupture
of the strangulated bowel. Either of these unfortunate and
lamentable accidents would imperatively demand, at all costs, an
immediate operation. There is no doubt in the writer's opinion
that the more or less old-fashioned treatment of strangulation by
the local application of an ice-bag does most undoubtedly facilitate
reduction of the hernia. Alternative local treatment occasionally
runs to the other extreme of hot fomentations with those who hold
518 Strangulated Hernia.
that cold is likely to increase still further the chance of gangrene in
the sorely tried howel.
When operation is decided upon, if the patient's condition allow
of it, a general is better than a local anaesthetic ; all the usual
precautions against shock must be taken, and the parts to be
operated on properly sterilised, but no time should be wasted,
especially when the hernia is a femoral one, in an attempt to attain
the ideal if this means anything like serious delay.
The superficial incision will vary according to the site of the
strangulation, but in all cases it should be free and of such size
that the deeper structures can subsequently be exposed without
difficulty. The sac must be defined and in all cases opened. It
frequently will contain some fluid, and this more than colour or
arborescent vessels will favour its recognition.
This fluid in the sac of the strangulated hernia may be serous,
blood-stained, more or less purulent, or muddy and offensive when
gangrene has occurred. Omentum may be merely inflamed,
congested or gangrenous. The bowel at first is lustrous, soon
becomes plum-coloured from congestion, later even being black
from extravasation of blood in its coats, yet still retaining its
lustre ; when passing into a state of gangrene the lustre is lost,
the colour is either an ashen grey or black. The best treatment of
omentum, inflamed, congested or gangrenous, is removal, ligaturing
it with all the precautions against subsequent infra-abdominal
haemorrhage previously mentioned. Should any bleeding occur
from the omentum after it has been returned into the abdomen, it
must be immediately dealt with by extension upwards of the hernia
wound, or even a deliberate laparotorny. Fatal bleeding from this
cause has before now occurred. The bowel, if obviously lustrous
and plum-coloured, may be safely returned ; so, too, if still
lustrous, its colour is black or nearly so, when this is due only to
extravasated blood. There are cases when it is difficult to say
whether the discoloration of the imprisoned bowel is due to blood
or to commencing mortification ; perhaps it is well to give it the
benefit of the doubt and to return it into the abdomen, leaving it
with a drainage tube which will, if necessary, carry away any
subsequent extravasation of bowel contents.
When the lustre is lost and the bowel obviously gangrenous,
several courses are open to the surgeon. He may open the bowel
and leave it in situ ; this is easy to do, but not always an efficient
way of treating a bowel paralysed and unable by its own peristaltic
movements to pass its contents out of the artificial anus or faecal
fistula so made. Another method is removal of the gangrenous
Strangulated Hernia. 519
portion and suture of the bowel to the wound, the deliberate
making of an artificial anus. This, if the patient recovers, may
well be found very difficult to close. The best, but at the same
time a proceeding attended with some considerable risk to a
collapsed patient the subject of gangrene, is to excise the gangre-
nous parts and suture the ends of the bowel together. This
anastomosis is difficult to perform, the bowel coats in the neighbour-
hood being inflamed and soft, and the ends of the gut perhaps of
unequal size. A comparatively large portion of bowel may require
excision before healthy ends can be approximated. In some cases
as much as 6 feet have been excised. Some surgeons recommend
an end-to-end, some a lateral, anastomosis ; some are for doing this
operation in the hernial wound, others would do a deliberate
laparotomy to effect their purpose.
If the patch of gangrene is but small, it may possibly be invagi-
nated by a Lembert suture of the neighbouring walls over the spot
of mortification.
In all cases of strangulated hernia it is as well to see the seat of
constriction, otherwise a minute perforation may be overlooked,
and a bowel so damaged passed back to infect the peritoneal
cavity. Dragging down the intestine for the purpose of this
inspection must be performed with extreme care and gentleness,
so that impending rupture or perforation shall not be completed
by the surgeon.
Another essential after reduction is to pass the finger along the
hernial canal into the abdomen to make sure that everything has
been returned. This might also enable the operator to detect some
hitherto undiscovered seat of obstruction apart and away from the
hernial sac. In a case of strangulated umbilical hernia under the
writer's care, a piece of intra-abdominal gangrenous intestine,
strangulated by an omental band, was in this way detected.
After-treatment. The after-treatment of cases of strangulated
hernia should be directed to the avoidance and treatment of shock.
Warm 'clothing, a warm operating table, and a warm bed are here
obviously indicated. The bed should be previously warmed by hot-
water bottles, and care must be taken that the unconscious patient
is not accidentally burned by having them put too close. It is well,
in fact, not to use them after he is once back in bed. Strychnine
subcutaneously, stimulants, saline rectal injections may be required,
or even the subcutaneous injection of saline in the tissues of the
thorax or other appropriate place. Warm subcutaneous saline
injection may be given continuously. Opium, the pre-operation
curse, may, in rare cases, when there is nothing to contradict it,
520 Strangulated Hernia.
be the post-operation blessing, but usually is not indicated. The
bowels should be left religiously alone even for four or five days
or longer ; nature should be given time to effect the restoration of
function of the damaged intestine. In some cases, which may have
gone on to the so-called f feculent vomiting, it is well, while the
patient is still on the operating-table, to wash out the foul contents
of the stomach. Vomiting of this material while the patient is
under the anaesthetic is dangerous, and before now has led to
death on the table from the vomit having entered the air passages.
A semi-recumbent or sitting posture will often allow an old
person with a tendency to bronchitis, or with laboured action of
the heart from flatulent distension, to overcome these very real
obstacles to recovery. Food may have to be administered at first
by means of nutrient enemata, but as soon as possible the feeding
should be in small quantities by the mouth. The amount of sick-
ness will determine to a large extent the method by which nutri-
ment can be given. The vomiting that follows an anaesthetic must
not be confused with the persistence of vomiting due to the effects
of the strangulation. The bowel, although released from its
imprisonment, may still by its paralysis offer a mechanical obstacle
to the flow of intestinal contents ; time alone can here do good.
Vomiting, too, may continue from some other source of intestinal
obstruction, or even from such an accidental or overlooked cause,
such as pregnancy.
It should be definitely ascertained that there is no second obstruc-
tion; if there is it must at once be suitably dealt with by operation.
The possibility of re- strangulation should not be overlooked.
The causes of Strangulated Hernia not doing well after
operation are many. Apart from collapse immediately afterwards,
death may occur from sepsis, peritonitis, or lung complications, such
as bronchitis or pneumonia. The damaged bowel itself may be
acutely inflamed (enteritis), may be paralysed or become the seat
of stricture. Adhesions may form in its neighbourhood, giving
rise to internal strangulation by kinking of the bowel or by an
omental band.
The bowel may be reduced en masse, and this, whether the
sac is multilocular or not.
Treatment of the condition of persisting intestinal obstruction,
which must not be confused with the somewhat similar symptoms
of simple peritonitis, is to find out its cause and locality, and not to
hesitate to perform a necessary laparotomy when thorough examina-
tion of all the rings show them to be patent and the seat of the
trouble to be elsewhere.
Strangulated Hernia. 521
Strangulated Inguinal Hernia. The operation for this condi-
tion in the initial steps is exactly the same as in the operation for
radical cure. The sac is exposed and opened. The constricting
point is usually found to be a circular fibrous ring in the neck of the
sac, sometimes a .structure outside it. In its division upwards the
relation of the epigastric artery should be remembered ; but the
danger of wounding this in an open operation when the external
oblique is slit up, all structures divided down to the sac, and the sac
alone is being dealt with, is infinitesimal.
The reduction of the intestine may present some mechanical diffi-
culty in large herniae, especially if the coils are distended with flatus,
and part of it before strangulation has been irreducible. Adhesions
of omentum and bowel to sac or-to each other must be separated,
and the sac during reduction of its contents must be kept tense and
not allowed to fall into folds. The surgeon should first reduce the
part nearest to the ring, unravelling the coils of intestine and
passing it back bit by bit. If one end of the bowel cannot be
made to move, attention should be paid to the other end, and any
redundant blocking omentum should be removed. To facilitate
reduction the rings should be relaxed by flexing the thigh on pelvis
and rotating it inwards. The exposed intestine should be kept
warm and covered by gauze or warm sterile sponges. Excessive
flatulent distension may require puncture of the bowel with a very
fine trocar ; after the relief thus afforded, a Lembert stitch or two
should be inserted to close safely the minute opening thus made into
the gut. Extreme care must be taken that nothing exuding from
the puncture is allo\ved to soil the sac or its contents.
The different varieties of inguinal hernia, except the interstitial,
the different shapes of the sac, e.g., hour-glass, present no diffi-
culty if only the parts are thoroughly exposed. Small incisions, not
involving the external oblique, and deep divings with hernia knives to
divide tense constricting bands of doubtful structure in interesting
anatomical neighbourhoods are as dangerous now as they were in
the past.
A deliberate open operation as for radical cure with the inguinal
canal fully exposed right up to the internal abdominal ring leaves
nothing of doubt and very little of difficulty.
After the strangulation has been rectified the radical cure is
proceeded with. The whole operation for strangulation in an
ordinary case takes very little longer than an ordinary radical cure,
but grave conditions of the bowel, such as gangrene involving
excision or other radical treatment, may very materially prolong the
duration of the operation and be accompanied by shock and collapse.
522 Strangulated Hernia.
The bowel in strangulated inguinal hernia is not, however, usually so
severely nipped as in the femoral variety where it is pressed against
the sharp edge of Gimbernat's ligament.
Strangulated Femoral Hernia. A strangulated femoral hernia,
if neglected, is a very serious matter, as the parts are tightly nipped
at Gimbernat's ligament. The bowel is soon seriously damaged,
gangrene or ulceration at the seat of stricture not uncommon,
the mesentery, too, may become thrombosed, with no pulsation of
its arteries. A loop of bowel with a thrombosed mesentery must
not be returned into the abdominal cavity, but resected as if it
were already gangrenous. There has been much discussion as to
whether it is safe or useful to divide the constriction if the intestine
is unfit to return ; some advocate the opening of the injured bowel
and the passing of a drainage tube into the interior of the distended
bowel above the constriction. Recovery after this method of treat-
ment has occurred in only 10 per cent., so, perhaps, resection,
even when it is to be extensive, i.e., some feet, is to be preferred.
The sac of a strangulated femoral hernia is often difficult to
define. Concentric layers of fat and tissues containing oedematous
fluid add to the difficulty. The sac itself, when bowel is the sole
occupant, may be adherent to its contents and its opening a matter
of difficulty and danger. If the intestine should be accidentally
wounded, the opening should be closed by a Lembert's suture, if
the general condition of the gut allows of this ; if not, re-section or
the making of an artificial anus may be indicated.
The constriction at the femoral ring must be divided inwards, or
upwards and inwards, cutting into Gimbernat's ligament. This
must be done on a director by a hernia knife, and care must be
taken to see that there is no overlapping of the bowel while it is
done. The nick should not be excessive, but it is no good attempt-
ing to reduce a damaged bowel through an opening insufficiently
enlarged. A too-careful, inexperienced operator, fearful of an
abnormal obturator artery, may easily waste valuable time in
attempts at a reduction of bowel which is mechanically impossible.
Too free a division of Gimbernat's ligament may favour recurrence
of the hernia ; but if the operation for strangulation is followed by
one of the methods of radical cure, as it should be, this is much less
likely than formerly. If by any unfortunate chance the obturator
artery is in the way and is wounded, the immediate haemorrhage
may be checked by pressure or clip pressure, the parts then freely
exposed and the divided vessel duly ligatured. If the haemorrhage
should, as sometimes happens, not immediately follow the injury,
the treatment when it does occur must be on the same lines.
Palliative Treatment of Hernia. 523
It is quite possible that a fairly free division of the abdominal
aponeurosis may be required to allow of the ligature of the bleeding
vessel.
It was suggested years ago that strangulated hernia should be
treated by laparotomy, and the strangulated parts pulled back into
the abdominal cavity. This would not allow of a radical cure being
performed, future hernia would not be prevented, adhesions of sac
contents to sac might make the proceeding impossible, and any
seriously damaged intestine might readily give way when pulled upon.
Strangulated Umbilical Hernia. It is sometimes difficult in
an old irreducible umbilical hernia to say whether it is strangulated
or merely obstructed. The urgency and gravity of the symptoms,
both local and general, will have to determine this question, so
important both to surgeon and patient. The un suitability of the
latter for a grave operation may well make the former unwilling to
undertake it when there is any doubt as to its absolute necessity.
The seat of strangulation, so often within a sac, with many
recesses, by-paths, and cul-de-sacs made up of omental and bowel
adhesions, may be difficult to find, and its rectification- involves much
handling and separation of adherent inflamed intestine.
In cases where the strangulation is one of recently descended
bowel only, no such difficulties may be encountered, but when a
small knuckle of strangulated intestine is tucked away in some
remote corner t>f a complicated sac containing old adherent intestine
and old sacculated ornentum its relief may be no easy matter. It
/ /
should be a rule of the operating surgeon to expose freely the parts,
so that he can see exactly what he is doing and how to do it. He
must take the ordinary precautions to prevent chill of exposed intes-
tine and avoid pulling and tearing at adhesions as much as possible.
If the condition of the patient allow of it, and all the hernial
contents can be reduced, a radical cure should be performed, but in
any bad case this may be impossible.
PALLIATIVE TREATMENT OF HERNIA.
Palliative treatment is treatment by trusses and belts. A truss
is a belt containing a stout spring encircling the body, fitted with a
pad by means of which the force of the spring is applied over the
internal ring and hernial canal. The pad is usually made of cork and
covered with chamois leather, and the spiral spring is also covered
with leather or some other suitable material. It may be necessary
to measure for a truss. In doing so the measuring tape passing
over the base of the sacrum should be brought midway between the
upper border of the great trochanter and the crest of the ilium
524 Palliative Treatment of Hernia.
round to the middle line above the symphysis pubis. The size of
the truss is measured by the number of inches thus traversed. In
fat people allowance must be made for their obesity in fitting the
pad of the truss, which must not rest on the pubic bone ; neither
must it press too lightly or too heavily. It is supposed by some
that atrophy of the abdominal wall or even enlargement of the
hernial ring may be caused by excessive pressure.
The double truss is easier to apply and keep applied than is the
single one. Looking to the natural weakness of both sides, even
when hernia has actually shown itself only on the one, a good
many surgeons recommend a double truss as being more efficient
than a unilateral one, especially as it can often be worn without
under straps.
When fitted, the truss pressure and support should be present in
all positions and movements of the body.
Certain forms of trusses are used for protection rather than
repression of irreducible hernial contents, and are called bag
trusses. Occasionally it may be necessary to prolong the pad
downwards in what is known as a rat-tail truss. Abdominal belts
are required for ventral and umbilical hernias ; they may when
necessary be combined with stays. Vulcanite or other waterproof
material may be used for trusses worn whilst bathing, or in children
or old people likely to soil them with urine.
Trusses of the spiral spring variety usually encircle the body on
the same side as the hernia, but in some varieties an opposite side
truss will give a better result.
A femoral truss is more irksome than is an inguinal one, and
in some cases of difficulty the pad may have to be incorporated in
a belt going round the upper part of the thigh.
It should be remembered that the wearing of a truss is not only
often a matter of inconvenience, but in the uneducated and ignorant
classes sometimes a positive danger, insomuch as they are
frequently put on over a descended hernia. It has already been
pointed out that this is frequently the cause of adhesions, and may
even induce obstruction or aggravate strangulation. It should be
a rule that a truss is put on when the patient is in the recumbent
position, and should be taken off after the patient is lying down in
bed at night. If any of the hernia is down it should not be worn.
If there is any redness, inflammation or excoriation of the skin,
this must be treated before any further truss pressure is allowed.
If a gland should enlarge and threaten suppuration, truss wearing
must be at once discontinued and rigid rest in bed be enforced. If
truss abscess should unhappily occur, the truss must not be again
Palliative Treatment of Hernia. 525
worn until the parts after operation are thoroughly healed. The
skin under the truss should be prepared for pressure by the local
application of spirit lotions to harden it, and in warm weather by
powders, such as starch, boracic acid, and oxide of zinc in equal
parts, to obviate the effects of perspiration.
The skin should be protected from direct pressure of the truss-pad
by a piece of silk ; a portion of an old silk-handkerchief does very
well for this. The efficiency of the truss when it is on should be
tested by making the patient forcibly cough while the rings are
relaxed by a bent position of the knees, hips and body. If there is
no descent of the hernia under these conditions, the truss is probably
efficient. The pressure should not be so hard as to be painful in
any way, nor so little as to allow any protrusion. The truss-pad
itself should be accurately applied over the internal ring, and if
there is any great difficulty in fitting the patient a plaster cast of
the parts may be taken and a truss "built " to fit them accurately.
The direction of the pressure naturally varies according to the
existing hernia.
In very young children femoral hernia is rarely seen, and
consequently femoral trusses are not required except for adults.
Some yielding at the umbilicus or definite small umbilical hernia is
common in infants, and requires a pad larger than the aperture
and pressure made either by a truss or strapping. As the child
grows the umbilical aperture is relatively smaller, and slight degrees
of hernia undergo spontaneous cure or leave but " a windy navel."
A carefully applied spica bandage with a pad over the inguinal
canal may be sufficient support for some children's hernia. The
latter should never be allowed to descend, especial care being taken
when the child is washed to keep good firm pressure with the finger
or vulcanite or indiarubber truss on the weak abdominal wall. An
intelligent mother or nurse can do much in this way. A good
digestion leading to a placid temperament and absence of crying or
screaming will be valuable aids. Such good digestion and placidity
is more often seen in breast-fed infants than in others less naturally
reared. No truss will cure a child when causes of straining, such as
constipation or phimosis hindering proper micturition, are left
unattended to.
A certain number of children treated by trusses appear to "grow
out " of the inguinal hernia of infancy. It may be that in some
the truss pressure and irritation causes peritoneal adhesion and
closure of the processal vaginalis at a later period than the normal,
but a large number remain, even if not the subjects of actual
hernia, potential sufferers from the malady in after life.
526
Palliative Treatment of Hernia.
" Rupture," which suggests the breaking of something, is a most
misleading term. When an adult becomes " ruptured " it is nearly
always (if not always) because, being the subject of a developmental
defect, his hernia has come down on some slight provocation or
strain into a previously existing but unused sac. A lack of muscular
and aponeurotic development in the groins and about the recti and a
protrusion of the median abdomen are frequent concomitants or
forerunners of actual hernia. The latter should be guarded against
by a belt or preventive bi-lateral truss. Thishernial predisposition,
almost diathesis* cannot be cured, but may in this manner be
obviated. Protective bag trusses are but poor things, and do little
in the way of protection ; when a hernia requires a rat-tail truss, it is
a difficult one to treat efficiently save by operation.
The pads of some trusses are made of horseshoe shape to avoid
pressure on such a structure as an undescended testis. They may
be difficult to put and keep on properly, and cases where they are
used cry aloud for operation.
A truss may be recommended for very young children both for
inguinal or umbilical hernia until such time as either the hernia has
been cured or the child is ripe for operation ; also for old people
not fit subjects for operation, on account of cardiac or lung com-
plications, or other visceral disease, and after operation in certain
cases, especially bad cases of femoral or umbilical hernia ; the
latter usually requires an abdominal belt. A truss should rarely be
wanted after operation for inguinal hernia, except in very voluminous
ones where the chief object of the operation has been to enable a
truss to be worn rather than a real radical cure, or in cases of
interstitial hernia not fit for operation. A large interstitial pad
is then required.
After operations for recurrence a truss may be advisable, but it
will depend much on how the first operation has been performed
and what was the cause of the recurrence.
Single truss for inguinal hernia.
Single truss for femoral hernia.
Palliative Treatment of Hernia.
527
Child's double truss for
inguinal hernia.
^^"^^^r
Child's umbilical belt.
Umbilical truss.
Salmon and Ody's truss for
inguinal hernia.
Abdominal belt for
umbilical hernia.
Truss for irreducible hernia.
G. R. TURNER.
528
INTESTINAL OBSTRUCTION.
THERE is no need, for the purpose of this article, to enter with
any minuteness into the pathology of the various causes that lead
to acute intestinal obstruction. For the most part they are due
to an antecedent, and usually to a localised, peritonitis. Bands of
lymph glue adjacent coils of intestines together, or anchor them to
the abdominal wall or the viscera. With the movement of the in-
testine these bands may stretch and form string-like bands, leading
to constriction by pressure, kinks, internal hernias, twists or other
causes of obstruction. If left alone the patient usually dies in about
a week or ten days. Successful treatment depends essentially on
early recognition and early operation. The cases are really simple
for the trouble is purely mechanical in its inception, and it must
therefore be relieved by mechanical means. It is necessary to re-'
state even so bald a surgical truism. Far too often early recognition
is not immediately followed by operative treatment. The patient
dies, simply because the medical man has not the courage of his
opinions. To wait for the text-book symptoms is to wait until there
may be no doubt ; but little hope either. To postpone operation, for
instance, until faecal vomiting has commenced is to procrastinate
until the effects of a general anaesthetic are ill-borne, until operative
difficulties are immensely increased, and until secondary com-
plications, such as distension, paralysis or even gangrene of the
intestine and toxaemia have set in and the prospects of recovery
have melted away owing to pusillanimous indecision. It is a sound
maxim that faecal vomiting is a symptom which ought never to be
seen at all ; it is little less disastrous to wait until visible peristalsis
is evident and distension has commenced.
A patient with a strangulated external hernia is usually submitted
to operation promptly enough, while a patient with an internal hernia
or practically similar obstruction is too frequently left unrelieved
until his case is hopeless. Yet the operation for an internal hernia
is almost as simple a proceeding in the early stages, while the effects
of neglecting to deal with it are far more disastrous. In dealing
with an external hernia, the sac and its cellular tissue investments,
loaded with toxic products, can be cut away. This is, of course,
impossible with an internal hernia, save, occasionally, when omentum
is involved. Poisoning is localised in the one case and not in the
Intestinal Obstruction. 529
other, and yet the graver ease is the one that is often more tardily
dealt with. The fact that there is no palpable visible tumour in the
one instance while it is present in the other ought to make no
difference. A patient who gives a history of a previous attack of
appendicitis or perimetritis, and is sei/ed with a sudden severe
abdominal pain, perhaps recurring three or four times with regular
intermission during the first few hours, and then subsiding into
a condition of comparative comfort, is just the person whose
condition imperatively cries out for operation. This quiescent
interval, more or less well defined, almost invariably occurs, just as
happens in the case of a perforated gastric or duodenal ulcer. Often
the patient vomits but once or twice only before the quiet stage sets
in. Unless the diagnosis is wholly at fault, the symptoms are
absolutely certain to recur. And when they do recur the patient's
chance, in any case doubtful, has been reduced by more than
50 per cent. It is during this period of calm that the surgeon of
any experience sees his best opportunity. He acts and wins, hold-
ing, if he is weak enough to take the point into account, that he
risks his reputation less by action than by delay. The inex-
perienced or timid man, buoyed up by a hope he does not really
feel, waits, and loses ; his failure conceivably mitigated by the tragic
irony of a newspaper paragraph to the effect that " a successful
operation was performed, but the patient died a few hours later."
When symptoms of the kind have occurred and the patient is seen
within the first twenty-four hours, the prospect of recovery is good,
and the operation if undertaken at once is easy and short. Even if
the diagnosis is wholly wrong and the operation results merely in a
profitless exploration, every surgeon of experience will agree that,
when there is any such history as described above, operative
measures are not only justifiable but imperative.
Broadly speaking, in the absence of any positive indication as to
the site of the obstruction, the best point to make for is over the line
of the right sacro-iliac joint. Local pain and tenderness are often
misleading symptoms. The vertical interval between two horizontal
lines, drawn across the abdomen at the level of the highest point of
the crests of the ilium and the anterior superior spines respectively,
indicates roughly the extent of this joint ; a line drawn directly
upwards through the middle of Poupart's ligament corresponds to the
distance at which the joint lies from the middle line. The best incision
is through the right rectus muscle, an inch from the middle line.
Incision through the semi-lunar line allows less ready access to the
other side of the abdominal cavity, and if at all extensive the nerves
supplying the muscle are necessarily divided. The various forms of
S.T. VOL. ii. 34
530 Intestinal Obstruction.
mechanical ileus occur more frequently on the right side, owing, no
doubt, to their being so frequently the result of appendicitis. The
incision can be prolonged readily up towards the gall-bladder, or down
so as to give access to the pelvis, with the least damage to the abdominal
wall or risk of subsequent ventral hernia. In cutting through the
abdominal wall notice should be taken of the condition of the
cellular tissue in the inter-muscular spaces ; if there is any
oedema there is likely to be pus within the abdominal cavity. The
wound will be more satisfactorily closed subsequently, if in the
lower half of the abdomen, if the transversalis fascia and the
peritoneum are divided together. When the intestine is at all
distended it lies in very close apposition to the peritoneum, and in the
case of children it must be remembered that the peritoneum is so
thin that it may be opened before it is recognised. The peritoneal
cavity being open, search for the obstruction must be carried out
on methodical lines. Rapidity is of the first importance, and a
prolonged search conducted in a haphazard way is very prejudicial.
As soon as the abdomen is open the finger is passed in towards the
right sacro-iliac joint. Whatever the form of obstruction, it will
probably be recognisable by the fact that something abnormally
hard can be felt. The twist of a volvulus seems hard. An
internal hernia seems hard; just as a large impacted gall-stone
or other foreign body, or a malignant growth, or a twisted ovarian
cyst, would seem harder than natural. It may be mentioned here
that a twisted ovarian cyst will give rise to symptoms which
closely resemble those of acute intestinal obstruction. If nothing
definite can be felt, the omentum, if it presents, should be pushed
upwards and to the left. Distended intestines should be ignored
and gently kept back while search is made for a collapsed
portion of the gut. This can be often felt with great ease without
allowing any of the abdominal contents to extrude. The moment
that a portion of collapsed gut is found it should be traced methodi-
cally upwards to the site of the obstruction. If the obstruction
involves the small intestine high up, a considerable length may have
to be drawn out before the exact site of the trouble is discovered ;
but there is no difficulty in replacing collapsed gut, and if the oblique
attachment of the mesentery is remembered, the operator will not
fall into the error of tracing the intestine in the wrong direction.
As the collapsed gut is passed through the fingers it should be
replaced within the abdominal cavity. On arriving near the actual
site of the obstruction great gentleness must be used, particularly if
symptoms have been present for some time. If possible, the portions
of the gut actually involved in the obstruction should be drawn
Intestinal Obstruction. 531
outside the abdominal cavity, and there dealt with. Frequently,
however, this is impossible. It is best to have a fairly long in-
cision when the obstruction is deeply situated, in order to secure
free and rapid access to the seat of trouble. When this is once
exposed any portion of the w T ound that is really not required is
packed off.
Even when the administration of the anaesthetic, if general, is in
the most skilled hands, the patient is apt to strain violently at some
period of the operation. If this complication comes about it is best
to wait for a little, rather than run any risk of handling intestine
roughly. When, as is usually the case, the intestines are dis-
tended, difficulties begin as soon as the peritoneum has been divided.
The coils of inflated gut tend to protrude at once ; as the relief to
the embarrassed breathing allows the diaphragm to act with more
freedom and power loop after loop may be forced out, particularly
in children. When the small intestine is involved, puncture
at this stage of the operation is undesirable, for .it will relieve
the distension over only a short length ; the process of
unloading the contents, gaseous or other, is a slow one. Still,
in extreme cases, puncture may have to be performed. A stout,
double silk thread may be passed through all the layers of
the abdominal wall on either side of the wound. This allows of
great control. The abdominal wall can be drawn forwards or the
edges of the wound approximated with ease. The intestines cannot
be efficiently kept back by packing in rolls of gauze. The rolls ball
at once. Thin flat pads of gauze to which tapes are attached serve
better. Flat marine sponges answer best of all. At no stage of
the operation is the value of skilled assistance more pronounced.
In extreme cases all the distended gut has been allowed to extrude,
protected by warm sterile cloths soaked in saline solution. The
temporary convenience is dearly secured. The site of obstruction
may be exposed, but will often be still within the belly. The shock,
always considerable, is likely to be formidable. The abdominal con-
tents are chilled : paralysis of the gut is likely to supervene for a
time while the difficulty of replacing the coils leads to undue hand-
ling, and often to bruising or even tearing of the distended gut. Dry
intestine is much more easily damaged than moist, and if there is
much difficulty in keeping back the abdominal contents, irrigation
from time to time with saline solution will be advantageous. The
serous coat is less likely to be split, the gut will absorb some of the
fluid, and such manipulation as is absolutely necessary becomes
more easy and safe. Rubber gloves, if at all dry, will damage the
gut more than the uncovered hands. When the distension is
342
532 Intestinal Obstruction.
more or less limited to the large intestine, the difficulty is not so
great nor are the effects of exposure so serious.
The site of obstruction being revealed, prompt decision must be
taken as to the best method of dealing with it. Obvious bands may
be divided between two ligatures. It is safer to ligature bands
rather than to clamp them between two clip forceps before dividing,
for not infrequently the involved intestine, directly the drag is
relieved, disappears altogether out of sight, carrying the clamp with
it, and this involves drawing it back again before ligating. Long
stretched out bands are almost avascular, but it frequently happens
that what appears to be a simple strand of lymph is really a drawn
out funnel of intestine. Consequently the division of what appears
to be a band really wounds the gut. If the small opening is not
dealt with at once, leakage may take place after release. "When
the small intestine is adherent to the abdominal wall, fixed
and acutely flexed or kinked, this kind of slender, diverticulum-like
process of the intestine is particularly likely to be formed. It
is quite safe in these cases to ligature the drawn out process of
intestine. It is seldom necessary to formally suture. Care must
be taken, when the band is relieved, that the occluded portion of
intestine does not recede out of sight, for its condition must be
carefully investigated.
If there has been much pressure the damage to the constricted
portion of the intestine has to be dealt with exactly as in the
case of an external hernia. It must be remembered that
when a portion of the intestine is tightly constricted, the destruc-
tive changes begin first in the mucosa and sub-mucosa, and next
in the muscular coat, while the serous investment holds out
longest. A piece of intestine that has been constricted may there-
fore appear to be comparatively little damaged when it really,
at the site of the obstruction, consists of little more than a tube
composed of serous membrane. Subsequent sloughing is certain to
occur. The state of the gut can be judged by its translucency.
If the constriction has only been moderately tight, if the
circulation shows signs of returning at the constricted part
and the warmth comes back, the intestine may be left within the
belly as it is. But for a time there will be paresis of the gut, and
frequently it will be seen that, after the constriction has been
relieved, the contrast between the distended and collapsed intestine
is as marked as it was before the division of the band. Inasmuch
as paresis of the intestine is one of the most serious complications
that may prevent recovery after an operation otherwise successful,
it is essential to take every possible measure to obviate this grave
Intestinal Obstruction. 533
complication. By gently stroking the distended gut so as to press
its contents, gaseous and fluid, into the collapsed portion, much
good may be done. Sometimes a feeble movement of the collapsed
intestine can be seen to occur almost at once, a little gas passing
on in the proper direction. If so favourable a phenomenon takes
place the case may be regarded without any great anxiety. But
where the obstruction has existed for a considerable time it is
usually disastrous to limit the operation to the mere relief of the
obstruction. A loop of the distended intestine above the con-
striction may be drawn out and a small Paul's tube inserted.
As a rule drainage for a time is preferable to immediate puncture
and closure of the puncture wound.
It must be remembered in dealing with obstruction by bands
that these are frequently multiple. At the same time no undue
prolonged search for possible multiple sites of strangulation, should
be made. The risk of death from shock is very great, and often
has to outweigh the possible risk of leaving the operative measures
incomplete.
An iutt'rnul licrnia, in any of the multifarious forms in which
it may occur, such as through a hole in the mesentery or omentum,
or in connection with a Meckel's diverticulum, can be dealt with
exactly as an external hernia, though greater care may be necessary
in dealing with the constriction. It is generally safer to stretch
gently the constricting material than to cut it. The constricting
ring may contain large blood-vessels, and these being exsanguine
at the time may pass unrecognised. Here, again, the line at which
the intestine is most damaged must be very carefully investigated,
The temperature of the herniated portion of the gut may form
a guide as to its vitality. Gangrenous intestine will on very slight
exposure become cold and remain cold. Short loops of bowel may
become herniated into any of the small peritoneal fossae, and with
such cases it is difficult to deal satisfactorily, owing to their deep
situation. Very extensive internal hernia may take place through
the foramen of Winslow, and here, of course, the utmost care must
be taken in dealing with the cause of strangulation.
Volvulus usually affects the large intestine, and commonly occurs
about the sigmoid colon. The condition is characterised by rapid
and marked distension. Strangulation occurs early. The occluded
loop is likely to be distended. The only portion of the gut likely to
be collapsed is the pelvic colon, and even this condition need not be
found. The distension, however, causes the involved portion of
intestine to bulge forwards, and the altered colour, due to conges-
tion, leads easily to recognition of the site of the trouble. The
534 Intestinal Obstruction.
induration at the actual site of the twist can be easily felt. Puncture
of the distended and occluded loop will often assist materially in
rendering the condition plain and the operation easy. Care must,
of course, be taken that the affected coil is not mistaken for intestine
distended above a malignant stricture of the pelvic colon or rectum.
As a rule the loop can be untwisted and replaced in position with-
out any difficulty, for adhesions are unlikely to have formed. The
chief difficulty is to decide what further action is necessary after
relieving the twist. Everything depends upon the degree of torsion
and the condition of the bowel. Often, in cases of volvulus, the
condition has been present in a mild degree for some time, and the
acute symptoms supervene as a result of distension or a little
increase of the twist. It is stated that unless torsion is through
180 degrees occlusion is not likely to be complete. In the majority
of case* the safest proceeding after relieving the twist is to drain the
intestine above the lesion. Short-circuiting or other similar opera-
tions are formidable proceedings on a patient in a state of toxaemia,
and if practised immediately are likely to lead to a fatal result.
Resection for volvulus would usually entail excision of a long length
of large inte.stine and will not often be necessary, as the gut, though
it revives slowly, has remarkable powers of recovery when it is once
emptied. Resection is not likely to lead to any better result than
simple drainage and the formation of an artificial fistula. The fluid
which is usually found in the peritoneal cavity should be carefully
swabbed out, as it is in all probability highly toxic. Irrigation is
now generally considered undesirable, but a drainage tube can be
left in the peritoneal cavity.
Volvulus may affect any part of the large intestine, and sometimes,
though rarely, is met with at the caecum. Occasionally it occurs in
the small intestine. In such cases the condition is likely to be pro-
duced by peritoneal adhesions. In rare instances practically the
the whole of the small intestine is in a condition of volvulus, being
twisted over, as a rule, towards the left side. This again is com-
monly associated with old peritonitis, and not very infrequently
follows on the relief by operation of a band or kink. This condition
is necessarily fatal. Delay in operation is perhaps more disastrous
in cases of volvulus than in any other form of acute intestinal
obstruction, owing to the extensive cutting off of the blood supply
and the rapidity and extent of the distension. Even after a
mechanically successful operation the condition is apt to recur.
If the operation has been performed at a sufficiently early
stage, the relief of the mechanical cause of an acute intestinal
obstruction, whether single or multiple, is all that is needed.
Intestinal Obstruction. 535
But too often the operator has to deal with cases of obstruction
which have existed so long that grave complications have
supervened. Not only are the local changes grave, but the
general condition of the patient, owing to the toxic absorption,
or the establishment in a greater or less degree of a septic
peritonitis, is infinitely more serious. The general state of the
patient must determine how much or how little has to be done ;
whether temporary drainage of the intestine must be practised or
an operation for short-circuiting or total resection. If puncture
and drainage is the proceeding selected, a portion of distended
intestine, not too near the site of the obstruction, should be chosen.
If close to the obstruction, the gut is less healthy and more likely to
be drawn back through the wound as it collapses. Occasionally any
more extensive operation can be safely deferred, provided that the
involved intestine can be drawn out of the wound. The condition
is desperate, but sometimes there is no other course open. Atten-
tion should be centred on the general condition of the patient rather
than on the local trouble. When, however, any portion of deeply
fixed strangulated bowel is on the verge of sloughing, actually
gangrenous, or when any perforation, however minute, exists, simple
drainage must be disastrous. Short-circuiting operations are rarely
called for when the small intestine is involved, though they may be
practised with advantage when an acute has supervened on a
chronic obstruction, as so often happens in malignant disease of the
large intestine. Resection of the gut takes a little longer than a
short-circuiting operation. It is more thorough and satisfactory
and on the whole safer to the patient.
Operative details of intestinal surgery are described elsewhere,
and it suffices here to allude only to general principles. If resection
is adopted the operator need not hesitate to excise a considerable
length of intestine. The all-important point is to cut through
healthy intestine. The ends may be united either by an end-
to-end or a lateral anastomosis. It is difficult to unite satis-
factorily a distended to a collapsed piece of intestine by the end-to- end
method, and there is likely to be a weak spot just at the attach-
ment of the mesentery. It must be remembered that, normally,
nearly one-sixth of the circumference of the small intestine is
uncovered by peritoneum. Very accurate apposition, therefore,
of the ends of the intestines at the site of the mesenteric attach-
ment is all-important. The suture should be passed through
both layers of the mesentery on each piece of intestine, so as to
provide a good serous investment for the portion of gut that is
normally uncovered by peritoneum. Serous surfaces when
536
Intestinal Obstruction.
united heal strongly, completely, and with extraordinary rapidity.
There is no need to prolong the process of suturing by using
very small needles and the finest silk. Continuous sutures are
now almost universally employed in place of the numerous inter-
rupted sutures formerly advocated. When the intestine is healthy
a second row of sutures is unnecessary. Lateral anastomosis
is, on the whole, a better proceeding, and though more suturing is
involved the operation can really be done as quickly. Multiplica-
tion of sutures is, again, quite superfluous. There is no doubt that
even the comparatively rough suturing of two portions of healthy
gut together may lead to perfect union. At any rate, rapidity should
be considered more than elaboration. The cut ends of intestine are
invaginated and sutured rapidly with
a continuous suture. The csecal ends
atrophy in the course of time, and
indeed it may be hard ultimately to
recognise whether an end-to-end or
a lateral anastomosis has been per-
formed. The use of Murphy's button
is now generally discarded. The sole
advantage of this contrivance lay in
rapidity, and its numerous drawbacks
are more than neutralised by the use
of continuous sutures and general
simplification of the methods of anas-
tomosing intestine. The sutures
should pass down to the sub-mucosa.
If some of them go deeper still and
enter the lumen of the bowel, no harm
will follow. The idea that needle
punctures and the presence of sutures through all the coats might
lead to leakage has now been shown to be imaginary. A rapid
method of end-to-end anastomosis, recently suggested, consists in
invaginating an inch or so of one portion of the gut into the lumen
of the other. The cut edge of the investing portion of intestine
is then folded inwards on itself for a short distance and the
doubled-back termination of the receiving intestine rapidly sutured
to the invaginated portion. Apparently the fear that an intus-
susception might follow is groundless. Theoretically, the establish-
ment of a nodal point in the intestine, such as is involved by any
form of end-to-end union, would be likely to form the starting point
of an intussusception, but it never actually occurs. The free end
of intestine probably shrinks back and atrophies. The particular
FIG. l.
Intestinal Obstruction. 537
method with which the surgeon is most familiar is the most rapid
in his hands, and it is unwise to adopt any novel form of procedure
without preliminary practice on the cadaver.
The obstruction may not be of any of the forms already dealt
with, but really only a secondary manifestation. Thus a malignant
growth of any part of the large intestine or elsewhere in the
abdominal cavity is extremely likely to lead to secondary
adhesions, any one of which may produce a mechanical obstruc-
tion. Usually, the surgeon, if judicious, has to be content with
a partial procedure. Elaborate or prolonged operations are
commonly fatal ; the main thing is to relieve the distended
intestine. If in the large gut, the best place for puncture and
drainage is probably the caecum. Malignant disease on the left
side of the abdomen is very frequently of the annular form, and is
particularly prone to affect deeply situated portions of the gut ;
the hepatic or splenic colon is liable to be bound down, and the
actual growth is sometimes extremely hard to discover. Even on
the post-mortem table elaborate dissection may be necessary to
reveal the precise site of the disease. With distended gut prolonged
search is wholly unjustifiable. The gut may give way and per-
forations form, either close above the actual site of obstruction or, as
not infrequently happens, at the caecum itself. When drainage has
relieved the distension, further measures may be much more safely
and easily undertaken if the patient survives, but it is best to delay
these for at least two or three weeks. Any short-circuiting operation
or attempts at excision of the malignant growth practised on gut
that has been greatly distended, paralysed, septic and loaded with
toxic products, is sure to be disastrous, though even in extreme
cases the patient will often survive for a few hours.
When a distended gut has to be drained, it is best to draw out a
fairly long loop. As the distension subsides the intestine is prone
to recede into the abdominal cavity. Moreover, if a large loop is
drawn out it can be clamped and secured in position before the
Paul's tube is introduced. Then on releasing the clamp the
contents escape without risk of soiling the wound or the peritoneum.
Even when the drainage tube is inserted into highly distended
gut escape of the contents only takes place at first to a limited
extent. Frequently there is a comparatively small escape of gas
and putrid contents ; but an hour or two afterwards, as the gut
recovers power and the effects of the anaesthetic pass off, an
abundant How ensues. The gradual emptying of a greatly distended
intestine like the gradual emptying of any other overloaded
viscus is less exhausting and far safer for the patient than sudden
538 Intestinal Obstruction.
evacuation. In extremely bad cases preliminary injection of
pituitary extract and spinal analgesia are to be recommended.
The closure of the abdominal incision may often, in cases of
intestinal obstruction, be found the most difficult part of the whole
proceeding. Any endeavour to close layer by layer often leads to
useless expenditure of most valuable time. If the wound is in the
upper part of the abdomen, it is almost impossible to suture the
peritoneum, transversalis fascia and aponeurosis of the transversalis
muscle at all satisfactorily. The fibres of the transversalis muscle
in the upper part of the abdomen frequently extend up to the middle
line and the retraction of this layer is, consequently, very vigorous.
Frequently the quickest and most satisfactory way is the old-
fashioned method of passing stout silkworm-gut sutures through
all the layers of the abdominal wall, drawing the peritoneum
towards the middle line as far as possible. Two needles are needed
on each suture, and these are passed right and left from within
outwards. If there is any difficulty in bringing the wound together
owing to distension, the operator should not hesitate to draw out a
loop of intestine and drain it.
No operation can be considered satisfactory or complete that
results in closing an abdomen containing much distended intestine,
or, rather, in dragging together, somehow or other, the surfaces of
the incision. Drainage always leaves a weak spot and a cicatrix
liable to stretch ; but the risks of subsequent ventral hernia should
not be considered for a moment when the life of the patient hangs
in the balance.
In many cases the performance of a surgical operation is but the
commencement of a grave responsibility, and this is constantly
true when dealing with acute obstruction. After-treatment is here
no matter of routine, nor one that can be entrusted to an assistant
or nurse, however watchful and experienced. Incessant and close
attention is essential ; but a patient can be over-nursed. Most
delicate judgment is required in deciding when to act and when
simply to watch. The patient should be removed from the
operating table lying on his side, and kept in that position with the
head raised as much as the general condition will safely allow.
Skilful and gentle action in moving the patient and placing him in
bed is a highly important detail to which far too little attention is
often given. Disturbance of a patient still unconscious from the
anaesthetic is sure to provoke vomiting. Frequently the best plan
is to leave the patient on the table for an hour or two.
Of the treatment of initial shock, following the operation, little
need be said here. The lines to be followed are the same as after
Intestinal Obstruction. 539
other grave operations. The main point is to avoid unduly energetic
measures. Recovery ensues best when it is slow at first but still pro-
gressive, however gradual. Continuous rectal irrigation is not ex-
hausting, and is particularly well adapted to these cases. The irriga-
tion greatly relieves the thirst, which is so distressing a symptom.
It is usually desirable, if there has been vomiting, to wash out
the stomach before the anaesthetic, whether local or general, has
been administered. Unless the condition is desperate the stomach
should be washed out again at the conclusion, and often the
contents will be found abundant and very foul. Post-operative
vomiting is, of course, a symptom of grave significance. If it is
borne in mind that vomiting may still, after an operation for acute
obstruction, be due to a variety of causes, the treatment is more
likely to be rational. Assuming that the mechanical cause has
been wholly relieved, the persistence of vomiting may be regarded,
broadly, as due to the presence of foul material in the stomach,
of paresis of the intestinal tract, of peritonitis, or of poisoning of
the visceral nerve centres. This last condition, which must be
present in some degree, had best be regarded as the pre-
dominant feature. Gastric lavage, though rather exhausting and
distressing to an enfeebled patient, is often tolerated owing to the
relief which it affords for a time. Little reliance can be placed on
drugs. Infundibular extract has been recommended for post-
operative as for other pareses of the intestines. Bell has used
it in a limited number of cases and states rather optimistically
that he has never known it to fail. The drug may be given in
doses of 15 min. intra-muscularly, and repeated in an hour.
Cocaine (in doses of ^ to -$ gr.) is one of the best purely
sedative remedies. But it does not mend the toxic state ; nor
can gastric lavage benefit the general accumulation in the rest
of the intestines. Ice should be absolutely avoided. The patient's
temperature is low enough as it is, and does not require further
beating down.
The cardinal indication is to expel the decomposing contents of the
intestinal tract. Enemata may assist, but if they merely wash out
the lower intestine are but as partial remedies as gastric lavage.
It may be noted here that the best of the stimulating enemata is
the " Enema Eutae " of the St. George's Hospital Pharmacopeia.
Not only does this remedy give great relief to the flatulence, but it
constantly leads to free evacuation of the bowels. It is far superior
to the ordinary turpentine enema. The rectum may be emptied
and the stomach washed clean ; but of what value is this if the whole
length of intestine is loaded with foetid contents ? Procrastination
540 Intestinal Obstruction.
may be fatal. The idea that the injured bowel must have a rest is
frequent cause of disaster. Constantly, after a successful operation,
the bowels act naturally within a few hours. Why, then, hesitate to
profit by the lesson and imitate natural processes ? Paralysis or
paresis of the intestine is one of the gravest after-troubles. "Why,
then, foster so undesirable a condition ? To give opium or
similar drugs after operation is to administer a potent poison. A
paralysed is not a resting intestine. The patient tends to die of the
toxaemia. Wherefore, get rid of the toxic material with all possible
expedition, for it is poisonous in itself, and, further, leads inevitably
to distension by its gas-producing properties. Irritant purgatives
are contra-indicated, but mild aperients can only do good. It is
difficult to understand why the obvious indication is so constantly
neglected until it is too late, or why people fail to recognise that the
intestine, like the heart, is never resting more efficiently than when
it is discharging its natural functions very quietly. Stagnation of
the intestinal contents implies gas-producing decomposition and
increased toxic absorption. Castor oil, if it does not make the
patient sick, is the safest of all aperients. The relief afforded by
an action of the bowels is enormous, for it is mental as well as
physical. Sometimes, in fortunate and promptly treated cases the
patient can, in the course of a few minutes, be almost seen to turn
the corner. Not infrequently, when this favourable turn has been
taken, and at a later stage of recovery, the patient is seized with a
sudden pain, usually pelvic, and in a few minutes becomes greatly
distended. The symptom is alarming, but not unfavourable, and is
due to the impaction of a mass of fsecal matter, commonly in the
pelvic colon. An enema will promptly relieve the trouble, which is
especially apt to follow obstruction from volvulus.
Prolonged rectal feeding is usually unnecessary, and suitable food
may be given by the mouth with advantage at a much earlier period
than is generally the practice. The writer has for some years been
in the habit of giving food by the mouth in cases such as gastro-
jejunostomy, or suture of perforating gastric or duodenal ulcer
within a few hours of the operation, and has never seen anything
but benefit result. Here, again, the stomach if quietly doing its
natural work to a mild extent is enjoying the best form of rest that
can be secured. A fortiori, after the intestinal lesions under con-
sideration, the same principles may be observed.
Secondary operations may be demanded, but the condition of the
patient rarely allows of any such proceeding. Drainage of the
intestine is, as a rule, all that can be done.
C. T. DENT.
INTUSSUSCEPTION.
ACUTE INTUSSUSCEPTION is by far the most frequent cause of
intestinal obstruction in children. It is most commonly met with
during the second half of infancy, and at this period of life it is
.the most important surgical emergency with which the practitioner
has to deal. Early diagnosis, followed by prompt and skilled
surgical treatment within twenty-four hours of the occurrence of the
invagination, will result in from 80 to 90 per cent, of cures. With
each additional twelve hours which is allowed to elapse before surgical
aid is obtained, the mortality rapidly and progressively increases.
If operative interference is delayed until forty-eight hours after
the first symptom, the mortality reaches about 76 per cent. The
time required for an acute intussusception to become irreducible
varies considerably; in exceptional cases this complication may
occur within twelve hours, while in other cases three days may
elapse before it occurs. In only six cases among the last hundred
operated on in the Koyal Edinburgh Hospital for Sick Children
was reduction with recovery obtained after forty-eight hours.
Fortunately the diagnosis of acute intussusception presents no
difficulty. The age of the patient, the acute onset of the illness,
ushered in by severe cramp-like abdominal pain, the repetition of
the spasms at intervals, the vomiting, the slightly collapsed look of
the child, the quick feeble pulse, and subnormal temperature, and
the absence during the first forty-eight hours of acute abdominal
tenderness and distension should make the practitioner think at
once of intussusception. The diagnosis is confirmed by the
presence of a tumour, often, though not always, sausage-shaped.
If there is any doubt about the presence of a tumour an anaesthetic
should be administered. One or two normal motions are often passed
soon after the onset of the illness ; later, blood-stained mucus takes
the place of faecal matter. This symptom may occur within a very
few hours of the invagination, while in other cases it is delayed
from twelve to twenty-four hours. If advice is sought early enough,
there is no reason why the diagnosis should not be made before the
discharge of blood-stained mucus. The practitioner should not
wait for this symptom before calling in the surgeon. It cannot be
too often repeated that, as in strangulated hernia and all other
forms of acute obstruction, so in acute intussusception, the early
542 Intussusception.
diagnosis is the all-important factor in regard to prognosis. The
responsibility, therefore, for the issue of the case lies entirely with
the medical attendant, as it is he who is called to the case in the
first instance. If he can obtain skilled surgical assistance within
twenty- four hours of the occurrence of the invagination, the chances
are ten to one that the child's life will be saved ; if, on the other
hand, the diagnosis has not been made until the invagination has
become irreducible, the chances are a hundred to one the infant
will die.
Up till recent years physicians, and indeed some surgeons, have
advocated that an attempt be made to reduce the invagination by
the introduction of air, water, or oil into the bowel before proceeding
to operation. During the twelve years the writer has been surgeon
to the Royal Edinburgh Hospital for Sick Children he has never
countenanced this procedure, because by such means complete reduc-
tion is only very rarely effected, and it is precisely in these cases in
which it is likely to be successful that laparotomy and manual reduc-
tion are, in experienced hands, practically free from risk. The
strongest argument against the bloodless method is that it is often
impossible to say until some hours later if the apex of the intussuscep-
tion has been reduced ; if not, valuable time has been lost, the infant
has to be anaesthetised a second time, the shock is augmented, and
it may be that the invagination has become irreducible, which is
practically equivalent to stating that the delay has been responsible
for the loss of the child's life. Another objection, although
perhaps a less forcible one if due care is exercised, is the risk of
rupturing the bowel.
Some surgeons still advocate inflation or injection of the bowel
as a preliminary step to operative treatment, on the grounds that it
can nearly always be counted on to effect at any rate a partial
reduction, and that in this way the size of the tumour may be so
reduced as to enable it to be delivered out of the wound through a
small incision, and without having to pull out a considerable
amount of the small intestine. In cases in which the intussus-
ception has reached the pelvic colon, or even the rectum, there is
seldom any difficulty in effecting a partial reduction through a
comparatively small laparotomy wound without any evisceration.
In cases of unusual difficulty the writer never hesitates to enlarge
the wound and pull out the small intestine. If this is done rapidly,
and if care is taken to surround the intestine with saline cloths, the
additional shock will, at any rate, be no greater than that induced
by the prolongation of the anaesthesia attendant upon the pre-
liminary injection of the bowel.
Intussusception. 543
Ouvry reports a case in which he saved the infant's life by
passing a Ne"laton's soft rubber catheter through an intussuscepturn
which had reached the rectum. A quantity of fostid liquid material
and gas escaped, after which the bowel was irrigated with saline.
The imagination had existed for four days, the abdomen was
distended, and the pulse almost imperceptible. Thirty-six hours
later spontaneous reduction took place. This is a method which
should be tried when operative assistance is not available.
The Operation. The operating room should be of a tempera-
ture at or a little above 70 F. The operating table should be
provided with a heating apparatus, the most convenient being a
large hot water bag, care being taken to see that the water in it is
not too hot, as infants are very easily burned. The chest and
limbs should be swathed in cotton-wool secured by bandages. As
the infants are generally robust, there is no objection to using
chloroform as the anaesthetic, but in weakly infants ether may be
given by the open method, or the latter may be substituted after
the patient has been put under with chloroform, or a mixture of
1 part of chloroform and 2 of ether may be used.
The incision should almost invariably be in the middle line
and about 3 inches in length. Whether the greater part of
the incision be above or below the umbilicus will depend on the
position of the tumour. When the tumour is situated in the right
lower region, the incision may be placed parallel to and a little to
the inner side of the outer edge of the right rectus. When, as HO
often happens, the greater part of the tumour is situated under the
left rectus, it is a mistake to make the incision to the left of the
middle line, because the first part of the reduction is readily
effected from the middle line, whereas the ileo-caecal region (some-
times the lower end of the ileum) which is the last and most
difficult part to disinvaginate, might be difficult to deliver into a
wound situated to the left. Moreover, as the last parts to be
reduced are those whose circulation is most interfered with it
is important that they should be brought well into view so that
the question of their viability may be settled. Another advantage
of the middle-line incision is that, besides giving access to
the intussusception wherever situated and at all stages in its
reduction, it helps to reduce the duration of the operation to a
minimum.
After the abdomen has been opened, search should at once be
made for the distal end of the intussusception. If it can be
reached and delivered out of the wound without coils of the small
intestine escaping so much the better, but if not valuable time
544 Intussusception.
should not be wasted in replacing them or in attempting to keep
them inside the abdomen by the introduction of gauze packs.
Should they prolapse, the best plan is to let them do so, indeed in
many cases the delivery of the distal end of the tumour can only
be effected after the greater part of the small bowel has been
withdrawn from the abdomen. As before stated, when the intus-
susception has reached the pelvic colon, disinvagination may be
effected to a very considerable extent with the tumour still within
the abdomen by compressing the distal end (apex) of the intussus-
ception in an upward direction between the thumb and two fingers.
If there is any difficulty in reaching the distal end there should be
no hesitation in enlarging the incision so as to admit the whole
hand. When the intussusception has reached the lower part of the
pelvic colon or the rectum, it is sometimes an advantage to get an
assistant to push upwards the intussusception by means of a finger
introduced into the rectum.
Having so far reduced the invagination as to enable the tumour
to be delivered out of the wound, further disinvagination is effected
by grasping the distal end of the tumour in the palm of the hand
in such a way as to compress the apex in the proximal direction, the
sheath being at the same time drawn downwards, that is to say, in
the distal direction. This movement is repeated at a higher and
higher level as the disinvagination proceeds. As a rule, there is
no difficulty in reducing the greater part of the invagination, even
if the intussusception should have reached the rectum.
In cases in which the intussusception has lasted for less than
twenty-four hours, complete disinvagination can generally be
effected without difficulty. Owing, however, to the increased
swelling of the apical portion of the intussusception (due to the
great venous engorgement and oedema, more especially of its
muscular and serous coats), there is often considerable difficulty in
disinvaginating the last portion of the intussusception. The
difficulty may be increased also by enlargement of the lymphatic
glands at the ileo-csecal angle. Such cases call for the exercise of
both patience and perseverance. The compression should be kept
up for some time in the hope of reducing the diameter of the intus-
susception by reducing the venous engorgement. The attempt
should not necessarily be abandoned as hopeless because the
peritoneal coat of the sheath commences to split. If this should
occur ihe operator should keep up steady compression before again
resorting to onward compression. Moreover, he should realise
that if reduction is not accomplished, the result is almost certain
to be fatal. After pretty considerable tearing of the peritoneum,
Intussusception. 545
the operator is often rewarded for his perseverance by the dis-
invagination of the appendix, possibly also of some engorged
lymphatic glands, and finally of the ileo-csecal valve. It is just in
these " touch-and-go " cases that one is not only justified, but often
helped in effecting the final reduction by making steady traction on
the emptying tube. It must be borne in mind, however, that it is
not only useless but actually harmful to do this at the outset ; on
the other hand, in critical cases it is occasionally the determinating
factor in effecting the final reduction. After the appendix and
ileo-csecal valve have been reduced, there still remains a deep
infolding of the outer wall of the caecum. This, which is the
result and not the cause of the ileo-ceecal invagination, is easily
reduced by a little manipulation. After reducing the ileo-csecal
junction it not infrequently happens that a primary enteric
intussusception, involving the lower few inches of the ileum, is
brought into view ; it must of course be disinvaginated, and here
more especially it may be necessary to make gentle traction on
the entering tube.
Having completely disinvaginated the intussusception, the next
step is to examine the bowel and adjacent mesentery so as to
ascertain how far it has been damaged. Many cases make an
uninterrupted recovery in spite of considerable tearing of the
serous coat. While the edges of the peritoneal wounds should be
brought together with a few sutures, it is quite unnecessary to
waste time in suturing up every tear completely. It is surprising
how severely the bowel may appear to be damaged and yet recovery
take place. In doubtful cases it is wise to give the bowel the
benefit of the doubt and return it into the abdomen, as it is more
likely to recover if returned to its natural position. Another strong
reason for returning it is the well-nigh hopeless prognosis following
resection. If the operator deems the bowel too much damaged to
warrant its being returned, he may adopt a middle course, viz.,
that of short circuiting the damaged portion by performing a
lateral anastomosis ; he must, however, consider carefully whether
the infant is likely to stand such a prolongation of the operation
as this procedure would entail.
Recurrence of the intussusception has occurred four times in the
last hundred cases operated on in the Hospital for Sick Children.
It is, of course, more likely to occur in cases in which reduction
has been effected easily and in which the bowel has not been
damaged. As a precaution against recurrence, especially in easily
reduced cases, and where there is a well-marked mesentery to the
ascending colon, it is advisable, before closing the abdomen, either
S.T. VOL. ii. 35
546 Intussusception.
to reef up the ileo-colie portion of the mesentery with one or two
catgut sutures, or, what comes to much the same thing, to suture
the lowest part of the ileum to the inner edge of the ascending
colon in such a way that the former is made to descend parallel to
the ascending colon on its way to join the caecum.
In cases which are being operated on early there is seldom any
difficulty in returning prolapsed intestine. In cases, however, in
which the operation has been delayed the small intestine is often
distended and some difficulty may occur. Eeposition is greatly
facilitated if the assistant keeps the edges of the wound held well
up with suitable grip forceps. When the intestine is still more
distended and -paretic, it must be emptied as far as possible by
puncturing it with a suitable trocar and cannula to which a rubber
tube is fixed so as to carry the contents well away from the field of
operation. The puncture is closed by a purse-string sero-muscular
suture, which should be introduced before the puncture is made ;
by tightening up the suture just as the cannula is withdrawn all
danger of soiling is avoided.
The closure of the abdominal wound is a matter of considerable
importance in infants. Several cases have been recorded in which
the wound has burst open, owing either to faulty suturing or to
too early removal of the sutures. In infants through- and-through
suturing is distinctly preferable to suturing in layers, especially
when a median incision has been made. The saving of time is
a very important matter. On no account should the sutures be
removed before the tenth day, and if they can be kept in until the
twelfth or fourteenth day so much the better.
The best material to use is silkworm gut, which should not be
too thin. To prevent the sutures cutting through the delicate skin
into the subcutaneous tissue they should each be threaded with a
piece of fine rubber tubing (about f inch long), in such a way that
when the suture is tied the part of the loop which overlies the skin
is surrounded by the tubing. Without this small but important
detail, the infant may suffer much discomfort, and an anaesthetic
may be required before the stitches can be removed. The intro-
duction of the sutures is greatly expedited and facilitated by using
a handled needle, such as Doyen's (the smallest of the three sizes).
When the intussusception is irreducible a variety of pro-
cedures is open to the surgeon, but unfortunately, owing to the
already collapsed and toxaemic condition of the infant, none of them
can be expected to hold out more than the remotest chance of
success. The procedures are :
(1) To relieve the obstruction by short-circuiting, the ileum on
Intussusception. 547
the proximal side of the intussusception being joined by lateral
anastomosis to the colon on its distal side. The intussusception is
returned into the abdomen, which is closed without drainage.
Eutherford and Parry have each reported a successful case by this
method. Although the stools were carefully watched after the
operation no trace of sloughed intestine was discovered, and what
exactly happened to the intestine itself is not known.
The advantages of this method are that it is a comparatively rapid
means of restoring the continuity of the canal, and that it is
attended with much less shock than resection. Moreover, the
infant can be properly nourished and no second operation is
required to restore the continuity of the canal.
When the bowel above the obstruction is distended and more or
less paralysed, and when every intestinal stitch puncture is likely
to be followed by a septic track, Mr. Henry Eutherford, of Glasgow,
points out the importance of drainage of the bowel contents. In
making an artificial anus he suggests that " it would probably be the
best procedure to select a loop low down and take it out to the extent
of 4 or 5 inches through an opening in the flank, tie in a glass tube,
and after assisting the adjacent coils to empty themselves, to close
the wound of exploration, which is presumably in the middle line.
" This, of course, is to be regarded as a temporary expedient.
Supposing the child to have recovered, it will, I believe, be best to
reopen the abdomen in the middle line and make such a lateral
anastomosis as may be practicable between the ileum above the
artificial anus and the colon below the intussusception. Such an
anastomosis should be free ; it is to be for life, and a large stoma
will simplify the treatment of the artificial anus. There is no
question of restoring the continuity of the bowel at this point ; the
ends will simply be freed, cut short down to their intact surfaces,
inverted and dropped into the abdomen."
The disadvantage is that should the intussusception be, or
become, gangrenous, the chances are the infant will succumb to
toxaemia and peritonitis. However, the results of resection with
or without the formation of an artificial anus are so uniformly bad
that to leave the intestine to take its chance is perhaps the lesser
of the two evils. Further results of this method of treatment will
be awaited with interest.
(2) If gangrene has already set in, the condition is indeed
desperate. Mr. Barker recommends that the neck of the intussus-
ception be stitched to the entering tube, after which a longitudinal
incision, about 2 inches in length, is made through the sheath close
to the neck. The gangrenous intussusception is then amputated,
352
548 Intussusception.
and the inner and middle tubes, which form the stump, are united
by a continuous through-and-through top stitch which unites the
opposing serous surfaces and at the same time checks the bleeding.
Care must be taken to include all bleeding vessels of the divided
mesentery. The operation is completed by closing the longitudinal
opening in the sheath in the usual way by a through-and-through,
followed by a sero-muscular uniting, suture. The author is not
aware that any successful case has been reported by this method.
The objections to it are that it is almost impossible to prevent
soiling of the peritoneum by such a method, and that the drainage
through the inner tube is liable to fail owing to the pressure
exerted on it by the thickening and engorgement of the middle
tube and mesentery.
(8) Another method is to resect the intussusception, and after
ligaturing the vessels of the mesentery, to establish an artificial anus
by bringing the divided ends of the bowel out of the wound and
introducing into each a small Paul's tube. Unfortunately this
method, too, has not been successful. Although it may occasionally
save the infant from obstruction and peritonitis, it is difficult with
a tube in the small intestine to maintain its nutrition sufficiently
to enable it to pull through the subsequent operation for the
restoration of the continuity of the alimentary canal.
If, after removing the intussusception, the patient's condition is
found to be fairly satisfactory, an attempt should be made to
restore at once the continuity of the canal. The operation must
be done as rapidly as possible, and every care should be taken to
prevent faecal contamination. The steps of the operation are as
follows :
The tumour is removed by dividing the bowel above and below
the tumour between two catgut or linen thread ligatures placed
about an inch apart. The vessels of the mesentery are clamped,
divided and ligatured. The divided ends of the intestine are
trimmed, disinfected, and the stumps invaginated by means of a
purse-string suture, after which the continuity of the canal is
established by lateral anastomosis, care being taken to make the
opening sufficiently large and not too near the invaginated stump.
One or two interrupted sutures are placed beyond the anastornotic
opening so as to anchor the stumps to the adjacent bowel. The
gap in the mesentery is closed by means of a few interrupted
catgut sutures, care being taken to avoid puncturing the vessels.
If there has been no faecal contamination, the abdomen is closed
without drainage.
The operation is facilitated and rendered cleaner by the use of
Intussusception. 549
clamps, which should be small and springy. The needles and
thread .(or silk) should be as fine as possible. The advantages
of the lateral anastomosis over end-to-end union are : that
the operation is cleaner, that no inconvenience is caused by the
difference in the size of the lumina, that the suturing does not
involve the dangerous meseuterie area, and that there is less risk
of the blocking of the lumen by the inverted edges of the gut.
After-treatment. Warmth and the introduction of saline per
rectum by the drop method, supplemented by saline injections
into the subcutaneous tissues of the infra-axillary region, are the
most reliable means of combating shock. Small doses of alcohol
may be given if necessary, but such active drugs as strophanthus,
digitalis, and large doses of strychnine do more harm than good.
A few minims of pituitary extract may prove of value in critical
cases by maintaining the blood pressure and stimulating the
paralysed intestine.
In simple cases the infant should be put to the breast as soon as
it begins to cry vigorously and show signs of hunger. If not on
the breast, albumen water, milk and water, or peptonised milk may
be given in small quantities at first. It is a mistake to give an
opiate after the operation. If the bowels have not been moved
within twenty-four hours after the operation small doses of calomel
may be administered. If vomiting persists after the operation the
stomach should be repeatedly washed out and the saline must be
continued until feeding by the mouth can be commenced. Paralytic
distension of the intestine is best treated by repeated small doses of
calomel, and if this fails to move the bowels, resort must be had to
physostigmin or pituitary extract.
Of the fifty-two cases of intussusception admitted into the Royal
Edinburgh Hospital for Sick Children during the four years
previous to July, 1910, thirty-three cases were operated on within
twenty-four hours of the onset of the invagination, and of these
twenty-eight (85 per cent.) recovered ; of the seven operated on
during the second twenty-four hours, five(71'4 per cent.) recovered ;
while of the twelve operated on after forty-eight hours, only three
(25 per cent.) recovered. All the irreducible cases (8 = 15' 4 per
cent.) died.
HAROLD J. STILES.
550
PERFORATION OF THE INTESTINE.
THIS, which constitutes one of the most urgent conditions of
abdominal cataclysm, is fortunately of rare occurrence. It is caused
in the upper part of the bowel by chronic peptic ulcers in the first
part of the duodenum or in the jejunum, near the site of a gastro-
enterostomy (usually an anterior anastomosis); in the ileum by
the ulcers of typhoid fever ; and in the colon by stercoral ulcers,
which may be above malignant or innocent strictures, or by the
giving way of false diverticula. Very .rarely a foreign body may
cause intestinal perforation, this generally occurring a few inches
above the ileo-caecal valve. In discussing the treatment of these
lesions it will be convenient to take the perforation due to typhoid
fever as the chief type and to deal with the other classes more
shortly.
PERFORATION OF THE INTESTINE IN TYPHOID FEVER.
The subject of the treatment of typhoid perforation assumes
a greater importance every year ; for the disease remains widely
spread all over the world, and although the general mortality
has been greatly reduced by such means as hydrotherapy, that
from intestinal perforation remains as high as ever, or indeed
higher than ever in proportion to the mortality from other
causes. First proposed by Leyden and carried out by Miculicz
in 1884, the operative treatment of this condition has been
universally accepted as the only one which holds out any
reasonable hope of success. And whereas Keen 1 was able to
collect 83 cases in 1898, Harte and Ashhurst 2 tabled 362 in 1903,
and since then the operation has become comparatively common.
But when the total death rate from typhoid perforation of the
intestine is considered it will be readily admitted that much
remains to be done in the way of a wider adoption of operative
measures ; for whereas in the United States alone, according to
Professor Osier, 3 about 4,422 cases die from typhoid perforation
annually, only 362 cases of operation are recorded in twenty years for
this condition all over the world ! 4 If we suppose that the American
mortality is half that of the whole world and that 200 operations
are now performed annually for this condition, the proportion of
cases operated upon is still only about 1 in every 44. It is
quite clear, then, that many of the medical profession require to
Perforation of the Intestine. 551
have the great importance of this subject brought home to them in
order that a greater number of patients may have the only chance
of life afforded to them.
The possibility of a case of perforated typhoid intestine recover-
ing without an operation is so extremely remote as to require the
dismissal of its consideration, and the only choice of treatment,
therefore, which we have to consider is the choice of the details of
the operation.
The Best Time for Operation. It would seem hardly necessary
to emphasise the importance of operating as early as possible if it
had not been for the fact that so eminent an authority as Professor
Keen had expressed the opinion that it is wiser to wait until twelve
hours after the perforation in order to avoid the period of shock
which accompanies the rupture of the intestine. But subsequent
observation has proved that this opinion was founded on insufficient
data (15 cases operated upon within twelve hours, with 4
recoveries, as compared with 20 operations between the twelfth
and twenty-fourth hours with 6 recoveries). The larger number of
figures given by Harte and Ashhurst show that the best results are
obtained from the operations performed within the first twelve
hours, but there is not that striking difference which one might
have anticipated between the first and second twelve hour results
(130 cases in first twelve hours with 34 recoveries mortality 73 per
cent. and 84 in second twelve hours with 22 recoveries mortality
73'8 per cent.).
It is quite true that the cases operated upon at comparatively late
periods show the lowest mortality of all (55 cases later than thirty-six
hours with mortality of 67'2 per cent.), but this is due to the fact
that only mild cases of small perforation with localising adhesions
survive to this period. So that we may lay down the rule that the
operation should be done as soon after perforation as possible, and
certainly within the first twenty-four hours.
The Anaesthetic. About this there is a considerable difference
of opinion, the alternatives being, general anesthesia by open ether
or gas and oxygen, spinal anesthesia or a local anaesthetic. Theoreti-
cally, spinal anesthesia is the ideal method, because it abolishes
shock and gives complete freedom from pain with full relaxation of
the muscles. Those who are accustomed to its use will therefore
be wise in employing it. Local anesthesia is quite efficient for the
abdominal incision, but it does not abolish the peritoneal sensibility
nor does it relax the muscles. It is very useful in those cases
when the diagnosis is in great doubt, the patient being very ill,
but the existence of a perforation not being certain. Under a local
552 Perforation of the Intestine.
anaesthetic (2 per cent, solution of novocaine with adrenalin) the
abdomen can be opened. If no exudate or adhesions are found the
wound can be closed and no harm is done. But if these exist and the
perforated coil requires to be searched for, a general anaesthetic can
then be given, gas and oxygen being very suitable for this purpose.
But as a matter of fact the great majority of cases have been
operated upon under general anaesthesia by ether or chloroform,
and if the operation is not prolonged it is doubtful whether this
adds very much to the risk.
Incision. About this, too, there is no general agreement, a
median incision having the advantage of the wider access to all
parts of the pelvis, but the right lateral approach being more
nearly over the probable seat of perforation. The actual mortality
tables seem to favour the lateral incision, but it is only fair to point
out that the median incision may have been chosen in 'the more
desperate cases.
The main question in choosing the incision is the ready facility
for quick performance of the operation, and any thought of post-
operative hernia must be set aside. There can be no doubt, then,
that a long lateral incision, made boldly down through all the
strata of the abdominal wall, best fulfils these conditions. It
should be about one-third of the distance from the right anterior
superior iliac spine to the navel at right angles to the line between
these points. It is very easy to draw coils of ileum into this
wound, even if the perforation is 8 feet away from the valve,
whereas it is often difficult in an adult to deal with the ciecum or
appendix through a median incision.
Location of the Lesion. The probable site of the lesion has
already been mentioned and it is seldom a matter of any difficulty
to find it. If it does not immediately become evident, the region
of the ileo-caecal valve, caecum and appendix is identified, and then
the small intestine rapidly followed up. The perforation, which is
generally on the anti-mesenteric border of the gut, may be very
minute, and a stream of fluid exudate is often the guide to it.
Having found one perforation, it is always worth while to examine
at least the terminal 18 inches of ileum for another hole or
suspicious ulcer.
Suture of the Perforation. In the case of a small hole, the
edges of which are not too friable, a simple suturing by Lembert's
stitches in two rows should be done. Perhaps the Halstead
mattress-stitch is a little less liable to cut out. It is important to
turn in all the doubtful thin edge which surrounds the perforation.
If, however, the hole in the bowel is so large that it cannot be
Perforation of the Intestine. 553
sewn up without seriously diminishing the calibre of the gut, and
if there are multiple perforations or several doubtful places, the
matter is much more difficult. Such conditions have been dealt
with Iry the tying in of a Paul's tube, the making of an enteric anus
and by resection. The results in all these cases has been very bad,
but considering the desperate state of the case it is perhaps rather
wonderful that success has ever been attained. Four cases collected
by Harte and Ashhurst in which an artificial anus was made all
died, but Wroth 5 had one success by this method, the patient
being left in a continuous bath from the twelfth day for two weeks.
It is very significant that of 16 cases in which a fistula
developed spontaneously after the operation, only 2 died, thus
showing that the artificial anus in typhoid fever is not per se very
dangerous. The mortality after resection is given differently by
various writers. Keen notes 5 cases with 2 recoveries ; Harte
and Ashhurst 5 cases with only 1 recovery, and Zezas 6 20
cases with 8 recoveries. All, however, are agreed that some of
even these cases do recover, and it is rather remarkable that in
several of which the details are published life was prolonged for
two, seven or eight days after the operation, from which it is
probable in concluding that the patient recovered from the per-
foration and operation, but died of the original disease.
In some cases a patch of gut, the integrity of which is in doubt,
may be covered over with the fringe of the great omentum. In one
case when no actual perforation but very extensive ulceration was
present, Solieri 7 wrapped several inches of ileum round with
omentum, and had the satisfaction of seeing his patient recover in
spite of very severe haemorrhage from the bowel, which indicated
progressive ulceration.
Probably the best treatment for cases with extensive ulceration,
or large or multiple perforations, will be to bring the whole of the
affected segment of ileum (i.e., the last 2 feet) outside the
abdomen, to rapidly resect the whole of this by means of the
thermocautery, the mesentery being securely ligatured. Two small
Paul's tubes are then tied into the two ends of the gut ; from the
proximal the faeces are allowed to drain away into a receptacle
through a rubber tube and into the distal continuous saline infusion
is given much more easily than into the rectum. This procedure
ought not to occupy longer than suturing several ulcers, and it will
give the best chance of immediate recovery. If the patient survives
until the tubes come away (about three days) he can be treated by a
continuous bath or an anastomosis can be made without requiring
any further anaesthetic. This method will remove the principal
554
Perforation of the Intestine.
focus of disease, it will prevent death from a second perforation
(which occurred in 11 per cent, of Harte and Ashhurst's cases),
and it will greatly facilitate the infusion of fluids.
Peritoneal Toilet. It is best to swab out all exudate from the
affected region and especially from the pelvis by means of gauze
mops. It is useless to attempt to wash out the infective material
FIG. 1. Operation suggested for the excision of the ulcer-bearing area of the ileum
in cases of Typhoid perforation. A loop consisting of the last two feet of ileum
is brought out through an oblique wound in the right linea semi lunaris. The
base of this loop is clamped in two places in the manner shown, and a stout
suture passed through the corresponding part of the mesentery. The whole loop
is removed with its mesentery by cutting just below the line of the upper forceps
I = Ileum. C = Caecum.
A = Appendix. M = Mesentery.
S = Suture for tying Mesentery.
unless one is prepared practically to eviscerate the patient and
flush every corner of the abdomen, a treatment which would
almost certainly be fatal in these cases. Any flushing less thorough
than this will only serve to carry infective material into parts of the
peritoneal cavity which are not yet infected.
Having dried the peritoneum, long wide drainage tubes, which
may be provided with gauze wicks, are placed right down into
Douglas's pouch and in the right loin and hypogastric regions if
Perforation of the Intestine.
555
these are affected. Usually a single large tube will be sufficient, one
end of this being at the bottom of the pelvis and the other at the
upper extremity of the parietal wound. The whole -operation ought
to be completed within half an hour or less.
After-treatment. The shock of the operation, if great, is
FIG. 2. Completion of the operation. The whole of the bleeding is controlled by
tying the mesenteric suture, and a Paul's tube is tied into both cut ends of the
ileum (P and D) which are then fixed in the parietal wound. The excised
portion of the ileum (2 feet) freed from its mesentery is seen above the operation
treated by an intravenons infusion of 2 pints of normal saline,
together with 1 c.c. of pituitary gland extract; or if a willing
relative is forthcoming an immediate transfusion of blood might be
performed. Directly shock is past, the patient is propped up in
the Fowler position (by means of a properly constructed bed frame)
556 Perforation of the Intestine.
and a. continuous rectal infusion of saline is begun. If an enterec-
tomy has been done this infusion should be given into the distal
piece of gut fixed in the abdominal wall. The infusion should be at
the rate of 1 pint an hour of fluid at 100 F., and should go on
for about forty-eight hours.
Probably the efficient carrying out of this infusion is the most
potent life-saving means at our disposal after the perforation has
been dealt with. To give illustrations of what success may some-
times attend this method, Wroth 8 in 1910, relates 4 cases, 3
of which were desperate ones with very large perforations, all of
whom recovered ; they all had 8 to 6 litres of saline each day
by the rectum. And Davis, 9 in 1908, reports 9 cases of typhoid
perforation with no less than 8 recoveries obtained by following
this plan.
The Mortality after Operation has already been referred to.
Although large series of cases are available which show that if opera-
tion is performed within twenty-four hours the mortality is about
73 per cent., yet it must be borne in mind, on the one hand, that
many fatal cases are not reported, but, on the other hand, the series
refer to cases which occurred before the modern methods of the
Fowler position with continuous saline infusion were introduced.
The improvement in results which we may expect from these
methods has already been indicated. Death rarely occurs during
the operation ; in the majority of fatal cases it takes place within
twelve hours, and in a still greater majority within twenty-four hours.
Death after this period is probably due to the original fever or to a
fresh perforation. In 89 cases the cause of death was said to be :
Peritonitis in 44 ; toxaemia and " exhaustion " in 14 ; a second per-
foration in 10 ; haemorrhage in 3 ; obstruction in 3, and other causes
uninfluenced by the operation in 15. lo
In conclusion, it may be fairly urged that a far better prospect of
success would be achieved if the very bad cases (i.e., cases with
numerous or larger lesions and those with much peritonitis
or toxaemia) were treat ad by the method suggested above, viz., by an
excision of the terminal 2 feet of the ileum, tubes being tied into
both ends of the bowel. Every one of the above-mentioned causes
of death, except the last (i.e., in 75 out of 89 cases), would be com-
bated by it. The peritonitis would be treated by the most efficient
form of transfusion into the upper end of the larger bowel.
Toxaemia would be minimised by the direct evacuation of the
infective material from the upper bowel. Second perforation and
haemorrhage would be prevented by removing the part of the bowel
where these occur and by keeping the large gut empty. Obstruction
Perforation of the Intestine. 557
would not occur if it were not for ill-advised attempts at excision
of large ulcers or immediate anastomosis of the bowel.
OTHER FORMS OF PERFORATION OF THE INTESTINE.
Perforation of the Duodenum. See Duodenal Ulcer.
Perforation of the Jejunum. The jejunum is the part of the
alimentary canal least liable to perforation or to ulceration. In
fact it is only as a sequel of gastro-enterostouiy that either of these
conditions occurs except as so rare a phenomenon as not to require
special discussion. Mr. H. J. Paterson u has collected 52 cases
of jejunal ulcer after gastro-enterostomy, of which 42 were anterior
operations, no case having been yet recorded after the posterior
no-loop operation. In 19 of these, perforation occurred into the
peritoneal cavity, in 28 into a localised inflammatory mass or
through the parietes, and in 5 into the colon. Of these, 29 cases
recovered, all living as the result of operative treatment ; 13 died
without treatment, and 8 died after one or more operations.
The formation of a jejunal ulcer occurs within one or two years
of the gastro-enterostomy, and its presence is indicated by a
recurrence of dyspeptic symptoms. These, however, may often be
cured by carefully dieting (especially the forbidding of meat), and
by the administration of bismuth or alkalies. The symptoms of
perforation are similar to those of a gastric rupture, and will
demand an immediate operation. If possible the ulcer is sutured,
but in some cases it has been necessary to resect the damaged
bowel and to reconstruct the gastro-enterostomy. If the limb of an
anterior gastro-jejunostomy has perforated and formed an external
fistula, it is best to entirely resect this part of the gut, close the
anterior stomach opening, and, if the necessity for a short circuit
still exists, to perform the posterior no-loop operation.
Perforation of the Colon, This is the most fatal form of per-
foration of the alimentary canal, but fortunately it is a very rare
event. In addition to such cases as enteric, tuberculosis, or
dysenteric ulcers, and the impaction of foreign bodies, there are two
causes of perforation almost peculiar to the colon. One is the
formation and rupture of diverticula and the other the rupture
above a malignant stricture, often through a stercoral ulcer. The
sigmoid flexure and then the caecum are the commonest sites of
perforation. The process may be preceded by protective adhesions
to the parietes or neighbouring viscera, in which case the perforation
will result in an abscess or fistula, either external or bi-iuucous ; or
the rupture may take place directly into the peritoneal cavity.
Two facts are remarkable about this catastrophe: First, that the
558 Perforation of the Intestine.
symptoms are often comparatively mild and patients have been
known to walk to the hospital when the peritoneal cavity is filled
with faeces; and second, its almost invariable fatality. It is
doubtful, in fact, whether there has yet ever been recorded a
recovery after perforation - of the large intestine direct into the
peritoneal cavity, although many cases have been operated upon.
In the majority of these cases, however, the exact diagnosis can-
not be made before the abdomen has been opened. When the lesion
has been found it has usually been sutured. If obstruction exists
below the rupture it will certainly be necessary to tie a tube into
the colon and fix it in the parietal wound. Probably this treatment
would give some success if applied to all cases of ruptured colon.
The peritoneal cavity is cleaned by dry swabbing and freely drained.
Continuous or intermittent saline infusions are to be given by
means of the colostomy tube.
ERNEST W. HEY GROVES.
REFERENCES.
1 Keen, W. W., "Surgical Complications of Typhoid Fever," Assoc. Philad.
Lond. 1898.
2 Harte and Ashhurst, " Trans. Amer. Surg.," 1903, XXI., pp. 580624.
3 Macrae, T., in "Osier and Macrae's System of Medicine," 1907, Vol. II.,
p. 98.
4 Quoted by Macrae, loc. cit.
5 " Annals of Surgery," 1910, LI., p. 842.
6 Zezas, "Wiener Klinik," 1904; Abstract in " Centralblatt f. Chirurgie,"
1905, XXXII., p. 385.
7 "Archiv. f. Klin. Chir.," Berlin, 1910, XCIL, p. 816.
8 Loc. cit.
9 " Surgery, Gynecology and Obstetrics," Chicago, 1908, VII., p. 590.
10 Harte and Ashhurst, loc. cit.
11 " Proc. Eoy. Soc. Med.," 1909, II. (Surg. Sect.), pp. 238310.
559
DISEASES OF THE COLON.
ADHESIONS OF THE COLON.
Non-Operative Treatment While much can be done by non-
operative methods to prevent the formation of adhesions after
abdominal operations or after an attack of peritonitis, they often
fail when the condition has become well established. When
abdominal pain and discomfort are the chief symptoms complained
of, a thorough trial should be given to non-operative methods
before proceeding to perform laparotomy. In those cases where
there are recurring attacks of obstruction, palliative measures
seldom do any good, and operation is often the only method of
relieving the symptoms.
It is usually impossible to tell how much benefit will result from
careful medical treatment, and it is therefore always advisable,
unless serious symptoms are threatening, to try the effect of
massage and exercises, before proceeding to perform laparotomy.
Much can often be done by properly applied massage. For this
to be effective, however, it must be well done, and combined with
other forms of treatment. A skilled masseuse is essential. All
abdominal massage should be commenced gently. At first the
patient should be massaged for not more than ten minutes
twice a day. When possible, massage should be combined with
electrical treatment to stimulate the movements of the bowel. The
electrical application should be given first, and should be followed
by massage. After the first week, exercises against resistance
should follow the massage. These exercises should be those which
contract the abdominal muscles and which flex the spine and thigh.
Such exercises do good by moving the parietal peritoneum through
the agency of the muscles in contact with it.
Treatment should be continuous at first, and the shortest time
for a course which will do any real good is from a month to six
weeks. During this period the patient should not be kept in bed,
except, perhaps for the first few days, but should be sent out daily
for a short time. After a course of treatment the patient should be
instructed to take regular exercise, and to keep the bowels acting
daily. The best forms of exercise are walking and riding. If
marked improvement follows, the patient should have a second and
560
Adhesions of the Colon.
shorter course of massage and electricity in about two months'
time.
Injections of fibrolysin, a drug which is said to cause softening of
adhesions, have also been used in these cases, and good results are
claimed. The treatment is too new to warrant any opinion as to its
benefit, but as the injections do not seem to cause any unpleasant
results the drug may be tried in conjunction with massage. The
injections should be given intramuscularly, preferably into the
muscles of the buttocks, every two or three days.
In many cases, although some improvement follows a thorough
course of massage, the patient soon relapses to the old condition,
and in the worst cases little, if any, improvement occurs. Where
a definite obstruction from kinking has occurred, nothing short of
operation will do any good. Operation is indicated when there is
FIG. 1. Diagram illustrating how adhesions of the colon may cause
obstruction. A. Two appendices epiploicas adherent to one another.
B. Kink caused by adhesions between two limbs of pelvic loop. C. Acute
kink caused by a band of adhesion in meso-colon. From Mummery's
" Diseases of the Colon," Wright.
serious difficulty in getting the bowels to act, and also when the
patient is so greatly incapacitated by his symptoms that he is
unable to attend to the ordinary affairs of life.
Operative Treatment. The operation consists in separating or
dividing adhesions and re-establishing the normal course of the
bowel. It is not sufficient merely to divide the adhesions in any
case, since, if raw surfaces uncovered by peritoneum are left, the
adhesions are almost certain to re-form and re-establish the original
condition. The prevention of subsequent adhesions constitutes the
chief difficulty in these cases. Various methods have been
advocated by different surgeons, and various substances have been
used to cover the raw surfaces with the object of preventing the
formation of adhesions. Thus, painting the raw surfaces with gum
or glucose has been tried ; covering them with gold-leaf has also
been tried, with apparently good results. Filling the abdomen
Adhesions of the Colon. 561
with salt solution and subsequently giving large rectal or sub-
cutaneous injections of water or salt solution is the practice of
some surgeons, while others believe in abdominal massage and
electricity applied to the abdomen for some time after operation.
Undoubtedly the best method is careful suture of the peritoneum
over all the raw surfaces left by division of the adhesions. This
involves some form of plastic operation and considerable care and
patience. It is often possible, after dividing a peritoneal band
transversely, to stitch the resulting wound in the peritoneum in a
longitudinal direction, so as completely to cover in the raw surface
and at the same time straighten the bowel. By these means, and
by utilising loose folds of peritoneum, appendices epiploicae, or
omentum to cover in defects in the peritoneum, much may be done
to prevent the recurrence of adhesions. Absolute asepsis and
great care in removing all bloodclot from the peritoneal cavity
are, however, the most important factors in preventing their
formation ; and a subsequent course of massage and electricity is
advisable.
When the adhesions are very firm, or serious difficulty is
experienced in straightening the bowel, the best procedure is to
resect the involved loop and unite ends of the bowel if this can
be done, or to short-circuit the obstructing angle by lateral
anastomosis.
P. LOCKHART MUMMERY.
S.T. VOL. II. 36
562
COLITIS.
COLITIS may be due to many causes and the treatment must to a
certain extent depend upon the cause ; thus, for example, one of the
most severe forms of inflammation of the colon with which we are
acquainted is that which occurs behind an obstruction, e.g., that
met with when there is a malignant stricture of the rectum or
sigmoid, but in such a case it would be folly to treat the colitis
unless we first recognised the cause of it. Still, there are certain
general principles underlying the treatment of colitis, and the first
of these is to keep the bowel empty. No inflammation of the colon
can be expected to heal so long as the mucous membrane is bathed
in faeces. Thus, when there is a general enteritis, in which the
colon often participates, due to decomposing or improper food,
the variety of enteritis so frequently seen especially in the summer
among the children of the poor, the first thing to do, except in the
few instances in which the child is too collapsed, is to give an
aperient such, for example, as castor oil or calomel or grey powder,
to empty the bowel and clear away the irritating article of food
and also the faeces. It is true that nature often tries to do this by
the diarrhoea which is commonly associated with colitis, but usually
the attempt is ineffectual and must be helped by the administration
of a non-irritating aperient. When the natural diarrhoea is very
excessive, e.g., some cases of cholera, some of dysentery, some of
summer diarrhoea, the drain of fluid from the body may be so
great that it may not be justifiable to give an aperient at once, and
then some astringent unless the patient is very young or has
nephritis, opium in some form is best must be given and
chlorodyne is very useful, and at the same time a subcutaneous
saline infusion will be necessary to compensate for the loss of fluid
from the bowel. Normal saline, at 100 F., should be slowly run
into the subcutaneous tissue of the axilla or thigh ; it will run in at
about the right rate if the receptacle containing the infusion is a
foot above the point of entrance of the needle into the subcutaneous
tissue. Again, with the object of keeping the bowel empty, very
little food should be given to a person suffering from acute
colitis ; for the first twenty-four hours albumin- water is enough.
This is made by mixing the white of two or three eggs with a pint
of water, and it may be sipped in small quantities every hour.
Membranous Colitis. 563
Then next day milk, either citrated (2 gr. of sodium citrate to
each fluid ounce of milk) or peptonised to prevent curdling, may
be given in small quantities every hour. A patient with acute
colitis should always remain in bed and be kept warm. Nothing
is more foolish than for patients to struggle about while they have
severe diarrhoaa. Acute colitis is nearly always due to a micro-
organism, and therefore some cases are benefited by soured milk.
About a pint or a pint and a half a day may be used, and the milk
must be properly soured by the Bulgarian bacillus. There are
many useless soured milks sold, and the administration of the
tablets that are taken by many patients is quite ineffectual. The
milk may either be bought ready prepared or prepared in one of
the various apparatus that are sold. The determination of the
micro-organism which causes the colitis is often difficult, but if in
any way the more likely micro-organism can be found, the use of
a vaccine prepared from it sometimes appears to do good. I think
I have seen benefit from the employment of vaccines of bacillus
coli and those of pneumococci in suitable cases. Acute colitis is
not an infrequent accompaniment of nephritis. Perhaps here it
is an attempt, by means of the diarrhcea associated with it, to get
rid of some of the ursemic poison ; indeed, diarrhoaa is one of the
symptoms of uraemia. When there is reason to believe that
diarrhea is really the means of ridding the body of some poison
we should not be in a hurry to restrain it.
Membranous Colitis. A certain number of persons, mostly
women, pass mucus with their motions. This mucus, while still
applied to the inner surface of the bowel, has become coagulated
so that sometimes a hollow tube of coagulated mucus which is a
cast of the interior of the intestine is passed. More often the tube
is incomplete, and often by the time it is passed it is broken up into
many little pieces ; the patient then often complains that she
passes " skins." In rare instances the inflammation of the colon
which leads to the formation of these membranes is due to some
cause outside the colon ; thus, it may be caused by injury, for
instance, it was present in a case in which a cab wheel passed
over the abdomen ; it has followed the swallowing of corrosive
sublimate ; it is a rare accompaniment of severe pysemia ; it may
be associated with Bright's disease, pneumonia or diabetes ; but
in all these cases it is of quite secondary importance and calls for
no special treatment.
Ordinary membranous colitis arises from local trouble within the
large bowel itself, and this trouble is nearly always constipation.
Sometimes the constipation is due to an organic cause ; thus
362
564 Membranous Colitis.
membranous colitis may be due to malignant disease of the bowel
or to appendicitis, and in every case careful search must be made
for some organic cause. It is important to try from the history
and other points to discover whether, when associated with
inflammation of the appendix, the membranous colitis is secondary
to the trouble in the appendix, for then removal of the appendix
will benefit the membranous colitis, or whether the trouble in the
appendix is merely part of the membranous colitis, in which case
removal of the appendix will not benefit the patient. When all
the points here mentioned have been considered it will usually be
found that there is no organic disease in the abdomen to which
the membranous colitis can be ascribed, and then the case is one
of ordinary membranous colitis. The cause of the disorder in
women is nearly always constipation, and even if at the time the
patient is first seen she does not complain of constipation (in
exceptional cases she may have diarrhrea), yet a survey of the
history will almost always show that the trouble began with con-
stipation. The patient will not be cured unless the constipation
is overcome and, as in other varieties of colitis, it is necessary in
order to effect a cure to keep the large bowel empty. Experience
has shown that in these cases by far the most satisfactory way to
do this is by giving castor oil, and many cases of membranous
colitis may be completely cured with this drug. The patient should
take it every morning on waking, and if, as many people do, she
wakes about 5 a.m. and falls asleep again, she should take it about
five. A few prefer to take it on going to bed, for in women it often
takes a long while to act. Whenever it is taken the dose should
be such as to ensure that the bowels are thoroughly and com-
fortably open after breakfast. Often oz. or 1 oz. is necessary ;
the patient may take it in any way she likes. Some prefer it by
itself ; others float it in a little brandy or a little coffee ; others
like lemon juice, or the oil may be added to a teaspoonful of
peppermint water and then a little brandy added till the oil
neither sinks nor swims. If the inside of the glass and the rim
are moistened with whatever vehicle is chosen and the castor oil is,
as far as possible between two layers of the vehicle, it is hardly tasted
when swallowed. There are many varieties of castor oil in the
market which are almost tasteless. The pharrnacopreal mixture is
not to be recommended as it is nasty. Many patients who at
first declare they cannot take the oil soon overcome their repug-
nance to it and a thorough trial should be given to it, for there is
no doubt that it is the best drug to use, and many women liable to
membranous colitis keep it permanently in check by taking castor
Membranous Colitis. 565
oil. There is no harm in this, indeed usually the dose may with
safety be gradually diminished, and in many instances after a
time the oil may be left off, but some women take a little
regularly every evening or once or twice a week. Should it be
quite impossible for the patient to take castor oil, sulphate of
magnesium may be employed instead, and if this too disagrees
calomel overnight may be tried.
Many patients suffering from membranous colitis go to
Plombieres. Here the same principle, namely, that of keeping the
large bowel empty, is carried out by washing out the bowel from
the anus with water. This is done by skilled assistants, and the
pressure is controlled by varying the height of he receptacle con-
taining the water. When properly done, this method undoubtedly
can be made to wash out the colon, and many patients are much
benefited by a course of intestinal lavage once a year at Plombieres.
When it is decided to try intestinal lavage, which may be reserved
for cases in which the taking of castor oil has not been a success,
it is best, if possible, to send the patient to Plombieres, which,
however, is only open from early in May to the end of September ;
should Plombieres be impossible, trial may be made of Buxton or
Harrogate, where similar treatment is carried out. The attempt to
wash the bowel out systematically at home is nearly always a
failure, for it is not an easy thing to do, and often a tube which it
is believed has passed up into the sigmoid is really coiled up in the
rectum. From 1 to 2 pints of plain water may be used ; its
temperature should be about 100 F.
Because the cause of the membranous colitis is constipation,
and this, in women at least, is often due to deficient muscular
power of the abdomen, abdominal massage is very useful. It
should be carried out by someone who has been thoroughly trained.
The best time is in the morning before breakfast; it should be
done daily. After it is finished the patient should lie still for a
quarter of an hour, then get up, have her bath and breakfast. It
is often of great advantage before the massage to make her perform
exercises with a view of strengthening the muscles. Any good
masseuse ought to be able to teach them to the patient. They
should never be done long enough to cause fatigue. The following
are useful : Exercise 1 : The patient should lie flat on her back on
a firm bed or the floor, with her hands by her sides. The knees
should be drawn up to the chest and then the legs straightened out
at right angles to the trunk. With the knees kept stiff, the legs
should then be slowly lowered until they again touch the bed.
Exercise 2 : With the patient lying as before, the right leg, with
566 Membranous Colitis.
the knee kept stiff, should be slowly raised till it is at right angles
with the body. It should then be slowly lowered again, still with
the knee stiff, stopping for a few seconds at different angles with
the trunk. Two or three stops should be made before the leg again
rests on the bed. The same exercise should be carried out with the
left leg. Exercise 3 : The patient should lie on the floor, with
her hands by her sides. Then, while her legs are held down, she
should slowly raise herself into a sitting posture without using her
hands. The body should then be twisted round, first in one
direction and then in the other ; she should then slowly lie down
again. Exercise 4 : The patient stands up and slowly raises first
one leg and then the other. Each knee should be brought up
until it touches the chest. Exercise 5 : The patient stands with
her hands on her hips, and slowly rotates the body first in one
direction and then in another. Exercise 6 : Repeat Exercise 2,
but with both feet together instead of alternately. Exercise 7 :.
The patient sits on the floor, and the feet are held down ; she then
slowly sways herself backwards and forwards from the hips.
Exercise 8: With the hands on the hips, the patient squats down
on her heels, then slowly raises herself into the standing position,
and again slowly lowers herself until she is sitting on her heels.
This should be repeated two or three times.
It is not uncommon to find that patients who suffer from
membranous colitis have one or both kidneys abnormally
movable. Their abdominal muscles are lax, and in a few cases their
intestines and stomach have dropped. The wearing of a proper
abdominal support is of great help in such cases, and this is best
effected by stays made to grip the iliac crests instead of the ribs.
These stays should have a centre vertical piece and lace up in two
lateral lines, each about 2 inches from the middle line ; the centre
piece is fixed by being attached to the stockings by means of
tapes. The patient stands in the erect posture and draws a deep
breath, by which means the abdominal muscles are drawn in and
the viscera are forced up, while she holds her breath the stays are
then laced up firmly from below upwards.
Sufferers from membranous colitis often attach an exaggerated
importance to the effect of diet. Whatever food the patient takes
she should masticate it well. The diet should be ample. Most of
these patients decline first one article of food and then another,
until at last their dietary is so restricted that they are not only
underfed but their digestive powers are overtaxed in some par-
ticular direction. An obviously indigestible dietary, such as one
consisting largely of made dishes or an undue preponderance of
Membranous Colitis. 567
sweets, should be avoided, but the patient should partake of any
ordinary food that is put before her. It should be well cooked and
the meals should be made as tempting as possible to the slender
appetite. Even if it is an effort she must eat well. She should
have her meals at regular times and should go to bed early and
always have eight hours sleep. Some have advised that the food
should be predigested and others, as von Noorden, have advised
that the diet should contain much bulky indigestible food. I have
known both these succeed, but ordinary diet succeeds as often as
either and has the advantage that it does not foster valetudinarian
habits.
Between the severe, attacks the patient should in all respects lead
as healthy a life as possible. She should take plenty of outdoor
exercise of a kind to interest her and take her out of herself ;
riding or playing golf is infinitely preferable to dull solitary walks
taken merely for the sake of exercise. A holiday and change of
scene to some such bracing place as Switzerland or Norway, or a
yachting cruisel are often of the greatest benefit. Indeed, these
patients derive much benefit from such a holiday, even when they
are not passing membrane. For a severe case, rest in bed, possibly
morphine injected subcutaneously, and the application of hot
fomentations to the abdomen may be necessary ; but opiates should
not be prescribed unless they are absolutely necessary, for not only
do they increase the constipation but sufferers from membranous
colitis are just the sort of people who may become addicted to an
excessive use of these agents. In some cases the daily passage of
high-frequency currents has certainly done good.
Some patients are unrelieved even if all the above methods of
treatment have been tried, still our object must be to keep the large
bowel empty of faeces. This might be done by a short circuiting opera-
tion, but there are objections to this, for it does not entirely prevent
the presence of faeces in the colon nor does it allow of a satisfac-
tory discharge of the natural secretions of the colon. In 1895
Mr. Golding-Bird and I published an account of a case in which an
artificial anus was established by opening the colon immediately
above the ccecnm. The fasces were passed through this and the
colon was washed through from the artificial to the natural anus.
By this treatment many cases of membranous colitis which
have not improved by non-operative treatment may be cured ; but
there are two objections to the operation, the most important is
that the faeces on the right side are very liquid and it may be very
difficult to prevent their causing inflammation of the skin and
secondly, to cure the disease it may be necessary to keep the
568 Ulcerative Colitis.
opening patent for a year, and in that time the colon may become
so shrunken from disease that it may be difficult to get the faeces
to pass along it. A far better operation is to open the appendix
(appendicostomy) and wash the colon through the opening. See
pp. 571573.
Ulcerative Colitis. The colon may be ulcerated as a result of
many diseases, e.g., tubercle, cancer and typhoid fever, but in this
country we understand by ulcerative colitis a disease in which the
ulceration is not due to any easily recognised cause, is extensive,
often destroying almost all the mucous membrane and looking very
much like the ulceration produced by dysentery. This is not the
place in which to discuss whether ulcerative colitis and dysentery
are the same disease,-but even if in all cases of ulcerative colitis the
ulceration is previously caused by one of the micro-organisms
which cause dysentery, yet by the time the case comes under
observation the ulceration is at any rate kept up by bacillus coli.
The treatment is difficult, indeed many sufferers die. The patient
must be put to bed and kept there many weeks. Citrated milk
with eggs beaten up in it forms a good diet. Three pints of milk
with an egg beaten up in each pint may be taken in twenty-
four hours. This is hardly enough food, so if possible two feeds a
day of Benger's, Allen and Hanbury's, or some similar infant's food,
may be given. Often the diarrhoea is so excessive that, as it
weakens the patient, it is necessary to give opium to check it.
There is no better way of doing this than giving chlorodyne, but if
there is not much diarrhoea it will be well to give small doses of
castor oil to keep the bowels thoroughly cleared out. When one
sees the state of the intestines after death it seems extremely
unlikely that intestinal antiseptics can be any use, but soured milk
may be tried or 3 min. of cyllin in capsules may be given four or
five times a day.
Whatever may have been the original cause of the ulceration, by
the time that many of these cases reach the chronic stage the
dominant micro-organism is probably often bacillus coli and some-
times good may follow vaccine treatment, the vaccine being
prepared from the patient's own bacillus coli. An instance of the
good that may follow is the case of a boy aged seventeen, seen in May,
1908. He had had severe ulcerative colitis for many months,
passing blood and mucus. He was wasted, confined to bed, had
seen many doctors, but no treatment had done good. Bacillus coli
communis was isolated from the faeces and a vaccine prepared.
He was given small initial doses, rapidly increased to 50,000,000 at
each dose given fortnightly. He gradually improved. The vaccine
Ulcerative Colitis. 569
treatment was continued until March, 1909, although in February,
1909, he was well, the diarrho3a and passage of blood and mucus
having ceased for a long while. He gained weight, went to his
work, and was still quite well two and a half years after he was
first seen. The following is another instance : The patient, a boy
aged twelve years, had had ulcerative colitis for four years, passing
blood and mucus and having pyrexia, pain and tenderness. Bacillus
coli communis was isolated from the fteces, an autogenous vaccine
was prepared ; he had doses varying from 5,000,000 to 50,000,000
at intervals of a week for three months. At the same time he was
given 2 pints of soured milk and three drops of cyllin three times a
day. The improvement was immediate and rapid and he was soon
well, and when seen some months later was still well. ,,
If the patient does not improve after any of the treatments here
mentioned or he relapses after a fair trial of vaccine treatment,
the appendix should be opened and the bowel washed through with
boiled water at the temperature of the body two or three times a
day. I have seen some remarkable successes after this operation.
W. HALE WHITE.
57
THE SURGICAL TREATMENT OF COLITIS.
CHRONIC MUCOUS COLITIS.
IT cannot be too strongly insisted upon that it is quite useless to
attempt the treatment of this condition either medically or
surgically unless the diagnosis has been carefully verified.
The mere fact that a patient is passing large quantities of mucus,
either in the form of shreds or membrane, in the stools, and is
suffering from attacks'of abdominal pain, is not sufficient to warrant
a diagnosis of chronic colitis. Such symptoms may and often do
result from such widely different lesions as cancer of the colon,
chronic appendicitis and floating kidney. From the symptoms
alone these conditions cannot b'e diagnosed with certainty from true
cases of chronic colitis. If steps are not taken to eliminate such
causes for the symptoms before proceeding to treat the case, failure
is more than probable. The greatest care must, therefore, be taken
to verify the diagnosis by examination of the abdomen, if necessary
under an anaesthetic, by microscopical examination of the stools
and by all the other means at our disposal. Of these by far the
most important is a direct examination of the pelvic colon by
means of the sigmoidoscope. In true cases of chronic mucous
colitis a sigmoidoscopic examination will reveal a chronic inflam-
matory condition of the mucosa of the pelvic colon. Quite
frequently, however, the examination reveals a healthy condition
of the mucosa, but some localised lesion is discovered in this or
some other portion of the large bowel. The symptoms, in fact,
may result from any irritative lesion in the colon, and an actual
inflammatory condition is only present in about 40 per cent, of
the cases presenting themselves for treatment. I do not personally
believe in the so-called hysterical or neurasthenic type of colitis.
Undoubtedly neurasthenia is often present to a marked extent, but
this is no proof that it is a cause of the bowel symptoms, and in
almost all cases a careful examination will reveal some definite
pathological cause. In some cases an exploratory laparotomy may
be necessary to ascertain the cause of the condition, but this should
not be done until other methods have failed.
The treatment of those cases in which an examination has
demonstrated the presence of some definite local lesion cannot be
discussed here, as it will naturally depend upon what is found, but
The Surgical Treatment of Colitis. 571
the treatment will be found elsewhere under the appropriate
heading, the obvious indication being to remove the cause when
possible. I shall here only describe the treatment for those cases
in which there is a definite chronic inflammatory condition of the
mucosa ; that is to say the cases in which a true colitis is present.
Surgical treatment is only indicated after a thorough trial has been
given to medical treatment and this has failed to give permanent
relief. There are a large number of cases in which no improve-
ment occurs after medical treatment, or which improve only to
quickly relapse again, and it is in these cases that surgical treat-
ment often gives relief and saves the patient from becoming a
chronic invalid.
We have to bear in mind that the condition is not a fatal one,
and that it is not, therefore, justifiable to perform operations which
involve a serious risk to life.
Surgery has attempted to deal with chronic mucous colitis in
two ways : (1) By deflecting the faecal current so as to give rest to
the colon ; (2) by establishing an opening through which the colon
can be washed out daily.
Of these the first was the method adopted in all the early cases,
a colotomy or caecostomy opening being established on the right
side and the faeces being prevented from passing to the anus.
Csecostomy. The results of this operation are quite satisfactory
as regards getting rid of the symptoms, but it is necessary to retain
the opening for a considerable time, at least a year in most cases,
or the symptoms will recur. The inconveniences of a csecostomy
opening, however, are so great that they more than counterbalance
any advantages from the operation. Fluid faeces are constantly
coming away from the opening, and the patient is rendered more
or less of a chronic invalid while the opening is maintained.
Moreover, a caecostomy opening is sometimes very difficult to close,
and may become permanent. i -,
Appendicostomy or Valvular Caecostomy.- By this is meant
establishing an opening into the caecum through which the colon
can be washed out. This operation is open to none of the objec-
tions of caecostomy or colotomy. If properly made the opening
does not leak at all and causes the patient no inconvenience
whatever ; moreover, it can be closed at any time without an opera-
tion. It is practically free from risk in experienced hands, and the
patient is in no way prevented from attending to his ordinary
occupation.
The Operation of Ajytendicostomy. The operation is performed
as follows : An oblique incision is made over McBurney's point
572 The Surgical Treatment of Colitis.
in the same way as in the ordinary operation for appendicectomy.
The incision need only be a short one, and 1 inches is often
sufficient. The " gridiron " incision is an excellent one, the
muscles being split in their length instead of being divided. The
peritoneal cavity is opened and the appendix found." The rneso-
appendix is then, if necessary, divided close to the appendix
for from ^ to 1 inch, depending upon the length of the appendix ;
but in any case care should be taken not to sever the artery of the
appendix. If it is cut there is risk of the appendix sloughing
through lack of adequate blood supply. The appendix is then
brought out of the wound and pulled up until the c<ecal wall comes
well up against the parietal peritoneum. One or two catgut sutures
are inserted, so as to anchor the csecal wall to the fascia and
parietal peritoneum. Two or three stitches will then suffice to
close the remainder of the wound. Lastly, a single stitch should
be passed through the wall of the appendix, so that it can be
anchored to the skin and prevented from retracting. The dressings
are then applied and the operation is finished. In applying the
dressings a roll of gauze should be placed on each side of the
appendix to prevent the blood supply being damaged by the pressure
of the bandage.
If there is any doubt about the patency of the appendix it should
be opened at once, but if it is large and healthy it may be left, and
opened two or three days later.
In performing the operation, and especially in closing the wound,
the importance of preserving the blood supply of the appendix
should be borne in mind.
On the second or third day after operation the dressings should
be removed and the appendix should be cut off about i to ^ inch
from the skin. It is better not to cut it flush with the skin. An
appendicostomy catheter (No. 7 or No. 10) can then be passed into
the caecum through the stump of the appendix, and irrigation
commenced. Later, any mucous membrane that projects above the
skin level can be cut away, but it is advisable in doing this to cut
one half at a time or to dissect out the mucous membrane and
suture it to the fibrous coat of the appendix stump or to the skin.
When the appendix is cut through the mucous membrane tends to
retract into the abdomen, and this if not detected will destroy the
opening. In dividing the appendix, therefore, care must be taken
to prevent the mucous membrane retracting. Some surgeons get
over this difficulty by passing a catheter into the appendix and
ligaturing the appendix on to it flush with the skin. In a few days
the ligature cuts through and the catheter can be withdrawn. The
The Surgical Treatment of Colitis. 573
objection to this is, that if the catheter is at all a tight fit it
may cause the mucous membrane to slough from the pressure
it exerts.
If the appendix is cut off at or soon after the operation, a certain
amount of superficial suppuration in the wound will probably
occur, and this often leads to some stricture at the orifice. The
catheter should only be inserted in the canal for irrigation. The
fluid used for irrigation of the colon through the appendix should
be plain water. Very weak solutions of argyrol or protargol may
be used (about 0'5 per cent.), but ordinary antiseptics are not
permissible, as a large amount of absorption takes place in the
colon.
It may happen that at the operation the appendix is found to be
diseased, deformed or rudimentary ; in such cases considerable
modification of the technique will be necessary, and in some cases
it may not be possible to utilise the appendix at all. Under these
circumstances it should be removed and some form of valvular
caecostomy should be performed.
Valvular Ccecostomy. A small opening is made in the wall of
the caecum just large enough to admit the end of a No. 10 rubber
catheter. The end of the catheter is passed through this hole for
about f of an inch. A series of Lembert sutures is then commenced,
well beyond the hole, and continued over the catheter for about
1 inches. These should be so placed that, when they are tied up,
the catheter will be buried in the wall of the csecum for about
1 inch. That part of the ceecal wall through which the catheter
passes is then anchored firmly to the bottom of the wound, the
base of the catheter is brought out of the wound, and the remainder
of the wound is closed.
This makes a very good opening which does not leak, but it is
necessary that a small rubber plug should be worn to prevent the
opening from contracting. In any case the opening should not be
closed too hastily, and at least nine months should be allowed to
elapse. If at the end of this time there has been no recurrence of
the symptoms, the opening may be allowed to close. This it will
do, as a rule, by the skin healing over it. If it is allowed to close
in this manner there will be no difficulty in reopening it later if
necessary.
As a rule, the symptoms rapidly clear up and the improvement
in the patient's general condition is quite remarkable.
Other operations which have been suggested for this condition
are ileo-sigmoidostomy and left inguinal colotomy. The latter is
quite useless and unjustifiable, as it does not get above the disease.
574 The Surgical Treatment of Colitis.
Ileo-sigmoidostomy is a serious operation and leads to considerable
trouble later, owing to the accumulation of faecal material in the
occluded colon.
KUEMORRHAGIC COLITIS.
This is a most serious disease characterised by profuse and
intractible diarrhoea, much blood in the stools and a high
temperature. It is an acute condition, and due, at any rate in
some cases, to a primary infection by the diplococcus pneurnonise.
Dangerous anaemia and emaciation occur rapidly and any tem-
porising with palliative measures is contra-indicated. The con-
dition can be diagnosed with certainty by a sigmoidoscopic exami-
nation. The best treatment is immediate appendicostomy, and the
colon should then be washed out with water or a weak solution of
Witch hazel until the solution leaves the anus quite clean. The
colon should then be washed out every few hours until all bleeding
has stopped, after which it may be washed out twice daily.
This treatment rapidly controls the haemorrhage and gets rid of
the poisons which are being absorbed from the colon.
PERICOLITIS.
By this we mean an inflammation (usually chronic) around the
colon. In the characteristic condition there is much thickening
(often tumour formation) and stricture, and, in addition, there may
be abscess formation. This condition often gives rise to much diffi-
culty in diagnosis, as it is easily mistaken for inoperable cancer. In
the more acute form it closely resembles in symptomology chronic
appendicitis, except that the locality is different. Pericolitis may
call for operation for any of the following reasons : (1) Stricture
of the colon ; (2) tumour formation with or without stricture ;
(3) abscess formation ; (4) perforation and peritonitis.
When there is a stricture with tumour formation the condition
may so closely resemble an inoperable cancer that it can only be
distinguished by microscopical examination, and many of the cases
in which patients apparently suffering from cancer of the bowel have
recovered after colotomy or exploratory laparotomy have been
cases of this description.
When stricture or a tumour due to pericolitis has been diagnosed
the best treatment, in fact the only treatment, is operation. The
affected portion of bowel should be resected and the ends
anastomosed or brought out and Paul's tubes tied into them.
While the former is the ideal operation, the latter is the safer
The Surgical Treatment of Colitis.
575
operation, and should be preferred when the patient's condition
causes anxiety.
Very good results also follow operations in which the affected
portion of colon is short-circuited by lateral anastomosis, and this
operation should be chosen in place of resection, when, owing to
FIG. 1. X-ray photograph showing a stricture in the pelvic colon
due to pericolitis ; note the narrow lumen and diverticulae which
have caused the condition.
surrounding adhesions or fixation of the colon, resection is likely
to be attended with much difficulty.
Localised Abscess. -The obvious treatment is to open the
abscess and adequately drain it, while at the same time preserving,
as far as possible, the natural adhesions which are protecting the
general peritoneal cavity. The abscess may be very extensive, and
in order to establish adequate drainage, counter-openings in the
576 The Surgical Treatment of Colitis.
loin may be required (see also Subphrenic Abscess, p. 643). Much
difficulty may be experienced in locating the abscess owing to
dense and extensive adhesions.
Perforation and General Peritonitis. In these cases, though
a careful toilet of the peritoneum and the establishment of adequate
drainage may suffice, it is advisable, if possible, to find, and close
by sutures, the perforation in the colon. Where the perforation is
due to the rupture or sloughing of a diverticulum it may not be
single, or other diverticula may be so nearly in the same condition
as to threaten to perforate. Also when, as often happens, the per-
foration has occurred in a dense mass of fibrous tissue and adhesions,
very great difficulty may be experienced in closing the perforation.
ULCERATIVE COLITIS.
I do not propose here to deal with tropical dysentery, but only
with ulcerative colitis as seen in this country. The condition is a
very serious one, and until quite recently, had a mortality of over
50 per cent. The diagnosis is readily made by means of the
sigmoidoscope ; it need hardly be said, however, that in these cases
the instrument should only be employed by an expert in its use.
Immediate operation is indicated in all cases, as although some
cases recover without operation, recovery under these circumstances
is slow and tedious and recurrences are frequent.
There are two methods of treatment by operation : (1) The
formation of an artificial anus in the caecum to give rest to the
colon ; (2) appendicostomy and irrigation of the colon.
Ileo-sigmoidostomy has also been suggested, but as it will almost
certainly involve performing an anastomosis with ulcerated bowel,
it is contra-indicated. Moreover, apart from this, the patient is
seldom in a condition to stand so serious an operation.
A right-sided colotomy usually causes arrest of the ulcerative
process, and good results follow the operation, but it is not always
possible to close the opening and the operation leaves a most
objectionable condition.
By far the best operation for these cases is appendicostomy,
and this operation has given excellent results ; the ulcers quickly
heal and the diarrhoea is controlled. It acts in two ways ; by
keeping the ulcerated areas clean it enables healing to occur, and
by removing from the colon the poisonous products of inflammation
and decomposition it prevents their absorption. It has none of
the disadvantages of a right-sided colotomy, and the results are
even better.
The operation should be performed as early as possible before
The Surgical Treatment of Colitis. 577
the patient has become seriously emaciated, though it will often
save life even when done as a last resort.
For a description of the operation the reader is referred to the
article on Mucous Colitis.
The colon should at first be washed out at frequent intervals
and later, when the diarrhoea has been controlled, twice daily. At
first some astringent, such as Witch hazel, may be added to the
water used for irrigation, or a weak silver solution may be tried,
such as 5 per cent, argyrol or protargol, but only a small quantity
FIG. 3. Ulcers in the colon, as the
result of chronic constipation
in an old woman.
(From Mummery's " Sigm'oidoscope," Bailliere.)
FIG. 2. Ulcerative Colitis, us seen
through the Sigmoidoscope.
should be used, say \ pint, and it should be washed out again in ten
minutes with plain warm water.
When the symptoms have all cleared up, the irrigation may be
stopped, but the opening should be kept patent for at least nine or
ten months.
P. LOCKHART MUMMERY.
REFERENCE
" Discussion on Ulcerative Colitis," Prop. Roy. Soc. of Med., 1909, II. (Med.
Sect.), pp. 5999.
S.T. VOL. II.
37
578
CANCER OF THE COLON.
CANCER of the colon may be very successfully treated by opera-
tion, and excellent results can be obtained as regards both the
subsequent comfort of the patient and freedom from recurrence of
the growth.
Growths of the colon tend to remain localised in the bowel wall
for a long time and do not readily cause secondary involvement of
glands. They increase slowly, and
but seldom, and only in their later
stages, give rise to metastatic deposits
in other parts of the body. They do
not readily become adherent to im-
portant organs, though an exception
to this statement must be made in
the case of growths of the transverse
colon, which frequently involve the
stomach. Large portions of the
colon can be removed without
causing the patient any serious sub-
sequent inconvenience or preventing
him from enjoying life.
The most important factor, as in
cancer anywhere else in the body, is early diagnosis. Our methods
of diagnosing cancer of the bowel have much improved in recent
years, and it is now the exception for a growth to reach a large
size before it is recognised. Perhaps, fortunately, cancer of the
colon draws attention to itself at an early stage by producing
obstruction. In many cases cancer is first detected at an operation
undertaken for the relief of obstruction. (For the treatment of
Acute Intestinal Obstruction the reader is referred to p. 528.)
I shall deal here only with those cases in which cancer of the
colon has been diagnosed or is suspected, and cases in which an
operation is undertaken on account of chronic obstruction in the
colon.
When there is chronic obstruction the choice of method must
depend upon whether or not it is possible to empty entirely the
bowel above the stricture. If it is possible by means of aperients
satisfactorily to empty the bowel, and the surgeon is certain that
FIG. 1. Cancer of the colon, as
seen through the Sigmoidoscope.
(From Mummery's " Sigmoido-
scope," Bailliere).
Cancer of the Colon. 579
there is no accumulation of faecal material above the growth, then
resection of the growth and immediate end-to-end or lateral
anastomosis of the bowel is indicated.
But if the bowel cannot be so emptied the case should be treated
in the same way as if acute obstruction existed, viz., by removal of
the growth and the establishment of a temporary artificial anus, or
by simple colotomy above the growth. This, though it entails the
patient undergoing at least two operations, is infinitely safer than
performing an anastomosis with an accumulation of faeces above
the line of suture.
An operation for cancer of the colon should aim at removal of
the growth, and also of the whole of the neighbouring lymphatic
area. This can be done without serious difficulty in most parts of
the colon, but it often entails sacrificing considerable lengths of
bowel in order to preserve the blood supply. The bowel should be
divided at least 2 inches away from the growth, both above and
below. Also, a large wedge-shaped portion of the mesocolon
should be removed, together with the growth ; and if any enlarged
glands are discovered in the root of the mesentery the peritoneum
should be stripped up and the fat and lymphatics cleared out as
freely as possible. Glands should be looked for along the inferior
mesenteric artery, as the main chain of lymphatic glands lies in
close relation to this vessel.
The mere fact that the growth is large is no contra-indication to
its removal ; adhesions, also, are not necessarily contra-indications,
provided that they do not involve important structures which
cannot be dealt with. Portions of the stomach and bladder have
been successfully removed, together with the growth, without
serious consequences. Other portions of bowel adherent to the
growth can be dealt with by resection. It is well to remember
that all enlarged glands in the neighbourhood of a growth are not
malignant. There have been several instances in which a growth
of the colon has been removed and enlarged glands left behind, in
which no recurrence has taken place.
Methods of Dealing with the Colon after Resection of the
Growth. There is considerable choice of methods, and the one
selected must depend, to a large extent, upon the conditions present.
(1) Immediate Anastomosis. This should only be performed
when we are quite certain that the bowel above the point of union
is free from any collection of faeces. The bowel may be joined
either by end-to-end or by lateral anastomosis. End-to-end
anastomosis is only suitable when dealing with the pelvic colon.
The ends of the bowel are controlled by clamps and brought out of
372
580 Cancer of the Colon.
the abdomen. Any mucous membrane which projects beyond the
other coats is trimmed off, and then the two mesenteric edges are
carefully stitched together by a suture taking up all the coats.
The sutures are then continued round each side of the bowel until
they meet at a point opposite the mesocolon. The knots should be
tied on the inner aspect of the bowel. When this line of suture is
completed, another uniting the peritoneal coats only is inserted.
Lastly, the two edges of the mesocolon are sewn together.
Lateral anastomosis is performed in the same way as for the
small bowel. Most of the failures which occur after anastomosis of
the colon are due to sloughing, owing to the blood supply having
been damaged, and great care must be taken to see that there is an
adequate blood supply to the edges of the anastomosed bowel.
(2) A Preliminary Short-Circuiting Operation followed by Excision.
This is a less severe operation than immediate anastomosis,
but entails two operations. A portion of the colon above the
growth should be united to a portion below by lateral anasto-
mosis, care being taken to go well wide of the growth or difficulty
will be met with when the growth is removed. The second opera-
tion should be performed three weeks later ; the growth is removed
and the ends of the bowel are closed.
(3) Paul's Operation. This consists in bringing the two ends of
the bowel out of the abdomen after resection, and tying a glass
tube into each. The two ends of bowel are joined side by side
with sutures for about 2 inches. A fortnight later the spur
between the two ends of bowel is destroyed by an enterotome and
the opening allowed to close. This operation, though it entails a
temporary colotomy, is by far the safest method, and has a very
low mortality.
Excision of Growths in the Csecal Region. These lend them-
selves readily to extensive resection, as the entire caecal angle of
the colon can be freed and removed together with the growth.
Any attempts to resect portions of the caecum will probably end in
failure, both as regards removal of the disease and also satisfactory
restoration of the parts. The best method of dealing with the
bowel after resection is to implant the ileum into the ascending
colon after closing the latter.
Palliative Operations. Even when the growth cannot be
removed much may be done, by the performance of a suitable
operation, to render the patient more comfortable and to prolong
his life. The operations which may be performed for this purpose
are :
(1) Excision of as much of the growth as possible.
Cancer of the Colon. 581
(2) Short-circuiting the growth.
(3) Making an artificial anus above the growth.
Some surgeons have advised that, even when it is found at the
operation that there are glands which cannot be removed, or
metastatic deposits in the liver, the best plan still is to excise the
primary growth, and that this will give the patient a longer lease
of life than short-circuiting. There is a good deal to be said for
this view. If the primary growth can be easily removed without
much danger to the patient, this is probably the best treatment ;
but it does not seem right to subject the patient to a dangerous and
prolonged operation if there are secondary deposits already present.
Short-circuiting the growth is undoubtedly the best method when
it is found that excision is impossible. It obviates the danger of
obstruction and saves the patient from the discomforts of a
colotomy.
Colotomy above the growth should only be performed when there
is acute obstruction, or when short-circuiting is impossible owing
to the growth being too low in the pelvis to leave any bowel below
it, with which an anastomosis can be established.
COLOTOMY.
The commonest form of colotomy is left inguinal colotomy.
There are a few cases, however, in which lumbar colotomy
is more suitable, and this operation will also be described.
Transverse colotomy does not differ in any important particular
from the left inguinal operation. "When it is necessary to establish
an opening into the right side of the colon, caecostorny or a right
lumbar colotomy is performed : the latter is preferable, as the
control obtained is better.
Left Inguinal Colotomy. A small vertical incision is made
through the abdominal wall over the junction of the middle and
outer thirds of the left rectus muscle, and with its upper end just
below the level of the umbilicus. The fibres of the rectus muscle
are separated with a blunt instrument and the posterior sheath of
the muscle and peritoneum divided. Through this opening a loop
of sigmoid is pulled out. The bowel is then pulled down until
that portion nearest to the descending colon which can be made to
reach the opening is found, and this is used to form the colotomy.
A spur ''is now made, either by means of a mattress-stitch passed
through the meso- sigmoid, or preferably by a glass rod or a clip
which is passed through the meso- sigmoid and allowed to rest on the
skin on each side of the wound. A stitch is passed through the skin
at the end of the incision and through the anterior longitudinal
582
Cancer of the Colon.
band. Such a stitch should be inserted at both ends of the wound,
to anchor the bowel and prevent any further prolapse. Unless a
large incision has been made, one stitch at each end is usually
sufficient. If there are any large appendices epiploicas, they should
be ligatured and removed.
In many text-books the position for the incision is given as the
junction of the middle and outer thirds of a line between the
umbilicus and the left anterior superior spine. While this incision
is directly over the colon, it has the disadvantage that afterwards,
l-lG.2. Method of performing inguinal colotomy, using a clip to
form the spur. (From Mummery's " Dis. Colon," Wright.)
when a cup has to be fitted over the colotomy opening, the end of
the cup tends to ride up on the iliac crest as the patient walks or
moves, and this results in leakage and discomfort.
The bowel is usually opened on the second day after operation.
No anaesthetic is required for this purpose. A small transverse cut
is made into the bowel with a pair of scissors. An alternative
method which makes it possible to keep the wound clean until
healing is almost complete, and which also is preferable if it is
advisable to open the colon at once, is to tie a Paul's tube into the
bowel. Eight days after operation the bowel should be completely
Cancer of the Colon. 583
divided by cutting it right across, and at the same time any
redundant bowel projecting above the skin can be cut off.
Several new methods of performing colotomy have been devised
with the object of giving the patient better control over the open-
ing. The earliest of these consisted in giving a twist to the bowel
above the opening, or in stricturing it by means of a ligature ;
these, however, did not prove satisfactory, and have been abandoned.
Witzel was the first to suggest making a valvular opening in the
abdominal wall. This was done as follows : A loop of sigmoid
colon was first brought out through the usual colotomy incision,
and another smaller incision was made below the pelvic brim. A
space was then opened up between these two incisions by separating
the internal and external oblique muscles, and the loop of bowel was
dragged through this space and stitched to the skin at the lower
opening, the upper opening being completely closed.
Bailey's modification of this method consists in opening up a
space between the skin and external oblique muscle, and bringing
the colon out through an incision just above Poupart's ligament.
The writer's experience of these methods of valvular colotomy
is that they give no better control than the operation already
described, as the opening tends after a short time to straighten out
and the valvular arrangement is obliterated. Also, they result in
the opening being very inconveniently placed.
Lumbar Colotomy. The patient is laid upon his side with a
firm cushion or sand-bag under the loin, in order to flex the trunk
sideways and open out the space between the last rib and the iliac
crest. The position of the colon is indicated by a vertical line
drawn upwards from a point ^ inch behind the mid-point between
the anterior and posterior superior spines of the ileum.
An oblique incision is made, with its centre over this line and
midway between the last rib and the crest of the ilium. The
incision should be about 3 inches long. The anterior edge of the
quadratus lumber um should be exposed in the back of the incision,
and, if necessary, partly divided. The wound is then deepened
until the transversalis fascia is met with. On dividing this the
cellular tissue and fat are seen, and when these are separated the
back of the colon will be exposed in the bottom of the wound.
The colon is pulled up into the wound and fixed to the skin by
sutures all round, an oval surface of colon being left exposed. If it
should be necessary to open the colon at once, a Paul's tube or one
of the writer's rubber tubes should be tied in, otherwise the colon
is opened by a longitudinal incision at the end of twenty-four
hours.
584 Cancer of the Colon.
If the colon is found to have a mesentery, and it is not possible
to expose it extra-peritoneally, the peritoneum should be opened in
front of the colon and the bowel brought out in the same way as in
performing inguinal colotomy. The colon is more likely to have
a mesentery on the right than on the left side.
Colotomy by Paul's Method. This is frequently the best
and safest method of dealing with the bowel after resection of part
of the colon.
The colon is exposed and brought out of the wound in the same
way as in performing inguinal colotomy. The wound having been
first shut off by gauze packing, the colon is divided, and a Paul's
glass tube of suitable size tied into each end by a silk ligature.
The two portions of colon are then sewn together side by side for
about 2 inches of their length with silk sutures, with the object of
ensuring the walls being in contact later, when the enterotome
is used.
The tubes come away in about a week, and some three weeks
later the spur is destroyed by means of an enterotome. After the
spur has been destroyed, the continuity of the bowel is re-established,
but a faecal fistula still remains, which in course of time usually
closes of itself ; but it may be many months before this occurs,
and it is better, as a rule, to close it by operation.
Caecostomy. This operation is performed when it is not possible
to perform colotomy, or when a colotomy opening will not be above
the seat of obstruction. It is also sometimes done to deflect the
faecal current from the colon in cases of ulcerative colitis.
The caecum is exposed through an oblique incision, the centre of
which lies over a point halfway between the umbilicus and the
right anterior superior spine of the ileum. The anterior wall of
the caecum is drawn out of the wound, and a small circular area of
the caecal wall about | inch in diameter is enclosed in a purse-
string suture. This portion of the caecal wall is then held up by
an assistant, and a small incision into the caecum is made in the
centre of the circular area ; through this one end of a Paul's tube
is pushed, and the purse-string suture is then tied firmly on
to the tube. The caecal wall is stitched into the wound and the
latter closed, leaving the Paul's tube projecting.
Owing to the liquid nature of the contents of the caecum, the
control over this opening is very unsatisfactory, and the surround-
ing skin often becomes sore and excoriated. This may to some
extent be prevented by keeping the parts well greased with lanolin.
P. LOCKHART MUMMERY.
585
CONGENITAL ABNORMALITIES OF THE COLON.
VERY few congenital abnormalities of the colon can be diagnosed
during life or are within the scope of surgical interference when
detected. Congenital abnormalities of the mesocolon are an
important cause of volvulus, but their treatment falls under that
heading. The only condition which we need consider in detail
is congenital dilatation and hypertrophy of the colon (some-
times called " Hirschsprung's Disease ")
When treating cases of this condition it is necessary to remember
that we have to deal with a colon which has become converted into
an enormous sac, often 6 or 8 inches in diameter, and that
this dilated colon is acting as a cesspool for faecal material. The
symptoms calling for treatment are usually those of obstruction
due to the outlet from the sac having become blocked or to the
formation of a mass of hard faecal material which cannot be
passed on.
J[7/<' xtittiptoms of acute obstruction hare occurred every effort
should be made to relieve the obstruction without resorting to
operation, for colotorny usually proves fatal, as the weight and size
of the colon cause the stitches to tear out. In the vast majority of
cases, if not in all, the obstruction can be relieved by repeated
large enemata injected into the bowel, and this treatment should be
persisted in until the obstruction has been removed. If the dilata-
tion extends down to the rectum the mass of faeces can sometimes
be broken up by the fingers or instruments, assisted by enemata.
In some cases the administration of an anaesthetic has relieved
the obstruction, probably owing to the relief of spasm, and if
enemata alone fail, this should be tried.
We have also to consider how this disease can be treated apart
from the obstruction to which it gives rise.
Non-Operative Treatment. The non-operative treatment of
this condition consists principally in getting the bowels to act regu-
larly by the administration of enemata and aperients. Aperients
alone are usually of little use, and enemata will have to be employed.
Large enemata, if carefully administered, will, in some cases, keep
the patient in comparative comfort ; but they will have to be used
daily in order to prevent accumulation of faeces in the dilated
bowel. Large doses of magnesium sulphate will sometimes relieve
586 Congenital Abnormalities of the Colon.
the constipation by rendering the contents of the colon fluid.
Stimulants of the intestinal muscle, such as strychnine, nux
vomica and ergot, may be tried, and abdominal massage and
application of the galvanic current will often allay the symptoms
for a time.
When these measures fail recourse must be had to operation,
which in most cases becomes necessary sooner or later.
Operative Treatment. Whenever possible operation should be
avoided when there are obstructive symptoms and the dilated bowel
is loaded with solid faeces. Every effort should first be made to
empty the bowel; even then the dilated colon is not easily dealt
with, and when loaded with many pounds of semi-solid faeces the
greatest difficulty may be experienced.
Colotomy. The record of cases operated upon show that the
mortality attending colotomy for this condition is very high,
higher in fact than for any other procedure. Thus, out of four-
teen cases collected by the writer, treated by colotomy, eleven died.
This might to some extent be accounted for if the operation had
been performed only for the relief of acute obstruction ; but the
cases show that, even in the cases in which colotomy was per-
formed when no acute symptoms existed at the time of operation,
it often proved fatal. Death occurred in most cases from general
peritonitis following the operation, and it was found at the post-
mortem examination that the bowel had torn away from the
abdominal wall or had leaked into the peritoneal cavity. If
colotomy has to be performed on account of obstruction, the
lumbar operation should be done.
Resection of the Dilated Portion of the Colon. This is the
operation which has been attended with the best results in these
cases, and in spite of the difficulty of resecting such an enormously
dilated bowel, it has not been attended by a high mortality.
In all but two of the collected cases in which this operation was
performed the dilatation was confined to the pelvic colon. In one
case, however, the entire colon was successfully resected for this
condition.
When the dilatation is confined to the sigmoid flexure, resection
of the dilated loop seems to be the best method of treatment. (For
description of operation, see Resection of Colon.)
When the whole or the greater portion of the colon is involved
the operation is certain to be attended by such difficulties, owing to
the size and fixity of the bowel, that it is doubtful if it is justifiable,
and a preliminary short-circuiting operation is preferable.
In one case I performed appendicostomy for this condition. The
Congenital Abnormalities of the Colon. 587
operation was done in the hope of being able to prevent accumu-
lation in the distended sigmoid by washing out the whole colon
daily with water through the appendix. The patient, a man
aged twenty-two, was quite well between the attacks of obstruction
from which he suffered, and it did not seem justifiable to subject him
to the danger of excision of the enormous loop of dilated bowel,
unless every other method failed. After the operation it was found
possible for him to keep his dilated sigmoid practically empty by
daily washing through from the appendix. A year after operation
he was still well.
It would appear that this operation is well worth trying before
proceeding to more serious measures.
Ileo-sigmoidostomy has been performed in a few cases; but,
although it may afford temporary relief, it cannot cure the con-
dition unless followed by resection of the dilated loop. The opera-
tion of narrowing the dilated bowel by means of Lembert sutures,
in a similar manner to the operation of gastroplication for the
relief of gastric dilatation, has also been tried, but no good results
have followed it. Fixation of the colon has also been unsuccessful.
P. LOCKHART MUMMERY.
KEFERENCES.
Mummery, J. P. Lockhart, " Diseases of the Colon." Lockwood, C. B.,
Brit. Med. Journ., 1882, II., p. 574. Osier, S., Johns Hopkins Hosp. Bull.,
1893, IV., p. 41.
5 88
MULTIPLE POLYPI OF THE COLON.
THIS is a rare disease in which there are large numbers of polypi
growing from the mucous membrane of the colon. As a rule, the
whole colon is more or less affected. The chief symptoms are
bleeding, profuse diarrhoea and progressive wasting. In most
cases the condition has only been detected in the rectum, and it
has been supposed that the polypi were confined to this part of the
bowel, whereas they really exist more or less throughout the large
bowel. Most of the operations performed for this condition have
consisted merely in the removal of as many polypi as possible from
the rectum. Needless to say, such operations have done no good
or have merely given temporary relief.
Caecostomy has been performed. This was done in Lienthall's
case, and the patient's symptoms were somewhat alleviated ; but no
diminution in the size or number of the polypi resulted. Colotomy
does not relieve the symptoms and only adds to the patient's
distress.
The disease is a very serious one and there is every probability
that cancer will develop, if it has not already done so.
Under these circumstances any operation would seem justifiable
that affords a possibility of removing the disease. The only
method that offers any reasonable prospect of dealing adequately
with it is resection of the entire colon. This was done in
a case of Lienthall's after a previous ileo-sigmoidostomy, and the
patient recovered.
Unfortunately, the rectum is usually affected together with the
colon, so that the whole of the disease cannot be removed ; but if
anastomosis is made low down, the polypi in the rectum can in
most cases be removed later ; and, at any rate, this operation
seems to be the only one at all worth considering.
Eesection of a cancer of the colon which is found to be associated
with multiple polypi is apparently not worth performing, unless the
rest of the colon is either removed at the same time or subsequently.
The evidence available seems to show that cancer will recur in some
other part of the colon, if it is not already present.
P. LOCKHART MUMMERY.
589
PERFORATING ULCER OF THE COLON.
THIS condition bears a close resemblance to perforating gastric
ulcer, for which it can easily be mistaken. There is often no
evidence of ulceration before the onset of symptoms of acute
peritonitis. The ulcer is often a single one and may be situated in
any part of the colon, though the commonest situation is in the
sigmoid flexure.
Treatment consists in opening the abdomen and either excising
the ulcer or closing it by suture, and treating the patient for
general peritonitis. Another method of dealing with the ulcer
is to tie a glass tube into the hole formed by it. The chief
difficulty in these cases lies in finding the ulcer, which may be
in any part of the colon. Not infrequently these ulcers cause
large abscesses, either sub-diaphragmatic or retro-peritoneal.
P. LOCKHART MUMMERY.
590
TUBERCULOSIS OF THE COLON.
THERE are two forms of tuberculosis of the colon which may be
met with : (1) Tuberculous ulcerationof the colon ; (2) hyperplastic
tuberculosis of the colon. Tuberculous ulceration of the colon
usually occurs as a terminal complication of advanced phthisis, and
there is little possibility of treating it by surgical means. If there
is serious diarrho3a or haemorrhage, and the patient's condition
renders it possible, appendicostomy and irrigation of the bowel may
help to ameliorate the condition.
Hyperplastic Tuberculosis of the Colon causes tumour
formation and obstruction from stricture of the bowel. It is
usually mistaken for malignant disease. The proper treatment
when the condition is diagnosed or suspected is either to resect the
affected portion of the colon or to short-circuit it by lateral anasto-
mosis. The best results have followed resection. When the lower
part of the pelvic colon is affected, colotomy may be performed,
but it is necessary to make certain that the opening is above the
diseased portion of colon.
The following table gives the results of operation in eighty-nine
cases :
Operation.
No. of Cases.
Recovered.
Died.
Mortality per cent.
Resection
63
47
16
24-5
Short-circuiting
16
13
3
18-7
Exclusion with colotomy
7
1
6
85
Exclusion with lateral
3
1
2
66
anastomosis.
Totals
89
62
27
P. LOCKHART MUMMERY.
VOLVULUS OF THE COLON.
THE treatment of acute obstruction due to volvulus of the colon
will be found in the article on Acute Intestinal Obstruction (p. 533),
to which the reader is referred, and I shall only deal here with
cases in which the obstruction has been relieved by untwisting
of the volvulus or in which a chronic volvulus giving rise to
FIG. 1. Diagram showing method of shortening the mesocolon by
Lembert sutures. The stitches pass through the outer peritoneum
only, so as not to constrict the vessels. The method of passing
additional sutures in order to remove a kink is also shown.
(From Mummery's " Dis. Colon," Wright.)
repeated attacks of partial obstruction has been diagnosed or is
suspected.
The cause of a volvulus of the colon being some abnormality
of the mesocolon, it is obvious that even though the volvulus
is untwisted and the acute symptoms relieved, there is a risk
of its recurring unless something further is done, since the pre-
disposing cause is still present.
The treatment adopted to prevent a recurrence of acute volvulus
is the same as that for chronic volvulus, which will alone be
described. No treatment other than operation can be of any use.
It must be remembered that at the operation it is most unlikely
592 Volvulus of the Colon.
that any twist of the colon will be found ; but a careful examina-
tion of the pelvic colon after the abdomen has been opened will
reveal an abnormal condition of the pelvic mesocolon allowing a
partial or complete twist to occur ; thus the mesocolon may be too
long or narrowed from side to side, or caught up in the middle by
adhesions. The most effectual means of dealing with the condition
is excision of the loop of colon and end-to-end anastomosis. This
is the only certain way of ensuring that no recurrence will occur.
The operation is, however, a somewhat serious one, and a good
result may often be obtained by measures involving less risk.
Since the condition is in most cases due to a deformity of the
mesentery, the indication is to correct this, and the procedure
which has most to recommend it is to shorten the mesocolon by
means of suitably placed sutures.
Another method which is sometimes used is to anchor the apex
of the loop to the parietal peritoneum by means of sutures ; but
while this may succeed in the case of volvulus of the caecal angle,
it is more than likely to fail when the sigmoid flexure is involved)
owing to the weight of this part of the colon when filled with solid
faeces, causing the adhesions to tear away.
Operation for Shortening the Mesocolon. The loop of bowel
forming the volvulus is drawn out of the abdominal wound and
held towards the inner side of the wound by an assistant, so that
the mesocolon is put slightly on the stretch. A row of Lenibert
sutures is then inserted, taking up the peritoneum only, right
across the mesocolon to within a short distance of the bowel on
each side. These sutures should be inserted on the outer or iliac
side of the mesocolon, and when inserting them care should be
taken to avoid injuring any blood-vessels. When this row of
sutures is tied it should form a pleat in the mesocolon. A second
similar row of sutures is then inserted over the first, so as to
shorten still further the mesentery, and if necessary a third row.
After the sutures have been inserted it will be found that a kink
has been formed in the colon at either end of the suture line. To
get rid of this a few more Lembert sutures should be inserted
parallel to the bowel wall and opposite any such kink (see Fig. 1).
If the sutures are properly placed the kink can be straightened out.
It is, of course, necessary to see that the blood supply of the loop
has not been interfered with by suturing, but if the stitches have
been carefully placed this should not occur.
P. LOCKHART MUMMERY.
593
DISEASES AND MALFORMATIONS OF
THE RECTUM AND ANUS.
DISEASES OF THE ANO-RECTAL AREA,
So many of the ordinary diseases of the rectum originate at the
line of junction of the proctodeum and the blind end of the gut that
it seems desirable to group them under the above heading.
The diseases included under this heading are as follows :
(1) Pruritus ; (2) fissure ; (3) abscess ; (4) fistula, including
that due to tubercle ; (5) infective ulceration ; (6) proctitis.
It is necessary to appreciate the smallness of the area which is
c.s.
FIG. 1. The fusion line of the proctodeum.
(From Wallis's Surgury of the Rectum, Bailliere.)
concerned in the production of these ailments, and the diagram
shown in Fig. 1 demonstrates this fact ; a practical point which
may be remembered here is that the ordinary rectal examination
need not extend beyond 1| to 2 inches, except for the purposes of
examining a growth or the upper limitations of a swelling.
PRURITUS ANI.
The essential symptom of pruritus ani is itching of a more or less
intense character, and it is necessary to differentiate between what
may be termed transient conditions and the chronic state. The
former are due to such things as excessive perspiration, errors of
diet and excessive smoking, eczematous or gouty conditions and,
rarely, threadworms and pediculi.
When the irritation is caused by perspiration it usually occurs in
S.T. VOL. II. 88
594
Pruritus Ani.
summer. In these cases the irritation is not so much at the anus
as where the buttocks meet and get chafed by the dried skin
secretion; if this is allowed to proceed unchecked a raw tender
area may gradually form on either buttock, which may even go
on to cellulitis. Associated also with it there may be suppurative
folliculitis.
The treatment of this is primarily cleanliness and then the
application of some emollient, such as vaseline or lanoline. If the
case is seen when the skin is definitely affected and possibly
cellulitis is commencing, the patient should be treated by continuous
Flu. 2. Three abrasions in the region of the proctodeum. The central abrasion is in
the most common situation. (From Wallis's Surgery of the Rectum, Bailliere.)
warm boracic hip baths until the inflammatory period is past, when
simple dressing of plain sterilised gauze dusted over with starch
and zinc powder may be applied until the skin is completely
healed.
Chemical irritants, such as carbolic, perchloride and the like,
are to be avoided ; never use iodoform or orthoform, as they are
likely to do more harm than good. Should suppurative foUicuUtia
be present it must be treated on the same lines as when it occurs in
the axilla, and the suppurating follicles must be opened up and
cleaned out with a spoon, and then swabbed with pure peroxide
of hydrogen. The after-treatment consists in warm boracic baths
and boracic fomentations.
Pruritus Ani.
595
When the irritation is due to errors of diet it will be more often
found that the error is in something that is drunk rather than in
something that is eaten. Beer, champagne, claret, whisky, are all
causes of transient pruritus ani in people who are gouty, and the
abstention from the particular beverage will often correct the
condition. If, however, there is already a skin abrasion around the
anus some local application is desirable, and that which probably
gives more relief than any other is resinol ointment. Two or three
applications of this are usually all that is necessary.
When there is a marked eczematous condition of the skin this
must be treated in the
same way as eczema in
any other skin area,
and local treatment is,
of course, associated
with constitutional
treatment (see Eczema,
Vol. III.).
The following pres-
criptions of lotions will
be found beneficial in
most cases of pruritus
due to eczema: f^.
Prepared Calamine, 3^ ;
Oxide of Zinc, 3 J ;
Solution of Subacetate
of Lead, fl.5j ; Glycerine,
fl.5J ; Lime-water, to
fl.5J; or fy. Wright's
Liq. Carbonis Deterg.,
5 j ; Glycerine, 3] ; Oxide
of Zinc, 3^; Precipitated Calamine Powder, 3^ ; Prepared Sulphur,
5^ ; water, 3vj. The part affected to be painted thickly over
twice daily and allowed to dry. This was a favourite prescription
of the late Mr. Startin and was also used by the late Mr. Allingharn.
In what may be termed genuine chronic pruritus ani none of
these remedies avail except as transitory palliatives, because in these
cases there is a definite lesion which produces both the symptoms
and the external appearance of the skin (see Fig. 3). The folds of
skin around the anus are hypertrophied and usually between the folds
the skin is cracked. Theperineal ridge is also thickened and in the mid-
posterior line between the buttocks the skin is often raw and tender.
It will be found on enquiry that these people have suffered for years,
382
FIG. 3. The anal skin in a case of chronic
pruritus ani.
596
Pruritus Ani.
and their night's rest is broken, their digestion is impaired, their
nerves are wrong and life is a misery. It is of little use trying to
patch these patients up with a local application. In these cases
there exists a definite lesion at the ano-rectal junction (see Fig. 2)
which is the cause of the disease. It is not easy to see the lesion
except when the patient is under an anaesthetic, but with a good
light and a bi-valve speculum one can usually demonstrate it. The
commonest place for the lesion is in the mid-posterior line, and the
speculum, well anointed, is introduced gently through the sphincter
FIG. 4. The line of incision in Sir C.
Ball's operation.
FIG. 5. Skin flap dissected,
showing nerves.
and then opened, when, if the lesion is present, it will be at once
obvious. More than one may be present or the actual abrasion may
be hidden by a hypertrophied papilla. If the lesion is not seen in
the mid-posterior line, the speculum must be gently worked round the
circumference of the bowel and each segment carefully investigated.
Whether the lesion can be seen by an ordinary examination or
not, there is no question as to its presence, and as nothing but some
form of operation will cure these cases it is better that the patient
should be prepared for an operation and then the demonstration of
the lesion can be followed by an operation for its cure.
Fissure.
597
When the case is comparatively recent and there is no marked
hypertrophy of the skin, but only an obvious internal lesion, one
application of the cautery or painting the lesion with pure lactic
acid will often check at once the irritation, and the lesion will heal,
but this can only be hoped for under the conditions which I have
mentioned.
The operations for the cure of this distressing malady are three
in number : (1) Sir Charles Ball's method of dissecting the skin flaps
and dividing the terminal cutaneous nerve twigs (see Figs. 4 and 5).
(2) A modification of this, recently invented by Dr. Louis J. Krouse
(arc Fig. 6), in which, as will be
seen, the skin flaps, instead of
being dissected towards the anus,
are dissected from it; the results of
this operation are said to be quite
good, but the risks of suppura-
tion of the skin with subsequent
stenosis must not be forgotten.
(3) The other operation, one
which has always been adopted by
the writer, is the dissection of
the complete ring of the ano-rectal
tissue, bringing down the healthy
mucous membrane to the skin,
and at the same time cauterising
any hypertrophied skin folds.
The success of this treatment
has been most marked, and
although I cannot claim that I
have never had a failure, there is
no doubt that the operation is a
sound surgical procedure which has the marked advantage of
removing the cause of the trouble. In two instances, both in elderly
gentlemen, there has been some subsequent return of the pruritus,
which has yielded completely after a few exposures to X-rays.
FISSURE.
Fissure is produced by a tearing down of one of the anal valves
(Fig. 7). The lesion is usually in the mid-posterior line. Con-
stipation is the usual cause.
The treatment of a fissure will depend upon its depth. When the
lesion is merely through the mucous membrane it is possible that
palliative measures may heal it ; at the same time the results of such
FIG. 6. Dr. Krouse's modification of
Ball's operation.
598
Fissure.
treatment are too often disappointing ; but under the above circum-
stances it may be as well to try for a few days what laxatives
will do, associated with the application of the following ointment :
1^. Subchloride of Mercury, gr. 20; Lanoline, 3J.
When the lesion is deeper than this and involves the fibres of the
external sphincter and possibly also there is some thickening of the
skin edges, it is useless to attempt any palliative measures and keep
the patient longer in a state of suffering which is often extremely
acute. Moreover, as I have pointed out elsewhere (Surgery of the
FIG. 7. An anal valve torn down, causing fissure.
(From Wallis's Surgery of the Rectum, Bailliere.)
Rectum), serious infection may arise through this source and lead
to a prolonged illness.
The operative treatment for fissure consists of :
(1) Forcible dilation of the muscle, tearing through the affected
tissues, and at the same time " paralysing" the muscle. The result
of this is that spasm ceases and with it the pain, and if the sphincter
remains sufficiently long inert the fissure may heal. It must be
remembered, however, that when the fissure has existed for some
time the sphincter becomes rapidly hypertrophied and unless the
stretching is sufficient to cause inertia for ten days, it is more than
possible that before the wound is healed the sphincter again becomes
active and the trouble commences once more.
Another warning must be given as to sphincter stretching. This
muscle differs materially in different people and the stretching of
Fissure.
599
the sphincter of a young woman is a totally different affair to that
of a middle-aged labouring man. Should the sphincter be over-
stretched or too much torn it may be months before proper control
is obtained, and indeed it is quite possible for some permanent
weakness to remain. It will be gathered from these remarks that
although the method is a recognised practice it is not one which is
to be recommended.
(2) The best treatment is to divide the fibres of the external
sphincter in the following manner :
The patient is anaesthetised and the bowel is emptied. It is
necessary to mention this, as usually, in spite of all preparation,
FIG. 8. The finger in the anus. The dotted line shows the incision.
patients do not voluntarily assist to empty the bowel because of
the pain. With the patient on the side or in the lithotomy position
a proper examination is made of the fissure, and with one finger in
the bowel, putting the fissure itself on the stretch, the outer fibres of
the sphincter are divided in a straight line by a blunt-ended scalpel
held in the other hand (see Fig. 8). It is not necessary to divide
the whole sphincter. The incision is washed over with pure
peroxide of hydrogen and some plain sterilised gauze is placed
in it. The wound is washed with saline and diluted peroxide each
day and an aperient is given on the third day, when the plug
either comes out or is removed. After this the bowels should act
once a day, and in addition to the dressing, which consists only of
600 Rectal Abscess.
plain sterilised gauze, the patient should sit in a boracic hip bath
once or twice a day for at least fifteen to twenty minutes. Com-
plete recovery usually takes place in from ten to fourteen days.
If circumstances do not admit of the patient taking a general
anaesthetic, and also if he is unable to lie up, the operation can be
done in the following manner :
(3) The patient is placed in the knee-elbow position and a
4 per cent, solution of eucaine is injected inch behind the
posterior limit of the fissure, and after a few seconds the needle is
pushed on behind the fissure, and so the whole area is anaesthetised
and the muscle is divided in the way already mentioned.
Haemorrhage is controlled by adrenalin or hazeline, and the patient
must not be allowed to leave the house until it is certain that all
haemorrhage has ceased. This is a rule that should be carefully
observed, as otherwise serious trouble from haemorrhage may occur.
It is not desirable to adopt this latter plan if by any means a
general anaesthetic can be given.
It has been, and still is, a common practice to treat fissure by the
application of solid nitrate of silver, but this treatment is usually
of no avail as far as healing goes, and often is the cause of
considerable increase of pain, and cannot in any way be recom-
mended.
lodoform or orthoform powders should not be used ; they do no
good, and iodoform has a most unpleasant smell, and finally both
these powders frequently cause acute dermatitis.
ABSCESS.
Abscesses of the rectum or of the tissues immediately outside
originate from a lesion in the bowel at the ano-rectal junction (as
in the case of fissure), and according to the line along which the
infection spreads, the abscess will be either : (1) Subcutaneous ;
(2) submucous ; (3) ischio-rectal ; (4) pelvi-rectal ; (5) retro-rectal.
In dealing with all these abscesses it must be remembered that
the usual sequel is a fistula, and it is unwise not to make this clear
to patients, as if this is not done the resulting fistula is too often
put down to bad treatment. If the abscess heals, leaving no
fistula, which is rare, so much the better, and if the possibilities of
a fistula have been put forward, all the more credit is given to the
medical man who has so successfully avoided it.
One or two observations on the examination and diagnosis of
these cases are of practical value in the treatment.
The subcutaneous abscess is easily diagnosed. It is treated
Ischio-Rectal Abscess.
60 1
by incision, as any other abscess, and this is all that need be said
about it.
The ischio-rectal abscess is the next easiest to recognise, but
it is frequently overlooked until the abscess has assumed large
dimensions, and this is particularly the case when the abscess is
bi-lateral. The symptoms complained of are dull aching pain,
and a feeling of weight and throbbing. All the symptoms are
referred to the rectum, and therefore an examination should
always be made, when it will be found that there, is definite hard-
ness of the peri-rectal tissues and tenderness on one or both sides.
FIG. 9. Abscesses. 1, Subteguinentary ; 2, Submucous ; 3, Ischio-rectal;
4, Pelvi-rectal. (From Wallis's Surgery of the Rectum, Bailliere.)
If, as is more usual, the abscess is limited to one side, a comparison
of the two sides will establish the diagnosis. There is always a
rise of temperature locally, and if the general temperature is taken
it will often be found to have risen. But this is not always the
case, and many instances have occurred of large abscesses being
present with a normal body temperature.
The treatment of this abscess is by incision, but there are
two ways of doing this. Fig. 10 shows what is too often done
in the treatment of these abscesses, viz., a small incision is
made over the most prominent part of the swelling and relief is
given to the tension, with comfort to the patient. Much the same
602
Ischio-Rectal Abscess.
relief occurs when the abscess bursts through the skin, but this
relief is in no way curative, and the patient continues with a foul
septic cavity in the ischio-rectal region, the infectivity of which is
kept up by the original lesion already spoken of.
When possible, a general anaesthetic should be given, and a free
incision, as in Fig. 11, should be made, and if necessary, another
incision should cross this, making the opening cruciform, the main
point aimed at being to obtain as perfect drainage as possible. In
addition to this, after the opening has been made, the finger should
be inserted into the abscess cavity, which should be thoroughly
explored, and any ramifications of the abscess made out; as
f
FIG. 10. A small incision which relieves tension, but
does not properly drain the abscess cavity.
far as possible, any obstructions such as bands, etc., should be
broken down and the interior made into one cavity, and thus the
best drainage is obtained. The cavity is then scraped with a blunt
spoon, and thoroughly irrigated at the same time with warm saline
solution. After this the cavity is swabbed out with pure peroxide
of hydrogen (strength 20 vols.). This, again, is washed away
with saline, and the cavity is packed firmly with plain sterilised
gauze. If the contents of the abscess cavity are very foul it will
be found that a solution of iodine and water (1 drachm to the
pint of water), used instead of the saline, is an excellent deodoriser
as well as a disinfectant. Before packing off the cavity the
operator should never forget to look for, and establish, the presence
Ischio-Rectal Abscess.
6o-
of the internal opening, which is at the ano-rectal junction. If
the track is a straight run into the' bowel, a probe-pointed director
is passed along it ; the end is brought out at the internal opening
and all the super jacent structures are divided (see Fistula). If, on
the other hand, it is thought that the track is not a simple one,
but that there are divergent ways, then it is not wise to do
more than thoroughly clear out the abscess cavity in the manner
just related.
After-treatment. An aperient is given on the third day (castor
oil for choice, about 5 drachms). After this has acted the gauze
should be removed, and as it is always extremely foul, for the
comfort of all parties
concerned, it should be
pulled out with forceps
into a bowl containing a
solution of 1 in 20 car-
bolic, or a strong solution
of lysol or iodine. After
the gauze has been re-
moved the cavity is
irrigated with hydrogen
peroxide (20 vols. per
cent.), with an equal
quantity of water added,
and after this has been
washed away with saline,
the cavity is now liyhtlii
packed with gauze. One
of the points of interest
in these cases is the
rapidity with which these
cavities close up, and it is for this reason that light packing
is necessary after the first dressing has been removed. The
wound is now to be dressed daily, and in addition, the patient
should sit in a warm boracic sitz bath night and morning
for about fifteen to twenty minutes. This boracic bath has
done more than anything else to hasten the recovery of rectal
wounds, and at the same time is of the greatest comfort to the
patient. When the original abscess has been a large one and
there has consequently been a large space to granulate up, it will
be found that after ten to fourteen days a change of dressing is
beneficial; lotio rubra [U.S.P. Zinci Sulphatis, gr..2; Tinct.
Lavand. Co., 111 10 ; Aquani, ad 3 j] , tincture of iodine, or a strong
FlG. 11. A crucial incision which gives good
drainage and allows thorough investigation
of the cavity.
604
Sub-mucous Rectal Abscess.
solution of perchloride of mercury (strength 1 in 500), may be
used. Healing, as a rule, goes on well, but sometimes in the
large cavities the last inch or two defies all the remedies used
and continues in a chronic state. When such is the case, or
even earlier, it will be found that the ionic treatment, by means
of zinc cataphoresis, often heals this indolent remaining sinus
after one application. This form of treatment, which was
introduced for rectal work by Dr. Ironside Bruce and myself some
two years ago, will be more fully dealt with in discussing the
treatment of ulceration.
The treatment of the pelvi-rectal and retro-rectal abscesses
does not differ much from that of the ischio-rectal, but as the
abscess is above the levator ani muscle the recognition is not
always easy, unless a
man has a knowledge
of how the ordinary
normal rectum feels on
examination.
Treatment. When
the abscess has been
diagnosed the patient
is put under an anaes-
thetic and then placed
in the lithotomy posi-
tion ; an incision is
made well away from
the external sphincter,
i.e., about midway between the tuber ischii and the anus, and when
the skin is incised the finger of the opposite hand is passed into the
rectum, and with this guide in the bowel, a pair of sinus forceps is
passed through the incision steadily on until the abscess is reached
and pus is seen to escape from the wound. The finger in the rectum
prevents the mucous membrane from being wounded. When the
abscess has been opened the skin incision is enlarged sufficiently
to admit the finger into the abscess cavity. This is thoroughly
explored with the finger and any diverticula are made out ; after
the finger is withdrawn a large spoon is introduced and the cavity
is scraped out and then irrigated with warm saline until it is quite
clean. The rest of the treatment is the same as in the case of the
ischio-rectal abscess.
The case of the sub-mucous abscess (Fig. 12) is somewhat
different. This abscess is diagnosed by the fact that there is a
definite swelling with inflamed mucous membrane immediately
FIG. 12.- A sub-mucous abscess.
(From Wallis's Surgery of the Rectum, Bailliere.)
Sub-mucous Rectal Abscess.
605
above the ano-rectal line, and if a speculum is introduced pus will
often be seen to escape from the initial lesion at the ano-rectal
junction.
Treatment. The patient is put under an anaesthetic and the
sphincter is moderately stretched ; the internal opening of the
abscess is found and enlarged with a pair of sinus forceps ; a blunt-
pointed hooked probe is now passed into the cavity and pulled down
(see Fig. 13) until the point of the director can be felt on the skin
outside the sphincter ; an incision is now made over the point and a
straight fistula director is passed in from the outside to the opening
a
I
FIG. 13. -Method of treating sub-mucous abscess.
inside, and the point brought out through the sphincter. All the
tissues lying above the sphincter are divided, including the external
sphincter muscle. By this procedure perfect drainage is obtained
and a rapid recovery ensues.
The wrong treatment in these cases is to incise the mucous
membrane and trust to chance that the abscess will heal. The
chances are greatly against healing for many reasons, and a serious
state of infective ulceration is more than likely to arise, and in any
case no time is gained and, indeed, a great deal may be lost in
many ways, by not adopting the method of treatment mentioned
above.
606 Rectal Fistulae.
Abscesses in connection with the prostate occasionally burst into
the rectum, and may be mistaken for an original bowel abscess ; but
the symptoms of a prostatic abscess are pronounced and urgent, and
are scarcely likely to be mistaken.
Abscesses in connection with bone (usually tuberculous) may
discharge externally in the same region as an ischio-rectal abscess.
The direction of the examining probe will not be towards the
bowel, and on digital examination the mucous membrane will be
found healthy.
FISTULA
As was mentioned when discussing abscesses, a fistula is always
the residue of an abscess which is produced by an infection
originating in the bowel. This may be caused by the bacillus of
tubercle, the bacillus coli communis or a combination of the latter
with pyogenic cocci. The extent of the fistula depends upon the
size and situation of the original abscess, the possibility of side-
tracks, and the virulence of the infecting micro-organisms.
The fistulae are either complete or internal, and a variety of these
two is seen in the horseshoe or semi-horseshoe variety. Further
fistulas may have various tracks leading from the main one ; there
may be multiple external openings on the skin, and there may be
more than one internal opening, but this is not common.
Before embarking upon the treatment of a fistula it is essential
to appreciate that this disease presents many varieties and that the
treatment of it may be a most simple matter or one which will tax
all the ingenuity of the surgeon, and must certainly exhaust all the
patience of the patient.
As fistulae are the results of abscesses, it follows that to a great
extent the varieties resemble each other, so that a subcuticular
abscess, when not treated, leaves a subcuticular fistula, and an
ischio-rectal abscess which bursts externally leaves a complete
fistula. A sub-mucous abscess may leave a tortuous blind internal
fistula, and the pelvi-rectal or retro-rectal abscess, as well as the
large ischio-rectal abscess, will leave a fistula of the horseshoe variety.
From any of these fistulae, except perhaps the subcuticular, side-
tracks may lead off from the main in any direction, and it is this
possibility which is so often the cause of failure of treatment of
fistulas, because one of these tracks is overlooked.
In the subcuticular variety the treatment consists of merely
laying open the sinus, scraping away the 'granulation tissue, at the
same time removing any redundant skin ; the wound is then packed
with gauze and allowed to granulate up.
Rectal Fistulae. 607
In the complete variety a fistula director is passed in at the
external opening and worked along the track, which is usually
obvious, to the internal opening, which can be felt somewhere
between the two sphincters.
When the external opening is situated in the posterior half of a
line drawn transversely across the middle of the sphincter, the
internal opening will be found in the mid -posterior line. When
the external opening is in the anterior half, the internal opening is
in a line opposite to the external one.
When the internal opening has been located, the probe is pushed
on towards it and pushed sufficiently far so that the probe point and
a part of the groove of the director can be brought outside the
sphincter. When this has been accomplished all the tissues lying
above the groove in the director are divided by a sharp pointed
bistoury. This incision usually includes the larger portion of the
external sphincter. The incision should be further enlarged by a
free division of the skin away from the bowel.
The haemorrhage, which may be temporarily copious, is soon
checked by pressure and a clip where necessary. The edges of the
wound are then held apart and careful investigation is made for
any side-tracks ; these are recognised by the unhealthy granulation
tissue ; also they will readily admit a probe. These tracks are
freely divided or enlarged, until their absolute limit is arrived at,
after which the whole of the infected track is carefully curetted and
then swabbed out with hydrogen peroxide, and after this has been
washed away with saline, the cavity and any diverticula are care-
fully and firmly packed with plain sterilised gauze. No chemically
prepared gauze should be used, nor should iodoform or orthoform
l)e dusted into or around the wound. The subsequent treatment is
the same as in the case of an abscess.
There is one detail which must not be forgotten, and that is the
possibility of what is known as " bridging " occurring, which
means that some deep part of the track breaks down whilst the
more superficial part remains healthy. This usually occurs after
the tenth day, and careful investigation must be made with a
proper rectal probe to see whether any such weak point exists, and
when this is found to be the case, the bridge must be broken down,
the cavity thoroughly swabbed out and firmly packed until healthy
granulations arise to the same height as the remainder of the
wound.
The treatment of an internal fistula is much the same as that
for a sub- mucous abscess. When the internal opening has been
established a curved director is passed into the opening and the
608 Rectal Fistulae.
point is dragged down until it can be felt through the skin on the
buttock external to the external sphincter ; the skin is then incised
over the point and all the tissues are divided, as in the treatment
of sub-mucous abscess.
But now the difficulty of these cases begins, as it is rare to find
the track of an internal fistula to be absolutely simple, since they
are more often sinuous and frequently involve a part of the
internal sphincter. The best way to treat the remainder of the
sinus is, after laying open the tissues up to the internal opening,
to pass a pair of sinus forceps up the remaining part of the track
and gradually stretch the tissues until the limit of the track can be
definitely established. Into this track a spoon is passed and the
granulation tissue is scraped away, after which the whole cavity is
swabbed out with hydrogen peroxide and then irrigated with saline,
and the sterilised gauze is passed up to the end of the track.
The subsequent treatment is the same as in the other cases
already mentioned.
It will thus have been seen that when once the whole area of the
track has been made out the treatment is then a simple matter ;
but for all its simplicity it will be found that unless scrupulous care
is paid to the various details mentioned, troubles arise only too
soon. The great point to bear in mind is that the personal care of
the man in charge is of the greatest importance with regard to the
well-doing of the case. An abdominal operation usually wants
little, if any, care from the surgeon after the operation; but in
practically all rectal operations careful inspection and careful
supervision must be made until the case is practically well, and in
no operation is this so much the case as in the operation for a bad
fistula.
Complicated Fistulae. As has been mentioned in the treat-
ment of abscess, there is occasionally a secondary opening high up
in the bowel which, indeed, is often large and ragged and the only
obvious opening to be found. Formerly it was the practice in
these cases to pass in a long director and to feel the point emerge
from this high lying internal opening, and then with a pair of
fistula scissors, or with a large bistoury, the whole of the tissues
above the director were divided. This included the external and
internal sphincters and also a large portion of the levator ani
muscle, with of course all the intervening mucous membrane, and
the ultimate result of this was that, whether it cured the fistula or
not, it was certain to leave the patient with more or less incon-
tinence for the rest of his life, and in the way of results nothing
can be worse than this. Here, again, the treatment is similar to
Rectal Fistulae. 609
that already mentioned in the treatment of abscesses, viz., make
as free an opening as possible on the buttock, but never divide the
internal sphincter and certainly " never divide the levator ani.
When the last 1^ or 2 inches of a long fistulous track refuses to
heal, it will be found that the ionic treatment by means of zinc
cataphoresis will frequently act like a charm, and often one
exposure to this is sufficient to cure.
The most distressing cases of fistula to treat are those which, by
a gradual spread of the infective process, involve the bladder and
open into it. Often this is first recognised by the patient himself
in that he notices that flatus is passed by the urethra and then
later the urine becomes foul and faecal matter is passed with it.
These patients become very ill with all the signs of chronic septic
absorption and they gradually drift into a " typhoidal " state and die.
There is only one thing to do under these circumstances, and
that is a colotomy. If this is done and the affected bowel is well
irrigated, the patient will rapidly improve and the opening into the
bladder will close. Whether eventually it will be advisable to
close up the colotomy opening will largely depend on the amount
of destruction which the fistula has done, and in any case it is not
a matter which should be in any way hurried.
Recto-vaginal Fistulae, when low down and recent, will often
close of themselves. When they are rather larger or higher up a
plastic operation through the vagina is necessary, and great care
must be taken not to allow any large accumulation of faeces to
pass suddenly. When the communication is high up and large a
temporary colotomy is necessary, after which a plastic operation can
be done for the closure of the fistulous opening under the best
auspices.
> Fistulae due to Tuberculosis. Although the original site of
infection in tuberculous fistula is the same as in the other diseases
already mentioned, namely, at the ano-rectal junction, the onset of
a tuberculous fistula is quite different from that which has just
been discussed, which is invariably preceded by an abscess. Tuber-
culous fistulae commence insidiously, and often attention is not
called to them until they are far advanced.
The local appearances show considerable undermining of the skin,
which has a livid appearance around the affected area. Induration
is generally absent, and the internal opening, i.e., the original area
of infection, is often large, ragged and ulcerated.
Pulmonary tuberculosis is usually present, and the patient pre-
sents the characteristic features which are usually present in
tuberculous people.
S.T. VOL. ii. 39
6io Infective Ulcerative Proctitis.
Treatment. The first thing to do is to disabuse one's mind of
the old-fashioned idea that because a fistula is tuberculous, it
must not be operated on. This, as I have pointed out elsewhere,
is erroneous and harmful.
It is certainly not desirable to give a general ansesthetic when
pulmonary tuberculosis is markedly active ; the condition is then
best treated in the following way. The affected area is anaesthetised
by injecting a 4 per cent, solution of eucaine subcutaneously. The
fistulous track is then laid open, broken down granulation tissue is
scraped off, and any overhanging skin is removed. Another
application of eucaine is made on the surface thus treated, after
which the whole area is freely swabbed over with pure carbolic
acid. The greyish-black appearance which follows this application
soon disappears and the surface assumes a vascular appearance.
Care must be taken that none of this strong acid trickles over on
to the surrounding healthy skin. The part thus treated is packed
with sterilised wool and is kept as dry as possible. The after-
treatment consists of daily boracic baths, after which the wound is
packed with dry sterilised gauze. The healing of the wound will
be materially hastened by an exposure to X-rays for about ten to
fifteen minutes three times a week.
The general health must also be attended to, and it is most
essential that these patients should not be kept in bed a day longer
than is necessary. The more they are in the open-air the better
for their local as well as their general condition. Patients
treated on these lines do extremely well ; not only do their
fistulge heal, but their general condition is also much improved,
especially if bovine tuberculin is given (see Vaccine Therapy,
Vol.. III.).
INFECTIVE ULCERATIVE PROCTITIS.
Infective ulcerative proctitis is much more common in women
than in men, and may occur in quite young children. The
symptoms are pain both during and after defaecation, lasting for
some time, a sanious discharge from the rectum, a rise of tempera-
ture, and often the anal tissues are swollen and oedematous. In
some instances one or more joints become at times hot, swollen
and distended with fluid, and there is a considerable rise of
temperature.
This disease may originate in some ano-rectal lesion, or it may
be a sequel to a gonorrhoeal infection from the vagina. In men it
may be a sequela of acute prostatitis, especially when an abscess of
the prostate has burst into the rectum ; but this is of so rare an
Infective Ulcerative Proctitis. 611
occurrence that it need hardly be taken into consideration. Some
of the worst cases are due to a protracted labour. Finally, it may
occur after an operation upon the rectum, such as an operation for
fistula.
Probably in no disease does the rapidity of the recovery depend
on early diagnosis so much as in ulcerative proctitis. When
it is recognised in the quite early stage it can, as a rule, be cured
by one application of zinc cataphoresis ; but to ensure this
desirable result it is essential that the mucous membrane should
not have been destroyed.
In the later stages cataphoresis is still by far the most effective
agent in stopping the further progress of the disease and getting
the already infected tissues into a healthy state. In these more
advanced cases, however, when once the mucous membrane has
been destroyed, it is not an easy matter, in fact it may be impossible,
to prevent the re-infection of the granulation tissue from time to
time, unless great care is taken to keep the surface clean and
re-apply the cataphoresis once every two weeks.
The eventual result of the healing is the formation of scar tissue,
with an amount of contraction dependent on the extent of i.he
ulceration, its depth and the position of the ulceration ; that is to
say, whether it has encircled the bowel or whether the complete
lumen has not been involved.
This contraction is one of the most common forms of rectal
stenosis, apart from malignant disease. When it has spread up
the bowel for 3 or more inches, the effects on the expulsory
powers of the muscles, apart from the absolute contraction itself,
are such that chronic intestinal stasis gradually supervenes.
Under these circumstances there is only one really effective
treatment, and that is a complete excision of all the affected tissue
right up to and beyond the strictured part, until healthy mucous
membrane has been reached and separated sufficiently to enable it
to be brought down to the skin edge.
This operation is better performed from the perineum than by
any other method ; but it must not be undertaken without a proper
appreciation of the extreme difficulty of the operation, which is a
far more serious matter than an ordinary excision of the mucous
membrane. The cause of the difficulty is the amount of fibrous
tissue which has to be cut through. This tissue is very dense and
has a large number of adventitious blood-vessels in it, which when
cut do not retract, but simply gape in the non-elastic tissue and
bleed profusely, and as there may be 2 or 8 inches of this tissue to
dissect away it can easily be imagined that the operation is not
892
6i2 Infective Ulcerative Proctitis.
easy. Should the operation be undertaken it is important to
remember that the loss of blood is easily checked by the introduc-
tion of some cotton -wool, soaked in hazeline and water at the
temperature of 110, and the strength 1 drachm to the pint.
This soon checks the haemorrhage, and the other side can be
attacked whilst the plugging remains in the opposite one, and so
one gradually works up through the fibrous tissue to healthy
mucous membrane.
There is often a considerable amount of shock after this operation,
and the patients require careful nursing for some days.
In some instances, where the ulceration has gone so high that
any such operation as has just been described is out of the question,
it is far better to dismiss any idea of a radical removal and to be
content with a colotomy. Probably in no other disease is this
operation so permanently beneficial as here.
F. C. WALLIS.
613
MALFORMATIONS OF THE RECTUM.
A NUMBER of malformations of the rectum are described, but for
the practical purposes of this work it is not necessary to enumerate
them.
In the case of an imperforate anus the commonest form is one in
which a thin membrane stretches across the anal outlet, and this
can be made tense by a pressure on the abdomen, or by making
the child cry. This malformation is easily rectified by incising the
membrane and dilating the orifice with the little finger, and the
dilatation should be done at least once a day for a week or ten
days.
Should, however, the blind end of the gut be separated from
the anal outlet for any considerable depth, such as J or J inch,
the child must be placed in the lithotomy position and a careful
dissection carried out, keeping strictly to the middle line until the
end of the gut is found and opened.
Stenosis in this case is much more likely to occur and is
difficult to overcome.
In cases in which the bowel is still further away the only opera-
tion worth considering is a colotomy ; but this is a severe operation
to which these small infants often succumb.
F. C. WALUS.
614
RECTAL NEUROSES AND OBSCURE RECTAL PAIN.
THESE are misleading terms which have hitherto been associated
with a certain set of symptoms for which no cause could be
assigned. The symptoms are pains of more or less intense
character which may start acutely and end suddenly, or may start
quietly and gradually work up to intense paroxysms, the attack
lasting for some hours and leaving the patient in an exhausted
condition.
They are not necessarily associated with any action of the
bowels, although this act is not unfrequently the starting point of
the pains, but apart from this the paroxysms of pain may start at
any time without any warning, and may even wake the patient up,
and they are therefore not necessarily dependent on any form
of exercise. As a rule, these patients suffer for years before any
relief is sought, and when this time arrives they are often in a
pitiable nervous condition, and their whole life is quite spoilt by
this untoward trouble.
In every case of this kind that has come under my notice I have
found one or more sub-mucous tracks running up from the sinuses
of Morgagni, under the mucous membrane for a distance of f inch
to 1^ inches, and in all these cases an absolute cessation of all the
symptoms has been effected by the excision of a complete ring of
mucous membrane, going well above the sub-mucous tracks and
bringing healthy mucous membrane to the margin.
These cases require careful treatment for some weeks after the
operation, and special care must be taken that the bowels act
regularly ; otherwise, if constipation occurs or the bowel becomes
distended with flatus, the paroxysmal pain may for the time being
return ; this, however, is easily avoided by care in diet and a
suitable laxative.
F. C. WALLIS.
HEMORRHOIDS.
FOE the purposes of treatment haemorrhoids may be divided into
two classes, external and internal.
An external htemorrhoid is simply a clot of blood in the super-
ficial anal tissues. There is usually only one, but there may
be more; the swelling is about the size of a filbert, tense and hard,
the skin over it is inflamed, and the whole swelling is extremely
tender.
When these cases are left alone they may either gradually sub-
side, leaving a large tag of skin, or they may suppurate and an
abscess may form and burst, often leaving a small subcuticular
fistula.
These swellings should at once be dealt with in the following
manner :
The swelling is frozen by spraying it with ethyl-chloride and it
is incised from end to end with a sharp-pointed curved bistoury,
the blood clot is turned out and an elliptical piece of the skin
removed. The remains of the cavity are swabbed out with pure
hydrogen peroxide and packed with dry sterilised gauze. No
chemical irritants or powders should be used. The gauze is soaked
off in a hip bath the next morning and vaseline is applied.
The relief afforded by this operation is immediate and the small
wound is healed in three or four days.
If the blood clot has been allowed to suppurate the case must be
treated as any other abscess and fomented, and at the same time a
freer opening for the discharge of pus must be made if necessary.
Internal haemorrhoids exist in the neighbourhood of the internal
sphincter, and they frequently prolapse and bleed. If by any
chance they are painful, advice for them is sought much sooner
than when the main symptom is haemorrhage.
The treatment of haemorrhoids is either palliative or operative.
As far as palliative measures go, there is no complaint for which
such a variety of drugs is advertised as there is in the case of
haemorrhoids, and all sorts of special cures are advertised at some
length and considerable expense in various papers, periodicals and
journals, and as these are repeated day after day, week after week,
and month after month, it can only be supposed that there is a
large sale for such preparations, but as for their efficacy one is
616 Haemorrhoids.
unable to get many facts, except in the form of statements from
interested individuals. The great trouble in these instances is
that the patient always diagnoses his own state, and such a
diagnosis must often be wrong, and thus much valuable time is
lost. But apart from this, there is no doubt that much may be
done in certain cases by palliative treatment.
Diet. This in a large number of cases will do much to relieve
symptoms and often will cure the patient altogether. And it is
well that such should be the case, as the patients who are benefited
by this treatment are usually those who eat and drink more than
is good for them, and are therefore bad subjects for operation.
The determining factor as to the success of this treatment is the
patient himself, and it depends whether he has sufficient moral
courage to go without those things which he likes only too well.
If a patient of " full habit " will go on a rigorous diet and become
a teetotaller and keep the bowels well regulated by mild aperients,
he will not only give himself the best chance of getting altogether
rid of a troublesome complaint, but he will also improve his general
health enormously. He will not only prolong his life, but will also
enjoy it in a manner which he will soon appreciate, is far different
from the transient enjoyment and certain subsequent depression
which follows on the periodic excesses which were his former
habit.
Drags. It is useless to try and keep pace with all the drugs that
come out every month as cures for haemorrhoids, and the best
method to adopt is to remember what are the most prominent
symptoms and to know of something which gives this or that
symptom relief.
The main symptoms complained of are haemorrhage, pain and
prolapse.
Haemorrhage. This symptom, especially when associated with
prolapse, is often severe, and a quantity of blood may be lost. As
an immediate treatment nothing is better or more effective than
the use of hot water at a temperature of 105, with 1 drachm
of the extract of witch hazel to the pint of water. Bathing with
this, and after a few minutes firm pressure with some cotton -wool
steeped in this hot solution will not only stop the haemorrhage,
but will also enable the piles to be reduced, and at the same time
alleviate the pain.
Profound anaemia is often the result of daily small losses of
blood, and I have seen more than one case of extreme anaemia due
to this cause which had been treated for everything but the
absolute cause, because it had not been mentioned by the patient
Haemorrhoids. 617
and was not thought of by the medical man. These cases are more
commonly met with in women, who are not apt to notice or at
least to pay much attention to these daily small losses of blood.
It is as well, therefore, in any case of anaemia, when the cause is
not obvious, to make it a routine matter to enquire whether there
is any loss of blood from the rectum.
Suppositories of hazeline or hemisine, made up in a particular
form by Burroughs & Wellcome and called " enules," are par-
ticularly serviceable in checking rectal haemorrhage, and should be
introduced into the bowel after it has acted, and this may be done
every day for about ten days, and will either greatly modify the
bleeding, or in a fair number of cases will stop it altogether for a
time ; but I have not seen any cases of well-established haemorrhoids
ever get cured by this treatment.
The following ointment will be found of use and comfort
to the patient : Cocaine Hydrochlorate, 48 gr. ; Bismuth Sub-
nitrate, 15 gr. ; Lanoline, 1 oz. This should be applied before the
bowels act.
Perhaps the best and most useful ointment is one made of sub-
chloride of mercury, 10 gr. to the ounce of vaseline. This is a
palliative, and has decided antiseptic qualities. Injections of cold
water are much advocated, especially as a preventative ; but
although this treatment has an astringent effect, especially if a
little hazeline extract is added, the results often cause a. consider-
able amount of discomfort, as all the fluid is not returned at the
time and comes away later. To obviate this a tube should be kept
in the rectum for a few minutes, from which the fluid escapes.
Pain. Pain is not such a common symptom in haemorrhoids as
would be expected, and the pain of an external haemorrhoid is far
more acute than from any form of internal piles, except when these
are prolapsed and strangulated. If a pile becomes inflamed, or
if it is associated with a fissure or a sub-mucous pocket, then there
will be acute pain, especially after defaecation, but these latter pains
are more the result of the added condition than of the pile itself.
The ordinary feeling caused by these internal piles is one of weight
and a dull ache, and with this there is a marked state of mental
depression.
When there is much tenesmus and bearing-down pain after the
bowels have acted, the following enema, taken from St. Mark's
Hospital pharmacopoeia, is of use : Heroin, gr. ; Glycerine, 1 fluid
drachm ; Water, to % fluid ounce ; but a hot hip bath and the sub-
sequent application of some of the cocaine and bismuth ointment
will be found more helpful than anything else.
618 Haemorrhoids.
A certain amount of relief can be obtained by the interstitial
injection of any pile which prolapses and can be reduced.
From 5 to 8 min. (dependent upon the size of the pile) of one
or other of the following prescriptions is injected by a hypodermic
needle into the centre of the pile, after which the pile is reduced into
the bowel : Liquified Carbolic Acid, 48 min. ; Glycerine, 2 fluid
drachms ; Distilled Water, 2 fluid drachms ; or Liquified Carbolic
Acid, 48 min. ; Ponds' Extract, | fluid ounce ; Water, ^ fluid ounce.
If this is done carefully no harm will happen ; in most cases
there is great temporary relief, and this may last for a year or
more, but it must not be regarded in any way as a permanent cure.
OPERATIONS.
Probably the best operation for a man in general practice is that
of ligature. It is an operation which is quite simple and as a rule
quite effectual ; but at the same time it cannot be said that it is free
from all risks. The risks are, secondary hemorrhage and post-
operative infective ulceration, also stricture may occur.
The operation is done as follows :
The patient is either on the side or in the lithotomy position.
The sphincter is moderately stretched and the extent, size and
number of the piles are ascertained. Forceps are applied to each
pile and those in the most dependent part are ligatured first.
The pile being pulled down, a pair of pile scissors held parallel
to the line of the bowel divides the skin inch from the anal
margin, and then cuts steadily up to the upper end of the pile, and
when once the pile area is passed the cut segment of mucous
membrane is narrowed considerably so that it only contains the
mucous membrane and the blood-vessels. The pile so separated is
now pulled down and held down by an assistant, whilst a stout silk
ligature is passed round the base of the pile and tied tightly. This
ligature must be tied close up to the end of the cut, otherwise the
knot may be just below a divided vessel, and when the ligature is
returned to the bowel haemorrhage will continue. This is troublesome
to control, as the whole process of applying the ligature has to be done
over again, without most of the facilities for doing it, but this must
absolutely be persevered in until all the haemorrhage has stopped.
After the ligature has been tied some operators leave the pile
mass and return it back into the rectum, with the object of prevent-
ing secondary haemorrhage, and no doubt as far as this goes there
is some definite object gained. The best way, however, to treat the
ligatured pile is to remove the bulk of it, leaving just sufficient of
Haemorrhoids. 619
the pile mass to prevent the slipping of the ligature and only a
small amount of the tissue need be left to ensure the safety of this.
The ligatures are now cut, leaving about 2 inches of each ligature
outside the anus. Four inches of a i-inch rubber tube are inserted
into the bowel, and between it and the bowel some narrow plain
sterilised gauze, steeped in hazeline solution, is packed in between
the tube and the operation area; some more gauze and cotton-
wool kept in place with a T-bandage complete the operation.
The bowels are opened on the third day and the ligatures come
away on the seventh or eighth clay. After the bowels are opened
the patient sits in a warm bath twice daily, and the wound itself is
further irrigated with some antiseptic solution, such as 1 in 1,000
perchloride of mercury, and some wool soaked in this lotion is
introduced into the bowel. The patient is sufficiently well to leave
the hospital or home in about fourteen days, and the wound is
usually healed in three weeks or a month. After the first ten days
the introduction of the cotton-wool can be discontinued and the
subchloride of mercury ointment introduced into the bowel. At
the end of three weeks a digital examination of the bowel should
be made to ensure that there is no commencing stenosis, and this is
particularly necessary when four or five large piles have been tied
and a large area has to granulate. Any such tendency is easily
dealt with when it is discovered at this stage, and it is a detail
which should never be omitted in the after-treatment.
Secondary Hemorrhage. This may occur during the first twenty-
four hours after the operation, or at the time when the ligatures
come away, although at either time hemorrhage is quite unusual.
The indications are pallor, extreme faintness, sweating and yawning,
and a typical pulse of haemorrhage. The patient should be at once
examined by the bowel, and as the finger is passed through the
sphincter a gush of blood will come and the rectum will be found
to be filled with blood and clots. The patient, when possible,
should at once be anaesthetised the open ether method being the
best possible and the rectum should be washed out with some hot
hazeline solution and the bleeding point sought for and dealt with.
Should it not be possible to find the bleeding point, then the rectum
should be packed firmly round a " petticoated " tube with some
gauze steeped in hazeline solution. This should be left for two days
and then should be carefully removed. The case is treated as
already indicated, but these patients want careful handling for some
days after, and as a rule their recovery is considerably delayed.
The operation by clamp and cautery is probably simpler than
that by ligature, and is done to best advantage when there are
620 Haemorrhoids.
three or four piles with a, narrow base. When this operation is
undertaken it is better that the patient should be in the lithotomy
position. Each pile is brought out and held apart from the others,
the clamp is applied to the base of the pile, and after the surround-
ing tissues have been covered with vaseline the cautery is applied
to the pile, which is removed by this means, leaving \ inch of
tissue above the clamp. The next pile is now treated in the same
manner, whilst the first clamp is left in position. After the second
pile has been removed the first clamp is removed quietly and with
as little disturbance of the burnt margin as possible. The next
pile is removed and then number two clamp is released, and so on
until all the piles have been removed. The mucous membrane is
allowed to return to the bowel and no further dressing or applica-
tion is necessary, unless there is some haemorrhage, when a tube is
inserted into the rectum and a dressing applied outside. A
purge is given on the third day, after which the bowel is irrigated
with perchloride of mercury solution (strength 1 in 1,000).
Some ointment of the same salt is introduced into the bowel twice
a day.
The patient is well enough to get about at the end of ten days,
and the wound is probably healed in three weeks.
A great deal has been said for and against this operation, but
under the circumstances just suggested the operation is a good one,
and has the advantage of simplicity. The post-operative sequelae
are the same as in the last operation ; but haemorrhage appears to
be more frequent, after the clamp and cautery.
These two operations are the best for general practice ; but in
giving a prognosis it is as well not to suggest that anything in the
shape of a radical operation has been done.
The only radical operation is one which removes the whole pile-
bearing area, and for the description of this operation I must refer
my readers to my book on "Surgery of the Rectum," where it is
set out in detail. The advantage of this operation is that in
addition to removing the existing haemorrhoids and the rest of the
pile-bearing tissue it is a preventive to the occurrence of abscess,
fistula, pruritus, and those other maladies which originate in the
ano-rectal area.
F. C. WALLIS.
621
PROLAPSE AND PROCIDENTIA OF THE RECTUM.
PROLAPSE of the mucous membrane of the rectum occasional!}"
occurs in children and is usually the result of constipation,
diarrhoea, or bad habits of children's nurses in making children sit
and strain until the bowels act.
These cases are, except when due to diarrhoea, which is usually
FIG. 1. Prolapsed bowel, showing lines for actual cautery.
produced by bad feeding, best treated with some gentle laxative and
getting the bowels to act whilst the child is lying down ; after this
the protruding mucous membrane is bathed with some alum lotion
and then returned. A few weeks of this treatment usually cure
these patients, audit is rare that any kind of operation is necessary;
it certainly is never desirable in children.
In adults the application of the actual cautery is certainly well
worth trying in a large number of cases, and this is done in the
following manner : The patient being anaesthetised and placed in
the lithotomy position, the prolapse is pulled down to its fullest
extent and a cautery is applied to the mucous membrane anteriorly,
posteriorly and each side, from the highest part of the prolapse
622 Prolapse and Procidentia of the Rectum.
FIG. 2. Complete prolapse of the rectum.
(From Wallis's Surgery of tne Rectum, Bailliere.)
down to the skin edge, and the mucous membrane is burned well
through three-quarters of its depth. The bowel is then returned,
FIG. 3. -The folding up of the muscular coat of
that part of the bowel from which the
mucous membrane has been removed.
(From Wallis's Surgery of the Rectum, Bailliere.)
and the patient put to bed and kept there for between two and
three weeks, the diet and bowels being during this period carefully
Prolapse and Procidentia of the Rectum. 623
regulated. This treatment is often effective after one application ;
but if some prolapse still remains there is no reason why the
process should not be repeated.
Operations. There are many operations which have been from
time to time invented for the cure of what is certainly a most
troublesome complaint ; but it must be said of some of them that
much ingenuity has been displayed to create an elaborate operation
for a trouble that can be cured by much simpler measures.
When the prolapse does not extend beyond 2 to 3 inches, it can
be treated by dissecting off the prolapsed part of the mucous
membrane, sewing the cut edge of the mucous membrane to
the skin edge, and treating the case as an ordinary excision for
haemorrhoids.
When the prolapse is considerable the best treatment is a
tigmoidoptxy, and this is best done by opening the abdomen in the
left semilunar line about 1^ inches from the iliac spine. The colon
is then pulled up until the prolapse has completely disappeared,
and an assistant's finger in the bowel' can tell when this has
occurred ; four to six sutures are now passed through the muscular
band on the colon, and tied up to the anterior parietes ; the
abdominal wound is closed in the ordinary way. The patient is kept
more or less flat in bed for at least six weeks, and during this time
the bowels are carefully regulated.
The results of this operation are, in my experience, so good that I
have never understood the necessity of resorting to any of the com-
plicated operations which render the rectum a rigid tube, and are
full of the possibilities of suppuration.
F. C. WALLIS.
624
SIMPLE TUMOURS OF THE RECTUM.
THE simple tumours of the rectum are : (1) Single pedunculated
polypi, (2) multiple polypi, and (3) adenomata.
The treatment of single polypi is quite simple ; they are usually
situated low down in the rectum and can be pulled outside the anus ;
as they are always pedunculated, a ligature can be tied round
the pedicle and the polypus removed with scissors. No further
treatment is necessary.
Multiple polypi are best left alone unless some urgent symptom
such as haemorrhage arises, which may necessitate a serious opera-
tion ; but this is rarely, if ever, necessary, as any excessive
haemorrhage can usuallybe controlled by injections of hot water
and hazeline.
If an adenoma is pedunculated it can be treated as a simple
polypus, but if it is sessile, and they mostly are, it is necessary to
remove an elliptical piece of mucous membrane with the base of the
tumour. This is a simple matter when the tumour is low down in
the bowel, but quite the reverse when it is high up, and the
operation should not be lightly undertaken.
It must always be remembered that these innocent tumours, if
left, are apt to become malignant, and so much is this my experience
that I have no hesitation in saying that when these tumours are
known to exist it is a positive duty to have them removed.
Villous tumours, although they may originally have no malignant
microscopical elements in their structure, are yet so peculiarly apt
to become malignant, if not thoroughly removed, that it is essential
that these growths should be treated as malignant.
F. C. WALLIS.
625
MALIGNANT GROWTHS OF THE RECTUM.
THE operative treatment of malignant growths of the rectum is
now in an interesting process of transition, and there is no doubt
from the recent pathological progress which has been made that the
operation known as the abdomino-anal operation will be much
more often performed than heretofore ; but here, again, each case
must be treated on its own merit and upon the strength, constitu-
tion and build of the particular patient, always supposing that the
growth is a removable one, and in many cases this cannot be
decided one way or another until the abdomen has been opened
and a thorough examination made. It is not within the scope of-
this work to discuss these, the most difficult operations in surgery,
in detail ; but it may be briefly said that although the future
operative measures for these growths may be even of a greater
magnitude than in the past, yet it is certain that far better results
will be obtained by these means than by most of those at present
employed.
A polypus or adenoma which has become malignant may be
removed through the anal opening, and a villous tumour may be
removed by the ano-coccygeal route; but nearly all malignant
growths originating in the mucous membrane of the bowel are best
dealt with by the abdomino-anal method, unless the patient is too
fat. And in almost all cases the abdomen should be opened as a
routine so that the extent of the growth may be thoroughly made out.
Growths involving the anus and also probably the sphincter
muscle must be removed quite freely, and at the same time the
inguinal glands on both sides are removed. These cases do well,
and it is extraordinary what a small amount of discomfort arises if
the bowels are thoroughly emptied with an enema each morning.
F. C. WALLIS.
COLOTOMY.
Se<> Cancer of the Colon, p. 578.
S.T. VOL. II. 40
626
DISEASES AND AFFECTIONS OF THE
PERITONEUM.
ASCITES.
As free fluid in the abdominal cavity may be due to many causes,
the treatment necessarily varies to some extent with the underlying
factor in each case. Thus, when the cause is known and is amen-
able to treatment, as in syphilitic disease of the liver, the backward
pressure of heart disease, ovarian papilloma with implantation
growths on the peritoneum, and tuberculosis of the peritoneum, it
should be thoroughly treated. In many cases, however, as in
simple chronic peritonitis, malignant disease and hepatic cirrhosis,
the treatment of ascites is mainly symptomatic or palliative. It
will be most convenient to describe in the first place the general
treatment of ascites and then to deal with special forms.
General Treatment. The patient should be kept at rest and
mainly in bed, the head and shoulders being somewhat raised so
as to obviate upward pressure on the diaphragm ; chill and
exposure to draughts should be avoided. In the chronic cases
in which the patient is not entirely in bed, some relief to the
feeling of weight in the distended abdomen may be obtained
by wearing a binder or belt. By strapping the abdomen firmly
with adhesive plaster an attempt is sometimes made to prevent
recurrence of ascites, but a careful watch must be kept to see that
it does not give rise to pulmonary embarrassment.
The method of restriction of the fluid intake is chiefly of use
in ascites due to cardiac failure and to renal disease. When
this plan is adopted, the amount of fluid should be gradually
diminished, the quantity being progressively curtailed day by day
until 20 to 30 oz. only are taken, and care must be taken to avoid
constipation and discomfort from thirst. A salt-free diet should
be tried in order to diminish the effusion of fluid into the
peritoneum due to the retention of chlorides, but the results
are somewhat disappointing.
The diet should be as nourishing as is possible in the
circumstances, and generally speaking should consist of eggs,
fresh fish, mutton, chicken, junket, milk puddings, bread, butter,
cream and some fresh fruit. Much farinaceous food, potatoes
and cabbage must be avoided on account of their liability to
Ascites. 627
produce fermentation and flatulence. Irritating articles, such
as spices and pickles, and alcoholic stimulants should be prohibited
or reduced to a minimum. The diet necessarily varies in different
cases and according to the patient's powers of digestion and other
factors; in secondary malignant disease of the peritoneum the
patient's own wishes may largely dictate the diet, whilst in hepatic
cirrhosis a simple diet, mainly of milk, should be enforced .
Pain and discomfort due to abdominal distension are aggra-
vated by tympanitic distension, and may to some extent be relieved
by minimising fermentation and the production of gas in the
intestines by careful dieting with restriction of carbohydrates,
by the administration of drugs which prevent fermentation, such
as guaiacol carbonate (5 gr., in a cachet three times a day), naph-
thalin tetrachloride (7 gr., three times a day), calomel (^ gr.,
three times a day) taken with food, and by carminatives, such
as a mixture of spiritus chloroformi 10 rnin., spiritus ammoniae
arornat. 30 min., aquae menth. pip. 5 ss., infusum caryo-
phylli ad 2 oz., or tablets of peppermint or powdered
charcoal. Purgation by blue pill at night, followed next morning
by magnesium sulphate (5 ss.) in hot water, will also diminish
flatulent distension. For the pain and discomfort due solely to
the ascitic accumulation, tapping is the proper remedy.
MEASURES FOR THE REMOVAL OF THE ASCITES.
If, with rest in bed and the appropriate' treatment of the cause,
the amount of ascites remains small or diminishes, treatment
by other means is unnecessary. But when the ascites is con-
siderable or increasing progressively, measures for its removal
must be taken; these may be considered under the following
heads, but more than one ma}' be employed at the same time.
(1) Purgatives. Moderate purgation may do good not only by
abstracting fluid but also by preventing intestinal auto-intoxication
and flatulent distension. Drastic purgatives, such as gamboge
or elateriurn, should be avoided, as the patient's resistance and
nutrition may suffer from excessive purging. Pilula hydrargyri
[U.S.P. Massa hydrargyri] (5 gr.) overnight, followed next
morning by \ oz. of magnesium sulphate in as small a quantity
of hot water as is necessary to dissolve it, may be given twice or
three times a week. Compound jalap powder (30 gr.) may also be
given, or repeated doses at three-hourly intervals of magnesium
sulphate and sodium sulphate, 2 drachms of each in water, until a
free action is obtained.
(2) Diuretics are most likely to be useful in cases in which the
402
628 Ascites.
ascites is not excessive ; for in the presence of a large peritoneal
effusion pressure on the renal veins may interfere with the action
of these drugs. The choice of a diuretic will depend on whether
the cause is known or not ; thus, in heart disease digitalis alone
or in combination should be given, a good combination being a
pill of powdered digitalis leaves (| gr., squill 1 gr., blue pill
[U.S.P. mass of mercury] 2 gr.). Digitalis, in the form of
a physiologically standardised solution, may be combined with
diuretin (5 to 10 gr.) or with citrate of caffeine (5 gr.), or
with theocin (3 gr.), and given three times a day. In cases in
which the cause is not clear, and the kidneys are not obviously
affected, a mixture containing liquor ammonii acetatis 1 drachm,
spiritus aetheris nitrosi 20 mm v spiritus juniperi 20 min., infusuni
scoparii ad 1 oz., may be given three times a day. Copaiba
resin (7 \ gr.) in keratin capsules, so as to avoid gastric irrita-
tion, may be given three times a day after food, and sometimes
acts extremely well, but care must be taken to see that it does not
disturb digestion. Tincture of apocynum (20, rnin.), given with
tincture of cannabis indica (2 min.) to counteract its irritating
effect on the gastric mucosa, sometimes has a good effect. Urea
(10 gr.) has also been recommended.
(3) Diaphoresis. The use of hot-air or hot-water baths, the
internal use of liquor ammonii acetatis and spiritus aetheris nitrosi,
and the hypodermic injection of pilocarpine (^ gr.), though useful
in the treatment of general dropsy due to renal disease, have
comparatively little effect on ascites alone.
Indications for Paracentesis. When the mechanical dis-
tension gives rise to abdominal pain and this is not relieved by
the administration of carminatives and the other remedies for
flatulence already mentioned (p. 627), the abdomen should be tapped
without delay. Eespiratory embarrassment, as shown by dyspnrea,
by oedema and crepitations at the bases of the lungs, and, in
extreme cases, by haemoptysis due to congestion, demands para-
centesis. The presence of other thoracic complications, such as
pleural effusion or general bronchitis, also renders this procedure
desirable. Abdominal distension, especially when repeated, may
give rise to eversion of the umbilicus, which becomes so thin that,
if the condition is allowed to persist, rupture may eventually occur;
this, of course, should be anticipated by removal of the ascites.
Another indication for paracentesis is a considerable diminution
in the urinary excretion. The occurrence of hsematemesis in
a patient with cirrhosis is a signal for paracentesis of concomitant
ascites. In alcoholic patients signs of incipient delirium tremens
Ascites. 629
make it advisable to tap a moderate ascites before the mental
symptoms advance further. As a general rule, an ascitic abdomen
should not be tapped merely because it contains fluid, but only for
one of the indications stated above. The reason for this caution
is that tapping may initiate or perpetuate a low grade of peritonitis.
Method of Tapping the Abdomen. The site of the tapping is
usually in the middle line midway between the umbilicus and the
pubes. When on account of adhesions no fluid is withdrawn in this
region, the puncture must be made elsewhere, for example at a
point halfway along a line drawn from the anterior superior spine
of the ilium to the umbilicus. In order to avoid the danger of
wounding the caecum, the left side is chosen rather than the right.
In very rare instances the trunk or a branch of the deep epigastric
artery has been wounded by the trocar, and severe or even fatal
haemorrhage has resulted. This accident should be suspected if
arterial blood comes in spurts. In such cases the artery must be
cut down upon and ligatured.
The patient should be propped up in a sitting position in bed or
if weak should lie on his back in bed with the head and shoulders
raised. The urinary bladder should be emptied, if necessary by a
catheter ; and the site of the proposed puncture, which has been
found to be dull on percussion, should be washed and rendered
aseptic. A many-tailed flannel bandage should be placed in posi-
tion behind the back, so that it can be tightened directly the
puncture is made. It is advisable to remove the fluid slowly by
means of a Southey's trocar and cannula rather than to use a larger
trocar which empties the peritoneal cavity more rapidly, as rapid
evacuation occasionally leads to faintness, though this should be
prevented by keeping up the intra-abdommal pressure by a bandage
or binder which is progressively tightened. The Southey's cannula
has a shield fixed on it close to its head by means of a screwed top ;
the object of the shield is to enable the cannula to be kept in
position by pieces of plaster. A piece of rubber tubing several feet
long is tied with thread over the screw top of the cannula ; the
tubing is then pulled tight over the top of the cannula, and the
trocar pushed through so that its point just emerges at the
end of the cannula. It is important that the pointed end of
the trocar and enclosing cannula should fit smoothly and accu-
rately, as any projection of the margin of the cannula will
interfere with the clean puncture of the skin and hurt the patient.
The skin is sometimes incised before the trocar is introduced, but
this is not necessary. In nervous patients the pain of the puncture
may be minimised by freezing the skin by a chloride of ethyl spray
630 Ascites.
or, less conveniently, by the application of a piece of ice ; or as an
alternative local infiltration anaesthesia of the skin with a solution
of jS-eucaine (1 in 500) can be employed.
The trocar and cannula, previously sterilised, are sharply plunged
through the abdominal wall at the selected spot, care of course being
taken to avoid any obvious veins ; the trocar is then withdrawn,
the cannula being left in position. The puncture in the elastic
rubber tube closes by retraction and should not leak. The shield is
kept in contact with the abdominal wall by two slips of adherent
plaster, in which little nicks are make to correspond with the
cannula. The many-tailed bandage is then tightened so as to main-
tain uniform pressure over the abdomen, and as it gets loose is
readjusted. The rubber tube is carried into a receptacle under
the bed and the abdomen is protected by a cradle. It usually
takes six to twelve hours for the fluid to run away ; if the flow
stops before the abdomen is properly emptied the indiarubber tube
should be " milked," starting from the cannula, so as to dislodge
any clot or other obstruction. In extremely fat women a special
trocar and cannula or even the trocar and cannula of an aspirator
must be used in order to get through the abdominal wall. When
the fluid has finally ceased to run, the cannula should be withdrawn
and the small wound covered with a pad of absorbent cotton-wool
soaked in collodion. The abdomen should then be compressed by
the many-tailed bandage, by a binder firmly pinned, or by strapping.
A saline purge should be given to prevent flatulence, and one
of the diuretics previously mentioned. In some instances of
recurrent ascites and in blood-stained ascites due to malignant
disease the re-accumulation has been obviated or delayed by the
injection through the cannula, before it is removed, of a drachm of
a 1 in 1,000 solution of adrenalin chloride in an ounce of water.
Bad results from paracentesis are rare. In exceptional instances
acute pulmonary O3dema, similar to that seen after paracentesis of
the chest, has occurred. The most valuable remedies for this grave
accident are prompt bleeding or dry cupping, and cardiac stimu-
lants. Wounding of an artery in the abdominal wall and the fact
that repeated tappings may favour chronic peritonitis have already
been mentioned. With due care perforation of an abdominal viscus
should not occur. A little local pain for two or three days is not
uncommon.
SPECIAL FORMS OF ASCITES.
Cardiac Ascites. It is important to restrict the intake of fluid
to 20 or 30 oz. only in the twenty-four hours ; this, as already
mentioned, should be carried out gradually, a progressive daily
Ascites. 631
reduction of a few ounces being made. If the amount is greatly
reduced suddenly, the patient may suffer from thirst and from con-
stipation. The condition of the heart should be treated by digitalis
in cases of mitral regurgitation or by strophanthus in mitral stenosis.
Digitalis is best given in the form of a physiologically standardised
solution, such as Parke, Davis & Co.'s fluid extract, 1 min. of which
is equal to 8 min. of the Pharmacopoeial tincture ; the equivalent of
10 to 20 min. of the B.P. tincture should be given four times a day
and may advantageously be combined with citrate of caffeine (gr. 5),
diuretin (gr. 5 to 10), or theocin (gr. 3). A well-tried combination of
digitalis is that with squill and mercury, in the following form :
Digitalis leaves powdered, gr. ^ ; squill, gr. 1 ; blue pill [U.S.P.
mass of mercury], gr. 2 (Matthew Baillie's pill) ; or digitalis leaves
powdered, gr. 1 ; squill, gr. 1 ; calomel, gr. 1 ; ext. hyocyam., gr. If
(Addison's pill, or pil. diuretica of Guy's Hospital). Nativelle's
granules of digitaline are a convenient and trustworthy preparation
dose 2i5o to ^o gr. in a pill. In mitral stenosis or in cases in which
digitalis does not agree, tincture of strophanthus should be given
in doses of 5 to 10 min. [U.S.P. 1 to 2J min.] three times a day.
In order to reduce the hepatic engorgement a blue pill (5 gr.)
should be given once or twice a week at night, followed early next
morning by a Seidlitz powder (pulvis sodae tartratis effervescens) in
8 oz. of water or by 2 to 4 drachms of magnesium sulphate in as
small a quantity of hot water as will dissolve it (Matthew Hay).
Operative Measures may be employed with different objects in
different conditions. In tuberculous peritonitis laparotomy with
removal of the fluid and no further procedure may be followed by
recovery ; but in cases which relapse after this simple operation
subsequent laparotomy with removal of a tuberculous focus which
is responsible for reinfection may lead to permanent cure (see
also article on Tuberculous Peritonitis).
In hepatic cirrhosis laparotomy and the formation of artificial
adhesions (Talma-Morison operation) has been extensively performed
in order to increase the collateral circulation.
In chronic and recurrent ascites, the peritoneal cavity has been
drained into the subcutaneous tissues of the abdominal wall or
through the femoral ring into the thigh. Permanent drainage
through the abdominal wall is dangerous from the risk of peritoneal
infection.
H. D. ROLLESTON.
REFERENCE.
Art. "Ascites" in Nothnugel's "Encyclopedia of Practical Medicine," 2nd
English edition, 1907, Vol. " Iisi>:i-s <>i Intestines ;md Peritoneum," p. 717.
632
ACUTE PERITONITIS.
THE peritoneum is a membrane of very great extent which
has evolved for the physical purpose of allowing free movement
of the abdominal viscera and for the physiological purpose of
protecting the body from the hosts of micro-organisms which have
been introduced into the alimentary tract. As the alimentary tract
is the most septic and dangerous region in the human body, the
functions of the peritoneum have become the most important, as
regards life, of almost any serous membrane in the body, and its
inflammation, peritonitis, one of the most serious conditions.
At the present time it is not known what are the precise
conditions which are necessary for the migration of micro-
organisms from the intestinal tract through the tissues to the
peritoneum. But there is reason to believe that such a diapedesis
is far more frequent than it is ordinarily thought to be, and
that peritonitis is really a superlative exaggeration of events,
then clinically recognisable, which are of daily occurrence in all
the higher races of animals ; hence the object of its treatment
must be to aid the processes of natural cure, by the resources
of the body, by destroying the storehouse or factory base of
the micro-organisms and by removing as much of them and
their poisonous products as is possible, so as to enable the
patient to withstand the continuance of the struggle between the
peritoneal resources and the hostile micro-organisms.
Peritonitis is a disease due to the action of the micro-organisms,
endangering the life of the patient and perhaps producing death
by poisoning the heart and nervous system with the toxines
absorbed. The power of absorption by the peritoneum is enor-
mous. And it is this absorption which kills the patient; it
stands to reason that the greater the virulence of the organisms
present and the longer time the patient is allowed to absorb their
toxines, the less chance of recovery from the disease ; hence it
is of utmost importance to commence treatment at the earliest
moment and to ascertain the organisms present. The peritoneum
naturally has the best chances of overcoming the organism with
which it is already familiar, e.g., the bacillus coli communis ;
whilst it has little chance of overcoming strange and powerful
infections, such as are produced by the pneumococcus or the
streptococcus.
Acute Peritonitis. 633
Table of Cases of Acute Peritonitis at St. Thomas' Hospital.
Due to Appendicitis
Intestinal Obstruction
Intussusception
Perforations of the Alimentary Tract
Affections of the Pelvic Viscera .
37 per cent.
24
15
11
6
Peritonitis of Unknown Origin .... 2
Unclassifiable Causes 5
It is seen that inflammation of the appendix is by far the
most frequent cause of peritonitis, and between the ages of five
and twenty it may be said practically to be almost the only
cause. This is an important point to remember in advising treat-
ment in such eases. Clinically and pathologically it is impossible
to separate intestinal obstruction from peritonitis, the paralysed
bowel in peritonitis causing intestinal obstruction, and the diapedesis
of organisms, ulceration, etc., in intestinal obstruction causing peri-
tonitis. Perforations of the alimentary tract occur clinically in
frequence in the following order : (1) Perforations of the appendix ;
(2) perforations of the stomach ; (3) perforations of the duodenum ;
(4) perforations of the rectum ; (5) perforations of the caecum.
The treatment of acute peritonitis is surgical and should be
undertaken at the earliest possible moment. No delay in carrying
this out should be allowed.
Before Operation. (1) Put the patient in the Fowler or semi-
sitting position, which keeps the infective process to the lower and
less absorptive part of the peritoneal cavity ; (2) avoid giving
food by mouth, and so to cause peristaltic rest and prevent the
diffusion of the infection by vermicular movements ; give saline per
rectum (with a tube and funnel) in J-pint doses every two or
four hours; (8) avoid morphia, as it gives a false sense of
security and improvement, and it lowers the patient's powers
of combating the infection ; if its use cannot be avoided give
the smallest doses which ease the patient, combined with atropine
sulphate; (4) wash the stomach out with a tube and funnel and
bicarbonate of soda solution (20 gr. to the ounce).
Operation. The less delay in performing this the better for the
patient. It is often possible to diagnose the cause of the peritonitis
before operation. But no one who has had much experience of
these cases can have failed to convince himself that his diagnosis in
acute abdominal cases is not infrequently wrong. This unavoidable
uncertainty is an additional spur to operation.
A general amesthetic, ether or chloroform, is better than spinal
or local anaesthesia, except perhaps in very young children.
634 Acute Peritonitis.
The abdomen is opened through the middle and lower part of
the right rectus muscle, for the following reasons : (a) It enables
the appendix, by far the most frequent cause of peritonitis, to
be examined ; (b) it enables the pelvis to be explored, in which
region catastrophes in the upper abdomen indicate their existence
by free gas, food, blood, etc. ; (c) this incision will be wanted to
remove food, blood or pus from the pelvis.
In almost every case the pus of appendicitis declares itself by
its smell; whilst perforated gastric and duodenal ulcers permit
the escape of gas, and more or less odourless material, with perhaps
recognisable particles of food. Thus, the lower incision will enable
the diagnosis to be made in the great majority of cases.
The next step is to deal with the cause of the peritonitis, e.g.,
the appendix or a pyo-salpinx should be removed. A perforated
ulcer should be sutured. If there is so much induration round
a perforation that it cannot be sutured, do not waste time ; it
must be sealed by stitching the omentum over it. In the vast
majority of cases of perforated gastric and -duodenal ulcers a
primary gastro-enterostomy is unnecessary, and from the patient's
point of view a mischievous exhibition of surgical gymnastics. In
a few cases it can be done with advantage.
The.abdomen is wiped out with gauze and closed except where a
drain in the pelvis comes out of the lower wound.
The anaesthetist then washes out the stomach and leaves in
it some bicarbonate of soda solution (20 gr. to the ounce).
The surgeon's object is to do the operation in the least time
possible and with the least manipulation possible. He must not
waste time and make manipulations in the attempt to remove
all infective material from the peritoneal cavity. That is impossible.
The surgeon removes as much as he can easily and quickly ; and
the patient must overcome what is left behind, if he is to recover.
The following figures, derived from the cases at St. Thomas'
Hospital, emphasise the points made :
Mortality.
Operation for appendicitis within the first twelve hours of
illness .......... Nil.
Operation for appendicitis between twelve and twenty-four
hours since the onset of the illness 9 per cent.
Operation for appendicitis between twenty-four and thirty-
six hours since the onset of the illness . . . .6 ,, ,,
Operation for appendicitis between thirty-six and forty eight
hours since the onset of the illness . . . . 23 ,, ,,
Appendicitis with local and spreading peritonitis . 18 '5 ,, ,,
Appendicitis with diffuse generalising peritonitis . 66'6 ,, ,,
Perforated gastric and duodenal ulcers . . 51 ,, ,,
Acute Peritonitis.
635
After operation the patient is returned to a warmed bed, placed
in the Fowler position, and the continuous rectal administration
of normal saline commenced. This administration of saline per
rectum is the most important item in the treatment of acute
abdominal disease which has been introduced of recent years.
It requires considerable attention, skill and care for its proper
administration, and its failure should be construed to mean its
improper administration.
The Continuous Administration of Fluids per Rectum.
Proctoclysis. As the patient is usually propped up, a solid
tube must be used to introduce the fluid, otherwise it will get
kinked. A tube answers well which is 1 foot in length and
J inch in diameter, made of pewter, with a slightly bulbous
FIG. 1. Fowler's position and rectal irrigation.
extremity, which is introduced into the rectum. At the end and
on all sides of this bulb holes are pierced so that fluid can
easily pass through them and at the same time flatus can escape,
and can be seen bubbling through the supply tank or funnel. If
only a single aperture is present in the tube, it is apt to be blocked
by faecal matter ; but when there are many openings the rectum
is equally distended above the sphincter and the obstruction of
the flow of fluid by faces does not occur. The tube is intro-
duced into the rectum for about 2 to 3 inches, and is
bent sharply at th'e anus so as to lie easily on the bed. To the
outside end a long rubber tube is attached, which leads to the
source of supply at the bedside. The most convenient vessel to
hold the saline solution is an "infusion flask" (Sahli's pattern).
This is triangular in shape and has a large base, and holds
636 Acute Peritonitis.
from 3 to 4 pints ; its neck is closed by a rubber stopper,
through which there are three openings ; the one admits a glass
tube, which at one end reaches to the bottom of the flask, and
at the other is attached to the rubber tube leading to the rectum ;
a second admits a thermometer and a third a tube, which acts as
an inlet for air. The whole flask is immersed in a bath of hot
water, beneath which a spirit lamp burns, so securing a constant
temperature of the saline solution. The best temperature is from
100 to 102 F. ; if the fluid is hotter than this it is not retained
well. Its temperature, when it reaches the rectum, is probably
3 or 4 degrees lower than that shown by the thermometer.
When the tube has been introduced into the rectum and the flask
attached, the latter should be elevated so that its base is from 3
to 6 inches higher than the rectum. The saline begins to flow,
and continues flowing, at the rate of about 1 pint an hour. It is
not desirable to introduce more than 1J pints, or at the most
2 pints during the first hour ; subsequently, a rate of 1 pint in the
hour should be maintained. The rapidity of the flow is altered by
raising or lowering the flask, and should be regulated by the
patient's comfort. If a feeling of tightness or distress is caused,
the flow is too rapid. As a rule, no uneasiness is caused till about
5 pints have been introduced, but then it may be necessary to retard
the flow for half an hour or an hour, or sometimes it is sufficient to
stop it for a few minutes. If the rate of flow is regulated properly,
and the temperature of the fluid not altered, from 7 to 10 pints can
be introduced without interruption. If flatus reaches the rectum, it
can escape by the tube. If, as rarely happens, the fluid introduced
acts as an enema, the tube may be replaced as soon as the bowels
have acted. Care and almost constant attention on the part of the
nurse are necessary to ensure a successful administration.
The largest quantity of fluid taken by any patient during the
first twenty-four hours was 16 pints ; the largest quantity adminis-
tered was 29 pints, extending over three days. These quantities
were borne quite easily, without any distress whatever. The change
in the appearance of a patient who is absorbing fluid so rapidly is
very remarkable. If the case is one of acute general peritonitis, the
patient, who looks livid, whose eyes are sunken, whose skin is moist
and cold, whose mouth is so parched that his tongue can hardly
move, begins in a few hours to look ruddy and clean, his mouth is
moist, his eyes are bright, and all his aspect is one of comfort and
contentment. The pulse gains volume and improves steadily in
character, urine is passed in large quantities, and the skin keeps
moist. Not a few patients say that they feel very hot, and some of
Acute Peritonitis.
637
them perspire freely. It is a question, perhaps, as to how far one
is justified in carrying this treatment. in patients whose kidneys are
defective.
Dr. Murphy, of Chicago, is of the opinion that in cases of acute
peritonitis the fluid causes a reverse current of the lymph in the
peritoneal lymphatics, so that instead of absorption taking place
from the peritoneal surface the mouths of the lymphatics pour out
fluid, bathing the peritoneum with this
free discharge, which then escapes by the
tubes ; that, in fact, the peritoneal cavity
is flushed out by the fluid.
Various devices have been tried to
obviate the care and trouble required to
maintain the saline at the right tempera-
ture, such as Paterson's, which requires
that electricity is available, or Dewar's
flask. The latter is small and has been
found experimentally to lose 2 degrees of
heat in half an hour.
Vaccine Treatment. : Vaccine treat-
ment is probably useless in this acute
condition, but apparently does no harm.
Serum Treatment. -- The serum is
best given hypodermically. No serum
can be trusted to give a reliable result.
Anti-colon serum in 25 cubic centimetre
doses has certainly improved the con-
ditions of some patients. It may be
given at the time of operation, and daily
afterwards, should disquieting symptoms
remain or arise. This action is readily
understood as the colon bacillus is by far the most numerous and
frequent organism in peritonitis.
Anti-streptococcus and anti-staphylococcus sera have done less
obvious good.
Artificial Leucocytosis. To increase the number of leucocytes
would appear to increase the numbers of the patient's army resist-
ing the organisms ; hence, it should do good. Clinically, this is
difficult to prove, though such p, leucocytosis is easily produced by
a hypodermic injection of a nuclein, such as that sold commercially
as phagocytin.
The dressings should be changed as often as necessary, and the
drains withdrawn and replaced in twenty-four hours, an anaesthetic
FIG. 2. Electrical apparatus
for proctoclysis.
6 3 8
Acute Peritonitis.
being given if necessary. A many-tail bandage, the tails of which
are long, holds the dressing in position.
Morphia and Opium are to be avoided if possible for the reasons
already given. If they must be given, let small doses be used and
repeated if necessary. Pain and anxiety do more harm to the
patient than a small dose of morphia.
Stimulants, such as adrenalin (10 min.) and strychnine solution
(10 min.), [U.S.P. strychnines hydrochloridi gr. ^j] , should be
given without hesitation. One often repents not giving them when,
after a temporary improvement on the first day after operation,
the heart "falls to pieces" on the next day. I have repeatedly
given 10 min. of strychnine solution every four hours for a day
or two. An ill patient can take an enormous dose without harm.
A simple (or turpentine) enema
may be given on the same day
or the next day after operation,
or a long rectal tube can be
passed to relieve abdominal
distension.
Purgatives are better with-
held, if possible, until all
sickness has ceased, when they
are given repeatedly in small
doses, e.g., i gr. of calomel
* IG. 3. Ileostomy tube. y
every hour until the bowels
act. After 2 gr. have been given it is better to administer an
enema to commence the action of the bowels. An enema in acute
abdominal disease should always be given with a tube and a funnel ;
never with a syringe.
Repeated Sickness is best treated by washing the stomach out
with a tube and a funnel, or making the patient wash it out by
drinking glasses of hot bicarbonate of soda solutions (20 gr. to the
ounce) .
Abdominal Distension is best treated with hot dry flannels, an
enema (or rectal tube), and gastric lavage if necessary. Only two
drugs are of use in relieving it, both given hypodermically, eserine
salicylate, every two hours in doses of $$ gr., and atropine sulphate,
in doses of -^ gr. every three hours. The injections are discon-
tinued if the patient is relieved and shows constitutional signs of
their action.
In severe and intractable cases where the distension is embarrass-
ing the heart's action, it is sometimes necessary to open part of
the wound and do a temporary ileostomy on a distended coil of-
Acute Peritonitis.
639
small bowel. For this purpose I would recommend the glass tubes
made for this purpose and illustrated by Fig. 3.
Hiccough is one of the most distressing symptoms which one
may be called upon to treat in cases of peritonitis. The patho-
logy of the condition is obscure and composite. It is often
associated with a dilated stomach ; hence, it is best treated by
gastric lavage, bicarbonate of soda (20 grs. to the ounce), and a
FlG. 1. Vaginal drainage.
mustard leaf to the epigastrium. Massage to the epigastrium and
neck may also help. Other drugs, such as cocaine, nitroglycerine,
bromides, turpentine, musk, etc., may be given, and at times seem
to do a little good, and it is true that the symptom may wear itself
out, cease or ameliorate when they are being used. At times
morphia must be given to give the patient sleep and temporary rest
from the hiccough.
Before saline was administered per rectum, either ^ pint to 1 pint
640
Acute Peritonitis.
every hour or two with a tube and a funnel, or by continuous
irrigation, it was needful to treat, after operation, restlessness,
thirst, toilet of the mouth, and similar clinical features ; now the
need has entirely disappeared. Such points resolve themselves
and do not require special attention.
In a similar way the feeding of the patient merely demands the
use of ordinary intelligence. Very great importance is attached by
the patient's friends, and
sometimes by the patient,
to the amount of food
given. It is useless to
attempt to give much in
the first twenty-four or
forty - eight hours after
operation. Liquid and
easily digestible food is
given in small doses, e.g.,
milk and water, milk and
soda, in doses of 1 oz.
every hour whilst the
patient is awake. Food
in the stomach often dis-
tresses the patient unless
relief is found by vomit-
ing ; hence, it is better to
give the patient very little
by mouth and to rely on
rectal infusion to maintain
Jjjg strength
After the bowels have
acfce( J ft ^ desirable to in-
Crease the amount of food
taken by mout h ; and this
is particularly so as the
rectal infusion is discontinued. In some patients the stomach
remains dilated and irritable ; if so, it is harmful to press the increase
of food, and it is better to avoid altogether " made up " or seasoned
foods, champagne, etc., on account of their containing elements
which will irritate the stomach and increase the patient's distress.
The desire to suck ice is frequently met with in this disease. It is
almost invariably associated with a dilated and irritable stomach,
which conditions are wrongly attributed to the ice. Ice is certainly
an uneconomical method of taking water, but it is certainly not
FIG. 5. Paths of peritoneal infection in appen-
dicitis. 1. Situation of a right subdiaphrag-
matic abscess. 2. Situation of a subhepatic
abscess. 3. Situation of a right ante-renal
abscess. 4 Situation of a left ante-renal
abscess. 5. Situation ot a pelvic abscess.
6. Situation of an abscess in the left iliac
fossa. 7. Situation of a left subdiaphrag-
matic abscess.
Acute Peritonitis.
641
responsible for the harmful results attributed to it ; still, it should
be checked and discontinued as soon as possible.
Appendicostomy has been done instead of appendicectomy in
certain cases of appendix peritonitis, the appendicostomy offering a
simple means of administering saline solution.
SPECIAL FORMS OF PERITONITIS.
Pneumococcus Peritonitis. Peritonitis due to a pneumococcus
is a very fatal form of infection. The peritonitis is practically an
incident in pneumococcus septicaemia.
In over half the cases there is another
gross pneumococcic lesion ; in some
cases, a general involvement of serous
membranes, such as the pleura, peri-
cardium, peritoneum and dura mater ;
hence, the mortality is very high.
Pneumococcus peritonitis is more
common in children than in adults, in
boys than in girls. It is seldom diag-
nosed before operation, when it is
suggested by the greenish pus, the
widespread distribution, and the
absence of any recognisable cause of
the peritonitis. Except in the locu-
lated and more chronic forms the
prognosis is bad. The treatment
follows the general lines laid down
under the treatment of peritonitis.
Special treatment by a serum or vaccine has not led as yet to hopes
of improved results.
Streptococcus Peritonitis. In streptococcus peritonitis the
peritonitis is an incident in streptococcus septicaemia ; hence it is
a very fatal form.
Staphylococcus Peritonitis. The Staphylococcus pyogenes
albus has often been isolated from cases of peritonitis, and seems
to be an auto-infection on the part of the patient. Its presence is
by no means a forerunner of a fatal termination.
The Staphylococcus aureus gives rise to a very serious form of
peritonitis, but not so fatal a form as that due to the Streptococcus
pyogenes.
Colon Bacillus Peritonitis. This is the ordinary infection in
cases of appendix peritonitis ; hence it is to the anti-colon serum
that we look to give improved results in these cases.
S.T. VOL. ii. 41
FIG. 6. Left Empyema from
Disease of the Appendix.
642 Acute Peritonitis.
Gonorrhoeal Peritonitis. Gonorrhceal peritonitis is in reality
a name given to peritonitis arising from the genital organs.
Naturally, it is more frequent in women than in men. It is most
often found in young women, but may be found in young girls and
even in female babies.
The diagnosis is made by the presence of peritonitis without
obvious cause and the presence of a .vaginal discharge. The treat-
ment consists of laparotomy, sponging away the fluid and draining
the pelvis, by the vagina or by the rectum for preference.
The prognosis to a great extent depends on the organisms present,
and has already been discussed.
Puerperal Peritonitis (see Puerperal Sepsis, Vol. IV.).
Tuberculous Peritonitis (see p. 645).
Thanks are due to Messrs. Constable & Co. for the use of many
blocks.
EDRED M. CORNER.
KEFERENCE.
" Clinical and Pathological Observations on Acute Abdominal Diseases,"
(Constable & Co.).
^43
SUBPHRENIC ABSCESS.
BY the term " subphrenic or subdiaphragmatic abscess " is meant
a collection of pus immediately under the diaphragm. On the right
side it lies between the liver and the diaphragm ; on the left side
between the spleen and the diaphragm. That on the right side is
most frequently the result of appendicitis ; that on the left side of
a perforated gastric ulcer. A subdiaphragmatic abscess is practically
never primary. It is always secondary to some intra-peritoneal
FIG. 1. Right Subphrenic
Abscess.
FIG. 2. Left Subphrenic
Abscess.
infection, such as those already mentioned, or to pelvic suppura-
tion. After a suppurative peritonitis has been operated upon, the
temperature, pulse rate and respiration rate subside ; when a sub-
diaphragmatic abscess is forming they begin to rise again, usually,
in the second week. The other physical signs are those of fluid,
dulness, absence of breath and voice sounds at the base of the lung
behind. Later the liver becomes pushed down below the costal
margin. Thus the bases of the lungs behind should be inspected
carefully if the temperature rises during the convalescence of intra-
peritoneal suppuration. The diagnosis being made, the treatment
is surgical. It consists of the anaesthetisation of the patient,
making an incision over the eighth rib as in Fig. 3, resecting
the eighth rib, incising the pleura, allowing the lung to retract,
suturing the parietal to the diaphragmatic pleura, incising the
412
644
Subphrenic Abscess.
diaphragm and exploring the space above the liver. In doing this
operation care must be taken to resect no rib above the eighth,
as then the movements of the diaphragm are too great to allow
of easy manipulation. Further, about 4 inches of rib should be
resected. Do not rely on the stitching of the parietal to the diaphrag-
matic pleura to prevent the infection of the pleural cavity ; reinforce
the stitching with a barrier of gauze.
The space above the liver is too large to be always explored
successfully through this costal incision, and it may be necessary
to combine with this operation an intra-peritoneal one made by
FIG. 3. Incision.
FIG. 4. Left Subphreuic Abscess
Discharging by the Lung.
making an incision over the upper part of the right rectus, as in
Fig. 3.
At the conclusion of the operation drain the abscess with a
rubber tube. A gauze " drain " more frequently acts as a cork
than a drain.
The mortality consequent upon the operation is high, being
somewhere about 30 to 40 per cent. But the mortality of cases of
subdiaphragmatic abscess which are not operated upon is far
higher. From time to time such an abscess discharges through the
lung without causing a septic broncho-pneumonia.
EDRED M. CORNER.
645
TUBERCULOUS PERITONITIS.
THE results of treatment in this condition when unassociated
with tuberculosis elsewhere are much more favourable when a
considerable amount of ascitic fluid is present. When little fluid is
present, and especially in the dry form with marked caseation of
the glands, the treatment has to be much more prolonged, and
the results obtained are less satisfactory.
General Measures. The patient should be kept under fresh-
air conditions. So long as fever is present, that is, so . long as
auto-inoculation is occurring, rigid and absolute rest should be
enforced. As in other tuberculous conditions, the diet should be
abundant and, if possible, solid. There should be a slight excess of
fatty foods in the diet, such as butter, cream, sterilised milk and
bacon fat. If indigestion or diarrhoea occur, suitable changes must
be made, and in both instances the fatty constituents of the diet
should be reduced to a minimum.
Medicinal Measures. In my experience it is seldom of value
to give medicines in the acute stage. Some authorities speak well
of sodium salicylate (gr. 5 to 15 thrice daily). Dr. Burney Yeo has
recorded satisfactory results, which he ascribes to the use of
iodoform internally in -gr. doses after food three times a day. In
addition Dr. Yeo recommends that an ointment composed of equal
parts of iodoform ointment and cod-liver oil be rubbed into the
surface of the abdomen twice daily. There is no question that
iodine and its preparations have a favourable effect in many cases
of tuberculosis, and such preparations from time to time are
regarded by some authors as being almost specific. The failures
under their use, however, are numerous. Older authorities spoke well
of the practice of rubbing J drachm of unguentum hydrargyri into
the abdomen, and the application then of a flannel binder. The above
measures are objectionable to the patient, and in my experience are
seldom necessary ; their use should be reserved until other measures,
and especially the administration of tuberculin (see below), has failed.
Certain complications may require treatment. If diarrhoea is
present the diet should consist of milk, with 10 gr. of sodium
citrate to the pint. The best drug is opium ; in children
minim [U.S. P. \ minim] of tincture of opium may be given thrice
daily for each year of the child's age. If this fails, tannalbin may
646 Tuberculous Peritonitis.
be given in 5 to 15 gr. doses thrice daily, or more frequently if
necessary, until the diarrhoea is under control. Pain is best met by
the use of Dover's powder. In the case of a child gr. may be given
for each year of its age thrice daily. If drowsiness is induced, the
dose of opium or of Dover's powder must be reduced. The anemia
usually improves rapidly under good hygienic conditions, rest and
careful nourishment, together with the administration of tuberculin.
If it is a troublesome feature, iron and arsenic may be prescribed,
with or without cod-liver oil. A useful pill is : Acid. Arseniosi,
gr. 4*8 ; Aloini, gr. J ; Strychnini, gr. T ^g ; Pil. Feme, gr. 2, twice
a day after food. A change to the sea or mountains is an advan-
tage when convalescence has commenced.
The Administration of Tuberculin. It is my experience that
tuberculin (T.R. or B.E.) properly administered is practically a specific
in cases of tuberculous peritonitis in which there is, or has recently
been, a considerable collection of ascitic fluid. Opinions are divided
on this subject, as indeed they are with regard to the effect of
tuberculin in other forms of tuberculosis. I can only say that in
the last three years I have had a consecutive series of sixteen cases
with the presence of fluid, in all of which tuberculin has reduced
the temperature to normal and caused the absorption of the fluid,
and restored the patient to satisfactory health. The ages of these
patients varied from eighteen months to sixteen years. Six of them
had had a previous attack, for which they had laparotomy per-
formed ; three of them had had a previous attack without laparotomy.
Three of them were transferred to me from the obstetric wards
after the abdomen had been opened and extensive miliary tuber-
culosis discovered. In only two of these sixteen cases has there
been a relapse, and in each case the further use of tuberculin has
given good results. In one case a fatal issue occurred four months
after discharge from the hospital owing to perforation. In this case
there was extensive matting of the intestines when the patient first
came under my care.
It is necessary to give the tuberculin cautiously, and to avoid
reaction (see Tuberculin Therapy, Yol. III.). The initial dose
should not be larger than Too 1 00o mg. T.E. or B.E. The dose
should be gradually increased until the temperature is subnormal.
When this has happened it is possible to proceed, as a rule, more
rapidly. It may take five or six weeks or longer to reduce
the temperature, but in many cases the response to tuberculin is
more rapid. It must, however, be understood that here, as in other
cases of tuberculosis, too large doses of tuberculin will do more
harm than good. In all cases it is wise to continue the use of
Tuberculous Peritonitis. 647
tuberculin for at least six months after apparent restoration to
health.
In those cases in which fluid is scanty or absent tuberculin does
not yield such satisfactory results. In such the initial dose should
not be more than ^QOCJOO m 'g- T.R. or B.E., and the increase in the
size of the doses must be very gradual. If the use of tuberculin leads
to an increase of fever or to pain, it must be discontinued. In such
cases we probably have considerable caseation of the glands, and it
is possible that surgical measures might be of service if, after the
laparotomy and such measures as might be possible for the removal
of the caseating glands had been carried out, irrigation of the
peritoneal cavity with normal saline were systematically carried
out, and tuberculin subsequently administered.
The Removal of the Ascitic Fluid. At one time laparotomy
was extensively performed for this purpose, and with considerable
success at any rate for a time. Subsequent relapses, and the
improved results from purely medical treatment, have led to this
measure being utilised much less frequently. The good results
were no doubt due to the fact that the ascitic fluid, as has been
proved in the laboratory, of tuberculous peritonitis is more
deficient in opsonic power than the blood. As soon as this fluid is
removed from the abdomen, it is replaced by lymph with a
sufficiently higher opsonic power to overcome the bacilli, which in
these cases has a comparatively low virulence. In my experience
it is rare for the fluid not to be absorbed during the administration
of tuberculin. If the case is a chronic one and absorption is
delayed, removal by tapping is probably all that is required.
ARTHUR LATHAM.
648
DISEASES AND AFFECTIONS OF THE LIVER.
THE SURGICAL TREATMENT OF ABSCESS OF
THE LIVER.
Pus may be found in connection with the liver in several
positions. For surgical purposes and also with some clinical and
pathological significance the following classification of collections of
hepatic pus is expedient: (1) Supra-hepatic abscess; (2) Intra-
hepatic abscess ; (3) sub- (or infra-) hepatic abscess.
(1) Supra-hepatic abscess is not a sub-diaphragmatic abscess.
The latter has a well-understood signification, and is altogether
distinct from the abscess here indicated. The pus in supra-hepatic
abscess accumulates between the layers of the broad ligament of
the liver, having the diaphragm above, the liver (which is here
destitute of peritoneum) below, and the folds of the peritoneum of
the great and lesser sac constituting its anterior and posterior
boundaries respectively. This abscess is, or may be, independent
of dysenteric infection.
It arises primarily in the tissues (probably in the lymphatics-
lymphangitis), between the layers of the broad ligament, usually
from the effects of " chill" alone. On the other hand, if the focus
of hepatitis which breaks down into pus is situated near the
posterior aspect of the liver, the contents of this abscess may find
its way backwards and upwards into the area between the folds oi
the broad ligament of the liver. Whatever its origin or cause, the
surgical treatment is the same.
(2) Intra-hepatic abscess is almost invariably associated with
dysentery, and owing to its frequent occurrence in tropical countries
is often referred to as a " tropical abscess." As a rule the abscess
is single, but not invariably so, and two abscesses may co -exist with
a thin piece of liver tissue between. An intra-hepatic abscess,
be it ever so large, is invariably confined to one half of the liver.
There can be no extension of pus from the right to the left half, for,
as the writer has shown, there is no communication between the
right and left sides of the liver ; neither the arteries nor veins,
neither the hepatic bile-ducts nor the lymphatcis of the right and
left halves communicate or anastomose. This anatomical fact
explains why a primary cancer of the liver is confined to one half,
why a hydatid of one side does not directly extend to the other,
Abscess of the Liver. 649
and why pus does not find its way from one side to the other.
There are practically two livers in juxtaposition as distinct in their
blood and bile circulation as are the kidneys ; and, as the writer
has demonstrated, one half of the liver is sufficient, as in the case
of one kidney, to carry on the work assigned to the liver when the
other half is destroyed.
(3) Sub-hepatic abscess is met with on the under surface of
the right half of the liver, parallel to, and to the right of, the gall-
bladder. Four cases only of this abscess have been recorded. It exists
as a sausage-shaped mass extending from the anterior border of
the liver to near the posterior aspect of the under surface.
THE SIGNS AND SYMPTOMS WHICH SUGGEST THE NECESSITY
FOR OPERATION IN A CASE OF LIVER ABSCESS.-
These are seldom definite, not in fact unless the pus has been
allowed to accumulate to an unjustifiable extent. Short of gross
clinical evidence, the presence of pus in the liver is usually arrived
at by a process of exclusion combined with some local clinical
evidence. There is, however, no single sign by which one can
conclude definitely that one has a liver abscess to deal with.
Night sweats, increase of temperature, the history of dysentery,
pain in the right side or in the right shoulder, loss of weight,
congestion of the base of the right lung, increase of area of hepatic
dulness, abnormal outline of liver dulness, etc., collectively suggest
the probability of pus in the liver, but singly they are of little
value. Pus, however, may exist in the liver without symptoms,
although there may be over a pint of pus in the liver requiring
evacuation. There is only one definite proof that a hepatic abscess
is present, and that is finding the pus by the hollow needle of an
aspirating syringe or by laparotomy.
When a liver abscess is suspected, no time should be lost in
clearing up the diagnosis by searching for the pus, but it is
imperative before doing so that preparations should be made to
complete the operation there and then if pus is found.
SEARCHING FOR PUS IN THE LIVER.
When an abscess in the liver is suspected, the pus may be searched
for by incision or by a hollow needle. If the evidence points to
the left half of the liver being involved there is usually a pro-
minence to be felt on the liver in the epigastric region, and here it
is unwise to insert a needle to clear up the diagnosis, but it is
necessary to proceed at once to expose the liver by an incision
over the indicated seat of the trouble. If, on the other hand, the
650 Abscess of the Liver.
pus is believed to be in the substance of the right half of the liver,
and especially when it is far back or supra-hepatic, search should
be made by a hollow needle.
It must be remembered that pus deeply placed in the substance
of the liver may give no evidence of its presence when the liver is
exposed by abdominal incision. Time and again the liver has been
exposed and examined, and, as nothing abnormal was apparent,
the abdominal wound has been closed, while subsequent history
demonstrated the fact that the abscess was missed.
Introducing a Needle in Search of Pus in the Liver.
Owing to fatal haemorrhage having occurred in several recorded
operations by competent surgeons, after the introduction of a needle
into the liver, considerable hesitation has arisen in following this
method' of exploring the liver for pus. With the object of allaying
so alarming a possibility the writer has drawn up certain rules to
be followed, whereby the danger may be reduced to a minimum, if
not wholly removed. The importance of getting rid of the dread
of such a calamity becomes at once apparent when it is considered
that by the needle and the needle alone can the presence of pus
in the liver be definitely ascertained. Do away with this method
of diagnosis or allow the danger of fatal haemorrhage occurring to
cause delay in using the needle, and the patient's chances of
recovery are rendered precarious in the extreme. That needle
punctures in the liver bleed, it may be freely, into the cavity of the
abdomen has been proved conclusively, as the following instance
will show. After tapping a man for ascites the writer inserted a
needle into several places of the liver whilst yet the ascitic fluid
was escaping through a cannula introduced just above the pubes.
Almost immediately after puncturing the liver with the needle the
ascitic fluid became tinged with blood ; the tinge grew deeper and
deeper until there seemed to be only blood escaping through the
cannula. In considerable alarm the cannula was withdrawn, the
patient placed in a recumbent position, and a firm bandage applied
over the abdomen. No untoward symptoms occurred ; in fact, the
opposite obtained, for the patient was greatly relieved, more
especially as the liver was enlarged and congested. Haemorrhage
from needle punctures made into the liver substance is not fraught
with danger, and it must be due to some large vessel being wounded
that fatal haemorrhage may occur. Without entering into ana-
tomical details, it will be evident that of the vessels entering or
leaving the liver the blood might come from either the portal vein
or the inferior vena cava. The portal vein is not likely to be
punctured by a needle unless it is introduced low in the epigastrium
Abscess of the Liver.
651
and pushed deeply, a procedure which should not be adopted. The
inferior vena cava has alone to be considered, and it is probably
this vessel which has been punctured when fatal haemorrhage
occurs. To obviate this accident occurring the writer made a
study of the exact position of the inferior vena cava in the region
of the liver, its relation to the surface of the body, and the depth
at which it lies.
The summary of these investigations is as follows :
The inferior vena cava occupies a position in the " operable area "
for liver abscess equidistant from the surface. By the operable
area is meant the region over the liver between the middle line of
--c
FlG. 1. Diagram of a section of a body, 32 inches in
circumference, through the hepatic region, showing
the inferior vena cava to be equally distant from the
surface of the body in the " operable " area of the
liver. I.V.C. = Inferior vena cava. I. = Liver.
A, B, 0, D = Radii of a circle having the inferior
vena cava as a centre, c. = Colon, gf. = Stomach.
sp. = Spleen, k. k. = Kidneys, a. = Aorta.
the body in front and the angles of the right ribs behind.' This
fact can only be ascertained by a study of transverse frozen sections
of the body made in the hepatic region. These show that the
inferior vena cava occupies a position at equal distances from the
surface of the body in the hepatic region. The diagram (Fig. 1)
will best interpret the facts.
The usual circumference of the body at the hepatic level (of the
sections measured) is 32 inches, and it will be found that the
distance of the centre of the inferior vena cava from the surface of
the body in a body of 32 inches circumference is 4 J inches. But the
cava at this point measures 1 inch in diameter, so that it is not safe
to use a needle longer than 3| inches at most, to avoid wounding
the cava.
652 Abscess of the Liver.
OPERATIONS FOR LIVER ABSCESS.
(1) "When the Pus is Supra-hepatic or Deep-seated
in the Right Lobe of the Liver. (a) Trans -thoracic Operation
by Trocar and Cannula. This operation was devised by Sir
Patrick Manson ; the apparatus here described was devised by the
writer.
Special instruments required : Aspirating syringe ; trocar and
cannula ; hepatic drainage tubes ; stretching rod, with piece of glass
tube and 5 feet of indiarubber tubing.
Chloroform should be the anaesthetic administered. The patient
should be placed so that the right side of the body is towards the
light. The skin over the liver is prepared in the usual way ; the
area in which the operation is to be performed is painted with
tincture of iodine.
Percuss afresh the region of the liver and select the spot where
abnormal dulness prevails for the introduction of the needle.
Puncture the skin with a knife before introducing the hollow
needle ; this tends to obviate the plugging of the channel of the
needle by a wad of skin. Wash the needle out with sterilised water
(not carbolic or other disinfectant) before introducing it. See that
the plunger is driven home before introducing the needle. Insert
the needle at the puncture in the skin previously made, and push it
onwards horizontally by pulling the barrel off the piston, not by
pulling the piston out of the barrel. The piston-handle is steadied
in one hand whilst the barrel is moved onwards ; in this way the
moment the hollow hi the needle reaches the pus it is sucked into
the syringe.
If pus is not found with the first stab the needle is withdrawn,
sterilised water drawn into and ejected thrice from the syringe,
and the liver punctured in another likely place. This may be
repeated six to eight, even to ten, times before concluding that
further search is useless. The punctures may be made anywhere
from between the angles of the ribs behind, to as far forwards as
2 inches from the edge of the sternum.
Where pus has been found introduce the trocar and cannula
along the tract followed by the needle. The skin over the spot is
cut to the extent of about | inch, and through this the point of the
trocar is inserted and pushed onwards between the ribs until no
resistance is felt, or to the depth from the surface at which pus was
struck by the needle. The trocar is now withdrawn, and through
the cannula an indiarubber tube 12 inches long stretched on a metal
rod with forked end is introduced until it is stopped deeply by the
abscess wall. The cannula is now withdrawn by pulling it over the
Abscess of the Liver. 653
stretched rubber tubing whilst the metal rod is held steadily in
place. On the cannula being removed the indiarubber is allowed
to slacken, when it contracts towards the bottom of the wound on
the stretched rod. The rod is now withdrawn and the tube stitched
to the skin at the edge of the wound. Into the projecting end of
the indiarubber tube a glass tube some 4 inches long (of a diameter
to fit the tube) is inserted, and to the distal end of the glass tube a
piece of indiarubber tube long enough to reach from the bed to a
bucket or basin on the floor. In the basin a few pints of water are
placed, and the distal end of the rubber held beneath the surface of
the water by a weight ; a Spencer- Wells forceps clipped on one
side of the mouth of the lower end of the tube suffices to keep the
tube under the surface of the water. A syphon is now created of
great potency, and the pus is speedily drawn into the water in the
basin.
If after a time blood is passing too freely, the basin must be
raised off the floor by a stool or low chair, so that it is only just
below the level of the exit of the tube from the patient's side. The
syphonage is kept up until pus ceases to ,flow and the fluid coming
away is seen to be deeply tinged with bile a period varying from
a few days to a few weeks when the large rubber tube in the side
is withdrawn and a smaller one inserted in its place. From day to
day this tube is shortened and reduced in size until the track
gradually closes.
This operation is simple in the extreme. It can be performed
single-handed, a point of much importance, seeing that operation
for liver abscess has often to be performed in out-of-the-way parts
of the tropics, where help cannot be had. The operation involves
no such serious undertaking as opening the abdominal cavity, or of
cutting down and removing a piece of a rib or two, opening the
pleura, cutting the diaphragm and traversing the peritoneum to
reach deep-seated pus in the liver a procedure which may be
undertaken in a well-appointed hospital, but when attempted in an
improvised hospital " in the wilds," where asepsis is impossible, is
one that can only end in disaster.
Under any and every condition, however, be it in a completely
equipped general hospital with skilled surgeons and trained nurses,
the operation by trocar and cannula and a stretched indiarubber
tube and syphonage is the operation par excellence, for it is by far
the most successful for deep-seated hepatic abscesses, as the
published cases of the writer have shown (22 deaths in 123 cases) ;
it yields, moreover, by far the best drainage, which is, after all, the
chief aim when operating for liver abscess.
654 Abscess of the Liver.
(b) Trans-thoracic Operation by Incision and Removal of a Piece of
Rib. With the patient prepared as described above, an incision
some 3| to 4 inches in length is made parallel to a rib over the
seat of the abscess. The outer surface of one or two ribs is exposed,
the periosteum incised and raised from the rib (or ribs) all
round the circumference. The bone is then cut through by forceps
in two places, some 2 or more inches apart, and the detached
piece raised carefully and removed. Should intercostal vessels
bleed, they are tied. If the pleura is exposed, an attempt is made
to stitch its two layers to the diaphragm, leaving an area of exposed
diaphragm through which the operation can be continued. The
diaphragm is now cut or split, the margins of the wound made in it
held apart, when, if the pus has not been reached, the peritoneum
has to be traversed, its cavity packed off by gauze around the tract
of the operation and the liver incised in the hope of reaching the
pus. When the pus is reached the liver substance is distended by
the expanding blades of a forceps and a large rubber tube (or two
tubes) inserted. The tube is stitched to the skin, the wound around
the tube packed by gauze, and the whole covered by layers of gauze
and wool. Fortunately for the operator, this intricate and formid-
able procedure, owing to delay or hesitation in operating, is not
often required, as the pus is usually met with immediately below
the piece of rib removed, when the operation resolves itself into one
of the simplest nature. The delay, however, is not conducive to the
patient's welfare.
(2) Operation by Abdominal Incision. --When a hepatic
abscess is in the left half of the liver, or when in the right half it
presents towards the abdominal wall in front, it should be reached
by incision. If attempts at diagnosis by inserting a needle are
made in this region, it is necessary to employ the utmost caution to
prevent rupturing the abscess cavity by the pressure employed
whilst inserting the needle, and also to beware of pushing the
needle too deeply, otherwise the stomach, the gall-bladder, or even
the portal vein may be pricked.
An incision is made over the most prominent point of the
" lump " to be felt. It is preferable always to go through a rectus
muscle and not the aponeurotic tissue at its outer margin, nor
through the middle line. A vertical incision 3 to 4 or more inches
long is made through the skin and subcutaneous tissues, the
anterior layer of the aponeurotic sheath -of the rectus is incised
vertically, the rectus muscular fibres separated, the posterior sheath
of rectus incised and the peritoneum opened. The finger is now
introduced to ascertain the presence of adhesions, or to explore the
Abscess of the Liver. 655
surface of the liver if no adhesions are present- If the abscess
projection conveys the sensation of fluctuation, the peritoneum is
packed off by gauze and the abscess opened and evacuated. The
gauze may be left in situ, a drainage tube inserted, the tube stitched
to the skin, the wound partially sutured, and dressings applied.
Instead of leaving the gauze in situ, the forefinger may be intro-
duced into the cavity of the abscess to facilitate stitching the
margins of the wound in the liver to the peritoneum as the gauze is
withdrawn. Some operators before opening the abscess stitch the
cut edges of the parietal peritoneum to the peritoneum, covering the
liver around the site of the abscess by a continuous suture. An
outer row of interrupted stitches may, in addition, be inserted inch
beyond the inner row, so as more completely to insure that the
pus may not reach the peritoneal cavity before the abscess is
opened. In the exposed area the liver is incised and the pus
evacuated, or the opening of the abscess may be delayed if there is
no urgency for twenty-four hours.
These elaborate precautions are not, however, necessary, as liver
pus is almost invariably sterile, and seldom causes untoward
symptoms even if it does gain access to the peritoneal cavity in
small quantity.
The dressings are changed as required, the size of the rubber tube
reduced, and the wound allowed gradually to heal.
(3) Treatment when a Hepatic Abscess has Burst
Upwards through the Lung. A supra-hepatic abscess and a
deep-seated abscess on the right half of the liver frequently finds
exit, if operation has been delayed, by way of the lung.
The pus is coughed up, and it is possible the cavity may be
satisfactorily emptied and the patient forthwith cured of his ailment.
This, however, is not the rule. After the primary evacuation
the pus coughed up gradually lessens in quantity, the temperature
subsides, and all seems well. After a week or two or more the
expectoration may cease, the temperature rises, pain supervenes, and
in a few days a sudden gush of pus is expectorated. This may be
repeated at intervals of weeks or months for a year or two, but even
at so remote a period the patient may get well without operation.
It is not, however, wise to allow these recurrences to go on
indefinitely. If, therefore, a recurrence takes place more than once,
operation is necessary.
The question arises, when should an operation be performed ?
The answer is : During the period when the expectoration ceases,
when the temperature is up and pain present, for then and only
then is it possible to hit the cavity in the liver. If, whilst the
656 Abscess of the Liver.
expectoration is free and the temperature normal, an attempt is
made to search for the cavity of the abscess by a needle, disappoint-
ment is almost certain, for there is practically no cavity. The
evacuation by expectoration being free, the walls of the abscess are
collapsed and in contact, and to hit a space no thicker than a piece
of paper is well-nigh an impossibility. When, however, the fever
recurs and the cough stops, showing that pus is collecting in the
cavity, it is possible to ascertain its presence by a needle introduced
at this period. When the pus is reached, the trocar and cannula
should be introduced and the whole steps of the operation gone
through as above described. In old- standing cases the channel of
pus through the chest will be found most frequently between the
lung and the pericardium ; the walls of the channel become thick
and fibrous, and to reach the tract from the right side of the chest
is fraught with difficulty. The writer has found it necessary, on
account of the depth, to excise a portion of a rib or ribs, to traverse
a portion of condensed lung and puncture the thick-walled channel
whilst in contact with the pericardium. As this is usually some
7 to 8 inches from the surface of the skin in the axillary line it is
not a proceeding that can be lightly attempted.
To allow pus to find exit by way of the lung should be prevented
at all hazards. It means either that the abscess has not been
diagnosed a pardonable error, or that there has been unjustifiable
delay in operating an unpardonable error. Since operation by
the trocar and cannula is so simple that it can be undertaken at
once wherever the patient may be, and however unhygienic the
surroundings, delay in operating is not justified.
JAMES CANTLIE.
657
ACUTE YELLOW ATROPHY.
As it is now known that this disease is not invariably fatal, it is im-
portant to take prompt prophylactic measures in cases of jaundice in
which acute yellow atrophy may possibly follow. Thus, in jaundice
in pregnant women, catarrhal jaundice associated with much drowsi-
ness or toxaemic symptoms, and jaundice in the subjects of secondary
syphilis, an attempt should be made to dimmish the toxaemia. In
such circumstances the patients should be kept in bed for a time
in a well-ventilated room, and the diet confined to milk and
carbohydrates. The milk may be flavoured with coffee, cocoa
or tea, and may be thickened with cornflour. Three to four
pints may be given daily. When there is difficulty in digestion
peptonised milk-gruel or Benger's food may be substituted
in part or entirely for milk. Sugar and chocolate are of use
in preventing acidosis. The patients should be encouraged to
drink plenty of water so as to dilate the toxins and increase
excretions ; for this purpose alkaline mineral waters, such as Vichy
or Vals, are especially suitable. The bowels should be kept very
freely open by calomel (3 to 5 gr.), followed by salts (magnesii
sulphatis, 333, or sodii sulphatis 2 drachms and sodii phosphatis
2 drachms in water) next morning twice a week, with cascara
sagrada on the intervening days. The degree of purgation must
be regulated by the progress of toxsemic symptoms. If necessary,
the urinary excretion may be further stimulated by citrate of
caffeine (5 gr.) or diuretin (7| gr.) combined with digitalis. The
jaundice should be met by urotopin (7 gr.) combined with sodium
salicylate (10 gr.), and bicarbonate of sodium (15 gr.), three times a
day before food. Acids should be avoided. Intestinal antiseptics in
one of the following forms may be tried : Beta-naphthol (5 gr.),
naphthalin tetrachloride (7% gr.), calomel ( T \, gr.), salol (5 gr.),
rubbed up with insoluble powder or given in the form of an
emulsion so as to prevent the formation of calculi, acetozone (1 in
2,000 parts of water) sweetened with syrup of lemon [U.S.P.
syrup of citric acid] (2 oz. to 1 pint), \ to 1 pint daily, or salicylate
of bismuth (10 gr.). In jaundice in secondary syphilis, mercurial
treatment or a single injection of Ehrlich's dioxydiamido-arseno-
benzol (" 606 ") is essential.
S.T. VOL. II. 42
658 Acute Yellow Atrophy.
In cases in which, from the presence of nervous symptoms and
considerable diminution of the liver dulness, the onset of acute
yellow atrophy seems fairly certain the above measures should be
pushed, and in addition enemas or subcutaneous or intramuscular
transfusions of saline solution should be carried out to obviate the
toxaemia. Sodium bicarbonate should be given in larger quantities
(1 drachm) three or four times daily by the mouth or in the
enemas or transfusions (3 drachms to 1 pint). As the condition is
thought to depend on autolysis of the liver, I gave horse serum,
which has an anti-autolytic action, in one case in which recovery
eventually occurred.
Vomiting should be treated by careful feeding, small doses of
cocaine (^ gr.), dilute hydrocyanic acid (ij|2^), or small
hypodermic injections of morphine (^ gr-)- Sleeplessness and
delirium should be met by tepid sponging, ice-bags to the head,
bromides, morphine, veronal or trional. Chloral and its allies
should be avoided, because the chloroform which is formed exerts a
toxic action on the liver cells. The circulation should be main-
tained by the hypodermic injection of liquor strychnines Ou3) or
digitalin (^ gr.).
H. D. ROLLESTON.
REFERENCES.
Legg, J. Wickham, " The Bile, Jaundice and Bilious Diseases," 1880, London.
H. Quincke Nothnagel's " Encyclopedia of Practical Medicine," English edition,
1903, Vol. on " Diseases of the Liver," p. 47.3. Eolleston, H. A., " Diseases of
the Liver, Gall-bladder and Bile-ducts," 1905, London. Thomson, J.,
"Jaundice in Newly-born Children." Allbutt and Eolleston, "System of
Medicine," 1908, IV., Part I., p. 98.
659
ANOMALIES IN FORM AND POSITION OF THE
LIVER.
DISPLACEMENT of the liver by a large pleural effusion, pneumo-
thorax, or subphrenic abscess on the right side, or by a gigantic
pericardial effusion, is of course treated by relief of the causal factor.
A Wandering Liver (Total Hepatoptosis) is nearly always a
manifestation of visceroptosis (Glenard's disease), and the treat-
ment is mainly on the same lines as in that disease. As
prophylactic measures, women with pendulous abdomens should
be specially careful about getting up after childbirth, and should
wear a straight-fronted corset or the form designed by Gallant.
The corset should be carefully fitted and moulded in the first
instance, and should always be put on in the supine position.
Tight-lacing and all ill-fitting corsets must be forbidden. For the
pain which may accompany hepatoptosis rest in the horizontal
position with the foot of the bed raised gives relief. The abdominal
muscles should be strengthened by exercises and, if necessary, by
massage. The patients often require feeding up, but care must be
taken to avoid flatulence. In cases in which a properly fitted
abdominal support fails to give relief, the liver has been fixed in
position by suturing (hepatopexy). This may be necessary in
extreme cases, but it must be remembered that a wandering liver
is usually part of general visceroptosis, and that relapses may
occur after hepatopexy.
Linguiform Lobe (Riedel's Lobe ; Partial Hepatoptosis).
When there is pain in connection with this comparatively common
deformity, treatment must in the first place be directed to any
underlying condition such as gall-stones, cholecystitis, or distension
of the gall-bladder. Tight- lacing and badly-fitting corsets must be
avoided and a straight-fronted corset should be worn. Two forms
of operative treatment have been advocated : (1) Excision of the
lobe ; (2) fixation of the lobe to the abdominal wall.
H. D. ROLLESTON.
KEFERENCES.
F., " Los ptc>si>< viscerales," Paris, 1899. Keith, A., " Hepato-
Allbutt and Rolleston, " System of Medicine," 1908, IV., Part L, p. 11.
422
66o
CIRRHOSIS OF THE LIVER.
PORTAL OR COMMON CIRRHOSIS.
Prophylactic Treatment. Portal or multilobular cirrhosis of
the liver is the final result of the repeated occurrence of small
areas of necrosis of the liver cells produced by toxins reaching it
by the portal vein. The toxins are absorbed by the alimentary
canal and are mainly the result of indigestion, most commonly of
alcoholic origin. The prophylactic treatment of portal cirrhosis,
therefore, includes that of dyspepsia (see Vol. I.) and chronic
alcoholism (see Vol. I.). The diet should be carefully regulated
so as to avoid highly-spiced food containing condiments such as
curries ; alcohol in all forms and even medicinal tinctures should
be forbidden. It may be wise for the patient to change his
occupation, for example, to give up work as a barman.
Early Stages. In a patient suffering from dyspepsia whose
liver is found to be enlarged, but who has no other symptoms of
cirrhosis, these restrictions in diet may advantageously be supple-
mented by a course at a spa such as Harrogate, Homburg, Vichy,
Karlsbad, Kissingen or Marienbad. In this stage and after a
single attack of hfematemesis strict attention to diet, abstinence
from alcoholic stimulants, and freedom from dyspepsia may be
followed by arrest of the disease and the patient may remain well.
But it is important that he should realise that the condition is
compensated for, not cured, and that he should maintain the life
of strict moderation, otherwise the symptoms may return. Even
when the disease appears latent, copious gastro-intestinal haemor-
rhage may occur with little or no warning except a feeling of
faintness and nausea. The hgemateniesis should be treated by rest
in bed for four or five days, and nothing not even water should
be given by the mouth for two days ; as a rule it is unnecessary to
give nutrient enemas during this short period, but an enema of a
pint of water should be given three or four times daily to relieve
thirst. A drachm of calcium chloride may be put into the first
water enema so as to diminish the tendency to haemorrhage. As
the bleeding commonly comes from dilated and ulcerated veins at
the lower end of the cesophagus, 20 min. of a 1 in 1,000 solution
of adrenalin chloride in an ounce of water may be given by the
mouth for its local action on the bleeding spot. Tannic and gallic
Portal Cirrhosis of the Liver. 66 1
acids, perchloride of iron, and turpentine have been given with the
same object, but are somewhat irritating and rarely necessary. If
the patient is anxious and nervous a hypodermic injection of
morphine (J gr.) may be given. In rare cases in which there is
serious collapse as a result of the haemorrhage, subcutaneous,
intramuscular, or intravenous transfusion of 1 to 2 pints of
saline solution should be given at blood heat. On the evening of
the second day a blue pill [U.S.P. mass of mercury] should be given
followed next morning by magnesium sulphate (jss in 4 oz. of
water), so as to get the bowels freely open. On the third day, pro-
vided there has been no recurrence, feeding by the mouth may be
started with peptonised milk, peptonised milk gruel, and gradually
improved. For a week or so milk up to 4 pints a day should be taken ;
it can be flavoured with coffee or tea, or given in the form of junket
or Benger's food. The after-treatment is of importance, for it is
often only after an attack of haematernesis that the existence of
cirrhosis is suspected and that the patient can be sufficiently
impressed with the need for temperance. As the patient improves,
the dietary should be extended ; soft and easily digested fish,
pounded fish and rice, eggs lightly boiled, minced chicken,
mashed potatoes, butter and stale bread, milky puddings and
vegetable soups may be given. Meat soups and extracts, highly
spiced foods and irritating articles must be avoided. Iodide of
potassium should be given in 10-gr., increasing to 15-gr., doses
three times a day, unless syphilis can be excluded. Constipation
must be prevented by simple waters such as Apenta, Hunyadi Janos,
Karlsbad or Epsom salts, or a mixture of rhubarb and soda,
compound jalap powder (30 gr.), cream of tartar (jss), or
calomel (3 gr.), followed by magnesium sulphate (^ss) next
morning. Undue looseness of the stools, which, by abstracting
food, would impair the patient's nutrition, should be prevented by
salicylate of bismuth (15 gr.), aromatic chalk mixture, or tannigen.
Intestinal fermentation and putrefaction should be prevented by
diet, and if necessary, by calomel (^ gr-)> guaiacol carbonate
(5 gr.), or naphthalin tetrachloride (7 gr.) three times a day.
No drug will remove the fibrous tissue in the liver, but some
patients improve while taking ammonium chloride (10 to 15 gr.)
three times a day.
Tonics, such as tincture of nux vornica (5min.) [U.S.P. (12 min.)]
in combination with sodium bicarbonate (10 gr.) and infusion of
gentian (jss) twice or three times a day before food, may be
required at intervals. Arsenic is best avoided, as it appears to be
capable of inducing cirrhosis.
662 Portal Cirrhosis of the Liver.
The course of portal cirrhosis may be conveniently divided into
(1) the pre-ascitic stage in which hsematemesis may occur, and
(2) the stage of ascites accompanied by coxic symptoms. The onset of
ascites is sometimes preceded by the rapid appearance of ti/nipanitic
distension, which may be so excessive as to be dangerous. This
should be met by the remedies mentioned above in connection with
the prevention of intestinal fermentation and putrefaction, and
also as it is probably toxic in origin by diuretics, such as caffeine
citrate (5 gr.) with tincture of digitalis (15 min.) three times a day,
and also by purgatives. The treatment of ascites and the indica-
tions for tapping have been considered elsewhere {see article on
Ascites, Vol. I.), but reference must be made here to the surgical treat-
ment of the ascites of hepatic cirrhosis by producing vascular peritoneal
adhesions. This method, first suggested by Talma and carried
out in this country by Morison, is often called the Talma-
Morison operation. Its object is to increase the anastomoses
between the portal and the general systemic veins, and thus to lead
to absorption of the ascites ; but it may also act by improving the
nutrition of the liver cells and so enabling them to exert their
antitoxic function more effectually. The operation should not be
undertaken in an advanced stage of the disease, as shown by
marked debility, wasting and toxaemia ; when there is consider-
able jaundice ; or in the presence of definite cardiac or renal
disease. The really suitable cases, which are not very common,
are those in which the general condition is good and in which
the symptoms are those of obstruction rather than of toxaemia.
The details of the operative procedure vary, but the essentials
are to scrape the adjacent peritoneal surfaces of the liver and
diaphragm so as to favour adhesive peritonitis. Some surgeons
turn the omentum up and fix it between the liver and the
diaphragm ; others, again, scrape the surfaces of the spleen and
adjacent peritoneum. Omentopexy, or suturing the great omentum
to the abdominal wall, has also been carried out. According to
Sinclair White's analysis of 227 cases, 87 per cent, were cured and
13 per cent, improved as the result of the Talma-Morison operation.
Ascites has also been treated surgically by fixing the great omentum
under the abdominal muscles and externally to the parietal
peritoneum (Schiassi); by introducing the omentum into a sub-
cutaneous pocket in the abdominal wall (Narath) ; by permanent
drainage into the tissues of the thigh through the femoral ring
(Wynter and Handley) ; and even by anastomosing the peritoneal
cavity with the saphenous vein (Soyesima).
Late stages. As tox&mia is a prominent feature, the diet
Hypertrophic Cirrhosis of the Liver. 663
should consist of milk (3 to 4 pints in the twenty-four hours) ;
to avoid monotony it may be flavoured with coffee, tea or
cocoa, or given in the form of junket. When milk or milk diluted
with barley water sets up nausea, skimmed milk or koumiss may
be tried. If the patient improves, the milk diet should be supple-
mented by the cautious addition of Benger's food, peptonised milk
gruel, milk puddings, eggs, and eventually pounded fish.
The hamorrkagic tnulciicy should be met by the administration
of calcium salts. For example : Calcii Lactatis, gr. 10 ; Magnesii
Lactatis, gr. 7^ ; Syrupi, 53 ; Aquam, ad jj, t.d., for six doses.
Acidosis, as shown by a purple colour on adding a few drops of
liquor ferri perchloridi to the urine, should be treated by Sodii
Bicarbonatis, gr. 30 ; Syrupi, 533 ; Aquam, ad gj, three times a
day. For drowsiness due to toxemia, purgatives and diuretics
should first be tried, then hot water or hot-air baths, copious
enemas of water at blood heat, and lastly, transfusion of saline
solution (1 to 3 pints). If there is evidence of acidosis, bicarbonate
of sodium (2 drachms to I pint) should be added to the saline solu-
tion. Medicinally, besides iodide of potassium, which, as already
mentioned, should always be tried unless syphilis can be excluded,
a tonic such as Tinct. Nucis Vom., iti7 ; Sodii Bicarbonatis,
gr. 15 ; Aquam Menth. Pip., ad ^j [U.S. P. Tinct. Nucis Vom., irilS ;
Sodii Bicarbonat., gr. 15 ; Aquam Menth. Pip., ad jj], may be given.
Arsenic should not be given. The patient's general health should
be maintained by fresh air and sun when the weather is suitable,
but exertion, cold, damp and east winds must be avoided.
Extract of liver substance has been recommended, and the daily
administration of 3 oz. of pulped pig's liver has been stated to
have been beneficial (Widal). A grape cure, in which as much as
5 Ibs. of ripe grapes are taken daily, has also been advocated
(Cavazzini).
REFERENCES.
Kelly, A. O. J., in " Osier and McCrae's System of Medicine," 1908, Vol. V.,
]). 7S(i. Rollrston, H. D., " Diseases of the Liver, Gall-bladder, and Bile-ducts,"
London, 1905. White, W. Hale, " Common Affections of the Liver," London,
.1908. White, Sinclair, "Brit. Med. Journ.," 1906, II., p. 1287.
HYPERTROPHIC BILIARY CIRRHOSIS (HANOT'S DISEASE).
As this somewhat rare disease may depend on infection by means
of water, special attention should be paid to this point, and if the
residence is damp and low lying the patient should move to a drier,
664 Syphilitic Cirrhosis of the Liver.
more elevated and sunnier spot. Every effort to improve the general
health should be made. Fresh air and regulated exercise are
desirable; cold and damp, exposure to east winds, and over-
fatigue must be avoided. The diet should be more generous than
in portal cirrhosis, but stimulating and spicy food and alcohol
should be forbidden. During the attacks of fever and increased
jaundice a milk diet should be enjoined. In the early stages
benefit may result from treatment at Harrogate, Ems, Vichy,
Homburg, Neuenahr, or a mild course at Karlsbad.
Constipation should be prevented by mineral waters, such as
Hunyadi Janos, Condal, Karlsbad. As the disease may be infective
a mixture of Urotropin, gr. 5 ; Sodii Salicylatis, gr. 7ss ; Sodii
Bicarbonat., gr. 10 ; Aquam Menth. Pip., ad j, may be given
twice a day before food every alternate week. Calomel, T \y to
\ gr. every four hours for three days in each week for a month, has
been stated to do more good than any other drug. Pruritus should
be treated on the lines indicated on p. 670.
Surgical treatment in the form of drainage of the gall-bladder for
periods up to three months has been followed by good results in a
number of cases, but the diagnosis in these cases is perhaps open
to criticism.
REFERENCES.
Fletcher, H. Morley, Allbuttand Rolleston, " System of Medicine," 1908, IV.,
Part I., p. 194. L6r6boullet, " Les Maladies du foie et leur Traiteinent," Paris,
1910, p. 315.
SYPHILITIC CIRRHOSIS OF THE LPVER.
IN Tertiary Syphilis of the liver, mercury and its compounds
should be given either by the mouth, by intramuscular injection,
or by inunction. The choice of the method must depend on
circumstances ; usually the oral administration of the green iodide
(| to 1 gr.) in the form of a pill made up with sugar of milk, or of
a mixture of perchloride of mercury solution On 30 to 5J) [U.S. P.
corrosive mercuric chloride, gr. ^ to gr. T v] in combination
with iodides (see below) is the most convenient form. But if
salivation or gastro-intestinal irritation is set up, or in the case
of patients who cannot be relied upon to take their medicine,
the intramuscular injection of mercurial salts, either soluble, such
as the perchloride ( gr.), the cyanide ( T ^ gr.), or succinimide (j^gr.),
or the insoluble salts, such as the salicylate(| gr.), calomel (^ gr.)
Syphilitic Cirrhosis of the Liver. 665
should be employed. The injection is made deeply into the
substance of muscles, such as the gluteal, once a week. Inunction
and fumigation are most commonly given at spas such as Aix-la-
Chapelle and Luchon. Iodides should be given at the same time
as mercury. Beginning with 10 gr. three times a day before food,
the amount should be increased, provided severe symptoms of
iodism do. not appear, until 30 gr. three times a day are given.
It is probably best to give the iodides of potassium, sodium and
ammonium in equal doses. In cachectic patients large doses of
decoction of sarsaparilla (up to a pint in the day) have been
recommended. It must be remembered that symptoms due to a
gumma will be relieved, whilst those due to a syphilitic cicatrix will
not be influenced by treatment. In some large gurnmas incision
and scraping out the caseous contents has hastened a cure by drug
treatment. The reports of the effects of injections, intramuscular
or intravenous, of dioxydiamido-arsenobenzol (Ehrlich's 606), point
to a rapid and easy cure of tertiary lesions.
For the treatment of congenital syphilis of the liver see Article
on Syphilis (Vol. I.).
H. D. ROLLESTON.
666
DISEASES OF THE BLOOD-VESSELS OF THE LIVER.
Thrombosis of the Portal Vein is usually associated with
cirrhosis or with some other grave affection of the liver, such as
new growth or syphilis. Symptoms suggesting its presence are
sudden and considerable ascites, which rapidly recurs after removal
and gastro- intestinal haemorrhages ; these should be treated as in
cirrhosis. When pylethrombosis is suspected, citric acid (30 gr. in
water every four hours for four days) may be tried in order to
reduce the excessive coagulability of the blood and so to prevent
the extension of the thrombosis ; but it must not be given in the
presence of a general haemorrhagic tendency, which it would tend
to increase. If there is evidence of past syphilis this should be
treated. In cases of obliteration of the portal vein as a result of
past thrombosis, shown clinically by splenic enlargement and
recurrent haematemesis, it would appear reasonable to perform
the Talma-Morison operation for promoting vascular anastomoses
around the liver (see p. 662). But this procedure has not often
been carried out, and when done has not been successful.
Suppurative Pylephlebitis. As the blood is usually sterile and
the causal organism cannot be determined, vaccine therapy must
be hypothetical ; a streptococcus vaccine or a polyvalent anti-strep-
tococcus serum may be tried. Apart from any attempt of this kind,
the treatment must be directed to relief of the symptoms ; thus,
the alleviation of local pain should be effected by soothing applica-
tions, and if necessary by morphine hypodermically. The general
symptoms are those of septicaemia and should be treated on
those lines. Surgical treatment can hardly be expected to do
good ; but in a few instances recovery has followed opening a
small hepatic abscess in cases resembling, if they were not,
pylephlebitis ; so that if the condition of things be explained to the
patient and he wishes the risk to be taken an exploratory operation
may be performed.
The prophylactic treatment, namely, the removal of a cause
likely to produce pylephlebitis, for example, an inflamed appendix,
is all-important.
Obstruction of the Hepatic Veins may be due to thrombosis,
stricture by fibrosis in the neighbouring parts of the liver, or
Obstruction of the Hepatic Veins. 667
chronic periphlebitis and endophlebitis. The symptoms are very
much the same as those of thrombosis of the portal vein, and the
treatment should be on the same lines.
Aneurysm of the Hepatic Artery is very rare and has hardly
ever been diagnosed. When found at an exploratory laparotomy
the treatment is ligature, but even then the outlook is bad ; out of
six cases thus operated upon recovery occurred in one (Kehr). The
symptoms, usually simulating those of biliary colic or duodenal
ulcer, must be treated by anodynes.
H. D. ROLLESTON.
BEFERENCES.
Disease* of the Portal and Hepatic Veins: Brown, W. Langdon, "St. Bart.
Hos. Rep.," Lond., 1901, X XX V 11., p. 62. Hess, A. F., " Amer. Journ. Med.
Sciences," 1'hilad., 1905, ' CXXX., p. 986. Herringham, W. P., Allbutt and
Rolleston, " System of Medicine," IV., Part I., p. 153.
Ant'ui -ysms "of the Hepatic Artery : Kehr, H., "Miinchen. Med. Wchnschr.,"
903, L., p. 1861. W. Holland (abstract of forty cases), " Glasgow Med. Journ.,"
90S, LXIX., p. 342.
668
DEGENERATIONS OF THE LIVER.
FATTY LIVER.
UNDER this heading will be included the conditions formerly
spoken of as fatty infiltration and fatty degeneration of the liver.
An excessive quantity of fat occurs in the liver in a large number
of conditions, such as obesity, some cases of cirrhosis, alcoholism,
poisoning by arsenic, phosphorus and iodoform, and in infective
conditions such as gastro-enteritis and pulmonary tuberculosis.
There are no special symptoms referable to fatty liver apart from
those due to the causal disease, and the treatment is that of the
primary condition.
Intense fatty change in the liver is such a prominent feature in
delayed chloroform poisoning that a brief reference to its treatment
should be made here. Prophylactic measures consist in feeding
the children before chloroform narcosis, especially when from
vomiting, diarrhea or other causes, the liver has been deprived of
food. It is important that sugar and alkalies, such as bicarbonate
or citrate of sodium, should be given both before and after opera-
tions on badly nourished children in order to obviate acid intoxica-
tion. The sugar may be given by the mouth or per rectum, and
the alkali in the strength of 2 drachms to the pint of water, either
by the bowel or under the skin. Beddard advocates intravenous
transfusion of a solution of 6 per cent, of dextrose after symptoms
of acid intoxication have appeared.
\
KEFERENCES.
Beddard, A. P., Lancet, 1908, I., p. 782. Guthrie, L. G., " Clin. Journ.,"
Lond., 1907, XXX., p. 129. Hunter, W., Art. "Delayed Chloroform Poison-
ing," Allbutt and Eolleston, " System of Medicine," 1908, IV. r Part I., p. 136.
FUNCTIONAL DERANGEMENT.
THIS condition of the liver is common both as the result of gross
structural change and of poisons reaching it from the alimentary
canal. The conditions popularly described as "torpid liver," "liver
not acting " and " biliousness," are not due to a primary functional
insufficiency of that organ, and these titles are usually euphemisms
for constipation, indigestion and gastro-intestinal catarrh, and over-
indulgence in food and drink. The appropriate treatment should
be directed to correct constipation, dyspepsia and dietetic errors.
H. D. ROLLESTON.
669
HYDATID CYSTS OF THE LIVER.
THE liver is the commonest seat of Hydatid Cysts which in the
majority of cases affect the right lobe. Active treatment is almost
always indicated, for although the cysts sometimes die and dry up
or calcify, in most cases they continue to enlarge and ultimately
rupture or suppurate.
The older methods of treatment, aspiration, aspiration followed
by injection, and electrolysis, will not be discussed, for they are
very uncertain in their action and involve great risks. At the
present time, two methods of treatment are available : (1) Enuclea-
tion, and (2) Incision and drainage.
Enucleation. This is obviously the ideal method when it
is practicable. It is especially suitable for cases in which the cyst
is small, near to the surface of the liver, and not suppurating.
A vertical incision is made over the cyst and the surrounding
peritoneal cavity is carefully packed off. The endocyst is emptied
as far as possible by an aspirator or by incision, and is then care-
fully separated from the ectocyst. The resulting cavity is obliterated
by catgut sutures, and if this is effected satisfactorily, the abdominal
wound is closed without drainage.
Incision and Drainage. This procedure is the one more
commonly practised, and is the safer for large cysts and for those
in which suppuration has occurred. Some authorities recommend
that it should be carried out in two stages ; this may be advisable
for suppurating cysts when there are no adhesions to the anterior
abdominal wall, but as a rule the operation may safely be completed
in one stage.
The cyst is exposed and thoroughly isolated by gauze packs.
Some of its fluid is withdrawn by an aspirator, and a small incision
is made into it ; a finger is passed into the cavity, and the cyst is
emptied as far as possible. The edges of the incision are then
carefully sutured to the deeper layers of the abdominal wall, and a
large drainage tube is inserted. Throughout the operation every
precaution must be taken to protect the edges of the wound, owing
to the risk of hydatid infection of the raw surface.
Occasionally when the cyst occupies the highest part of the right
lobe of the liver, it is necessary to deal with it through the thoracic
wall, portions of two or three ribs being resected.
T. CRISP ENGLISH.
670
JAUNDICE.
THE radical treatment of jaundice must, of course, be directed to
underlying cause, and accurate diagnosis in each case is therefore
essential. But before considering the treatment of some special
forms of jaundice it will save time to deal with the treatment of the
symptoms which may occur in jaundice, however caused.
SYMPTOMATIC TREATMENT OF JAUNDICE GENERALLY.
Constipation should be prevented by drinking plenty of water
before breakfast and at bedtime ; in the morning the patient should
walk about while sipping the water which, when necessary, should
contain Karlsbad salts (5J to 5iij), or sulphate of sodium (5J) and
sulphate of magnesium (5J), or sulphate of sodium (5J) and
phosphate of sodium (5J). The salts may be made more palatable
by the addition of a little infusion of quassia or cinchona. Karlsbad,
Marienbad, Kissingen, Condal, Apenta, Friedrichshall, and other
waters may be taken instead of the plain water. If necessary,
calomel (gr. 2 to 4), or blue pill [U.S. P. mass of mercury] (gr. 3),
may be taken the night before. Vigorous purges should be avoided.
Benefit often follows spa treatment at Harrogate, Karlsbad,
Neuenahr, Homburg, Vichy. For flatulence, guaiacol carbonate
(gr. 7), in cachets, may be taken three times a day, or salicylate of
bismuth (gr. 10), naphthalin tetrachloride (gr. 7), calomel (gr. ^o),
or salol (gr. 5), rubbed up with carbonate of magnesium in order
to prevent the formation of salol calculi. Fresh ox or pig's bile
(gr. 7|), in capsules or keratin-coated pills, are sometimes given.
Pruritus may be the most troublesome symptom and may
become very serious from the sleeplessness that it induces. In some
instances it may be necessary to try several remedies before relief
is obtained, and sometimes nothing but morphine hypodermically is
effectual. In the first place, the local application of carbolic acid to
the skin should be tried ; it may be employed as a lotion of 1 part
in 40, and dabbed on the skin with a small sponge, or by means of
strips of lint which are kept moist by the addition of the lotion from
time to time. A 2 per cent, solution in olive oil may also be
employed in the same way. These applications should not be pre-
scribed when the skin is excoriated by scratching, as there is the
risk of toxic results from absorption. As the itching is often
Jaundice. 671
worse at night a warm bath containing 8 oz. of bicarbonate of
sodium or potassium may be taken, the skin being afterwards
rubbed with an ointment of equal parts of boracic acid ointment
and lanoline. A bath containing hydrochloric acid has also been
recommended, but it must be given in a special wooden bath.
When these local measures fail, the following should be tried :
Menthol, either in the form of spirit (menthol, gr. 5 to the ounce),
or of an ointment (menthol, gr. 30, olive oil, 5Jss, lanoline, ^ij) ;
ichthyol in water (1 to 4 per cent.) or mixed with equal parts of
alcohol and ether (ichthyol, 5ijss, alcohol and ether equal parts,
Relief may sometimes be obtained from the internal administra-
tion of (1) nervine sedatives, such as antipyrin, aspirin, bromides,
and chloral ; (2) calcium salts ; the unpleasant taste of calcium
chloride may be minimised in the following prescriptions : 1^ .
Calcii chloridi, gr. 15 ; Ext. Glycyrrhizse liq., 553 ; Aquam
Menth. Pip., ad 3] ; or 1^. Calcii Chloridi, gr. 15 ; Syrupi Aurant.,
588 ; Aquam Chloroformi, ad 5J [U.S. P. 1^. Calcii Chloridi,
gr. 15 ; Fluid Extract. Glycyrrhizse, 5ss ; Aquam Menth. Pip., ad
5J ; or H. Calcii Chloridi, gr. 15 ; Syrupi Aurant., 588 ; Aq. Chloro-
formi, jss; Aquam, ad jj]. (3) Thyroid extract. These internal
remedies should be tried in conjunction with the local applica-
tions and in the order given. Pilocarpine given in ^ to J gr.
hypodermically or by the mouth sometimes gives good results. As
has already been mentioned, all remedies short of hypodermic
injections of morphine may fail, and unfortunately even this is not
infallible.
In cases of severe jaundice in which there is a tendency to
cutaneous and mucous haemorrhages calcium salts should be
given ; a suitable prescription is : 1^ . Calcii Lactatis, gr. 7% ; Magnesii
Lactatis, gr. 7^; Aquam Chloroformi, ad jj [U.S.P. 1^. Calcii
Lactatis, gr. 7$; Magnesii Lactatis, gr. 1\ ; Aq. Chloroformi, 333 ;
Aquam, ad ^j]. One such dose to be taken three times a day for
three days every ten days. Horse serum may also be given by the
mouth in doses of 10 c.c. twice a day for two or three days.
The diet will necessarily vary to some extent with the degree of
indigestion and the patient's appetite. Fat of all kinds should be
avoided, and carbohydrates and proteins given in an easily digested
form, for example bread, rusks or biscuits with jam, marmalade or
honey, bread and milk, gruel, blancmange, potatoes preferably
mashed, and rice puddings. Pounded fish, kedjeree, pounded chicken,
chicken cream, lightly curried fish or chicken, game and a little
meat ; fresh fruit, such as grapes, bananas, and baked apples ;
6j2 Jaundice.
well-diluted coffee or tea, or Vichy water are suitable. Alcoholic
drinks should be proscribed in ordinary jaundice, but in malig-
nant disease stimulants are usually desirable. In cases of con-
siderable wasting sterilised oil (388 twice a day) has been injected
under the skin (Hale White).
TREATMENT OF SPECIAL FORMS OF JAUNDICE.
(1) Icterus in the Newly-born may be due to various causes,
and the treatment must be determined accordingly.
In the Physiological Jaundice of new-born infants which occurs in
from 30 to 90 per cent, of all infants no special treatment is neces-
sary. In rare instances successive infants become jaundiced and die
without any organic cause ; this condition has been regarded as an
intense form of the jaundice of the newly-born, and in such cases it
is worth while to treat the mother during pregnancy with urotropin
and salicylate of sodium and small doses of calomel (^ gr.) three
times a day, in order to counteract any intestinal infection or
intoxication.
Infective Jaundice of Umbilical Origin has a very high mortality,
as it is extremely likely to lead to septicaemia. Since the infec-
tion is often due to streptococci, the use of polyvalent antistrepto-
coccus serum or of vaccines would appear to be reasonable. Care
and aseptic treatment of the umbilicus are obviously essential as
prophylactic measures.
Infective Jaundice of Intestinal Origin may occur in epidemics
and has a high mortality ; it has been called Winckel's disease and
is closely related to Buhl's disease. Repeated small doses of calomel
(^ gr.) should be administered and plenty of water by the mouth.
Acetozone (1 in 3,000 parts of water) with syrup of lemon [U.S.P.
syrup of citric acid](l drachm to 1 oz.) may be given as an antiseptic,
about 2 oz. in the twenty-four hours. Enemas of saline solution
should be given, and subcutaneous transfusion of saline solution is
necessary. The stools should be disinfected and burnt.
Catarrhal Jaundice is very rare in babies, and no hard and fast
line can be drawn between it and mild infective jaundice. It
should be treated in the same way as infective jaundice of
intestinal origin except that transfusion is unnecessary.
In Congenital Syphilis jaundice is most unusual, except in the
very rare instances in which the ducts are affected ; in the latter
cases the condition exactly resembles that of congenital obliteration
of the ducts. The treatment of congenital syphilitic disease of
the liver is that of congenital syphilis. Syphilised mothers and
Jaundice. 673
those who have had stillbirths or miscarriages thought to be due to
this cause should be put on specific treatment during pregnancy.
In Congenital Obliteration of the 'Bile-ducts no benefit can be
expected from operative interference, and the same is unfortu-
nately true with regard to medical treatment. In rare instances
syphilis affects the larger ducts and gives rise to a clinical picture
exactly resembling that of congenital obliteration of the ducts, and
moreover cases diagnosed as congenital obliteration of the ducts
have recovered after mercurial treatment. On these grounds the
infant should be given hydrargyrum c creta (^ gr.) three times a day.
Salol ( gr.) or guaiacol carbonate (1 gr.) may be given to diminish
intestinal auto-intoxication. In the later stages haemorrhages are
apt to occur and should be combated by calcium lactate (1 gr.) three
times daily.
(2) Catarrhal Jaundice. In the early stages, when there is still
some gastro-duodenitis, it is important to treat this and to avoid
further irritation of the stomach by food. Gastric irritability
should be met by a few doses (six in the first thirty-six hours)
of a mixture such as 1^. Bismuthi Carbonatis, gr. 15; Sodii
Bicarbonatis, gr. 10; Tinct. Cardamom. Co., nj.15 ; mucilaginis
Tragacanth., q.s. ; Spiritus Chloroformi, irj.10 ; Aquam, ad j, to
which, if vomiting is persistent, 5 min. of chlorodyne or
10 min. [U.S. P. 6 min.] of tincture of opium may be added for a
few doses. The patient should be in bed, and for the first day or
so may with advantage be starved, though he may take as much
water, Vichy water, or water containing bicarbonate of sodium as
he feels inclined. Instead of absolute starvation diluted whey,
which is much the same, may be allowed. Rest to the stomach is
extremely important, for the main cause of an early relapse is
excessive food at this stage. Epigastric discomfort may be relieved
by the application of poultices or warm compresses frequently
changed.
As the gastric irritability subsides, milk containing citrate of
sodium (10 gr. to the pint) and diluted should be given, beginning
with 1^ pints in twenty-four hours, and increased gradually. The
bismuth mixture should now be stopped and the bowels moved by
a dose of calomel (3 gr.), followed by Karlsbad salts (2 drachms) in
water early the next morning ; or a pill of hydrargyr. c creta (1 gr.)
may be taken three times daily ; in order to prevent the diarrhoea
1 or 2 gr. of powdered chalk may be added (Murray). The
following mixture may then be taken : fy. Sodii Salicylatis, gr. 1\ ;
Sodii Bicarbonat., gr. 10 ; Urotropin., gr. 7 ; Spiritus Chloro-
formi, in 10; Infusum Caryophylli, ad jj. During this period large
S.T. VOL. n. 43
674 Jaundice.
rectal injections (Krull's irrigations) of water at a temperature of
60 to 65 F., or even cold, have been recommended, with the object of
producing vigorous peristaltic contractions of the gall-bladder and
bile ducts, and so driving bile through into the intestine; as a
rule, however, this course is not necessary. Pruritus, when present,
should be treated on the lines given on p. 670.
As the appetite returns, cautious additions to the milk diet
should be made in the form of thin clear soup, gruel made with
arrowroot, toast, eggs, souffles, pounded fish, kedjeree, chicken
cream and rice puddings. Fatty food, especially liquid fat and
melted butter, should be avoided. Intestinal fermentation should
be prevented by keeping the bowels open with compound liquorice
powder, 1 drachm at night, and if necessary a Seidlitz powder
(pulvis sodae tartratis effervescens) the next morning ; or by ^ gr.
doses of calomel three times a day, or salol (5 gr.), or naphthaliu
tetrachloride, 7 gr. twice a day. Convalescence is now commencing
and the patient may be up and, provided he avoids chills and expo-
sure to the east wind, may go into the fresh air. As a safeguard
against chills a cholera belt may be worn. The medicine contain-
ing urotropin and salicylate of sodium should be taken in a rather
smaller quantity twice a day, and tincture of nux vomica (5 min.)
[U.S.P. 12 min.] should be added to each dose. A mixture
containing acid and somewhat of the following composition :
1^. Tinct. Nucis Vom., rn,5 ; Acidi Nitrohydrocblorici Dil., iri.10 ;
Infusum Calumbae, ad ^j [U.S.P. 1^. Tinct. Nucis Vom., ir[12;
Acidi Nitrohydrochlorici Dil., trilO; Infusum Calumbae, ad jj] is
often given, but personally I prefer an alkaline medicine. In
prolonged cases ammonium chloride (10 gr.), with syrup of lemons
[U.S.P. syrup of citric acid] (5 ss.), may be given three times a
day. Jaundice, in the course of secondary syphilis, rapidly yields
to mercurial treatment (hydrargyr. c creta, 1 gr., t.d.s.), but is very
resistant to the ordinary treatment of catarrhal jaundice.
In cases of catarrhal jaundice which do not clear up and in which
there is no other reason to suspect any graver condition, benefit
may result from a visit to a spa such^as Harrogate, Llandrindod
Wells, Vichy, Evian, Neuenahr, Ems, Homburg, Karlsbad,
Marienbad. At the spa the water should be sipped slowly when
walking about before breakfast.
(8) Chronic Haemolytic Jaundice. This condition is extremely
resistant to treatment, but at the same time it must be remembered
that in many instances, especially in the hereditary and congenital
cases, the patients suffer little or no inconvenience from it, and
that it may persist through a long life even up to seventy years of
Lardaceous Disease of the Liver. 675
age. The anaemia, which is more prominent in the acquired than
in the congenital cases, may be benefited by iron, but arsenic is
useless. The patient should lead a quiet and regular life, and
avoid factors which increase the symptoms, such as fatigue,
exposure to cold and excitement, and unsuitable diet. According
to Tileston and Griffin the attacks of abdominal pain are not
a necessary part of the disease, but are due to concomitant
cholelithiasis, arid should therefore be treated on appropriate lines
(see p. 682).
H. D. ROLLESTON.
LARDACEOUS OR AMYLOID DISEASE OF THE LIVER.
LIKE fatty change, this is a local manifestation of a general cause
and, except that in children ascites sometimes seems to be thus
caused, does not give rise to any symptoms as apart from signs.
It is due to syphilis, to prolonged suppuration, for example, a psoas
abscess or a chronic empyema, and in rare instances to other
cachexiae. It is therefore essential to treat it by removing the
cause if it be still present. Thus syphilis should be energetically
combated, and any suppuration brought to a conclusion by surgical
interference. The general health should be improved by residence
at the seaside, open-air, good nourishing food and hygienic sur-
roundings. Tonics, iron and dilute nitro-hydrochloric acid should
be given a prolonged trial. Ammonium chloride has also been
recommended.
H. D. ROLLESTON.
432
6 7 6
" TROPICAL LIVER."
TROPICAL LIVER or tropical hepatitis, as it may be more correctly
designated, may be due to several causes, and the treatment of the
condition will necessarily depend on which of these is present. The
commonest causes of the condition are (1) dysentery (amoebic),
(2) malaria, (3) a hot climate, and (4) over-eating and drinking in
the tropics.
Amoebic hepatitis may coincide with the acute attack of
dysentery, or it may follow it, or it may be associated with a
latent phase of that disease, no dysenteric symptoms being present.
In his book " Fevers in the Tropics," Leonard Eogers 1 discusses
this question in a chapter entitled, " The Pre-suppurative Stage of
Amoebic Hepatitis," clearly showing that many cases of hepatitis
and obscure pyrexias with a leucocytosis are due to infection with
amoebae, and that dysenteric symptoms in such cases are often
absent. The treatment of frank attacks of amoebic hepatitis, or of
attacks of hepatitis occurring in a country where amcebiasis is
common, should always be by ipecacuanha in large doses (sec article
on Dysentery, Vol. III.). Eogers (loc. cit.) has had splendid results by
the use of this drug, and lately using a similar treatment in several
cases of hepatitis in England, where an amoebic influence could not
be absolutely put out of court, I have also been successful. The drug
should be administered in large doses (20 gr. once or twice aday,
or 30 gr. for an initial dose) this being reduced by 5 gr. a night
till a dose equivalent to the latter figure is reached. When the
temperature is high and the condition acute the patient must be
kept strictly in bed, poultices should be applied and a very low diet
prescribed. If there is any evidence of an abscess having formed,
then a surgeon should be called in to operate (see Treatment of
Tropical Liver Abscess, Vol. III.).
Malaria has been given as one of the principal causes of tropical
liver. An acute hepatitis due to the malarial parasite is by no
means uncommon, and is undoubtedly responsible for a certain
number of cases. Calomel at night, followed by an ample dose of
salts in the morning and then appropriate doses of quinine, is the
treatment to adopt. In more chronic cases with an old history of
malaria I have found painting the skin over the liver with linimentum
iodi beneficial.
Tropical Liver. 677
The treatment of cases of tropical liver arising from over-eating
and drinking or from excessive hea-t is largely a question of diet.
Many apply the term tropical liver only to such cases, and strictly
speaking this is correct enough. Our first step, then, in dealing
with such a case should he to relieve the acute congestion of the
liver, and this in a mild case can readily be accomplished by the
free use of Carlsbad salts. A strict diet must be prescribed and alcohol
cut down to its narrowest limits. The question of exercise should
not be forgotten, and the patient must be led to understand
that any indiscretions will certainly give him another attack.
In severe cases, where there is pain and tenderness over the
liver with pyrexia, the patient should be placed in bed, and hot
poultices or turpentine stupes should be applied over the region of
the liver. Very little in the way of food should then be given, the
diet consisting of milk alone or milk and water, or if the patient
cannot take these, barley-water and weak beef-teas. All alcohol
should be stopped, and a sufficient dose of salts to produce a free
motion of the bowels every morning should be administered.
Under such measures improvement rapidly takes place, and after
the temperature has become normal and all pain disappeared the
patient may be allowed up in his room every day. If all goes well,
the patient may return to ordinary life, say, in seven days or less.
Ammonium chloride (in 20 gr. doses, three or four times a day)
has been strongly recommended in such cases by some authorities.
As Sir Patrick Manson 2 says, " it does no harm," but I am inclined
to share his view that it also does little good. Where the condition
becomes chronic, the patient should leave the tropics, and pay a visit
to Carlsbad 3 or Harrogate if possible for a course of special treatment.
I know of no better directions for treatment than those given by
Sir Patrick Manson (loc. cit.) for this class of case, and therefore I quote
him more or less closely in the following : The patient should start the
morning by sipping 1 pint of boiling water in which a tablespoonf ul
or more of Carlsbad salts (Sprudel salts in powder) have been dissolved.
This takes from fifteen to twenty minutes for completion. Gentle
exercise may be indulged in while doing this, but in some people there
is a tendency to sickness, and such individuals should remain quietly
in bed. No food should be taken till from half an hour to one hour
afterwards. A light breakfast is then permissible. The quantity of
the salt must be increased if the bowels do not move freely ; the exact
amount required will soon be ascertained by the patient himself.
The salts should be taken for two or three weeks, and a strict diet is
to be rigidly adhered to. Butter, fat, nuts, fruits, pastry, preserves,
tinned foods, cheese, salads, wines, spirits and beer are all
678 Tropical Liver.
contra-indicated, and meat is only to be taken once a day. After the
cure a country life in a temperate climate with its active pursuits
is best for the patient, precautions in the shape of warm clothing,
avoidance of cold baths, alcohol and high living being scrupulously
observed and a weekly saline purge taken.
Dyspepsia may be troublesome in this late stage of tropical liver.
Davidson 4 recommends the use of nitro-hydrochloric acid and nux
vomica for this. In cases where anaemia is present I have found
injections of arsenate of iron very serviceable. If mental depression
is present, frequent change of scenery is best, as it takes the
patient's mind off himself, and tends in time to make him forget
his complaints.
G. C. LOW.
REEEKENCES.
1 Rogers, L., "Fevers in the Tropics," Oxford Medical Publications, p. 173.
2 Manson, Sir P., " Tropical Diseases," 4th edit., Lond., 1907, p. 484.
8 Young, " The Carlsbad Treatment for Tropical Ailments " (Calcutta,
Thacker, Spink & Co.).
4 Davidson, Andrew, article on " Tropical Liver," Allbutt and Rolleston,
"System of Medicine," 1907, II. Pt. II., p. 571.
679
TUMOURS OF THE LIVER.
Secondary Malignant Growths are much commoner than
primary, in about the proportion of 1 to 80. The treatment of the
two forms is the same except for two points : (1) In some cases of
primary new growth it may be possible to excise the tumour ;
(2) in secondary malignant disease of the liver symptoms due to the
primary growth, for example, in the stomach or colon, may require
treatment.
Pain may be relieved by local applications, such as belladonna
plaster, but morphine hypodermically should be given without
scruple. Dragging and a feeling of weight due to traction exerted
by the heavy organ when the patient sits up or stands may be
mitigated by a belt. Ascites, if considerable, should be tapped.
For pruritus, sec p. 670. Constipation must receive attention.
Vomiting may be treated by bismuth subnitrate (gr. 15), with
cerii oxalat. (gr. 10), as a powder repeated three times in the
day; or chlorodyne On.10), in an ounce of water. For the pro-
gressive weakness, Tinct. Nucis Vom. Tit7; Nitrohydrochloric.
Acid. Dil., ir|.7J ; Syrup. Limon., 533; Aquam ad 5J [U.S.P. Tinct.
Nucis Vom., 111 18; Nitrohydrochloric. Acid. Dil., iil7 ; Syrup.
Citric. Acid., 533 ; Aquam ad j], should be given three times a
day after food. Alcoholic stimulants are generally required. The
patient should be allowed to take as generous a diet as possible.
In rare instances innocent tumours of the liver such as
single adenomas, solid or more rarely cystic, simple cysts,
and angiomas occur. The treatment is surgical. Hydatid cysts
also should, when large, be treated surgically, the cyst being freely
exposed and not tapped through the abdominal wall (see p. 669).
Lymphadenoma when it attacks the liver is usually rapidly fatal.
It should be treated by arsenic by the mouth or by soamin or
other arsenical injections.
For actinomycosis of the liver large doses of iodide of potassium,
30 gr. or more, three times a day, should be given.
H. D. ROLLESTON.
68o
INJURIES AND DISEASES OF THE GALL^
BLADDER AND BILE DUCTS,
INJURIES OF THE BILE PASSAGES.
INJURIES to the bile passages are, as might be expected, much less
common than injuries to the liver, and they are apt to be con-
founded with the latter, though in reality they present many points
of difference.
They may be caused by stabs or gunshot wounds, or by violent
blows or severe compression in the region of the liver. These
injuries appear to be more common in persons who have already
suffered from biliary calculi or from inflammatory lesions of the
gall-bladder or ducts.
The fundus of the gall-bladder, the most exposed portion of the
bile-excreting apparatus, is the part most frequently injured, both
in penetrating wounds and in subcutaneous injuries.
In the case of penetrating wounds the neighbouring organs are
frequently injured, e.g., the liver, stomach, or colon.
Courvoisier collected forty-eight cases, of which three were
subcutaneous ruptures and fourteen penetrating wounds of the bile
passages.
In all the museum specimens where the history is appended, the
fact of the long survival after so serious an accident is notable, and
the lesson is manifest that operation would in each case have given
good hopes of success. As a result of a wound or rupture of any
part of the biliary secreting apparatus, extravasation of bile occurs
into the peritoneum. As a rule the bile occupies the right half of
the abdomen, extending down to the iliac fossa. It is confined to
this portion of the abdomen by the insertion of the mesentery, but
occasionally it extends to the pelvis, or even into the left loin.
After a certain time the collection of bile becomes encapsuled by
the formation of a false membrane on the surrounding viscera.
This false membrane frequently seals the opening in the gall-bladder
or ducts, preventing the further escape of bile, and rendering it
difficult at an operation to detect the actual situation of the
injury.
If the bile is aseptic there may be no peritonitis, and in some
cases spontaneous recovery has undoubtedly occurred.
Injuries of the Bile Passages. 68 1
Recovery has also occurred after the spontaneous formation of a
biliary fistula.
As a rule, even in cases in which the bile is aseptic, gradual
emaciation occurs, ending in death, probably owing to the absorption
of some toxic matter from the extravasated bile.
Septic peritonitis may occur at any time, as the bile may be
already septic from previous gall-bladder disease, or infection may
arise from proximity to the bowel, or after exploration or aspiration.
Courvoisier collected thirty-three cases, in eighteen of which the
extravasated bile had been removed by aspiration. In eleven of
these recovery followed. He advocated repeated aspiration before
resort to laparotomy. Occasionally a single aspiration has been
successful ; more usually multiple aspirations are required before
recovery ensues.
Terrier and Auvray (Chimrgie de Foie) collected seventeen cases
in which aspiration (in most cases repeated) had been performed.
Of these, ten recovered and seven died.
Laparotomy may be performed as a primary or a secondary
operation. The former will probably be restricted to cases of
penetrating wounds, while the latter will be performed in cases of
subcutaneous injury.
Secondary laparotomy will usually be performed in cases of
subcutaneous rupture, owing to the difficulties in diagnosis until
jaundice appears. In many eases it will be impossible to detect
the wound owing to the formation of false membrane. In these
cases the bile should be washed out with saline solution and the
abdomen drained, or drainage may be adopted without irrigation.
If a small wound is found in the gall-bladder, it may be sutured
or the gall-bladder may be drained through the opening. If the
gall-bladder is extensively lacerated, or if the cystic duct is injured,
cholecystectomy should be performed.
If a wound of the hepatic duct is discovered, it may be possible
to close the opening by sutures, but as a rule reliance must be
placed on drainage.
Terrier collected twelve cases of secondary laparotomy for injuries
to the bile ducts and gall-bladder, with six recoveries. If rupture
of the common duct is discovered, he recommends ligature of both
ends of the duct and cholecystenterostoray.
A. W. MAYO-ROBSON.
682
CHOLELITHIASIS.
Prophylaxis. The factors responsible for cholelithiasis are
inflammation of the gall-bladder and stagnation of bile. According
to Naunyn, bacterial infection of the gall-bladder is the essential
factor, stagnation of bile being important only in so far as it favours
infection ; but more recently (Aschoff and Bacmeister) evidence has
been brought forward to show that stagnation of bile in the gall-
bladder without inflammation may give rise to the formation of
single pure cholesterol calculi. The prophylactic treatment of gall-
stones, therefore, concerns the prevention of cholecystitis and of
stagnation of bile. The form of cholecystitis that gives rise to gall-
stones is of a comparatively mild grade and is mainly due to infec-
tion with Bacillus coli and B. typhosus, though other allied bacteria,
such as B. paratyphosus, may play a causal part. In typhoid fever
the bile constantly contains the pathogenetic organism, and it is
therefore reasonable during the course of this fever and in con-
valescence to give short courses of Urotropin, gr. 7| ; Sodii Salicylat.,
gr. 7 ; Sodii Bicarbonat., gr. 10; Infusum Caryophylli, ad j.
In fat persons, especially women, and after typhoid fever,
influenza and pregnancy, measures should be taken to diminish
the liability to stagnation of bile ; thus, gentle exercise in the open-
air and breathing exercises are indicated. For a flaccid condition
of the abdominal wall a belt and graduated exercises are useful.
Tight-lacing must be prohibited. A visit to a spa, such as
Harrogate, Bath, Homburg, Neuenahr, Karlsbad, Marienbad,
Kissingen, Ems or Vichy, is a valuable precautionary measure.
The medical treatment of gall-stones will be considered under
the two main heads of (1) the general treatment, (2) the treatment
of certain manifestations, biliary colic and intermittent hepatic
fever.
(1) General treatment should be directed: (a) To prevent stagna-
tion of bile. Exercise by producing contraction of the diaphragm and
abdominal muscles leads to emptying of the gall-bladder. Breath-
ing exercises or somewhat active exertion which necessitates deep
respirations are therefore better than walking. A flaccid condition
of the abdomen may be remedied by a suitable belt and by massage,
the region of the gall-bladder being avoided. Intestinal peristalsis,
in which the gall-bladder shares, should be maintained by meals
Cholelithiasis. 683
at short intervals and when necessary by purgatives. Of the
numerous drugs described as cholagogues nearly all act by increas-
ing the output of bile from the gall-bladder. The only ones which
increase the secretion of bile are salicylate of sodium and bile.
Salicylate of sodium acts not only as a cholagogue but as an anti-
septic, and may conveniently be given twice a day for ten days in
every month in the following combination : Sod. Salicylat., gr. 7| ;
Sod. Benzoat., gr. 7^ ; Urotropin, gr. 5 ; Spirit. Chloroformi, irtlO;
Infusum Caryophylli, ad jj. Ox or pig's bile (gr. 7) in capsules
or keratin-coated pills, may be taken three times a day ; or sodium
glycocholate (gr. 10) three times a day.
(/>) To prevent and remove infection oj the bile passages.
Dyspepsia and constipation should be guarded against by careful
dieting and by the methods recommended in the symptomatic treat-
ment of jaundice (p. 670). The condition of the teeth should be
attended to and food should be thoroughly masticated. The
abdomen should be kept warm so as to avoid chills ; for this purpose
a cholera belt is useful. Infection of the bile passages should be
treated by increasing the flow of bile and by the administration of
salicylate of sodium and urotropin (see above).
(c) To attempt to dissolve or remove calcidi from the g all-bladder.
Although it has been shown experimentally that calculi inserted
into the healthy gall-bladder of an animal dissolve in the bile
(Harley and Barrett, Bain), this can hardly be anticipated in
human beings with symptoms of cholelithiasis, as the gall-bladder
almost always shows morbid change. Although gall-stones dissolve
slowly in olive oil, this cannot be effected by the ingestion of
oil. This agent, however, inhibits hyperchlorhydria, which often
accompanies cholelithiasis, and so relieves pain due to that cause.
The attempt to massage gall-stones out of the gall-bladder is too
dangerous to be employed.
(d) To spa treatment, as this is of use in flushing the ducts and gall-
bladder, and thus preventing stagnation and infection. The most
suitable spas are Harrogate, Bath, Karlsbad, Neuenahr, Kissingen,
Homburg, Marienbad, Ems, Vichy. The Karlsbad cure can be carried
out at home, though less satisfactorily. Hot Karlsbad water should
be sipped while walking up and down an hour before breakfast and
in the afternoon, about f pint being taken on each occasion and
three-quarters of an hour being devoted to the process. The taste
of the salts is less disagreeable if some infusion of quassia or
cinchona is added. No food should be taken until an hour after
the last dose of water is taken.
(e) Diet. The meals should be small and frequent and should be
684 Cholelithiasis.
simple and easily digestible. A mixed diet should be taken with a
preponderance of protein constituents. Sugary and much starchy
food should be avoided. In the absence of jaundice, butter and fats,
such as cold fat bacon, may be taken. Alcohol should be avoided
or only taken in small quantities and well diluted.
(6) Biliary Colic. The pain is often so severe that it is abso-
lutely necessary to give morphine (-J to % gr.) combined with atropine
(TOU 8 r -) subcutaneously. In such cases ihe hypodermic injection
may with advantage be followed by the inhalation of chloroform in
order to relieve the pain until the morphine acts. The hypodermic
syringe should never be entrusted to the patient.
In less severe cases the patient may be put in a hot bath (104 F.)
and a hot sponge applied over the region of the pain ; a pint of
hot water may be taken by the mouth. The following draught
may be given: 01. Terebenth., it(,15; Spiritus Athens, 111 30;
Tinct. Belladonnas, rn.20; Spirit. Chloroforrni, n\_l5 ; Aquam ad j
[U.S.P. 01. Terebenth., in 15; Spiritus Athens, m80; Tinct. Bella-
donna Fol., ivi 28 ; Spirit. Chloroform., in 12; Aquam ad j], and
repeated every two hours for three doses in all. Good results have
also been ascribed to the administration of sod. salicylat. (gr. 30 to
45) in a single dose ; or of aspirin, antipyrin, or exalgin (1 gr.) in hot
water every half -hour for three or four doses (Robson). Relief has
also been ascribed to salicylate of methyl (1 to 2 drachms) painted
over the painful part and covered with gutta-percha to favour
absorption.
For the reflex vomiting draughts of water containing bicarbonate
of sodium (5] to 1 pint), hot applications or repeated injections of
morphine in small doses (^ gr.) may be employed.
Surgical interference during acute biliary colic should only be
undertaken when one of the following complications is believed
to have supervened : (i.) Rupture of the gall-bladder or ducts ;
(ii.) acute suppurative inflammation of the biliary passages with
peritonitis ; (iii.) acute intestinal obstruction due to volvulus.
Intermittent Hepatic Fever. This condition, due to a gall-
stone " floating" in the common duct, is characterised by recurrent
attacks of fever, jaundice, pain and vomiting, with periods of
quiescence. Under medical treatment the recurrent bouts of infec-
tion may be diminished in frequency and in rather rare instances the
calculus is passed. In order to combat the infection Sodii Salicylat.,
gr. 10; Urotropin, gr. 7| ; Spirit. Chloroformi, inlO; Infusum
Caryophylli, ad 33. ; should be taken three times daily every alternate
week, or constantly if necessary. The other methods of general
treatment of gall-stones should be carried out. For the troublesome
Cholelithiasis. 685
gastric symptoms, which are mainly reflex, the effects of dieting
are disappointing. Pain should be treated on the same lines as in
biliary colic.
Inasmuch as a stone in the common duct may give rise to grave
complications, such as various forms of pancreatitis and suppurative
cholangitis, it is important that if medical treatment fails to give
relief surgical treatment should be seriously considered. Generally
speaking, the time devoted to unsuccessful medical treatment
should not exceed two months, but each case must be considered
on its merits. The constitutional condition of the patient is a most
important factor in considering the advisability of operation, and it
must be borne in mind that the results of the operation, which is
by no means an easy one, vary much with the experience of the
surgeon in this special line of work. If, in cases in which opera-
tion is inadvisable or declined, there is evidence from the agglu-
tination reaction and from the opsonic index that there is infection
of the ducts with B. coli or other micro-organism, a vaccine should
be given.
The treatment of the other complications of gall-stones is mainly
surgical.
H. D. ROLLESTON.
REFERENCES.
Aschoff, L., und Bacmeister, C., " Die Cholelithiasis," Jena, 1909. Moynihan.
B. Q. A., " Gall-stones and their Surgical Treatment," Lond., 1905. Robson,
A. W. Mayo, "Diseases of the Gall-bladder and Bile-ducts," 3rd ed., Lond.,
1904. Rolleston, H. D., "Diseases of the Liver, Gall-bladder, and Bile-ducts,"
Lond., 1905.
686
THE SURGICAL TREATMENT OF CHOLELITHIASIS.
WHEN gall-stones have once formed, no medicine, so far as is
known, can dissolve them or produce permanent relief, though much
may be done by medical and general treatment for the relief of the
catarrh so regularly associated with cholelithiasis, which may, in
fact, bring on attacks not to be distinguished from true gall-stone
seizures.
Medical treatment must therefore always be tried fully before
surgical measures are resorted to ; but if after a fair trial medical
means fails, surgical treatment should be adopted before serious
complications supervene and before the patient is reduced by
jaundice, suppuration, or other untoward manifestations.
While cholecystotomy is generally recognised as the operation
to be aimed at in the treatment of affections of the gall-bladder and
bile ducts due to gall-stones, it is often impossible to say what
operation will have to be done until the abdomen is opened and the
exact state of affairs made out, for a contracted or dilated gall-
bladder, a suppurating or merely a distended viscus, concretions in
the gall-bladder or cystic or common ducts, the condition of the
surrounding organs, the presence or absence of adhesions, and a
host of other conditions, will all influence the subsequent action of
the surgeon, who always begins the operation as an exploratory one,
the subsequent steps being altered according to the circumstance
mentioned.
Operation is indicated under the following circumstances :
(1) In frequently recurring biliary colic without jaundice, with or
without enlargement of the gall-bladder.
(2) In enlargement of the gall-bladder without jaundice, even if
unaccompanied by great pain.
(3) In persistent jaundice ushered in by pain, and when recurring
pains, with or without ague-like paroxysms, render it probable that
the cause is gall-stones in the common duct.
(4) In empyema of the gall-bladder.
(5) In peritonitis, starting in the right hypochondrium.
(6) In abscess around the gall-bladder or bile ducts, whether in
the liver or under or over it.
(7) In some cases where, although gall-stones may have passed,
adhesions remain and prove a source of pain and illness.
The Surgical Treatment of Cholelithiasis. 687
(8) In fistula discharging mucus or inuco-pus.
(9) In certain cases of chronic jaundice with distended gall-
bladder dependent on some obstruction in the common duct,
although the suspicion of malignancy is entertained. In such
cases the increased risk must be borne in mind, as malignant
disease may be the cause of the obstruction, and operation in such
cases is attended with greater danger than ordinary.
(10) In phlegmonous cholecystitis and in gangrene of the gall-
bladder.
(11) In gunshot injury or in stab wound over the region of the
gall-bladder.
(12) In suspected rupture of the gall-bladder without external
wound.
(13) In some cases of chronic catarrh of the gall-bladder or bile
ducts.
(14) In infective and in suppurative cholangitis.
(15) In certain solid tumours of the gall-bladder where there is
no evidence of secondary growths in the liver.
(16) In certain cases of biliary fistula, if it is thought that the
cause of obstruction may possibly be removed.
(17) In acute, subacute, or chronic pancreatitis due to gall-stone
obstruction or to secondary infection from the biliary passages.
No surgeon should attempt the removal of gall-stones unless he is
prepared for any of the various operations on the biliary passages,
such as choledochotomy or cholecystectomy, as it is almost impos-
sible to say beforehand what may be required until the ducts have
been explored by the fingers and the condition of the affected viscera
ascertained ; no operation should, as a rule, be concluded until it is
clearly made out that the ducts, including the hepatic and common,
are free from concretions, otherwise disappointment and dissatisfac-
tion are certain to follow.
Since in the majority of cases, then, an operation for gall-stones
is in the first place simply exploratory, the actual operation on the
gall-bladder or bile ducts being only determined by the condition
found when the abdomen is opened, it may be well first to consider
a simple abdominal section in the gall-bladder region.
With regard to instruments, a gall-stone scoop is the only special
appliance I employ. All the instruments are boiled for half an hour
before being used.
My sutures and ligatures are of iodised catgut, Nos. 1, 2 and
3 ; they are strong and reliably aseptic. For stitching the incision
in the duct in choledochotomy, the " 00 " green chromic catgut
prepared by the iodine process answers well, as it does not become
688 The Surgical Treatment of Cholelithiasis.
absorbed before the second or third week. As showing the dis-
advantage of non-absorbable sutures, a case came under my notice
in which a silk suture used in a choledochotomy formed the nucleus
of a gall-stone, which fortunately passed without further operation.
The patient is prepared by having an aperient given so as to
secure the bowels being moved the day before operation, and an
enema is given the evening before if the operation is to take place
early the next morning. If there is any feebleness of pulse, 5 min.
of liq. strychninae [U.S.P. strychnin, hydrochlor., gr. ^] are given
subcutaneously on the afternoon and evening of the day before
operation and 5 min. before the operation is finished. Should there
be chronic jaundice or a tendency to haemorrhage, calcium chloride
or lactate is given ; for although there is a greater tendency to
bleeding in chronic jaundice from pancreatic disease than when
jaundice is due to gall-stone obstruction, I think there can be no
FlG. 1. Gall-stone scoop used by author.
doubt that in all cholaemic conditions the blood becomes so altered
that the coagulability becomes seriously diminished, and that these
factors demand serious attention before any operation is undertaken
in cases of common duct cholelithiasis.
The skin of the patient over the operation area is prepared the
day before by thoroughly washing with ether soap ; if needful,
shaving is then done. A dressing of lint, wet with 1 in 1,000
biniodide of mercury solution in methylated spirit diluted with one-
third of water, is then applied, and over this oilskin or gutta-percha
tissue. The dressing is changed early the next morning and a
similar one applied.
If the patient is feeble, a pint of normal saline solution with 1 oz.
of brandy is given by the rectum a short time before the operation.
As shock is intensified by exposure to cold, my patients are
always enveloped in cotton wool, which is conveniently done by
making a suit of gamgee tissue that can be readily run together by
the nurses in a hour or two the day before operation,
The Surgical Treatment of Cholelithiasis. 689.
LINt OF IHCISION
NOH ADOPTED
The operation is performed on a special table that can be raised
at the level of the liver so that the common and hepatic ducts are
brought several inches nearer to the surface. By opening out the
costal angle and tending to make the intestines slip down from
the liver it acts like the Trendelenburg position in pelvic surgery.
A vertical incision is made over the inner third of the right rectus
in a line parallel with its fibres ; the sheath of the rectus is then
separated by the fingers aided by scissors at the lineae transversse and
the rectus muscle is retracted, the posterior sheath of the rectus and
peritoneum being divided together. When the gall-bladder is
distended and there is no jaundice, a small incision of 2 or 3 inches
only may be required ;
but when it is neces-
sary to explore either
the hepatic, common,
or deeper part of the
cystic duct, instead of
prolonging the in-
cision downwards, as
was formerly done, I
now carry it upwards
in the interval between
the ensiform cartilage
and the right costal
margin as high as
possible, thus expos-
ing the upper surface
of the liver very freely.
It will be found that
by lifting the lower
border of the liver in bulk (if needful first drawing the organ
downwards from under cover of the ribs), the whole of the gall-
bladder and the cystic and common ducts are brought close to the
surface, and as the gall-bladder is usually strong enough, my
assistant can take hold of it with his fingers or forceps, and by gentle
traction can keep the parts well exposed at the same time that, by
means of his left hand with a flat compress under it, he retracts the
left side of the wound and the viscera, which would otherwise fall
over the common duct and impede the view.
It will now be observed that instead of the gall-bladder and cystic
duct taking a considerable angle with the common duct, an almost
straight passage is found from the fundus of the gall-bladder to the
entrance of the bile duct into the duodenum, and if adhesions have
S.T. VOL. ii. 44
FIG. 2.
,690 The Surgical Treatment of Cholelithiasis.
been thoroughly separated the surgeon has immediately under his
eye the whole length of the ducts with the head of the pancreas
and duodenum. So complete is the exposure that if needful the
peritoneum can be incised over the free border of the lesser omentum
and the common duct separated from the hepatic artery and portal
vein, but this is not necessary except when a growth or glands
have to be excised. The surgeon, whose hands are both free, can
deal with the gall-bladder, cystic, common, or hepatic duct quite
easily: for example, with his left finger and thumb he can so
manipulate the common or cystic duct as to render prominent any
concretions, which can be directly cut down on, the edges of the
opening in the duct being caught by pressure forceps. The assistant
can now take hold of the forceps with his left hand, as they with
the sponge will form a sufficient retractor, since the duct is so near
the surface.
When the duct is incised there is usually a free flow- of bile, which
it must be remembered is probably infective, but by packing the
kidney pouch with a gauze pad and rapidly mopping up the bile as
it flows, any soiling of surrounding parts is avoided, and if thought
necessary the bulk of the infected bile can be drawn off by the
aspirator either from the gall-bladder or from the common duct
above the obstruction before the incision into the bile passage is
made.
After removing all obvious concretions the fingers are passed
behind the duodenum and along the course of the hepatic ducts
to feel if other gall-stones are hidden there, and when the
common duct has been incised a gall-stone scoop is passed into
the primary division of the hepatic duct in the liver and down to
the duodenal orifice of the common bile duct, and if thought
necessary to ensure the opening into the duodenum being patent,
a long probe is passed into the bowel.
The incision into the bile duct, if one has to be made, is now closed
by an ordinary curved round needle held in the fingers without any
needle-holder, a continuous catgut suture being used for the margins
of the duct proper, and a continuous fine green catgut thread being
employed to close the peritoneal edges of the duct.
Where the gall-bladder is contracted and the pancreas is in-
durated and swollen from chronic pancreatitis, and likely to exert
pressure for a time on the common duct, I insert a drainage tube
directly into the duct, passing it upwards into the hepatic duct, and
closing the opening around it by a purse-string suture, the tube
being fixed into the opening by a catgut stitch which will hold for
about a week ; but when this is not done and the size of the gall-
The Surgical Treatment of Cholelithiasis. 691
bladder will permit of it, I usually fix a drainage tube into the
fundus of the gall-bladder in the same way, as this drains away all
infected bile and avoids pressure on the newly sutured opening in the
duct.
So easy is it to remove impacted stones after this method of
exposure that I now never spend a long time in manipulating
stones impacted deeply even in the cystic duct, but at once incise
the duct, remove the concretions, and close the opening without
damaging the duct by much pressure and prolonged manipulation.
Although there is seldom any fear of leakage or infection, yet
where the ducts have been incised and extensive adhesions separated,
there is usually some tendency to pouring out of fluid in the first
few hours. I therefore generally insert a gauze drain through a
split drainage tube, bringing it out by the side of the gall-bladder
drain or through a separate stab wound. This is usually removed
within twenty-four hours.
The wound is closed by continuous catgut sutures, first to
peritoneum and deep rectus sheath, and next to the anterior
rectus sheath.* Lastly, the skin margins are brought together
by means of Michel's clips. From one to three interrupted
silkworm gut sutures are inserted quite 1 inch from the line of
incision, and brought out 1 inch beyond the incision on the
other side ; they take up the anterior sheath of the rectus and
serve to support the whole wound.
To those having little experience in these operations the modifi-
cations I have employed may seem trivial, but to those who have
experienced the difficulties of the ordinary operation of removing
gall-stones from a contracted gall-bladder or from the cystic or
common ducts, I feel sure the method I have described, which
enables the whole of the bile passages to be dealt with as a
straight tube close to the surface, will be sufficiently appre-
ciated.
In these operations I employ forcipressure for the immediate
arrest of haemorrhage, but I find it is more satisfactory also to ligature
all the bleeding points, as in jaundiced cases the compressed and
unligatured vessels are apt to bleed subsequently and to lead to
complications that are avoidable by careful haemostasis. For the
same reason I prefer to divide and ligature firm visceral,
especially hepatic, adhesions, when this is practicable, rather than
as formerly to separate them with the finger or tear them
through.
If the liver is slightly torn in separating adhesions, the bleeding
must be carefully arrested before the abdomen is closed. Sponge
442
692 The Surgical Treatment of Cholelithiasis.
pressure is usually sufficient if the laceration is small ; but if the
laceration is extensive, deep catgut sutures applied by means of a
round intestinal needle, will usually accomplish the desired effect ;
or this failing, gauze pressure, the plug being left in until it
becomes loose, will be certain to answer.
Nothing can be simpler than an ordinary cholecystotomy with a
distended gall-bladder or even with a gall-bladder of ordinary size,
where a small incision suffices to expose the sac, which is emptied
by the aspirator. The collapsed viscus is then brought through
the wound and surrounded by sterilised gauze ; it is then incised
through the point where the needle was inserted, and through the
wound in the fundus the gall-stone scoop is inserted and all gall-
stones are removed, a probe or the finger being employed to prove
the ducts clear. A firm rubber tube, much firmer than the drainage
tubes ordinarily sold, is then inserted from ^ to 1 inch into
the gall-bladder, the edges of the incision being drawn firmly
around it by a catgut purse-string suture, which is tied and cut
short, the tube being fixed in position by a catgut suture, which
transfixes the tube and the edges of the incision in the gall-bladder.
The edges of the incision in the gall-bladder are then fixed to the
aponeurosis by three or four catgut stitches, but never to the skin
unless a permanent biliary fistula is intended. This tube is
sufficiently long to pass into a bottle by the side of the patient ; it
drains all the bile away from the wound, and by the time the catgut
has dissolved the wound will have healed by first intention except
where the tube was, and that part heals by granulation within the
next week or two if the ducts are clear.
What has been called the " ideal " operation, in which the
opening in the gall-bladder is immediately closed and returned into
the abdomen, was suggested by Langenbach ; but as it does away
with the beneficial effects of drainage, and is, moreover, attended
with more risk than the ordinary operation, it is not satisfactory.
A simple operation is quite the exception, the gall-bladder being
usually contracted and surrounded by adhesions ; moreover, in
these cases the obstruction will usually be found in the cystic or
common ducts. The advantage of the complete operation that I
have described, in which the edge of the liver is lifted up and the
bile passages brought well under view, will be experienced in this
class of cases.
The next question will be : How is the contracted gall-bladder
to be dealt with ? If it is too small to be brought to the parietes
and otherwise healthy and sufficiently large to admit a drainage tube,
the method of fixing the tube by purse-string suture just described
The Surgical Treatment of Cholelithiasis. 693
will be quite safe, even if the opening in the gall-bladder has to be
left 2 inches or 3 inches from the surface, for the onientura can be
made to lie against the tube, and by the time that the catgut is
dissolved a track of adhesions will have formed that will quite
effectually prevent extravasation ; but in order to make assurance
doubly sure, especially if there has been any unavoidable soiling, I
frequently insert a small split drainage tube with a little gauze in
it quite down to the gall-bladder and bring it out by the side of the
first tube.
If the gall bladder is so contracted as to be incapable of admit-
ting a tube, it may either be closed by suture, the line of union
being protected from hurtful leakage by a strip of gauze laid over
it and brought to the surface through a rubber tube, or the con-
tracted and useless remains of the gall-bladder may be removed by
cholecystectomy.
When the gall-bladder is very much contracted, cholecystectomy is
both easy and effectual, as the attachments to the liver are readily
dissected off without tearing the liver substance. The duct is
seized with strong pressure forceps and crushed, thus making a
groove in which the ligature, preferably of catgut, lies quite snugly.
Any vessels that bleed are ligatured, and, as a matter of precaution
(for the parts being dealt with are necessarily infected), a strip of
gauze is left in contact with the end of the ligatured duct and
brought to the surface through a split drainage tube.
If, as frequently happens, gall-stones are so firmly fixed in the
cystic duct that they cannot be pressed backward into the gall-
bladder, it is better not to use force but to incise the duct over the
stone and, after clearing the duct, to close it by a double row of
sutures to mucous membrane and serous coat respectively.
If the concretions are in the common duct, either fixed or
floating, it is just as easy, with the duct well under the eye and
near the surface, to incise it and remove the stones as it is to open
the gall-bladder. All such instruments as handled needles and
Halsted's hammer are quite unnecessary, for the incision in the
duct can as readily be closed by means of a curved round needle
(sewing-needle pattern) in the fingers as by any more complicated
apparatus. But before closing the duct it is of the utmost
importance to ascertain that there are no stones left either in the
ampulla of Yater or in the hepatic duct ; and although the fingers
manipulating the outside of the ducts can give information as to
any large stones, it would be easy to overlook small ones unless the
scoop is passed freely upwards into the hepatic ducts and down-
^yards behind the duodenum, or if necessary the opening in the
694 The Surgical Treatment of Cholelithiasis.
duct can be made sufficiently large to admit the finger for explora-
tion.
I usually pass a large probe down into the duodenum through
the papilla to be sure that the passage is quite free. In one case,
not being able to pass the probe beyond the papilla, I opened the
duodenum and found a stricture of the common duct close to its
termination, which I divided by freely laying the papilla open over
a director.
In quite a number of cases, after the common duct has been
cleared, I have found stones in the hepatic ducts which I have
removed by the scoop.
In some cases the common bile duct is found dilated to the size
of the small intestine, and if the gall-bladder and cystic duct are
small and so contracted as to be useless for drainage, a firm rubber
tube is inserted into the incision in the duct and pushed a little
way up into the hepatic duct, the tube being surrounded by a purse-
string suture and fixed in position by one or two catgut stitches.
If a stone is impacted in the duodenal end of the common duct,
it may sometimes be more easily reached through a vertical
incision in the second part of the duodenum (duodeno-
choledochotomy), when the concretions can be directly cut down
on through the posterior wall of the duodenum, or the papilla can
be laid open over a director ; it is then easy to pass the gall-stone
scoop up the common duct in order to be certain that it is free
from concretions. All that is now necessary is to close the anterior
duodenal wound by a continuous catgut suture for the mucous
membrane, and a continuous silk or celluloid thread for the serous
margins.
With the better exposure of the common duct secured by the
operation just described, duodeno-choledochotomy will be seldom
called for, as the gall-stone scoop can so freely be used through
the incised duct.
Cholecystenterostomy has been advocated by some surgeons
for obstruction in the common duct by gall-stones, the gall-bladder
being connected to the duodenum. In my earlier practice I
performed a number of these operations, but since adopting the
easy and effectual method of exposing the whole length of the bile
ducts I have practically discarded this operation for gall-stones,
for it leaves the cause untouched, and should the artificial opening
close, the symptoms inevitably return.
Cholelithiasis and Enlargement of Pancreas. In common
duct cholelithiasis, especially when there is a small floating gall-
stone, it is common to find the head of the pancreas enlarged and
The Surgical Treatment of Cholelithiasis. 695
hard, the result of chronic pancreatitis ; this may give rise to the
suspicion of cancer of the head of the pancreas, and may lead to
an unfavourable prognosis being given, but it is well to reserve
our opinion in such cases and to give the patient the benefit of the
hope of cure through long-continued drainage by the operation of
cholecystenterostomy.
Malignant Disease. When gall-stones are associated with
cancer of the gall-bladder, liver, or pylorus, a much more extensive
operation may have to be done, as in the following cases :
Excision of cancer from liver, gall-bladder and pylorus ; recovery.
A woman, aged 63. History of pain and jaundice. Great loss
of flesh and strength. Tumour in gall-bladder region. Operation,
August 10th, 1900. Mass of growth discovered in liver, gall-
bladder and pylorus. Cholecystectomy, pylorectomy and partial
hepatectomy performed. Good recovery. Patient well, and in
good health some years later. Microscopic examination showed
the disease to be cancer.
Excision of cancer of liver and gall-bladder ; recovery. A man,
aged 46. Seven years' gall-stone attacks. Infective cholangitis.
Loss of 4 stone in weight. Jaundice. Operation, June 26th,
1899. Tumour of liver adjoining gall-bladder excised by wedge-
shaped incision ; gall-bladder also excised. Large number of gall-
stones removed and choledochenterostomy performed. Complete
and perfect recovery. Patient in excellent health at present time,
eleven years after operation. Microscope showed disease removed
to be cancer.
But these are exceptional cases, as there were no secondary
manifestations of disease in the liver or elsewhere. Had there
been such, I should have simply concluded the operation as an
exploratory one.
Intervisceral Fistula. In detaching adhesions it may be found
that there is a fistula between the gall-bladder and stomach, pylorus
or bowel, and a careful search must always be made for this, lest
an opening into one of the hollow viscera be left, which would
probably mean extravasation and death.
Cholelithotrity. I have now entirely given up cholelithotrity
as a set operation, as although in some of my earlier cases it
answered well, in several the fragments did not pass and gave
further trouble. Moreover, the very complete exposure which the
complete operation gives renders all uncertain methods, such as
crushing, quite unnecessary.
After-Treatment. Expedition in operating is an important
factor in lessening shock, especially in abdominal surgery, for it
696 The Surgical Treatment of Cholelithiasis.
stands to reason that prolonged manipulation and exposure of
the viscera in patients so ill as the class of cases we are now
considering must generally be will be badly borne, for it is not
only the work of the surgeon but the deep anaesthesia that adds
to the shock, since for these operations to be expeditiously
performed the muscles must be well relaxed. Choledochotoniy
should occupy from half an hour to an hour, and only in case of
unusual complications a little longer.
After operation 1 pint of saline fluid, with 1 oz. of brandy,
is given by enema, and 5 niin. of liq. strychnine [U.S.P.
strychnin, hydrochlor. gr. -%~\ are given subcutaneously, this being
repeated if called for. Subcutaneous injections of saline fluid or
intravenous infusion are only rarely required.
Beyond sips of hot water or hot tea from time to time, all
feeding is by the rectum for the first twenty-four hours. After forty-
eight hours, if there is no vomiting, milk and soda and barley-water
can be freely given. A little plasrnon dissolved in the tea or beef-
tea or barley-water considerably adds to the nutritive value of
the fluid. Light custard pudding is usually given on the fourth
day, fish on the fifth, and chicken on the sixth, after which the
diet becomes almost normal.
The bowels are not disturbed before the fifth or sixth day,
and then only by enema, unless there is vomiting or distension,
and in case of either of these complications 1 gr. of calomel is
administered, and followed by 2 oz. of apenta water every two
hours until it acts or until flatus passes freely, this being at times
helped by the rectal tube or by a turpentine enema.
Morphine is avoided, if possible, after all my abdominal
operations, as it tends to paralyse the intestines and leads to an
accumulation of flatus. I believe that abstention from the use of
morphine as a routine measure is a great feature in the success of
abdominal surgery, just as I feel sure that in the past it has killed
may patients who would otherwise have done well.
If a sedative is needed, 10 gr. of aspirin will be found useful, and
this can be repeated in two hours if required. In case of vomiting
being troublesome or epigastric distension persisting, gastric lavage
will be found useful, and when the stomach is emptied a dose of
apenta water may be left in it to incite peristalsis. Under these
circumstances no food or fluid is allowed by the mouth, but plenty
of fluid in the shape of normal saline is given by rectum.
As a rule recovery is uneventful, and for the most part after-
treatment is negative. The stitches are removed on the eighth day,
and the tube usually comes away about the same time ; the wound
The Surgical Treatment of Cholelithiasis. 697
will generally have healed by first intention, and the spot where the
tube was heals by granulation. The dressings are of the simplest:
sterilised gauze and sterilised wool.
The chief points to bear in mind are that we should operate earlier,
before serious complications have ensued, and that when operating
we should be thorough and expeditious.
A. W. MAYO-ROBSON.
698
FISTULA OF THE GALL-BLADDER AND BILE
DUCTS.
FISTULA in connection with the bile passages are by no means
uncommon, and their variety is considerable. They result from
operation or from disease, and in the latter case they are due to
ulceration resulting from gall-stones or cancer.
The fistulous channel may either be direct or indirect, in the
former being caused by an advancing ulcer setting up local peri-
tonitis and causing adhesion of the gall-bladder or bile ducts to one
of the neighbouring hollow viscera, or to the parietal peritoneum.
The extension of the ulcer continuing, a communication is
established with the contiguous channel or with the surface. In
the indirect variety the perforation occurs first into an adjoining
parenchymatous organ or into a localised abscess, and then into an
adjacent hollow viscus or on to the surface of the body at some
part.
A fistula may also arise from a local abscess forming outside the
biliary passages around the primary focus of inflammation and then
bursting into the adjoining cavities, which are thus made to
communicate.
Although the establishment of a fistula is at times dangerous,
and at others excessively annoying or uncomfortable, in many cases
it forms one of nature's methods of relief, and the surgeon in
forming a permanent biliary fistula in otherwise incurable jaundice,
or in making an anastomosis between the bile passages and the
intestine for the like purpose, is taking a leaf from nature's
book.
Many of the fistulse are mere pathological curiosities, quite undiag-
nosable, and only capable of being discovered post-mortem. Many
must form and heal, leaving the patient cured, and thus not only
are they not discovered, but they are probably not even suspected ;
for, contrary to what one might suppose, fistulse betwen the bile
passages and other hollow viscera in the majority of cases heal
spontaneously, leaving only visceral adhesions, so that the fistulse
are comparatively rarely found post-mortem.
Post-operative Fistulae may be mucous or biliary.
Mucous Fistulce are occasionally seen after the operation of
cholecystotorny, when the obstruction in the cystic duct has not
been overcome, or when that duct is the seat of stricture.
Fistulae of the Gall-Bladder and Bile Ducts. 699
The treatment consists in removing the obstruction or, where that
is impracticable, in performing cholecystectomy.
Biliary Fistula following on operation is quite a different matter
from mucous fistula, as although in some cases it is compatible
with good health, the inconvenience caused by 30 oz. of bile flow-
ing from the fistula daily produces so much discomfort that in
all the cases which have conie under my notice the patients have
preferred to accept the risks of operation rather than to retain their
disability.
The treatment of biliary fistula should, where possible, be effected
by removing the cause ; but as in certain cases this is impracti-
cable or impossible, other means have to be considered.
If the ducts are clear and the fistula is small, the application of
the actual cautery to the margin of the fistula will frequently result
in its closure.
Or the fistula may be dissected from the skin margin without
opening the peritoneum, afterwards doubling in the mucous edges,
suturing them accurately, and over this applying one or two layers
of buried sutures before bringing together the skin.
When, however, the ducts cannot be cleared, and the gall-bladder
is large enough to permit of it, the operation of cholecystenteros-
tomy may be performed.
Pathological Surface Fistulae usually open at the umbilicus,
the abscess following the course of the remains of the umbilical
vein ; but they may form at any part of the abdominal wall, even
near the pubes, or on the left side of the abdomen.
In operating on these cases it is advisable to purify the fistula as
far as possible, and to scrape away all granulations before opening
the peritoneal cavity to get at and clear the bile ducts. By adopting
these precautions no untoward results are likely to occur.
Biliary Gastric Fistula is less common than might be thought,
for the pylorus is not infrequently adherent to the gall-bladder.
Operation may be necessary on account of the irritation caused
by gall-stones and infected bile in the stomach.
A. W. MAYO-ROBSON.
700
INFLAMMATORY AFFECTIONS OF THE GALL-
BLADDER AND BILE DUCTS.
ACUTE and chronic catarrhal jaundice are subjects of medical
rather than surgical interest ; but it must not be forgotten that
chronic catarrhal cholangitis, by simulating jaundice due to organic
mischief, such as cholelithiasis, pancreatitis, cancer, or hyatids, has
some important surgical bearings, and that when medical means
have failed, surgical treatment must be considered.
It should also be borne in mind that the jaundice accompanying
cancer of the liver is frequently catarrhal, and therefore capable of
being relieved by treatment, although the original disease persists.
Also that the evanescent jaundice following on cholelithic attacks
is often catarrhal, and not due to the mechanical obstruction of a
gall-stone.
The treatment of chronic catarrhal jaundice is at first medical.
If the disease proves obstinate, a course of treatment at Leamington,
Bath, Harrogate, or Carlsbad will be likety to do good if the ailment
is functional ; but that failing, the question of some organic cause,
such as gall-stones that may be removable by surgical treatment,
should be considered. Even when the obstruction is not removable,
as in disease of the head of the pancreas compressing the common
bile duct, great relief may be given by drainage of the bile duct
either by means of cholecystotomy or by cholecyst-enterostomy.
If the disease of the pancreas is malignant, relief only will be
effected, but if the pancreatic swelling is dependent on interstitial
pancreatitis the operation may prove completely curative.
Catarrhal Cholecystitis or, " chronic catarrh of the gall-bladder
without jaundice," forms a distinct and definite disease, and I have
seen several cases in which cholelithiasis had been diagnosed and
operation advised, but where neither the gall-bladder nor ducts
contained anything firmer than thick ropy mucus, which was
apparently the cause of painful contractions of the gall-bladder
simulating gall-stone seizures.
Should medical treatment fail to relieve, it may be difficult to
distinguish chronic catarrh of the gall-bladder from cholelithiasis ;
but if, under the belief that the case is one of gall-stones, the gall-
bladder is exposed and no concretions found, cholecystotomy,
followed by drainage, will be likely to effect a cure.
In chronic catarrh of the gall-bladder, regular exercise, massage
Inflammatory Affections of the Gall-Bladder. 701
over the hepatic region, the avoidance of anything tight around
the waist, which will increase the dependence of the fundus of the
gall-bladder, careful regulation of the diet, and the judicious
employment of saline aperients, should be adopted in all cases.
The spasmodic attacks may require the administration of a
sedative, and I have found 10 grains of aspirin of great service.
The dose may be safely repeated in an hour or two if required ;
but in some cases nothing short of the subcutaneous injection of
morphia will do any good.
If after a few weeks of general treatment the symptoms are not
relieved, the case will probably be thought to be one of gall-stones,
and operative treatment may be considered advisable.
Even if the gall-bladder and ducts are found free from gall-stones,
cholecystotomy and drainage should nevertheless be performed,
and it will be found useful after the third day to gently syringe a
little sterilised warm water through the drainage tube daily so as
to wash out the ducts. After a fortnight or more the tube may be
left out and the wound allowed to close.
General treatment directed to the cause should be continued for
some time afterwards. In fact, obstinate catarrh of the gall-
bladder should be treated like catarrh of the urinary bladder, first
by medical and general remedies, and these failing, physiological
rest should be secured by means of drainage.
Obliterative Cholecystitis and Cholangitis. It is now well
recognised that repeated attacks of appendicitis may ultimately
lead to obliteration of the veriform appendix, which may be dis-
covered as a simple cord without any lumen, in the centre of firm
adhesions.
The same state may be brought about in the gall-bladder and
bile ducts by repeated attacks of inflammation, so that it is not
very uncommon to find the gall-bladder and cystic duct represented
by a mere fibrous cord surrounded by adherent viscera, and unless
carefully sought for it may be thought that they have been con-
genitally absent.
Between this form, which may be conveniently termed oblitera-
tive cholecystitis, and the ordinary contracted gall-bladder so
frequently seen in operating for gall-stones, every degree of
deformity may exist.
The gall-bladder may be only partly obliterated, and the small
amount of mucous membrane left may continue to secrete a little
mucus, and keep up a constant state of irritation resembling true
gall-stone seizures, or the cystic duct may be obliterated, and the
gall-bladder may form a cyst containing mucus, quite separated
702 Inflammatory Affections of the Gail-Bladder.
from the bile channels proper. In nearly all these cases the
recurring pains call for operation, and unless the apparently
insignificant and almost obliterated remains are taken away, the
attacks of pain often associated with fever will continue and lead to
serious deterioration of health.
Croupous Inflammation of the Gail-Bladder and Bile Ducts.
It had been noticed as far back as 1820 by Dr. Richard Powell
that membranous or croupous enteritis was frequently associated
with attacks resembling gall-stone seizures.
From a number of cases that I have seen and observed, some of
them having been submitted to operation without finding gall-
stones, but where there was abundant evidence of inflammation of
the gall-bladder and bile ducts, I formed the opinion that the cause
of the painful attacks followed by slight jaundice, in cases of
membranous enteritis, is the formation of membrane in the bile
passages, which, partly obstructing the bile flow, sets up spasm of
the gall-bladder, just as a gall-stone or even a lump of tenacious
mucus will do.
Owing to the disintegrating effect of the bile and of the intestinal
secretion it seldom happens that a true cast of the gall-bladder or
bile ducts is discovered, as occurred in a case related by Dr.
Clennell Fenwick.
If under treatment by saline aperients, such as Carlsbad salts
given the first thing in the morning and careful dieting, the
symptoms do not abate, the question of drainage of the gall-bladder
by cholecystotomy will be well worth considering, and at the time
of operation adhesions of the gall-bladder to the neighbouring
viscera should be broken down.
Simple Empyema of the Gall- Bladder. Suppurative catarrh
or simple empyema of the gall-bladder, or suppurative cholecystitis,
is as a rule associated with gall-stones ; but tumours of the bile
ducts, typhoid and other fevers, and unexplained conditions may
also be the predisposing factors, though infection by pyogenic
organisms is probably in every case the true exciting cause.
Empyema of the gall-bladder must always be looked on as a
serious affection, both on account of its causes and its sequelae, but
from a clinical standpoint there is one form which is decidedly less
serious than the other. The treatment of the less serious will be
considered first under the term " simple empyema of the gall-
bladder " ; the more serious form will be considered later as a distinct
and special disease under the name of " phlegm onous cholecystitis."
The pus may form an abscess, which may even burst at a
distance from its origin for instance, over the pubes or over the
Inflammatory Affections of the Gall-Bladder. 703
caecum or it may, after setting up adhesions to adjoining viscera,
be discharged into the duodenum, colon, stomach or pelvis of the
kidney ; or passing into the liver it may lead to abscess of that
organ ; or perforating the diaphragm, it may discharge into the
pleura and set up empyema, or into the pericardium and incite
pericarditis, or into the peritoneal cavity and produce acute general
peritonitis.
There are generally peritoneal adhesions which prevent
extravasation into the general peritoneal cavity, but the pus may
make its way into neighbouring organs. On several occasions
I have found a cavity in the liver containing pus and gall-stones
communicating with the diseased gall-bladder.
In several cases I have evacuated and drained successfully a
large subphrenic abscess between the liver and diaphragm, due to
a ruptured empyema of the gall-bladder.
If we bear in mind the pouch of peritoneum in front of the right
kidney, it is not to be wondered at that a collection of pus should
at times form in that region resembling a peri-renal abscess, though
inside the peritoneum and limited by adhesions.
An abscess of the gall-bladder requires treating on general
surgical principles by opening and draining ; but the cause must
not be overlooked, as it may often be removed at the same time
that the abscess is evacuated.
The walls of the gall-bladder may be found so friable as to be
incapable of holding sutures, or there may be small abscesses in
the inflamed wall of the gall-bladder itself; in such cases
cholecystectomy may be required, as, indeed, it is whenever the
walls of the gall-bladder are seriously damaged or the cystic duct
is ulcerated or strictured.
In abscess due to empyema of the gall-bladder reaching the
surface at some distance from the seat of the origin, it may be
wise at first simply to open and drain the abscess, and on some
future occasion to perform cholecystotomy or cholecystectomy.
But it may be feasible after opening the superficial abscess to
dilate the fistula leading to the gall-bladder and remove the stones,
afterwards leaving a tube in the gall-bladder. This may possibly
be effected without detaching the adherent gall-bladder from the
surface.
In some cases of empyema the patient may not be in a fit
condition to bear a prolonged operation, and it may, therefore, be
wiser to perform a simple cholecystotomy, and to defer the removal
of the cause until an examination of the discharge shows it to be
sterile or nearly so.
704 Inflammatory Affections of the Bile Ducts.
Acute Phlegmonous Cholecystitis and Gangrene of the Gail-
Bladder. Acute or phlegmonous inflammation of the gall-bladder
was described by Courvoisier in 1890 under the name of acute
progressive empyema of the gall-bladder, and he states that it
usually terminates fatally in a few days from diffuse peritonitis.
Only seven cases are regarded in Courvoisier's statistics.
Potain also mentions that, in addition to the ordinary variety
of empyema of the gall-bladder, there is a very grave condition of
acute empyema which is followed by rapid peritonitis and death.
In one case which he describes death occurred on the second day
after the onset of the attack, and although there was no perforation
of the walls of the viscus, infection had spread through the coats
to the general peritoneal cavity.
Although the condition is usually associated with gall-stones,
acute cholecystitis may arise quite independently, in this way
resembling appendicitis, which may occur without the presence of
concretions or foreign bodies.
Typhoid and typhus fevers, cholera, malaria, sepsis after
operation, puerperal fever, and other conditions may give rise
to it.
Eelief of pain by subcutaneous injections of morphia will
probably always be demanded as a primary measure, and as it is
often impossible to make a diagnosis of the serious condition within
the first few hours, warm applications should be used and absolute
rest enjoined, all feeding by the mouth being stopped and the relief
of symptoms as they arise being attended to ; but as soon as the
diagnosis of acute cholecystitis is suspected and it is found that the
patient is getting worse, an exploratory incision should be made,
and if phlegmonous cholecystitis is found, the gall-bladder should
be removed and the right hypochondrium drained.
If in the subacute cases the inflammation becomes localised,
and a swelling with tenderness be found beneath the right costal
margin, incision and drainage is called for, when 1 at the same
time cholecystotomy may be performed, and if gall-stones be present
in the gall bladder or ducts they may be removed. If the patient
is too ill to bear a prolonged operation, the latter procedure may be
left to a subsequent occasion.
Gangrene of the gall-bladder is an advanced stage of phlegmonous
cholecystitis and requires the same treatment, cholecystectomy.
Infective Cholangitis. Infective cholangitis or infective catarrh
of the bile ducts was first described by Charcot under the name of
intermittent hepatic fever. It is usually due to gall-stones in the
common duct, which favour the entrance of organisms from the
Inflammatory Affections of the Bile Ducts. 705
intestine through the duodenal orifice ; but anything causing
obstruction of the common or hepatic ducts may lead to infection
of the retained bile. Thus I have known infective cholangitis to
follow on chronic pancreatitis, cancer of the pancreas, cancer of the
common bile duct, hydatid disease, ascarides in the bile duct,
pancreatic calculus, and stricture of the common duct, besides
general ailments such as typhoid fever and influenza.
Drainage of the bile ducts either by cholecystotomy or chole-
dochotomy is the first essential, but if possible the cause should at
the same time be removed.
There can be no doubt in the minds of those who have observed
many of these cases that it is better to anticipate the complication,
and as soon as medical treatment has been fairly tried and failed,
the removal of gall-stones by surgical means should be resorted to
before infection of the bile passages has occurred.
Suppurative Cholangitis. Suppurative cholangitis or suppu-
rative catarrh of the bile passages is a subject of deep interest, and
a disease of serious import, not only on account of its causes but
from the combined effects of biliary obstruction and stagnation with
septic infection, and their local and constitutional effects.
Besides gall-stones, hydatid disease, ascarides, cancer of the bile
ducts, typhoid fever, and influenza may cause Suppurative cholan-
gitis, and it is probable that the disease not infrequently complicates
other acute infectious ailments.
Unless free evacuation and drainage of the infected contents of
the bile passages can be accomplished, either naturally or arti-
ficially, treatment is practically useless. Therefore, if practicable,
cholecystotomy should be performed, and free drainage established
and continued until the bile is sterile or nearly so.
Although good results cannot be expected in all cases, an
amelioration of the symptoms may be looked for in a fair proportion,
and complete relief in others.
If a localised abscess is discovered in the liver, it should be opened
and drained, and though it is scarcely to be expected that operation
can be always successful in these more serious cases, the chance of
permanent benefit is worth snatching at, even in the most desperate
conditions.
Of general means, warm applications to the hepatic regions, an
initial mercury purge followed by milder laxatives, the employment
of intestinal antiseptics, such as bismuth and salol, the relief of
pain by sedatives, and the treatment of symptoms as they arise
will afford some amelioration, though they will probably only give
temporary relief.
S.T. VOL. 11. 45
706 Inflammatory Affections of the Bile Ducts.
Drainage of the bile ducts by cholecystotomy or choledochotomy is
the operation called for, and at the same time the obstruction,
if one is present, should if possible be removed, though in some
cases, where the patient is extremely ill, the latter part of the
operation may be deferred until the drainage has cleared away
all the infective material.
Thanks to the opening in the gall-bladder, a certain number of
important therapeutic results follow :
First. The septic contents of the gall-bladder are evacuated.
Second. Calculi, which are most frequently present there, are
removed.
Third. The other biliary passages, more or less obstructed
either by calculi or by swelling of their walls, are rendered as free
as possible.
Fourth. The septic bile is allowed to escape and mechanically
washes out the lower passages, carrying away through the drainage
tube many of the infective elements.
Fifth. The relief of pressure prevents absorption of the septic
matter.
Sixth. The relief to the kidneys, by allowing the bile to escape
freely, is also of importance, as they are thus enabled to perform
their function more freely in relieving the system of septic and
other materials.
Seventh. The swelling of the head of the pancreas, " chronic
pancreatitis," so often present when the common bile duct is
obstructed, subsides owing to the indirect drainage of the pancreatic
ducts.
Stricture of the Gall-bladder and Bile Ducts. Stricture
of the bile ducts is, I should judge by my experience on the
operating table, very common, especially stricture of the cystic
duct, yet, if we might judge by museum specimens alone, it would
seem to be one of the rarer sequelae of ulceration.
If the stricture is in the hepatic duct it will lead to jaundice
without distension of the gall-bladder; if in the cystic duct,
to distension of the gall-bladder without jaundice ; but if in
the common duct, both to jaundice and distended gall-bladder,
unless the latter is contracted as the result of previous gall-stone
trouble.
Where extensive changes have not already taken place in the wall
of the gall-bladder, distension of the organ with mucus or muco-pus
will occur. If relief is not afforded by operative measures, suppu-
rative or phlegmonous cholecystitis may occur, or the distended
organ may rupture into the peritoneum or discharge its contents by
Inflammatory Affections of the Bile Ducts. 707
the formation of a fistula between the gall-bladder and duodenum,
stomach or colon ; or the gall-bladder may gradually dilate so as to
form a tumour resembling an ovarian cyst.
Needless to say, stricture of the bile passages will scarcely call
for diagnosis apart from its cause, though different treatment will
be demanded when the disease is recognised at the time of opera-
tion. In stricture of the cystic duct the gall-bladder should be
removed, otherwise a recurrence of the symptoms will occur when
the wound closes, or there will be a permanent mucous fistula.
As an alternative the gall-bladder may be short-circuited into the
intestine.
In stricture of the common duct cholecystenterostomy must be
performed, otherwise a permanent biliary fistula will certainly
follow. At times, however, this may be impracticable, and in such
cases drainage alone may be feasible.
Perforation of the Gall-bladder and Bile Ducts. Perforation
of the gall-bladder or bile ducts must always be serious on account of
an escape of the visceral contents into the peritoneal cavity, the
imminence of the danger, however, depending on two factors, first,
the nature of the extra vasated fluid ; and secondly, the time allowed
to elapse before surgical relief is afforded.
The presence of healthy bile in the peritoneum, due to an injury,
such as a stab, a bullet wound, or a blow, in a healthy individual
may be tolerated for some time without serious damage, as in a
case recorded by Thiersch, who successfully removed over 40
pints of bile-stained fluid from the abdominal cavity after the gall-
bladder had been ruptured by a blow.
It is of far more serious moment when the extravasated bile is
pathological as it is for the most part where there is distension of
the gall-bladder or any disease of the bile ducts, for in such cases
the bile is infective, and rapidly sets up a diffuse peritonitis, which,
unless speedily operated on, ends fatally.
Even in such cases, if the diagnosis is made at once and early
operation done, the prognosis is hopeful.
In rupture of the gall-bladder from sudden pressure induced by
straining at stool, vomiting, sneezing, efforts in parturition, or even
by blows over the hepatic region, there is in all probability in the
greater number of such cases a predisposition to rupture in the shape
of thinning by ulceration or by long-continued distension, otherwise
the accident would be much more common.
Such cases show conclusively that it is folly to permit patients
with distended gall-bladders, even though symptoms be only occa-
sionally present, to go unoperated on.
452
708 Inflammatory Affections of the Bile Ducts.
A careful operation in these cases is almost devoid of risk, but
rupture is hazardous in the extreme.
Massage in cases of distended gall-bladder is dangerous, as
attempts to force impacted calculi onward by pressure are well
calculated to rupture the thin wall of the gall-bladder or bile ducts,
or to cause perforation through the base of an ulcer, leading to
extravasation of infective matter into the general peritoneal cavity,
and probably to fatal peritonitis.
In the greater number of cases perforation occurs slowly, an
adventitious cavity being formed, shut off from the general cavity
of the peritoneum by adhesions of the neighbouring viscera.
In some cases the primary perforation may lead to the forma-
tion of a second cavity bounded by plastic lymph, which may again
rupture and lead to a fatal peritonitis.
Erdman gives a record of thirty-four cases of perforation with
four recoveries. Of these thirty-four cases twenty-seven were not
operated on, and all died. Of the seven cases in which an operation
was performed four recovered and three died. He strongly advo-
cates cholecystectomy, and does not approve of cholecystotomy or
of repair of the perforation by suture.
The perforation may occur into adjoining parenchymatous organs.
On several occasions I have removed gall-stones from cavities in the
liver produced by ulceration and perforation of the gall-bladder
or bile ducts, and direct passage of the contents into the liver
tissue.
If the ulceration and perforation occur from the common duct
into the substance of the pancreas, acute pancreatitis may follow,
or if less acute, an abscess of the pancreas may result and require
evacuation.
If the ulceration advances towards the adjoining hollow viscera,
stomach, duodenum or colon, adhesions as a rule form, and the
perforation is effected quietly.
In several cases I have known large gall-stones to ulcerate their
way quietly, and to perforate the stomach or intestine, only pro-
ducing serious symptoms from mechanical irritation or obstruc-
tion.
Barely gall-stones have perforated into the pelvis of the right
kidney, producing symptoms of renal calculus.
Not infrequently the perforation may occur after adhesion to the
parietal peritoneum, when a superficial abscess may follow, discharg-
ing gall-stones.
In perforation of the bile passages medical treatment is useless,
and to give opium for the relief of pain so disguises the symptoms
Inflammatory Affections of the Bile Ducts. 709
that a fatal sense of security is given for a time, and when the
mistake is discovered it may be to.o late to operate.
As soon as it is clearly made out that perforation has occurred,
or even if it is suspected that such is the case, the abdomen should
be opened in the right semilunar line.
If pus and bile are found, they should be rapidly wiped away with
gauze or wool sponges, and if the extravasation has gone beyond
the local area of disease, the abdomen should be flushed with hot
sterilised saline solution.
The patient may be too ill to bear a prolonged operation, and
if so, free drainage will probably do all that is necessary.
In drainage it should be borne in mind that the right kidney
pouch forms a distinct peritoneal pocket, and that a drainage tube
applied through a stab opening in the right loin affords a free
exit for extravasated fluids coming from the neighbourhood of the
gall-bladder. If the whole peritoneal cavity has been soiled, a
puncture above the pubes large enough for a tube to be passed into
the pouch of Douglas may be an advantage.
If the patient is in sufficiently good condition to permit a search
for the rupture, and it can be found, it may be closed by fine silk
or catgut sutures, but it will be wise to open and drain the gall-
bladder at the same time.
Should marked cholecystitis be found, the question of cholecys-
tectomy arises ; but when the patient is in a critical condition it is
a mistake to attempt too much, and, as a rule, cleansing and free
drainage will be all that are necessary or advisable at the time, the
removal of the cause being left until the patient is better able to
bear a more prolonged operation.
A. W. MAYO ROBSON.
REFERENCES.
Brit. Med. Journ., 1898, L, p. 1072, Journ. de Med. et Chir., November,
1882 ; Annals of Surgery, Phila., 1903, XXXVII., p. 878.
710
TUMOURS OF THE GALL-BLADDER.
Distension of the Gall-bladder. A tumour is felt as soon as
retention occurs under tension, when the cyst full of fluid often
gives the sensation on palpation of a pyriform solid, it being so
hard.
A perceptible tumour formed by distension with gall-stones is
rare, unless it happens that some have become impacted in the
cystid duct, when a gradual enlargement from the retained mucus
will follow. Occasionally a large single stone may form a hard
perceptible swelling below the liver.
The treatment is by cholecystotomy if the obstruction can be
removed and the gall-bladder and cystic duct are not seriously
affected, or cholecystectomy if the gall-bladder is diseased or the
cystic duct ulcerated or strictured.
Calcified gall-bladder, which is due to cholelithic catarrh, may
lead to the formation of a hard, rounded, painless tumour, which can
be readily excised if causing trouble.
Hydrops and Dropsy of the Gall-bladder are terms used to
denote distension of the gall-bladder by mucus. It may result from
any obstruction in the cystic or common ducts, whether due to gall-
stones, stricture or growth in the ducts, or to cancer of the head of
the pancreas, provided that the gall-bladder has not atrophied as
the result of previous gall-stone irritation. It is due to the gradual
accumulation of the natural secretion of the mucous lining, and may
attain such a size as to be mistaken for an ovarian cyst, as in cases
reported by Lawson Tait, Mayo and Kocher, though it is uncommon
to find the tumour of greater size than 15 to 20-.oz. capacity.
Where the tumour is small and the cause is removable the gall-
bladder may be drained after the obstruction has been removed,
but when the tumour is of considerable size cholecystectomy should
be performed.
Empyema of the Gall-bladder. If the obstruction is asso-
ciated with inflammation the contents of the gall-bladder may
become purulent and an empyema of the gall-bladder may result,
necessitating cholecystotomy or cholecystectomy.
Hypertrophy of the Gall-bladder, forming a large tumour,
is not infrequently seen as a result of cholelithiasis. The contents
may be mucus or muco-pus, and gall-stones may or may not be
Tumours of the Gall-Bladder.
711
present when the tumour is removed, though probably in every
case biliary concretions have ac.tually initiated the trouble by
obstructing the outlet and producing cholecystitis.
Firm adhesions to the neighbouring organs, the result of local
peritonitis, form a distinct feature of these tumours, and though
their separation may be tedious, this should be done, and should be
followed by cholecystectomy.
Hydatids of the Gall-bladder. Hydatid disease of the gall-
bladder may occur primarily, but it is more common for the disease
to originate in the liver and then to burst
into the gall-bladder, producing symptoms
resembling gall-stone seizures.
Complete removal of the hydatids and
drainage of the gall-bladder i"s advisable.
Actinomycosis of the Gall-bladder
is extremely rare, a case which came
under my care being the only one with
which I am acquainted.
Evacuation of the soft, putty-like con-
tents of the gall-bladder, followed by
drainage and the administration of large
doses of iodide of potassium, proved
completely curative.
New Growths. Of the tumours
dependent on new growth, cancer of
the gall-bladder is the most important,
innocent growth, except of inflammatory
origin, being extremely rare.
The alleviation of symptoms, especially FIG. i. Adenoma of gall-bladder
of pain by sedatives, is usually all that removed by author,
can be done, except in those rare cases where the disease is
limited to the gall-bladder, when cholecystectomy may be per-
formed.
In a limited number of cases in which the liver is affected by
direct extension from the gall-bladder it may appear feasible to
remove the whole disease. In such it is probably right that the
patient should get what chance there is of complete cure.
The question of operation is always worth considering seriously,
since the possibility of the trouble being dependent entirely on
inflammation, the result of gall-stone irritation, and not on new
growth, cannot always be pre-determined. Indeed, even after the
abdomen has been opened it is not always easy to be sure of the
exact condition of affairs until adhesions have been broken down.
yi2 Tumours of the Gall-Bladder.
It is not very uncommon to find a gall-bladder containing pus and
gall-stones in the centre of a mass of omentum and adherent viscera
so hard as very closely to simulate new growth. In such cases, of
course, all that is necessary in order to effect a cure is to remove
the gall-stones and drain or remove the gall-bladder.
"Whether it is worth trying thus to remove a localised cancer of
the liver and gall-bladder is a question which can only be solved by
more extended experience, but I am inclined to think from the after-
history of several cases on which I have operated that, even when
recurrence took place, the respite gained to the patient more than
counterbalanced the danger of the operation. In similar cases,
where no attempt at radical treatment was made, the course .of
events does not seem to have been nearly so satisfactory, for the
disease steadily progressed to a fatal termination, and the patients
had not even the satisfaction of a respite, or the hope of recovery
engendered by the knowledge that the malignant disease had been
removed ; moreover, in two cases the patients were well after some
years.
Sarcoma of the gall-bladder is much less common than carcinoma,
but it is occasionally found. Musser collected three cases of
sarcoma, and Rolleston (Clinical Journal, April 7th, 1897) has
reported another, which on examination was found to be a case of
spindle-celled sarcoma. If recognised in time, removal might be
possible.
Simple groicths in the gall-bladder are as a rule not of great
clinical importance, except as precursors of malignant disease,
though I have removed the gall-bladder successfully on two occa-
sions for simple adenoma.
A. W. MAYO-ROBSON.
EEFEKENCE.
Boston Med. and Surg. Journ., 1889, CXXL, p. 581.
7*3
TUMOURS OF THE BILE DUCTS.
Cystic Tumours. Tumours of the bile ducts, per se, only occa-
sionally form a projection so large as to be distinguished through the
abdominal walls. A tumour is, however, in some cases present
sooner or later on account of the obstruction in the ducts and
secondary distension of the gall-bladder. The common duct has
been found dilated to such a size as to form a cystic tumour, pre-
senting all the characteristics of a distended gall-bladder, the gall-
bladder itself being atrophied.
I have had a personal operative experience of three cases. Tn
one the operation of choledochostomy was performed after chole-
lithotrity had been done, the patient making an excellent recovery ;
in the other choledochenterostomy after cholecystectomy, the
patient also doing well. In the third case, after removing the gall
bladder, I short-circuited the tumour formed by the distended
common bile duct into the duodenum. The patient, a lady of
twenty-eight, made a good recovery and has remained well for seven
years.
Simple drainage and the establishment of a biliary fistula has
been almost always fatal in similar cases reported by Terrier and
others.
Solid Tumours of the bile ducts may be simple or malignant.
Simple tumour is rare, though several have been reported,
and in one case I was able to remove an adenoma of the cystic
duct.
Primary malignant disease of the bile ducts is almost invariably
fatal, as might be expected from their histological structure,
columnar-celled carcinoma. Musser collected eighteen cases, and
found all of them to be formed by cylindrical-celled carcinoma ;
while out of other sixteen collected by Rolleston, fourteen showed
similar histological characters, and two were cases of encephaloid
cancer. That the growth may in the first instance be a papilloma,
subsequently assuming malignancy, is suggested by the fact that
the tumour usually projects into the lumen of the canal as a
villous-like mass, while at the same time the submucous tissue is
infiltrated to a greater or less extent.
The tumour is most frequently situated in the common duct
Tumours of the Bile Ducts.
towards its lower end ; but the cystic or hepatic ducts may be first
affected. In Musser's eighteen cases the hepatic ducts were alone
involved three times, the cystic and hepatic ducts once, and the
common duct fourteen times. Rolleston reported seventeen cases,
and in these the common duct alone was the seat of the tumour on
fifteen occasions (the lower end of the duct being involved ten
times) and the cystic duct twice ; but in one of the latter cases
there was also an apparently distinct growth at the lower end of the
common duct.
If discovered sufficiently early, removal of the tumour may be
attempted, and has in fact been carried out by Halstead, Mayo and
Moynihan, though the relief was only for a short time.
In the cases I have seen the disease had advanced too far for
radical treatment, though relief to the jaundice was given by the
performance of cholecyst-enterostomy when the growth involved the
common duct.
Cancer of the Ampulla of Vater. This condition was probably first
described by McNeal in 1835. 1
BILE Ducr
OF S/tHWX/Nt
FIG. 1.
The growth may arise in the mucous membrane covering the
duodenal surface of the biliary papilla, in the mucous membrane of
the ampulla of Vater, at the termination of the common bile duct and
at the termination of Wirsung's duct. The accompanying diagram
illustrates these distinctions.
Confusion may also arise between carcinoma of the head of the
pancreas and primary carcinoma of the ampulla Vateri. Carcinoma
of the pancreas, however, is spheroidal-celled, while carcinoma of
the ampulla of Vater is columnar-celled. Growth may also extend
to the ampulla of Vater from the termination of the common bile
duct or from Wirsung's duct. The treatment of this condition is
merely palliative by the performance of cholecyst-enterostomy, which
Tumours of the Bile Ducts. 715
by establishing another route for the bile entering the intestine
relieves the most distressing symptoms due to jaundice.
A. W. MAYO ROBSON.
EEFEKENCE.
1 In the North American Archiv., Baltimore, and was later drawn attention
to by Stokes in 1846 (Dublin Quart. Journ. of Med. Sci., 1846, N. S., II.,
p. 505). More recently the subject has been fully dealt with by M. Hanot
(Archiv. Gen. de Mcd., Paris, 1896), M. Durand-Fardel (La Presse Medicale,
1896, VIII 6 , Ser. VI., p. 547), M. Kenduand H. D. Eolleston (Medical Chronicle,
1896, N. S., IV., p. 241, and Lancet, 1901, I., p. 467), who in a most instructive
paper on the subject of carcinoma of the ampulla of Vater, draw attention
to the varieties of malignant, growth which may be met with in this region.
yi6
INJURIES AND DISEASES OF THE PANCREAS.
INJURIES OF THE PANCREAS.
INJURIES of the pancreas for operative treatment may be divided
into (1) lacerations due to direct violence, (2) bullet wounds,
(3) penetrating wounds and stabs.
The treatment at first will be directed to the shock and collapse
which usually accompany the accident, but as soon as reaction has
been established the question of operative interference will arise. If
there are signs of haemorrhage, the abdomen must be opened and
an attempt made to secure the bleeding points. If a laceration of
the gland is found, deep and superficial sutures must be applied,
but care should be taken to avoid including Wirsung's duct.
In the treatment of gunshot injuries and stab wounds, if the
patient is in a position where operation can be efficiently under-
taken, the earlier it is carried out the better.
Any bleeding points should be secured, and a careful but rapid
search made for injury to the stomach, intestine, liver, etc. The
wound of the pancreas may be sutured, but if there is much
laceration it may be necessary to re-sect a portion of the gland and
unite the clean-cut edges by sutures. Care must be taken to avoid
the main duct, the superior mesenteric artery and the portal vein.
Complete disorganisation of the gland can only be treated by plug-
ging and drainage, for it is practically impossible to remove it, and
the attempt is not justifiable on physiological grounds. When
suture is possible drainage should always be adopted, for there is
invariably a certain amount of leakage, and if an exit is not pro-
vided for the exuding secretion local disturbances and peritonitis
may result. It is noteworthy that in two cases where an injury of
the pancreas was sutured, but no drainage was provided, a localised
destruction of tissue was found post-mortem. Drainage has usually
been provided through the abdominal wound, but a posterior open-
ing, such as Jephson adopted in his case, and which was also carried
out by me in another instance, is probably more efficient. It is
frequently stated that wounds of the pancreas are almost always
fatal, but this is not necessarily the case if suitable operative
measures are quickly undertaken. Of the twenty-one cases of injury
of the pancreas due to gunshot wounds of which I have found records
Inflammatory Affections of the Pancreas. 717
fifteen were operated on, and nine of these recovered (Brarnann
two, Hahn, Nini, Borchardt, Slavsky, Jephson, Otis and Becker).
Of the six in which death occurred the injury of the pancreas was
not discovered in three, so that in nine out of twelve instances it
may be considered that the operation saved the patient's life, for all
but one of the cases in which operation was not resorted to died.
A. W. MAYO-ROBSON.
7 i8
ACUTE PANCREATITIS.
THE pain at the onset is so acute as to necessitate the administra-
tion of morphine, and the collapse will probably demand stimulants,
which, on account of the associated vomiting, may have to be given
by enema. In the early stages the symptoms may be so indefi-
nite that the indications for surgical treatment are often not clear
enough to demand immediate operation ; but as soon as acute
pancreatitis is suspected, the surgeon must not wait until collapse
has passed off, as that may be dependent on septic absorption, which
can only be relieved by operation. The simulation of intestinal
obstruction will probably lead to efforts to secure an evacuation of
the bowels and relief to the distension. Just as in perforative or
gangrenous appendicitis an early evacuation of the septic matter
is necessary to recovery, so in this equally lethal affection an early
exploration through the middle line above the umbilicus is indicated,
in order, if possible, to relieve tension, to evacuate septic material,
to secure free drainage, and to arrest the haemorrhage which leads
to disintegration and necrosis of the pancreas. The after-treat-
ment will be chiefly diracted to combating shock and keeping up
the strength until the materies morbi, both local and general, can
be thrown off. Even if no pus is found, no harm should accrue
from such an exploration, which can be made in a few minutes
through an incision in the middle line above the umbilicus.
After establishing the diagnosis by the discovery of a swelling in
the region of the pancreas, with effusion of blood and associated
with fat necrosis, a posterior incision in the left costo-vertebral
angle will sometimes enable the diseased organ to be very freely
drained for the evacuation of pus and gangrenous material without
risk to the general peritoneal cavity, and with little danger of
retained septic matter, as the drainage will be a dependent one.
If, however, the inflammatory collection in the tensely distended
and inflamed gland is directly incised through the anterior
abdominal wound, gauze packing and gauze drainage may usually
be relied on to prevent general infection of the peritoneum. If there
are signs of an obstructed common bile duct, the gall-bladder should
be drained, and if gall-stones are discovered they should be removed,
if this can be done without seriously adding to the length of the
operation ; otherwise they may be left and removed on a subsequent
Acute Pancreatitis. 719
occasion if free drainage of the bile passages can be secured. I have
had six cases of acute pancreatitis under my care, and have operated
on four, of which two recovered. Of the two cases where operation
was not consented to, and where medical treatment alone was
carried out, death occurred in the first case on the third day, and in
the second case after a week's illness, attended in both with great
pain and incessant vomiting.
A. W. MAYO-ROBSON.
720
SUBACUTE PANCREATITIS.
THE subacute form of pancreatitis is more amenable to treatment
as the indications are so much more definite, and there is more time
for careful consideration. Though it has usually been attacked
only when an abscess has formed and is manifestly making its way
to the surface, yet there is no reason why in some cases surgical
treatment should not be adopted at an earlier stage. As in the
acute condition, morphine may be required to relieve the pain and
to lessen the collapse. Distension, if present, demands attention,
and may have to be relieved by lavage of the stomach and turpen-
tine enemata, or by the administration of calomel by the mouth.
Calomel is also of benefit as an intestinal antiseptic, for which
purpose it may be given in small repeated doses followed by a
saline aperient. As soon as the constipation is relieved, diarrhoea
is apt to supervene, when salol and bismuth, with small doses of
opium, may be given. If surgical treatment is decided on, a median
incision above the umbilicus will enable the operator to palpate
the pancreas and to locate any incipient collection of pus, which, if
practicable, should then be evacuated by a posterior incision in
the left or right costo-vertebral angle. If the posterior incision is
thought impracticable, the collection of pus may be removed by
aspiration and the cavity opened and packed with gauze, which
may be brought forwards through a large rubber tube, which
procedure will, in the course of twenty-four to forty-eight hours,
establish a track isolated from the general peritoneal cavity.
In abscess of the pancreas, which usually assumes the form of
subacute pancreatitis, and which we must distinguish from the
acute suppurative pancreatitis where the pus is diffused through
the gland, or where the abscesses are small and multiple, the
suppurating process is limited by a pouring out of lymph, so that
should the patient survive the initial more acute stage and a
discovery of the pus-containing cavity is made, the condition is one
decidedly amenable to treatment by drainage. The anatomical
relation will readily explain the course along which the pus burrows
should it burst through its lymph barriers ; for instance, in one
case an abscess formed and was opened in the right loin of a young
man, aged twenty-four years, that had been mistaken for a perirenal
abscess, yet the kidney was quite healthy and the grumous pus had
Subacute Pancreatitis. 721
come from the pancreas and passed behind the peritoneum covering
the second part of the duodenum : the patient recovered completely.
In another case an abscess was opened in the left iliac region that
had apparently started from the body of the pancreas, and which
had burrowed in the same way behind the peritoneum. The
patient recovered from the operation, but developed trouble in the
left side of the thorax and died suddenly several weeks later. In
one case the abscess was subphrenic. In another, where the
symptoms were rather acute and the patient was extremely ill, pus
was discovered between the liver and the stomach, and although
drainage was apparently complete, the patient succumbed in a few
days to exhaustion due to the septic process that had been initiated
before the abscess was opened. In two other cases the sequence of
suppurative catarrh, abscesses of the pancreas were successfully
drained through a tube in the common bile duct after removing the
gall-stones which had obstructed Wirsung's duct. In one of these
cases the patient, a woman, aged seventy-two, recovered completely.
The other, a man, aged forty, recovered from the operation, but
three months afterwards died from exhaustion, and at the necropsy
the empty abscess cavity was discovered in the head of the
pancreas, the rest of the gland being affected with chronic
interstitial inflammation. In one case in a man, aged thirty-five
years a pancreatic abscess burst into the stomach, setting up
acute gastritis, the condition having been proved by an exploratory
operation. It was treated by gastro-enterostomy to drain away the
foul stomach contents. The patient is now quite well, eight years
later. In another case, in a married woman aged twenty-six, the
abscess apparently burst into the bowel, and though recovery was
tardy, she ultimately got well without operation. The diagnosis
was made from the symptoms and by an examination of the
swollen pancreas under an anaesthetic and subsequently by the
presence of a pancreatic reaction in the urine. It is important in
these cases to see that the cause is removed, if that be possible for
instance, gall-stones or pancreatic calculi so that if recovery occurs
there may be no fear of relapse.
It will thus be seen that out of eight cases of abscess of the
pancreas, seven were operated on, with recovery from operation in
five, though in one of the cases the relief was only for a few weeks
and in another for a few months.
When inflammation of the pancreas has ended in abscess, chronic
interstitial pancreatitis will also probably be present, as was shown
at the necropsy of one case that died some months subsequently.
It is possible that in some cases the interstitial change may be
S.T. VOL. n. 46
722 Subacute Pancreatitis.
local, though in others it will be general, and may then lead to
atrophy of the gland and to glycosuria.
A search through literature reveals a considerable number of
pyaemic abscesses of the pancreas, but those resulting from subacute
pancreatitis have been rarely recorded. Besides seven operations
for abscess of the pancreas with two deaths above referred to, there
have been seven others recorded with three deaths. Thus, of fourteen
cases five died, giving a mortality of 35'6 per cent.
A. W. MAYO-ROBSON.
7 2 3
CHRONIC PANCREATITIS.
BEFORE considering either the "medical or surgical treatment of
pancreatitis the importance of preventive treatment must be insisted
on by attention to the causes, some of which, such as gall-stones, are
removable by operation in the very early stages with a very small risk,
certainly not more than 1 per cent, in skilled hands. Duodenal
catarrh as a cause of pancreatic catarrh and of interstitial pan-
creatitis is remediable by medical treatment ; and duodenal ulcer,
another cause, if not remedied by careful and thorough general
treatment, can be cured by gastro-enterostomy with a very small risk.
If after a fair trial of general treatment, care in diet, wet packs to
the epigastrium, rest, and mild mercurial purges, not too long
continued, the symptoms persist and the signs of failure in
pancreatic digestion and metabolism are manifesting themselves,
the question of surgical treatment should be seriously considered,
especially when the disease is associated with jaundice, for the
condition is one that, if not relieved early, will certainly lead to
serious degeneration of both the liver and pancreas, and become
dangerous to life in several ways.
Rational treatment should aim at the cause, whether that be gall-
stones, pancreatic calculi, duodenal catarrh, duodenal or gastric ulcer,
alcoholism or syphilis.
In operating for chronic pancreatitis, when medical treatment has
failed to relieve, the surgeon must be prepared to do a thorough
operation so as to expose the whole length of the common bile duct
;is well as the head of the pancreas. He will then be able to remove
the cause, should it prove to be a gall-stone, or a pancreatic calculus,
or any other removable condition. In the absence of some obvious
removable cause, it is advisable to secure efficient drainage of the
infected bile duct and pancreatic duct, either by cholecystotomy or
cholecyst-enterostomy, preferably the latter. Where the pancreatic
disease is dependent on duodenal catarrh associated with ulcer of
the duodenum, it may be advisable at the same time that the bile
passages are drained to perform also a gastro-enterostomy in order
to cure the original cause of the disease. Experience has taught
that if the cause can be removed at an early stage an absolute cure
is possible ; and though restoration of the damaged gland in more
advanced cases cannot always be promised, yet the arrest of the
morbid process may be looked for, and the remaining portion of the
pancreas will be able to carry on the metabolic and even, if in-
completely, the digestive functions of the gland.
A. W. MAYO-ROBSON.
46-2
724
PANCREATIC CALCULI.
RELIEF to pain may be given by sedatives, and other treatment
must be adopted as occasion arises, but as soon as pancreatic stones
can be diagnosed, they should be removed, as destruction of the
pancreas is otherwise certain, and it is quite clear that medical
treatment can do no real good in these cases.
Surgical treatment has until quite recently been merely palliative,
but fortunately it now offers a reasonable hope of cure.
Operation of Pancreo-lithotomy. Eor the purpose of
removing calculi from the pancreas an incision 1 inch to the right
of the middle line above the umbilicus will be found the most
convenient, as the fibres of the right rectus can be split, or better,
the rectus drawn outwards, and the incision lengthened upwards
and downwards without necessarily weakening the abdominal wall.
A sand-bag under the lumbar spine will bring the gland several
inches nearer the surface. If the opening of the duct of Wirsung
has to be explored, the second part of the duodenum may be incised
and the papilla common to the bile duct and pancreatic duct laid
open, when the edge of the opened diverticulum of Vater can be
seized with small catch forceps and drawn to the surface ; a probe or
fine forceps can then be readily passed into Wirsung's duct and the
concretions removed. If the .calculi are more deeply placed in the
ducts, the pancreas may be exposed either through the gastro-
hepatic omentum by drawing the stomach downwards, or by lifting
the stomach it may be reached through a slit in the omentum or by
raising the colon, by a slit in the transverse meso-colon ; or by
freeing the duodenum from the parietes the back of the pancreas may
be readily reached. The calculi may be then cut down on and
extracted by scoop or forceps. Any bleeding must be arrested by
ligatures. The duct can be sutured and the incision in the gland
must be brought together by buried sutures, the peritoneal covering
being coapted by a continuous suture. If leakage is feared, a gauze
drain may be applied ; but the position may be difficult for this,
and if it has to be done, the gauze must be surrounded by a rubber
drainage tube and brought through it to the surface. In a case of
pancreo-lithotomy in which I removed a calculus from the centre
of the pancreas, the closure of the gland was so secure as not to
require gauze packing, and the result justified its not being used.
Pancreatic Calculi. 725
When the duodenum is opened it must be closed in the usual way
by a muco-muscular and serous suture, the latter being of fine
cellulose thread. The incised papilla need not be sutured. If a
calculus is felt in the head of the gland but not in the duct of
Wirsung, it may be reached by incising the peritoneum over the
duodenum and separating it gently from the head of the pancreas,
or if more deeply placed near the back of the gland, the reflection of
peritoneum from the duodenum to the abdominal wall may be
incised and the duodenum may then be displaced inwards, when
the back of the pancreas will be exposed and if thought advisable it
may be incised and treated as in the incision from the front.
A. W. MAYO-ROBSON.
726
PANCREATIC CYSTS.
IT is quite clear that medical treatment can be of no avail in the
case of pancreatic cysts, and that surgical treatment alone is
available for relief or cure.
Aspiration and other forms of tapping are inadequate and
ineffectual methods, which are attended with more danger than is
the operation of incision and drainage. They are therefore not to
be recommended even for diagnostic purposes. Occasionally com-
plete extirpation of the cyst may be performed as in a case that
came under my care where the tumour returned a few months after
it had been apparently successfully treated by drainage, and in
another case recently operated on where haemorrhage at the time
of operation caused some anxiety, though the ultimate issue was
good. But the greater difficulty in performing excision, its imprac-
ticability in certain cases and the greater mortality attending it, as
compared with the operation of incision and drainage, make it quite
clear that drainage should always have a fair trial unless the
circumstances prove to be very exceptional, as, for instance, in the
case of a cyst of the tail of the pancreas, or in the case of a
pedunculated cyst.
As to the situation for drainage, that will depend on circum-
stances. The tumour will usually be attacked most readily from
the front, at a point where it very nearly reaches the surface.
Occasionally, however, it may be drained from the loin.
Fistula does not, as a rule, follow the drainage of pancreatic
cysts, but in some cases a small fistula may persist and may go
on for years without hurt to the patient and with very [little
discomfort.
The following is a description of the operation usually per-
formed : An incision is made through the parietes opposite the njost
prominent part of the cyst. When the peritoneum is opened, the
finger can be employed to ascertain the relations of the cyst and its
attachments. If the stomach is in front of the cyst, it will be
better to displace that viscus upwards and to make a slit through
the great omerjtum in order to expose the cyst wall ; if the colon is
in front, it may be displaced downwards. But no rule can be
formulated, as the cyst must be reached in the most convenient way,
and that can be ascertained only when the abdomen is open. By
Pancreatic Cysts. 727
means of an aspirator the fluid is then drawn off and an opening
made in the cyst sufficiently large -to allow of a drainage tube being
inserted. The tube may then be fixed to the margin of the incision
in the cyst by a single catgut suture, and if the opening into the
cyst is surrounded b}- a purse-string suture which can be tightened
around the tube, all fear of leakage from the cyst into the
peritoneal cavity is avoided. Any vessels coursing over the cyst
must be avoided, but should an artery or vein be pricked it must
be caught between pressure forceps and ligatured.
The edge of the cyst may then be fixed to the aponeurosis by
three or four sutures, but it is better not to attach it to the skin.
The abdomen is then closed, and if the tube is sufficiently long it
will readily drain into a bottle containing some antiseptic fluid. If,
on exploration, the cyst is found to have a narrow attachment to
the pancreas and the adhesions are not too extensive, it may
possibly be shelled out, or the pedicle may be ligatured, but this is
rarely feasible.
Some surgeons have suggested the desirability of fixing the cyst
to the surface and only opening it after a few days, when adhesions
have formed, but the operation <i deux temps seems to be quite
unnecessary.
Statistics. In the cases that I have personally operated on, two
cysts were enucleated, recovery following ; drainage was carried
out in ten cases of true cyst, recovery following in nine, whereas of
two pseudo-cysts, one due to traumatic heemorrhagic pancreatitis
and the other to necrotic pancreatitis, one recovered.
Out of the 160 cases of operation recorded by others there were 140
recoveries ; in four cases the ultimate issue was doubtful ; in eight
out of the 140 reported recoveries after operation the patients
died subsequently one from diabetes four months later, one from
haemorrhage one and a half years later, one from concomitant
peritonitis seven weeks later, one from zymotic fever a few weeks
later, and three, from causes not stated, a few weeks later. Death
is recorded as the result of operation in twenty cases. In five of
these the cause of death and the time after operation are not given.
One patient died in collapse, one died before operation could be
completed (the next day), one died from " ileus," one died eighteen
days after operation (cause not stated), two died from shock, one
died from gangrene of the pancreas, and eight died at an interval
not stated, one after ninety-six hours, one after six days, one after
an exploratory incision, two after two days, one on the eighth day,
and one on the second day. In 138 cases incision and drainage
were performed, with sixteen deaths, equal to a mortality of 11*6 per
728 Pancreatic Cysts.
cent. In fifteen excision was performed with three deaths, equal to
a mortality of 20 per cent. In seven partial excision was done, with
one death, equal to a mortality of 14'3 per cent.
The evidence is clearly in favour of drainage, but the mortality
should be reduced by at least one-half.
A. W. MAYO-ROBSON.
729
CANCER OF THE PANCREAS.
MEDICAL treatment must be purely symptomatic ; morphia, if
needed, for the relief of pain, calcium chloride for the prevention
of haemorrhage, pancreatic extract to assist digestion and other
remedies for symptoms as they arise. Surgical treatment is not
very hopeful and has usually been undertaken under the idea that
the cause of the jaundice might be a removable one, or that
drainage of the bile ducts might afford relief to the jaundice, but if
the disease has involved the head of the pancreas treatment can
only be palliative.
Treatment may be radical or palliative. Ruggi, of Bologna,
removed through the loin a cancer of the pancreas weighing
23 oz. It was probably growing from the tail of the gland.
Complete recovery followed, and the patient was well for three
months, after which secondary disease developed and the patient
died at the end of six months. Cades's was the second successful
case, in 1895, a tumour of the tail of the pancreas of the size of a
child's head being removed. Terrier, in 1892, removed a tumour
weighing 5 lb., but lost his patient. Of seventeen, operations
for removal of solid tumours of the pancreas, nine recovered
from operation, which, considering the difficulty of the operation
and the depth of the organ to be operated on, is better than
one would have expected. Where the after-histories have been
recorded, the disease recurred within a few months in all the
malignant cases. Successful pancreatectomies, it will be seen, are
exceptional and are feasible only when the growth is not involving
the head of the gland ; they, however, clearly demonstrate that a
tumour of the body or of the tail of the pancreas may be removed
with equal chance of recovery, and should the disease be primary
and no secondary growths or glandular involvement have occurred,
great prolongation of life is quite possible.
The palliative operation of cholecyst-enterostomy for the relief of
jaundice in cancer of the head of the pancreas is well worth trying,
if the patient is seen at a fairly early stage of the disease. I have
operated on over thirty of these cases. Many of them were too far
advanced to hope for anything more than merely temporary relief,
but in some of the less advanced cases life has been prolonged in
comfort for many months or even into the second year.
A. W. MAYO-ROBSON.
730
AFFECTIONS AND DISEASES OF THE
KIDNEY AND URETER.
URINARY DISORDERS.
ACETONURIA.
ACETONURIA is a symptom of a profound disturbance of metabolism
which occurs as a complication of a number of morbid states, and
which results in the formation of /3-oxybutyric acid, often in large
amounts, by the breaking down of fats and proteins. I^rom
/3-oxybutyric acid aceto-acetic acid is readily formed, and from
aceto-acetic acid acetone, as the respective formulae show :
CH S CH 8 CH 8
CHOH CO CO
CH 2 CH 2 CH 8
'COOH COOH
j8-oxybutyric Aceto-acetic Acetone,
acid. acid.
No simple clinical test is available for the detection of /3-oxy-
butyric acid, but aceto-acetic acid yields the familiar ferric chloride
reaction of Gerhardt, and acetone is readily detected by the nitro-
prusside tests of Legal and Eothera.
Mere withdrawal of carbohydrates from the diet of a healthy
man, and d fortiori abstinence from all food, suffices to cause
acetonuria. Of morbid states diabetes is that in which the
metabolic disturbances which underlie acetonuria play the most
conspicuous part. As regards carbohydrates the diabetic subject
may be said to starve in the midst of plenty, for although his
blood is rich in sugar, he has lost, to a greater or less extent, his
power of utilising it. The bodies of the acetone group are believed
to play the leading role in the causation of diabetic coma.
Persistent vomiting, from whatever cause, also tends to induce
acetonuria, to employ this term in the widest sense as including the
excretion of all the members of the acetone group, and the condition
is seen, in a very pronounced form, in the rare affection of children
known as cyclic vomiting. There can be no question that acetonuria,
Acetonuria. 731
and the acidosis of which it is a symptom, are much more readily
induced in children than in adults. The aeetonuria of delayed
chloroform poisoning may also be due to vomiting, which is a leading
symptom. The fatty condition of the liver which is met with alike in
cyclic vomiting, in delayed chloroform poisoning and in diabetes, may
also be ascribed to excessive mobilisation of fats. However, it is
difficult to reconcile clinical experience with the view that, in the
conditions under consideration, the carbohydrate starvation which
results from persistent vomiting is the sole cause of the acetonsemia,
for in some cases there is much acetone and aceto-acetic acid in the
urine at an early stage of the attack, whereas in some other cases
in which there is frequent and continuous vomiting acetonuria
is absent. Nor is it easy to explain on such a theory the
frequent occurrence of acetonuria in children suffering from
broncho-pneumonia.
If the primary causal condition is itself amenable to treatment
the most effectual means of coping with the acetoneemia will be
the removal of its cause, but this is not always possible ; and
acidosis, in itself, is so serious a trouble, and in its extreme forms so
threatening to life, as to call for special therapeutic measures. We
are compelled to treat the disease within the disease.
In discussing the measures to be employed it must be borne in
mind that the bodies of the acetone group have little specific toxic
action, and that the observed effects depend upon the acid pro-
perties of the more important members of the group. For their
neutralisation the fixed alkalies tend to be withdrawn from the
blood and tissues. Nature herself makes an attempt to combat
the mischief, for in carnivorous animals and in man a protective
mechanism has been evolved, and some of the ammonia which
normally goes to the formation of urea is intercepted and employed
to neutralise the abnormal acids, and thus the fixed bases are spared
to some extent. In vegetivora, on the other hand, which, owing to
the nature of their diet, are little liable to acidosis, this protective
mechanism is not developed. Hence it comes about that, in man,
when acetonuria is present the excretion of ammonia in the urine
is unusually large and varies according to the quantities of acid to
be neutralised, whereas when fixed alkalies are given by the mouth
the output of ammonia is thereby diminished, there being less call
upon the protective mechanism. Conversely in any given case, a
decrease of the excreted ammonia after the administration of a
fixed alkali has been accepted as evidence that the previous excess
of ammonia in the urine was due to acidosis.
The principles upon which the treatment of acetonaemia is based
732 , Acetonuria.
may be summed up as follows : If any drug is being taken which
is capable of provoking the formation of the acetone bodies, such
as a salicylate in large doses, its administration should at once be
stopped. If there is persistent vomiting our treatment should be
mainly directed to its arrest. If there is reason to think that
carbohydrate starvation is concerned in the causation of the
condition we should strive to supply the need for this class of food-
stuffs ; and lastly, fixed alkalies should be given with a view to
controlling the drain upon the fixed alkalies of the blood and
tissues.
In cases of diabetes, in some of which such acidosis occurs in its
most pronounced form, we are in a less favourable position for its
treatment than when the underlying cause is a temporary one. In
such cases the bodies of the. acetone group are being formed in fresh
quantities as fast as they are neutralised, whereas in some toxic
conditions their formation may be practically at an end before treat-
ment is begun, and all that is required is to neutralise the acids
already in circulation.
The treatment of diabetes and of its complications is discussed
elsewhere in this work, and it will suffice to point out, in this place,
that it is easier to bring about acetonaemia by a rapid reduction of
the carbohydrates of the diet than to control it by relaxation of
diet when danger threatens.
Sodium bicarbonate is the alkaline drug most often employed in
the treatment of acidosis, and it has the advantage of containing
a base which is comparatively innocuous, an important consideration
when large doses are required. The bicarbonate may be adminis-
tered in large and frequently repeated doses, according to the
severity of the case. If taken for long the necessary doses may
upset the stomach, but they are usually well tolerated, and the
difficulty encountered in rendering the urine alkaline in severe
cases bears eloquent testimony to the quantities of acid which call
for neutralisation.
In non-diabetic cases, in which vomiting is a prominent symptom,
it may be necessary to give sodium bicarbonate by the rectum, or
even to inject a dilute solution intravenously. In such cases sugar
may also be administered by the mouth or by the bowel. It must
be remembered that no inverting ferment is present in the lower
bowel, and it is therefore necessary, in rectal administration, to
administer a monosaccharid such as glucose, since disaccharids
such as cane-sugar and lactose cannot be dealt with.
In cases of diabetes the question whether dietary restrictions
should be relaxed when acidosis threatens, and if so to what extent,
Albumosuria and Peptonuria. 733
is one of no small difficulty, and upon which opinions differ. In
some cases laevulose is comparatively well dealt with, and may
prove a valuable aid in the relief of carbohydrate starvation. In
spite of certain theoretical difficulties, the fact remains that some,
but only some, diabetic patients from whose urine sugar has dis-
appeared under a strict dietary regimen, can take considerable doses
of laevulose without passing sugar. That the Isevulose is actually
utilised in such cases is shown by its effect upon the respiratory
quotient.
Lastly, as Otto Neubauer has suggested, alcohol, with its high
calorie value, may lend material aid in restricting the breaking
down of the tissues from which the acetone bodies are formed, and
so counteract to some extent the tendency to acidosis.
ALBUMINURIA.
The excretion of albumin in the urine, although one of the most
important of symptoms, and often a valuable guide to treatment,
in itself hardly calls for therapeutic measures. Even in cases of
parenchymatous nephritis, in which the output of albumin in the
urine is greatest and may continue over long periods, the loss of
protein involved is of quite subsidiary importance, as compared with
the failure of the excretory functions of the kidneys by which it is
accompanied. From time to time drugs, such as rosaniline and the
salts of strontium, have been recommended as tending to diminish
the loss of albumin, but their use has not been attended with any
conspicuous success.
On the other hand, Sir Almroth Wright has shown that the
administration of calcium lactate is capable of arresting the
albuminuria in cases of the so-called functional kind, in which, as
he has found, the coagulability of the blood is lowered and clotting
is delayed. However, this is important rather as affording a test
for the differentiation of functional albuminuria from that due to
organic lesions of the kidneys than as a method of treatment.
The calcium lactate may be administered in a dose of 60 gr., or
in a few doses of 20 gr. each, and if the case is functional, the
albumin should disappear from the urine in a few hours or a few
days. In cases of nephritis, on the other hand, the albuminuria is
not affected by the taking of the drug.
ALBUMOSURIA AND PEPTONURIA.
The excretion of proto- and deutero-albumoses, often spoken of
as peptonuria, is often associated with albuminuria, from which it has
a quite different significance, for it points to morbid conditions behind
734 Cystinuria.
the kidneys. Albumosuria appears to be an indication of abnormal
protein breakdown, such as occurs during involution of the uterus
or the resolution of a pneumonic lung. It does not in itself call for
treatment, nor does it afford any clear indication for the treatment
of conditions to which it is due.
ALKAPTONURIA.
This very rare anomaly of protein metabolism is usually present
from birth, and persists through life. It is little amenable to and
makes no strong call for treatment. It is becoming evident that in
later life alkaptonuric subjects are very liable to develop the
peculiar pigmentation of the cartilages, and in some cases of
surface structures also, to which Virchow gave the name of
ochronosis, and it is probable that the chronic osteo-arthritic
changes which have repeatedly been met with in the subjects of
ochronosis, are causally related thereto. These are the only
pathological results which can be assigned to alkaptonuria.
The output of homogentisic acid, the excretion of which is the
characteristic feature of the condition, can be considerably reduced
by restriction of the protein intake, but even during fasting or on
a protein-free diet it only falls to about half its normal amount.
The lifelong imposition of a diet very poor in protein is certainly
not desirable, merely in the hope that by such a diet the tendency
to develop ochronosis or even a chronic joint trouble in later life
may be lessened to some extent.
If, however, as occasionally happens, there is a complaint of
dysuria, temporary restriction of protein foods may be thought
desirable.
CHYLURIA (NON-PARASITIC).
Of the pathology of that variety of chyluria which is not due
to the Filaria sanguinis hominis little is known, but it may be
presumed that in some way, which need not be the same way in all
cases, a communication has been established, as in the parasitic cases,
between the lymphatic system and the urinary tract. Complete
rest will, in some instances, bring about an arrest of the chyluria,
and sometimes over so long a period that one is tempted to hope
that the communication has closed and that a permanent cure has
been brought about. However, resumption of an active life is apt
to be followed by a relapse.
CYSTINURIA.
Cystinuria is one of the conditions which leads to calculus forma-
tion, and the great liability of its victims to this accident gives to
Haematoporphyrinuria. 735
this anomaly a very real clinical importance, in spite of its extreme
rarity.
It affords strong evidence of ' the working of other factors
besides the mere excretion of a sparingly soluble compound, in the
causation of calculus formation, for whereas one cystinuric patient
will produce a constant succession of stones, in other cases, and even
in the same case at a different period, cystin may be excreted in
equal quantities for years and yet no calculi be formed.
Cystinuria is an error of protein metabolism which leads to the
excretion of part of the cystin fraction of the food and tissue proteins
unchanged. It is probably congenital in most cases and persistent
throughout life, but in some cases appears to be ternpdrary. The
mere fact that crystals of cystin cease to be deposited from the urine
must not be taken as proof that the excretion of that substance has
ceased. As an inborn anomaly it is little amenable to treatment,
and its cessation in some cases cannot be ascribed to any therapeutic
measures adopted.
Some have thought that the administration of alkalies has proved
beneficial, by reducing the acidity of the urine, and so the readiness
with which cystin is deposited from it.
One fact definitely established, by the work of Alsberg and Folin,
and of Wolf and Shaffer, is that the output of cystin is dependent,
to some extent, upon the intake of protein, and their results point
to the desirability of prescribing a diet comparatively poor in protein
constituents for sufferers from the complaint. However, to bring
about a conspicuous diminution of the cystin excreted it is necessary
to put the patient upon a diet which is almost protein free, and such
as could hardly be conformed to over long periods.
It must be confessed that, up to the present, we have at our
disposal no efficient means of combating this metabolic error.
HAEMATOPORPHYRINURIA.
The name " haematoporphyrinuria " is applied to the excretion of
urine of various tints, from that of tawny port wine to almost
complete blackness, and which is shown by spectroscopic examina-
tion to contain considerable amounts of haematoporphyrin. The
colour of such urines is chiefly due to other less known abnormal
pigments which accompany the hsematoporphyrin.
In the great majority of cases, such haematoporphyrinuria
results from the administration of sulphonal or chemically allied
drags, usually in medicinal doses and over considerable periods.
Occasionally it occurs as a morbid symptom, apart from the taking
736 Haematuria.
of any such drug, and does not appear to have any very serious
import in such circumstances.
In the sulphonal cases, on the other hand, it is one of a group
of toxic symptoms of much gravity and which often usher in a
fatal ending. Of these symptoms vomiting and abdominal pain
are the most constant. Curiously enough, this condition is met
with almost exclusively in females. The development of haemato-
porphyrinuria is, in not a few cases, the earliest toxic symptom ; and
for practical purposes the excretion of red urine by a patient taking
sulphonal or its allies, even though it may not be possible to carry
out the necessary examination for haematoporphyrin, should be
regarded as a danger signal. The administration of the drug
should immediately be stopped, and sodium bicarbonate should be
given in large and frequently repeated doses. This treatment, with
an alkali, which was originally recommended by Franz Miiller,
appears to be of great value, and the writer's experience leads him
to believe that it not unfrequently averts a fatal ending. This
suggests that the condition is a form of acidosis, and the fact that
in some records of autopsies the liver has been found to be fatty,
as is the case in delayed chloroform poisoning with acetonuria,
lends support to this view of its pathology.
HAEMATURIA.
FEW symptoms of disease result from a greater variety of morbid
conditions than does haematuria. Among them are haemorrhagic
fevers and other haemorrhagic diseases, such as haemophilia and
scurvy, nephritis and local lesions situated in the kidneys or any
part of the urinary tract, including calculus formations, injuries to
the kidneys, bladder and urethra, and certain kinds of poisoning.
In some cases the loss of blood in the urine is so large that
treatment is imperatively demanded for its arrest, and when
possible such treatment will be directed to the cause to which
haematuria is due. The first desideratum is to ascertain if possible
in what part of the urinary tract the lesion is situated, for such
profuse haematuria usually has a local origin. For this purpose the
cystoscope is of very great service, since by its means it is possible
to ascertain whether the blood is derived from the bladder or
prostate, and if it has a higher source, whether it comes from one
ureter or both. If the source can be localised surgical measures
will, as a rule, be required. There remains a class of case in which
the cause of profuse haematuria remains obscure, or in which it is
due to some general disease little amenable to treatment, or again
in which the general condition of the patient, or doubt as to the
Lipuria. 737
integrity of the second kidney, is held to contra-indicate surgical
treatment.
In such cases we must endeavour to control the loss of blood by
the administration of styptic drugs, of which ergot is the most
commonly employed. In haemophilia or other conditions in which
coagulation of the blood is delayed the administration of calcium
lactate may be tried.
If, as is not unfrequently the case, the haematuria is brought on
by exertion or exercise, mere rest may prove a valuable therapeutic
measure.
INDICANURIA.
Indicanuria is a symptom which affords a measure of protein
decomposition in the alimentary canal under the influence of the
intestinal bacteria. The parent substance of the indol absorbed is
the tryptophane fraction of proteins. After absorption the indol
is oxidised to indoxyl, which is excreted in the urine, for the most
part in combination with sulphuric acid as an indoxyl sulphate, the
so-called urinary indican, and in small part as indoxyl glycuro-
nates.
Even in simple obstinate constipation the excretion of indican is
apt to be conspicuously above the normal, as also in any condi-
tion in which bacterial decomposition processes are abnormally
active.
Urine rich in indican is usually of normal tint, but in some
cases it is rendered brown by higher oxidation products of indol,
and, as the colour becomes much darker on exposure to air, such
indicanuria is liable to be mistaken for melanuria.
It is stated that when there is a collection of foatid pus in any
cavity of the body, such as a putrid empyema, indicanuria may
occur apart from intestinal decomposition. In a case of empyema
which the writer has observed, in which the foetid pus contained
bacillus coli as well as the pneumococcus, the indicanuria, which
was present, disappeared when the bowels were freely evacuated by
a dose of castor oil.
The treatment of indicanuria consists in the administration of
purgatives, and preferably of such as have an antiseptic action,
such as calomel.
LIPURIA.
By this is meant the excretion of fat in the urine as an isolated
symptom, and, apart from chyluria. Lipuria is chiefly seen after
fractures of bones and sometimes after the operation of osteotomy,
S.T. VOL. ii. 47
738 Lithuria.
the fat being presumably derived from the exposed bone marrow.
Again, lipuria may result from the administration of large
quantities of fat by the mouth, as when olive oil is freely given
in cases of cholelithiasis.
LITHURIA.
The term "lithuria " is a relic of an age of less exact knowledge,
which owes its survival to the difficulty of devising any euphonious
name which shall more correctly describe the phenomenon to which
it is applied, namely, the formation in the urine of sediments of .
amorphous urates, or of the familiar crystals of uric acid which
are modified in their tints and forms by included urinary pig-
ments.
Deposits of amorphous urates are met with in the urine of
sufferers from many diseases, and in certain circumstances in that
of healthy persons, especially in cold weather. As they form only
after the urine has been passed and has cooled to the temperature
of the air, they are only important as indicative of the presence of
conditions which favour the passing of the urates out of solution.
Such sediments must not be regarded as affording evidence of an
excessive output of uric acid, although such an excess in a given
specimen is one of the causes which favours their deposition. Such
an interpretation is very commonly put upon the uratic sediments
which are so commonly seen in the urine of gouty patients, but
elaborate researches have shown that the excretion of uric acid by
the gouty differs but little from that of healthy individuals, and that
only for brief periods immediately following acute attacks is there
any excessive output of that substance.
On the other hand, deposition of crystalline uric acid occurs, not
infrequently, within the urinary passages, and seeing that this
substance is one of the chief constituents of urinary calculi, such
a formation of crystals acquires importance. Even the presence of
the crystals as such may give rise to symptoms, and appears to be
one of the causes of hsematuria in infants.
However, such crystals may be passed in abundance and over
long periods by individuals who at no time develop calculi, whereas
the subjects of uric acid calculus formation may exhibit no special
liability to the deposition of crystals in their urine. There can be
no doubt that although the presence of one of the sparingly soluble
calculus-forming substances is a necessary condition of stone forma-
tion, and such materials are, of course, invariably present in the
urine, something more is required to determine concretion. This
Lithuria. 739
factor is almost certainly a catarrhal condition, to the production
of which the irritant action of the crystals may contribute. The
analogous formation of gallstones suggests the possibility or even
the probability of a bacterial origin of the catarrh.
Excess of uric acid is one, but only one, of the conditions which
favour the separation of uric acid crystals in urine. In some cases
of leukaemia in which the output of uric acid may greatly exceed
the normal limits, abundant crystalline deposits occur, but this
disease and thymus feeding are the only causes of such excessive
excretion, although a like phenomenon of minor degree is observed
in pneumonia and other morbid states. As a rule, the daily output
of uric acid by patients whose urine forms crystalline sediments is
not above, and may even be below, the average.
In a mixture so complex as the urine a variety of factors may
contribute to diminish the solubility of a particular constituent.
Among these the reaction holds an important place. From
alkaline or amphoteric urines uric acid crystals are not thrown
down, .whereas the addition of an acid determines their deposition
from any specimen. Concentration also plays a part, a relative
excess of uric acid having as potent an influence as an actual excess.
The nature of the salts present must also be taken into considera-
tion, and Kleniperer has shown that the essential yellow pigment of
urine, urochrome, has an inhibitory influence, so that the crystals
form more readily in specimens in which that pigment is but
scantily present. It is probable that in the future, when the
condition of calculus formation shall be better understood, we
may be able to control these, and possibly the good effects
obtained in the treatment of patients liable to stone or gravel by
certain mineral waters may be in no small measure due to their
effects upon the urinary tract. At present, however, our efforts are
chiefly directed to limiting, on the one hand, the excretion of the
peccant material, and, on the other hand, to bringing about the
conditions favourable to its being held in solution.
In the case of uric acid, a limitation of output can be effected
only by limiting the intake of its parent substances, the nucleo-
proteins and purin bodies of the diet. It is possible to allow the
patient to have a diet by no means poor in proteins, but in which
the nucleo-proteins and purin s shall be but sparingly present.
Thus, as Walker Hall points out, milk, butter, eggs and cheese
contain no purin nor purin-yielding substances, or quantities so
small that they may be neglected.
The various forms of meat do not differ widely in their purin
content, as the figures on the next page, given by Walker Hall, show :
472
740
Lithuria.
(Cod
I Plaice
I Halibut
1 Salmon
Mutton .
Veal
Pork
(Ribs
Beef | Sirloin
(Steak
Chicken .
Turkey .
Undried purins as
giimmes per kilo.
0-582
0-795
1-020
1-165
0-965
1-162
1-212
1-137
1-305
2-066
1-295
1-260
It will be noticed that the distinction so commonly drawn between
red and white meats finds no justification in their respective purin
contents. The glandular organs are comparatively rich, and thymus
gland, included as sweetbread, stands pre-eminent as a purin-rich
food, with 10'063 grammes of purin per kilogramme.
The general indications would seem to be to take meat somewhat
sparingly when a reduction of the uric acid is aimed at, to avoid
beef and especially beefsteak, and above all to avoid sweetbread.
It must be remembered, however, that the richness of a food in
purin substances may be counteracted to some extent by the fact
that it is as a rule partaken of but sparingly. Among vegetable
substances peas, beans, oatmeal, asparagus and onions contain
purins, and the output of uric acid is increased when they are
taken. The same applies to the various beers and also to coffee,
and to a less extent to tea. Meat extracts should be excluded from
the diet list.
Speaking generally, a diet such as appears suitable for a gouty
subject, who has an accumulation of uric acid in his blood, is
applicable in cases in which our aim is to reduce the risk of
deposition of uric acid in the urinary passages by limiting the
output. Only the exogenous uric acid is likely to be so affected by
treatment, and to its reduction our efforts will be directed.
Whereas from the above standpoint vegetable foods are for the
most part less to be objected to than animal, they have the further
advantage that, by reducing the acidity of the urine, they tend to
hinder the precipitation of uric acid. Such reduction of acidity
is also readily brought about by the direct administration of
alkalies, as recommended by the late Sir William Koberts, who
specially advised the giving of a large dose of potassium citrate
(40 to 60 gr.) at bedtime, to guard the night hours, during which
the urine excreted is most concentrated, is more highly acid, and
stays longer in the bladder. However, experience shows that
whereas the administration of alkalies usually suffices to arrest the
Melanuria. 741
formation of amorphous uratic sediments, its effect upon the
deposition of crystals of uric acid often falls short of our hopes.
Roberts further advised that the meals should so be arranged as
to take full advantage of the alkaline tide, and too long intervals
should not be allowed between meals.
Water may be freely drunk, either several glasses of hot water in
the day, or, better still, certain mineral waters, such as those of
Contrexeville, Vittel or Wildungen, which probably act beneficially
in other ways besides merely diluting the urine and so hindering
precipitation. A course of treatment at one or other of the above
spas will often have a good effect, especially if signs of calculus
formation are present or if gravel is being passed.
Gee has recommended the drinking of several cupfuls of whey in
the day, and this empirical remedy, for he did not attempt to
explain its action, is regarded as useful by not a few sufferers from
uric acid, sand and gravel.
Piperazine, which forms a very soluble urate, and in aqueous
solution readily dissolves small uric acid calculi, loses its solvent
power when dissolved in urine, and there are no grounds for
believing that this or any other known solvent is capable of effecting
the solution of a calculus in situ.
MELANURIA.
The name " melanuria " is applied to the excretion of urine which
has the following properties : It is usually of normal tint when
passed, but darkens on exposure to air, becoming brown and in the
end quite black. The addition of a solution of ferric chloride
produces immediate blackening, as also does nitric acid, even in the
cold. Bromine water produces a yellow or brown precipitate which
blackens quickly, and the addition of sodium nitro-prusside and
liquor potassse, followed by acidification with acetic acid, causes a
deep Prussian blue colour to develop.
Melanuria is a symptom of melanotic growths and does not in
itself call for treatment, neither does it afford an indication for
treatment, seeing that it is not manifested until the viscera, and
especially the liver, are invaded by secondary growths and the
case is beyond the reach of surgery.
It is stated that melanuria may occur apart from melanotic
growths, and in connection with marantic conditions, but the
recorded cases, upon which this statement is based, are capable of
other interpretations, and were for the most part described before
the more distinctive tests for melanuria were known. Some of
them, at least, appear to have been cases of indicanuria.
74 2 Oxaluria.
In practice, melanuria requires to be distinguished from indi-
canuria on the one hand, and from alkaptonuria on the other.
Both these conditions are to be recognised by simple and distinctive
tests, and in neither is the blackening with ferric chloride, which is
the most satisfactory test for melanuria, to be obtained.
OXALURIA.
Crystals of calcium oxalate are among the commonest of urinary
sediments, and it is to the occurrence of abundant deposits of such
crystals that the name " oxaluria " is usually applied. Strictly speak-
ing, the name should indicate an excessive excretion of oxalic acid,
which is a cause, but only one of the causes, of the formation of the
crystals, for they may be present in numbers in cases in which
the output of the acid is in no way increased.
The view which was widely held in the past that excessive
excretion of oxalic acid is the salient feature of a metabolic disorder
which gives rise to a well-defined group of symptoms, among which
acid dyspepsia and mental depression take a prominent place, no
longer meets with any general acceptance. The deposition of
calcium oxalate, which is often associated with hyperchlorhydria,
is now regarded as a secondary event, and as due to a more
abundant absorption of oxalate from the food under the influence of
the excess of hydrochloric acid in the stomach.
On the other hand, our knowledge is still very incomplete of the
occurrence of excessive excretion of endogenous oxalic acid in
morbid states, and the point upon which information is chiefly to
be desired is whether there are individuals who, even when oxalic
acid is eliminated from their diet, continuously excrete abnormally
large quantities of that substance.
Seeing that calcium oxalate is one of the commonest constituents
of urinary calculi, the conditions which determine the amount of
oxalic acid excreted and influence the solubility of calcium oxalate
in the urine call for careful consideration with a view to their
control. Apart from stone formation oxaluria has little clinical
importance, although when deposited within the urinary passages
the crystals, if abundant, may even excite haematuria, as witness
the hsematuria which sometimes follows the free consumption of
rhubarb or other articles of diet rich in oxalates. It may even be
that the slight degree of albuminuria, apart from any other signs
of renal disease, which is often associated with the presence of
calcium oxalate crystals, may be attributable to the mechanical
irritation which they set up.
Some account of what is known of the origin of the oxalic acid of
Oxaluria. 743
urine forms a necessary introduction to any profitable discussion of
the treatment of oxaluria, for in the present state of our knowledge
we are driven to rely upon theoretical considerations rather than
upon actual experience of beneficial results. Oxalic acid is a
constant constituent of normal urine, in quantities of from
0'015 to 0'02 milligramme daily in health and upon an ordinary diet.
It is in part derived from the food, but some oxalic acid is still
excreted by persons who have been kept for long periods upon an
oxalate-free diet, such as milk alone, and it does not wholly dis-
appear even during periods of fasting. It has been shown that
neither carbohydrates nor fats are its parent substances, and the
endogenous portion is presumably of protein origin. A clue to its
source is afforded by the fact observed by Lommel that feeding
with gelatine increases the output of oxalic acid, and a further
most important clue by the demonstration by Klemperer and
Tritschler that glycocol and kreatinine taken by the mouth cause a
conspicuously increased excretion.
Of the exogenous oxalic acid the great bulk is derived from
vegetable foods, some of which are rich in this constituent, but only a
small part of the oxalic acid introduced into the stomach is absorbed,
whereas the major part, passing into the intestine, undergoes destruc-
tion by the action of bacteria. Klemperer and Tritschler found that a
larger fraction of the oxalic acid contained in a foodstuff, namely
spinach, was absorbed than of oxalic acid administered as such. The
absorption is greatly favoured by the presence of hydrochloric acid
in the stomach, and when this acid is given together with an
oxalate the urinary output is thereby markedly increased, whereas
an opposite effect is observed by neutralisation of the gastric juice
by an alkali when the food is taken. Once absorbed into the lymph
and blood the oxalic acid is promptly combined up as a calcium
oxalate. This compound undergoes no further change, but is
excreted as such.
It seems certain that some patients excrete oxalic acid in excess
apart from dietetic influences, but such abnormal outputs cannot be
assigned as a constant symptom of any particular diseases. In
some cases of diabetes an unusually abundant excretion has been
observed, whereas in others it is wholly wanting, nor have we any
certain clinical evidence of the existence of a metabolic disorder to
which the name "oxaluria " can be applied in any strict sense. It has
been commonly taught that the solution of calcium oxalate in the
urine is mainly determined by the presence of acid sodium
phosphate ; but other influences are certainly at work and crystals
are sometimes deposited from strongly acid urines. The influence
744
Oxaluria.
of excess of oxalate has already been alluded to, and Klemperer and
Tritschler found that, even when the other conditions are favourable
to solution, crystals of calcium oxalate are deposited if more than 1'8
milligrammes of oxalic acid are present in 100 cubic centimetres of
urine. On the other hand, sediments of crystals are not uncommon
apart from any excessive output, and the same observers have shown
that the relative quantities of magnesia and lime present in the urine
play a very important part in this connection, magnesium salts
inhibiting and calcium salts favouring the throwing down of the
oxalate crystals. Ratios of lime to magnesia between 1 : 0'8 and
1 : 1*2 are the least favourable to deposition.
The aims of our treatment in cases of oxaluria should obviously
be to diminish, as far as possible, the excretion of oxalic acid in the
urine and to hinder the separation from it of calcium oxalate in
crystalline form. Even if this can only be so far delayed that
the crystals will not form until after the urine has been passed,
the wished-for result will have been obtained. As with uric acid,
the only means at our disposal for limiting the output of oxalic
acid is the restriction of the intake in the food. The effect of an
abundant intake is clearly seen in the copious deposition of crystals,
which is wont to follow free consumption of oxalate-rich vegetables,
such as rhubarb and spinach. It is therefore desirable to be
acquainted with the oxalic acid content of various articles of diet,
and such information is supplied as regards many such by the
following table compiled from Esbach's analyses, which were, it
should be mentioned, carried out by methods of estimation less
satisfactory than those in use nowadays.
Oxalic Acid in Foodstuffs. (Extracted from Esbach's Table.)
Quantities contained in 1 Kilogramme, Raiv, as delivered to the Consumer.
Black tea .
3-75
Cabbage .
. 0-003
Cocoa .
3
52 to 4-5
Beetroot .
. 0-39
Chocolate .
0-9
Salsify .
. 0-07
Pepper
3-250
Tomatoes .
0-002 to 0-052
Chicory coffee
0-795
Carrots
. 0-027
Haricots blancs
0-312
Celery
. 0-025
Potatoes
0-046
Haricots verts
0-06 to 0-21
Bread (good qua
ity)
0-047
Dried figs .
. 0-27
Crust .
0-130
Gooseberries
0-130 to 0-07
Barley flour
0-039
Plums
. 0-120
Maize flour
0-033
Raspberries
. 0-06
Sorrel
2
74 to 3-63
Oranges .
. 0-03
Spinach
1
91 to 3-27
Lemons .
. 0-03
Ehubarb .
2-46
Cherries .
. 0-025
Brussels sprouts
0-02
Strawberries
. 0-012
Lentils, rice, cauliflower, green peas, artichokes, cucumbers mushrooms,
onions, lettuce, apples, pears, apricots and peaches, contain traces of oxalic acid
or none at all.
Oxaluria.
745
The second factor which has to be taken into consideration in
prescribing a diet for a patient with oxaluria is the relation of lime
to magnesia in the several foodstuffs, and an ideal diet should
consist of the materials which are at the same time poor in oxalic
acid, relatively rich in magnesia and poor in lime.
The following table, extracted from that of Klemperer and
Tritschler, and based upon analyses of vegetable foods by Liebig
and of animal products by Bunge, will be found useful in this
connection :
(a) Percentage in Ash of Magnesia and Lime in Vegetable Foods.
(Liebig.)
-
Ash in 100 parts
of dry substance.
Of Magnesia.
Of Lime.
Cocoa
4-9
15-9
2-8
Rice
0-67
13-4
0-8
Nut kernels
13-3
8-6
Wheat flour
2-3
10-9
2-2
Apple
Coffee extract
1
0-27
3-4
8-7
8-6
4-0
3-6
Peas
2-8
8-1
5-1
Tea extract
3-1
6-8
1-2
Potato .
5-0
2-5
0-8
Grapes .
2-25
8-8
36-9
Cherries .
0-4
5-5
7-5
Plums
0-31
4-7
4-9
Asparagus
6-4
6-3
15-9
Pineapple
8'8
12-5
Spinach .
2-03
5'3
13-1
Cauliflower
8-8
Traces.
21-7
Cabbage .
11-6
3-7
12-6
Cucumber
4-9
3-0
6-9
Gooseberries
0-4
5-8
12-2
Lentils .
2-1
1-9
5-1
Beans
3-1
6-5
8-6
Sorrel
.
8-3
31-6
Pears
0-4
5-2
7-9
Strawberries
Traces.
14-2
Carrots .
5-4
2-3
5-6
Beef
(b) Animal Foodstuffs. (Bunge.)
In (sentiyrammes in the Dry Substance.
Magnesia.
15-2
White of egg
Human milk
Yolk of egg
Cow's milk .
13-0
5-0
6-0
20-0
Lime.
2-9
13-0
24-3
38-0
151-0
Milk and eggs, in which lime is so abundant a constituent, will
be excluded from the optimum diet in these cases, and some
vegetables, such as cabbage and cauliflower, which might escape
condemnation on the score of oxalic acid alone, will be excluded
746 Phosphaturia.
because they contain too much lime and relatively too little
magnesia.
Meats, on the other hand, fulfil all the required conditions, as do,
among vegetables, cereals and leguminous seeds, peas and beans,
and apples.
Taking the several factors into account we may prescribe for
oxaluric patients such a diet as the following :
Meat of all kinds, including fowl, game and fish, meat extracts,
bread, rice, and farinaceous foods of all kinds, potatoes, peas, beans,
and apples. Coffee should be taken in place of tea or cocoa.
Green vegetables and root vegetables are better avoided, as are
most fruits, except apples, and milk, eggs and jellies, on account
of the power which gelatine has of increasing the oxalic excretion.
Tea, cocoa, rhubarb, spinach, sorrel should be rigorously excluded
from the diet, and some of these substances are not only rich in
oxalic acid but are also relatively rich in lime.
In some cases oxaluria occurs in patients whose purin intake also
calls for restriction. In such circumstances resort must be had
to a diet of compromise, from which the foods which contain the
larger quantities of purins and of oxalic acid respectively are
excluded.
In order further to increase the magnesium of the urine small
doses of magnesium sulphate, such as 2 drachms in the day, may
be administered, and the free drinking of water, by diluting the
urine, will tend to check the deposition of calcium oxalate.
Maguire has recently advocated the administration of acid sodium
phosphate,- with a view to increasing the acidity of the urine, a
result which, as R. Hutchison showed, is more readily obtained with
this substance than by the administration of free acids. He recom-
mended that \ oz., 1 oz., or even 2 oz. of the acid phosphate should
be dissolved in 100 oz. of distilled water, and that the solution
should be drunk at intervals throughout the day. By such means
he claims to have effected the solution of an oxalate calculus within
the urinary passages.
Lastly, it should be mentioned that mineral waters, such as
those of Contrexeville, Vittel and Wildungen, which have a reputation
in connection with the treatment of calculous disorders, are believed
to be valuable in cases of oxaluria, as well as in those in which uric
acid is the stone-forming material.
PHOSPHATURIA.
When a patient habitually passes urine which is amphoteric or
alkaline in reaction and turbid from a precipitate of earthy
Phosphaturia. 747
phosphates, although free from ammoniacal decomposition, he is
said to suffer from phosphaturia. On standing, such urine deposits
a bulky sediment and the supernatant liquid may become quite clear.
The sediment consists of the basic phosphates of calcium and
magnesium with usually a small admixture of carbonates.
The name " phosphaturia " is a misnomer, and as such is apt to
mislead, for whereas the condition may be due either to an increase
of bases or a diminution of acids, it never has its origin in an
excessive output of phosphoric acid. Indeed such an excess would
have an opposite effect upon the urine, would cause an increase of
acidity and so prevent any deposition of earthy phosphates.
Phosphaturia may result from widely different causes, and is not
a manifestation of a single definite morbid state. Healthy persons
often pass such turbid urine two or three hours after a full meal, and
especially one rich in protein, during the period of the so-called
alkaline tide which is due to diminution of acidity during the
secretion of hydrochloric acid in the course of gastric digestion.
In the same way gastric lavage, repeated vomiting or even hyper-
chlorhydia, may give rise to phosphaturia.
A physiological phosphaturia may also result from an excessive
excretion of fixed alkali, such as follows the free drinking of alkaline
mineral water or results from a vegetarian diet. Vegetivorous
animals habitually excrete turbid alkaline urine.
"When it occurs as a persistent symptom, apart from the action of
any such recognised causes, phosphaturia is less easily explained.
It certainly has a close clinical relationship to neurasthenic
symptoms, and especially to the sexual variety of neurasthenia.
Perhaps because they are neurasthenic, the patients are wont to
attach an altogether exaggerated importance to these symptoms,
and, by exciting alarm, the condition of the urine tends, in a vicious
circle, to aggravate their neurasthenia.
The researches of Soetbeer, Tobler and others have brought to
light the fact that in a considerable number of cases of phosphaturia,
and especially of cases occurring in children, the symptom is due to
an excessive excretion of calcium in the urine. This excess of
calcium leads to the presence of basic phosphates in undue propor-
tion, and so to diminution of the acidity of the urine and to
phosphaturia. The increase is not of the total phosphoric acid
output, but merely of the basic calcium compound. The ratio
CaO : Pa0 5 is conspicuously disturbed, and may be changed from a
normal ratio of about 1 : 12 to that of 1 : 4.
As is well known, the bulk of the calcium excretion of the
organism is effected by way of the intestinal wall, only a
748 Phosphaturia.
comparatively small fraction of the total output appearing in the
urine, and the investigators referred to have further shown that, in
cases of the class under discussion, the excretion of calcium is not
increased as a whole, but that the excess in the urine is balanced by
a corresponding decrease of the calcium in the faeces. Such a
diminution of the excretive power of the intestine for calcium
suggests that some morbid condition of the alimentary canal is at
the bottom of the whole matter and that the phosphaturia is merely
a secondary effect thereof. Soetbeer ascribes it to a catarrh of the
colon, and evidences of the existence of such a catarrh have been
present in some at least of the observed cases.
What proportion of cases of phosphaturia are of this nature is not
yet known. It appears certain that the condition is occasionally
to be met with among adults, but on the other hand Langstein's
observations show that by no means all phosphaturic children
belong to this class ; and it is not improbable that further observa-
tions may show that the matter is not quite so simple as has been
supposed.
In the cases of Soetbeer's type, or of calcaruria, to employ the
somewhat uncouth designation which he suggests for them, the
results of treatment have been encouraging, and dietetic measures
have sufficed to control the trouble. The aim of dieting is to
limit the introduction of calcium in the food, since there is difficulty
in excreting this substance by the ordinary path. From the diet
prescribed foodstuffs rich in calcium should be excluded, and above
all milk and eggs, whereas meats of all kinds, farinaceous foods,
bread and vegetables fulfilling the required condition, such as potatoes
and apples, may be allowed. In prescribing such a diet the table
showing the calcium content of foodstuffs, given on p. 745, will be
found of use. If, however, an intestinal disorder underlies the trouble
our treatment should be directed to the improvement of the condition
of the bowel wall, at the same time as we aim at removing the
calcaruria by a suitable dietary.
In the ordinary cases, in which phosphaturia is associated with
neurasthenia of greater or less degree, attempts to restore the
natural acidity of the urine by the administration of acids or by a
diet rich in proteins are not unfrequently attended with little success.
Various acids are given by the mouth, such as lactic or hydrochloric,
but R. Hutchison recommends the administration of acid sodium
phosphate and has had decidedly better success therewith than with
free acids. It may be given in doses of 30 to 60 gr. every three
hours, or 2 drachms may be dissolved in a pint of water and the
patient directed to drink small quantities from time to time.
Bence Jones Protein. 749
As a rule, treatment directed to the general condition of the
patient, such as change of air and scene, rest and general massage,
together with tonic medicines, prove more beneficial than specialised
methods of treatment directed against the alkalinity of the urine.
PNEUMATURIA.
Except in the uncommon cases in which a fistulous opening has
been formed between the lower bowel and the urinary tract, usually
in connection with a malignant growth, the escape of gas with the
urine is a result of bacterial infection. In most instances the
subjects of such gas formation are diabetics whose bladders have
been infected, and the gas passed is carbon dioxide formed by
fermentation of the glucose contained in the urine. There is,
however, another class of cases, which has been specially studied
by Adrian and Hann, in which the urine contains no sugar and
the phenomenon is due to the action of the bacillus lactis aerogenes.
Pneumaturia of these latter kinds calls for treatment of the urinary
infection, and in cases of diabetes affords an additional indication
for dietetic treatment in the hope of bringing about the cessation
of glycosuria.
PYURIA.
The presence of pus in the urine indicates a morbid condition of
the kidneys or urinary tract, and may have such different causes as
tuberculous disease of the kidney, calculous pyelitis, rupture of an
adjacent abscess into the urinary passages, cystitis or gonorrhoeal
urethritis. The quantity of pus present may be very small or it
may form a thick deposit at the bottom of the containing vessel.
The reaction of the urine may be acid or alkaline, being to a great
extent dependent upon the nature of the infecting micro-organism,
and its appearance will largely depend upon its reaction. Alkaline
urine containing pus remains turbid, and is viscid when poured from
one vessel to another, whereas from acid urine the pus tends to
settle into a well-defined layer, leaving the supernatant liquid clear.
The cause of the pyuria can usually be determined by the
patient's symptoms, by physical examination and by microscopic
and bacteriological examination of the urine, and the treatment
employed will be directed to the underlying morbid condition.
THE BENCE JONES PROTEIN IN URINE.
The excretion in the urine of the peculiar protein first detected
by Bence Jones, and always called by his name, is a phenomenon
of much interest and of great diagnostic value. Jt is, in almost all
750 Bence Jones Protein.
cases if not in all, a symptom, and as a rule the earliest symptom,
of a disease of the bone marrow known as multiple myeloma. The
amount of Bence Jones protein in the urine is usually large,
and it is recognised by the low temperature, 50 to 60 C.,
at which coagulation occurs, and by the fact that the bulky
flocculent coagulum, which clings to the walls of the test tube,
disappears almost entirely before the boiling point is reached,
especially if a drop of acetic acid has been added, and reappears on
cooling. However, this clearing on further heating, which is largely
determined by the conditions of solution in urine, is not always
well seen.
Unfortunately no treatment has hitherto had any effect upon the
course of the disease, or upon the excretion of the protein, the mode
of formation and parent substance of which are still unknown.
A. E. GARROD.
EEFERENCES.
Acetonuria. Spriggs, E. I., " Critical Eevievr on Acidosis," Quart. Journ.
Med., 1909, II., p. 325. Bainbridge, F. A., Lancet, 1908, I., p. 911.
Albuminiiria. Wright, Sir A., and Eoss, G. W., Lancet, 1905, II., p. 1164.
Cystinuria. Alsberg, C., and Folin, G., Ainer. Journ. Physiol., 1905, XIV.,
p. 54. Wolf and Shaffer, Journ. of Biological Chemistry, 1908, TV., p. 444.
Garrod, A. E., " Inborn Errors of Metabolism," 1909, pp. 82 et seq.
Lithuria. Klemperer, G., " Verhandl. des Kongress, f. innere Med.," 1902,
XX., p. 219. Walker Hall, I., "The Purin Bodies and Foodstuffs," 1903.
Eoberts, Sir William, " Croonian Lectures," Lancet, 1892, I., p. 1399.
Oxaluria. Klemperer, G., und Tritschler, F.,"Zeitschr. f. klin. Med.," 1902,
XLIV., p. 337. Esbach, G., "Bull. Generate de Therap.," Par., 1883, CIV.,
p. 385. Dunlop, J. C., Journ. Path, and Bacterio., Edinb., 1896, HI., p. 389.
Maguire, E., " Proc. Eoyal Soc. Med.," 1909, III., Med. Sect., p. 1.
Phosphaturia. Soetbeer, Fr., und Krieger, H., " Deuteches Archiv. f.
klin. Med.," 1902, LXXIL, p. 553. Tobler, L., "Arch. f. exper. Path, ii
Pharmakol.," 1905, LH., p. 116. Langstein, " Med. Klinik.," 1906, II., p. 406.
Peyer, A., " Die Phosphaturie," Volkmann's " Saminlung klinischer Vortriige,"
Leipzig, 188690, Innere Med., No. 112, p. 3031. Hutchison, E., Brit. Med.
Journ., 1903, I., p. 1256.
BACILLURIA.
A NUMBEK of micro-organisms are found in the urine under
different conditions. It is probable that in most, if not all, instances
when organisms gain access to the blood-stream they also gain
access to the bladder. This is certainly true of the typhoid bacillus
and in some cases of tuberculosis. In such cases there is not neces-
sarily any local disease of the bladder, and consequently this sym-
ptom is usually dealt with adequately by means of urinary anti-
septics, such as urotropin (gr. 7^ to 10) three times a day.
In other cases the urine may contain large numbers of organisms
without the existence of any disease outside the urinary tract.
What local disease is present is frequently confined to the bladder.
In some cases there may be no decomposition of the urine and no
cystitis. In others we may have marked cystitis, which may lead
to acute general symptoms, or we may have slight cystitis with
symptoms of sub-acute toxaemia, such as lassitude and want of energy.
In many of these instances the offending micro-organism is the
Bacterium coli comrnunis. In all instances urotropin or other urinary
antiseptic should be freely used, and, if necessary, pushed to the
limits of tolerance.
In addition, an autogenous vaccine of the causal organism
should be used (see Vaccine Therapy, Vol. III.). In many of
the acute cases vaccine therapy gives brilliant results. In a
number of the more chronic cases the relief of the symptoms
afforded by this method of treatment is apt to be less marked.
In addition, the patient's life should be regulated in accordance
with the severity of the symptoms. The diet should be of a non-
irritating character. It is important that the bowels should be kept
thoroughly open, and sometimes the Plombiere method of washing
out the bowel is of service. In all cases the patient's general health
should be brought to as high a level as possible, and he should
carefully guard against the possibility of fatigue.
ARTHUR LATHAM.
752
ANEURYSM OF THE RENAL ARTERY.
Treatment. The condition will usually be discovered in the
course of an exploratory operation undertaken for a swelling in
the loin which has followed an injury.
Morris warns against opening up the sac. Only a small
opening should be made, sufficient to recognise the laminated
character of the contents.
In breaking down adhesions severe haemorrhage has taken
place, and necessitated plugging with gauze.
In such a dilemma, and in the case where diagnosis has pre-
viously been made, a vertical incision should be made in the
semi-lunar line and the peritoneal cavity opened.
The peritoneum is divided along the outer side of the colon
and reflected inwards. The pedicle of the kidney is exposed and
ligatured. It is sometimes very broad, and requires a series of
ligatures. The aneurysmal sac and kidney are then removed.
Results. Albert, Hahn and Keen have each operated success-
fully in one case. All the other patients in whom the aneurysms
caused a tumour died. The aneurysms, which were very small,
had caused no symptoms, and were discovered accidentally post-
mortem, the patient having died from other causes.
J. W. THOMSON WALKER.
753
RENAL CALCULUS.
PROPHYLACTIC TREATMENT.
THE prophylactic treatment of stone consists in the treatment of
oxaluria, of lithiasis, of phosphaturia, and the removal of local
conditions which may assist the formation of stone. The subject
usually comes under discussion when a patient has passed a stone
or undergone an operation for stone, and an attempt is to be made
to prevent recurrence.
(1) The treatment of oxaluria is discussed elsewhere.
(2) When the patient passes acid concentrated urine with uric
acid crystals, it is advisable to limit the quantities of nitrogenous
food, but it is unwise to cut off meat entirely. Beef and mutton
should be taken sparingly. Cellular organs, such as brain, sweet-
breads, kidney and liver, contain excessive quantities of nuclein
from which uric acid is derived, and should be avoided. White
meat is less harmful than red, but veal and pork are unsuitable
articles of diet. Duck and goose among poultry, and high game
should be avoided. Fish may be taken, except salmon, mackerel,
lobster and crab. Bread, all the cereals, roots, fruits and green
vegetables should form part of the diet. Butter, milk and eggs
may be taken. Tea and coffee, if taken, should be weak. Sugar
and fats are harmful, and should be eaten sparingly. It is better
to avoid wine altogether ; but should it appear necessary to permit
some wine, the lighter Moselle and white French wines or a light
claret should be selected. Heavy wines, such as Burgundy,
Australian and Californian wines, are especially harmful. Port
and champagne should be interdicted. New port is slightly less
pernicious than old. Whisky may be allowed in very moderate
amount.
Careful attention must be paid to regular action of the bowels,
and a course of waters containing sulphates of soda and magnesia,
such as Hunyadi and Friederickshall, is beneficial. Half a
tumblerful or more should be taken on waking, and followed by a
tumblerful of hot water. Courses of three or four weeks with
intervals of two or three weeks may be prescribed. Watson speaks
highly of calomel, given in doses of J to \ gr. at bedtime for a
week at a time.
The urine should be diluted and the acidity reduced. A large
glass of hot water should be taken in the early morning and at
S.T. VOL. ii. 48
754
Renal Calculus.
night. Aerated distilled waters, such as Salutaris, are bene-
ficial. Alkalies, and especially those which are also diuretic,
are useful. The citrate and acetate of potash should be given in
doses of 30 to 60 gr. four times daily, or the carbonate or citrate
of magnesium or lithium. The boro-citrate of magnesia (in doses
of 15 gr. thrice daily) is well borne. Alkaline mineral waters, such
as Contrexeville (Pavilion), Vittel (Grande Source) and Evian
(Cachet), should be given, and a visit to one of these spas is often
beneficial.
The most powerful effect is obtained by drinking the water after
fasting. For this reason a large draught should be taken in the
early morning and another in the late afternoon.
Uric acid solvents should be administered by the mouth. The
following is a selection :
Name.
Composition.
Method of Action.
Dose.
1. Piperazine .
Diethylene -diamine
Forms soluble urates
4 to 15 gr.
with uric acid
2. Sidonal
Piperazin quinate
Quinic acid encour-
H gr-
ages excretion of
precursors of uric
acid
3. Hex a methyl ene-
Contains Formalde-
Solvent action on
5 to 15 gr.
tetramine. Syno-
hyde
uric acid, and urin-
nyms : Urotro-
ary antiseptic
pine, Forrnin,
Cystamine, Cys-
togen, . Metra-
mine, Uritone
4. Helmitol
New urotropine
Do.
15 gr.
5. Hetraline
Contains 60 per cent.
Do.
7i to 30
of hexamethylene-
gr.
tetramine
6. Cystopuriu .
Hexamethy lene - te -
Do.
30 gr.
tramine and so-
dium acetate
7. Chinotropine
Urotropine quinate
Do. See also Sidonal
Up to 90
gr.
8. Urocedin
Lithium and sodium
Eeduces acidity of
15 gr.
citrates and sodium
urine
sulphate
9. Uraseptin
Combination of uro-
Uric acid solvent and
4 drachms
tropine, benzoate
urinary antiseptic
of soda and lithia
piperazine and
lead acetate
Turpentine, an old remedy, is of undoubted benefit. It should
be given in 10-minim doses in capsules thrice daily for a week or
ten days.
Renal Calculus. 755
Exercise, bathing and Turkish baths, and radiant heat baths
are important adjuncts to treatment.
(3) The treatment of pkosphaturia has already been discussed.
(4) Treatment of local conditions which assist the formation of
stone. These consist in urinary infection and obstruction. For
the treatment of chronic renal and pelvic infections the reader is
referred to the chapter on these diseases. The treatment of
chronic vesical infection and obstruction will be discussed later.
TREATMENT OF CERTAIN SYMPTOMS.
Renal Colic. The pain of renal colic varies greatly in
severity. In severe attacks the following measures should be
adopted : The patient is placed in a hot bath and a hypodermic
injection of morphine sulphate (J to ^ gr.) with atropine sulphate
(200 8 1 '-) given. On his return to bed hot poultices or fomentations are
applied over the loin and abdomen. The pain usually subsides in
about half an hour after the injection. Occasionally it is necessary
to repeat the hypodermic injection after some hours. Rarety it is
found necessary to administer chloroform and to keep the patient
lightly under its influence for an hour or more. If this becomes
necessary and the stone is known to lie at the upper end of the
ureter, a ureteric catheter may be passed and the stone pushed back
into the renal pelvis. The injection of a small quantity of
sterilised oil into the ureter has facilitated the passage of a
descending calculus.
Renal* Haematuria. Haematuria is seldom alarming in renal
calculus, but may be severe after exertion or a fall or blow. The
patient should rest in bed with an ice-bag over the kidney. Ergot
may be given, but is of doubtful value. A hypodermic injection of
morphia should be given, and 10 or 15 gr. of calcium lactate
administered by mouth every four hours. For persistent severe
hsematuria operation is necessary.
Calculous Anuria. The following points are of importance
in regard to operative interference in calculous anuria.
Calculous anuria may occur under the following conditions :
(1) The ureter of a single functional kidney is blocked by stone.
The second kidney is absent (six in forty-three cases), atrophied,
or completely destroyed by disease. This is the most common form.
(2) The ureters of two functional kidneys are simultaneously
blocked by calculi (twelve in forty-three cases, Donnadieu).
This is a less common form.
(3) The ureter of one functional kidney is blocked by stone and
the function of the second kidney is suppressed by reflex influences
483
756 Renal Calculus.
(uretero-renal reflex). The second kidney is always diseased, and
this renders it more susceptible to reflex influences.
If symptoms of calculus have been present on both sides, the
side on which symptoms were last present is that of the active
kidney.
The recently active kidney is frequently tender and may be
enlarged. There is often rigidity of the abdominal muscles over the
side where other symptoms are absent. Radiography may assist
the diagnosis and locate the position of the calculus. Extensive
shadows in one kidney will point to this organ being inactive or
feebly functional, and a shadow of a calculus in the opposite ureter
would indicate and localise the cause of the anuria. A calculus
may be felt in the lower ureter per rectum or per vaginam.
Cystoscopy may show absence of a ureteric orifice, or there may be
signs of a stone impacted low down in the ureter on .the recently
active side.
The ureteric catheter will give no useful information in regard
to the side affected or the position of the offending calculus.
Calculous anuria is sometimes incomplete, a few ounces of urine
being passed each day or at intervals, or complete anuria may be
interrupted by the escape on one or several occasions of large
quantities of urine. These variations cannot be regarded as
indicating that a fatal issue will not take place. There is usually
a latent, silent or tolerant stage, which may last as long as ten
days, but more usually seven or eight days. This is followed
by a uraemie stage. The patient may die without developing
ursemic symptoms. Death occurs rapidly after symptoms of
ursemia appear ; rarely it is delayed one or two days. Death
usually occurs about the tenth or eleventh day in unrelieved cases.
Spontaneous recovery has occurred in 28'5 per cent, of recorded
cases. Legueu found sixteen unoperated cases out of fifty-six
recovered. The date of spontaneous relief of the anuria was the
third day in one, fifth to tenth day in ten, thirteenth day in one,
fourteenth day in one, and fifteenth day in one, and in two
cases later than the fifteenth day.
The obstructing calculus is situated at the upper end of the
ureter in most cases, less frequently at the lower end of the ureter,
and rarely in the middle portion.
Huck found the following numbers at the different levels :
Pelvis and upper ureter, 80 ; middle, 5 ; lower ureter 11.
Indications for Operation. Operation should be performed at
the earliest possible moment in all cases of calculous anuria.
It has been held that operation may be delayed until the fifth or
Renal Calculus. 757
sixth day as uraemia symptoms do not supervene before this time.
This delay could only be justified by a large proportion of
spontaneous recoveries. Such fortunate results do not obtain.
Death does not take place as a result of the operation, but as a
result of the condition for which it is performed.
Huck's statistics show that the mortality rises each day that
the operation is delayed.
Operations before the fourth day have a mortality of 25 per cent.
fifth ,, 30'7
sixth ,, 42-1
Operation should therefore be performed as soon as anuria is
established and the - diagnosis clearly made. The presence of
urseniic symptoms does not contra-indicate operation. Successful
cases of operation under these conditions have been recorded.
The Xaturc' of the Operation. The nature of the operation will
to some extent depend upon the position of the obstructing stone,
the possibility of accurately localising it, and the ease or difficulty
with which it can be removed. The operation for calculous anuria
is one of emergency performed under the worst possible conditions,
and it should be realised that it is more important to relieve the
obstruction and do it quickly than to carry out. an operation for the
removal of calculus of the ureter. Nephrotomy should be
performed when the stone is localised to the renal pelvis, when no
accurate localisation of the stone has been possible, and when the
stone has been localised in the ureter, but its position is such as to
necessitate a prolonged operation, which the patient is considered
unfit to undergo.
If the stone is found, it should be removed ; if it is not found, a
large drainage tube should be placed in the pelvis, and the wound
in the kidney lightly packed with gauze. After the anuria has
been relieved an operation for the removal of the obstructing
calculus will be undertaken.
Ureterotomy should be performed when the obstructing calculus
has been accurately localised and is easily accessible, as in the
lateral vaginal fornix, or in the middle or upper segments of the
ureter.
The nature of the operation in forty-nine cases collected by
Morris was : Nephrotomy, thirty- four ; pyelotomy, five; ureterotomy,
seven.
Results. Morris gives the following statistics from collected
cases :
(1) Forty-eight cases not operated gave thirty-eight deaths and
ten recoveries.
758 Renal Calculus.
(2) Forty-nine cases operated gave twenty-four deaths and
twenty-five recoveries.
That is 20*8 per cent, of unoperated cases and 51 per cent, of
operated cases recovered. Huck has shown that the mortality of cases
operated before the fourth day is 25 per cent. These results are
sufficiently striking to give strong support to the surgeon in urging
immediate operation in all cases. In the future these figures will
be greatly improved when the necessity for early operation is fully
realised.
OPERATIVE TREATMENT OF RENAL CALCULUS.
Cases Unsuitable for Operation. (1) Extensive bi-lateral cal-
culous disease, either aseptic with signs of progressive failure of
the renal function, or when there is widespread sepsis and ursemic
symptoms are present or are easily induced by exposure or other
causes. These patients are in the last stage of calculous disease.
Operation would certainly be followed by death from anuria or
uraemia. Without operation life may be prolonged for some time.
(2) Cases in which small calculi are frequently passed, and the
X-rays do not show a large single shadow, or a collection of small
shadows in the kidney. These cases are suitable for diuretic
treatment.
In all other cases, when a small stone is shown by the X-rays,
a trial of diuretic and medicinal treatment may be given, but
this should not be unduly prolonged. Two or three months should
be the limit set to medicinal treatment.
The following points should be borne in mind in considering
operation :
(1) A small stone may become engaged in the renal pelvis and
cause hydronephrosis by obstructing the outflow of urine.
(2) A small stone in its passage down the ureter may become
arrested at some part at which its removal by operation is very
difficult.
(3) Arrest of a stone in the ureter frequently causes dilatation of
the ureter and hydronephrosis.
(4) Hfematogenous infection of the urinary tract occurs in the
majority of cases of renal and ureteral calculus. Pyelonephritis
or pyonephrosis results.
(5) Calculi remaining in the kidney increase in size and destroy
the organ by pressure and chronic inflammation.
(6) The second kidney becomes affected with calculus in 50 per
cent, of cases.
Renal Calculus. 759
(7) The removal of a calculus from the kidney reduces the risk
of disease in the second kidney.
(8) The absence of pain does not indicate that the calculus
has ceased to increase in size, or that the destruction of the kidney
tissue has been arrested. The largest renal ' calculi are usually
painless.
The following information should be in the possession of the
surgeon before commencing an operation for the removal of stone
in the kidney :
(1) The position and number of calculi. The whole urinary
tract must be examined by the X-rays, both kidneys, ureters, the
bladder and the urethra being included. The X-ray examination
must be made within a short time of the operation. The assistance
of an opaque bougie in the ureter is sometimes necessary to
distinguish doubtful shadows. Sounding of the ureter is often of
assistance in accurately localising ureteric stone. The bladder
must be examined by the cystoscope.
(2) The presence of a second kidney and its functional state.
This is ascertained by the examination of the ureteric orifice and
the observation of an efflux, by catheterisation of the ureters, and
the examination of the urine drawn from each kidney, and the use
of the tests for the renal function.
This information is absolutely necessary when there is a
possibility of nephrectomy being performed.
The operations which may be performed are : Nephrolithotomy ;
pyelolithotomy ; nephrectomy.
Nephrolithotomy. In nephrolithotomy the kidney is exposed
by a lumbar incision and separated from its fatty capsule as far as
the hilum. It is then carefully palpated for a hard nodule which
would indicate the presence of a stone. The pelvis is also examined
and the finger pressed into the sinus of the kidney. The further
procedure will depend upon whether a hard nodule is discovered or
not. If a nodule is felt in the substance of the kidney it should be
exposed either by an incision on the convex border of the organ,
or if it is near the anterior or posterior surface it may be cut
upon directly.
Needling the kidney or a nodule felt in its substance is an
unnecessary procedure, for the reason that if the nodule is a stone it
must be cut upon, and if it is not a stone, and also if no nodule can
be felt, the surgeon cannot rest content with the meagre information
afforded by passing a needle into the kidney substance, but will
proceed to explore the organ by a free incision.
If nothing has been felt, the kidney should be explored. The
760 Renal Calculus.
ureter is first separated from the vessels at the hilum, and the
vessels are compressed with the finger and thumb, or with a rubber
band fixed with a pair of pressure forceps. An incision is made in
the convex border of the kidney 4 millimetres behind the most
prominent line. The incision is placed in the middle of the
organ and extends for 2 inches or more. The cut surfaces are
separated and the finger introduced into the renal pelvis, and with
this and a metal sound a careful search is made for the calculus.
Instead of making a single large incision, a smaller incision may
be made into each pole of the kidney, and by this means the
extremities of the organ are searched and the portion intervening
between the incision is easily examined. If a stone is felt in
the pelvis or a calyx, the incision should be extended so that it is
exposed. By means of forceps, or a fine scoop and the forefinger,
the calculus is removed. In some cases when there is a short
pedicle, or in a stout or muscular patient with a narrow loin, the
FIG. 1. Thomson Walker's stone forceps.
kidney can only be partly brought into the wound. In such cases
I use long, fine forceps with an angled grasping extremity, which
can be passed along the forefinger and grasp the calculus just
beyond its tip. (Fig. 1.)
A search for multiple calculi should be carefully made.
Each calculus should be examined for facets, and for each facet a
calculus must be found. A good radiogram is of great assistance,
and should be before the surgeon at the operation. In isolated
scattered calculi it is of especial value. A number of small stones
lying close together frequently appear as a single shadow. Small
seed-like calculi or soft phosphatic material are removed by a
copious stream of warm lotion from an irrigator, after packing the
peri-renal space with gauze.
Having removed the stones from the kidney, the ureter should
be carefully examined. The upper portion is easily palpated with
the finger as far as the brim of the pelvis. A long, fine, gum-
elastic bougie of even calibre is now passed down the ureter into
Renal Calculus. 761
the bladder. Should this be arrested at any part of the ureter, the
finger is passed along the outside of the ureter, and at the end of
the bougie a calculus may be discovered.
A complete radiographic examination of the urinary tract,
together with sounding the ureter before the operation, will shorten
this part of the operation. After removal of the calculi the kidney
wound should be closed with sutures. Soft catgut sutures are most
suitable catgut preserved in iodine and chromic catgut are too
hard and cut out. The sutures are introduced with round, straight
needles and are passed about 1 inch from the edge of the wound.
They are placed about \ inch apart, and five or six interrupted
sutures usually suffice. ' They are tied slowly and not too tightly
lest they cut out through the friable kidney substance. When
the kidney substance has not been destroyed these sutures will
suffice, but occasionally it is necessary to introduce a mattress
suture to control bleeding from a large vessel. If mattress
sutures are used, a second row of interrupted sutures nearer the
edge of the wound will be required, as the lips of the renai wound
become everted.
When the kidney substance has been much reduced, there is
more difficulty in closing the wound satisfactorily. The thin lips
become everted or inverted and there is some danger of the sutures
tearing out. In the cases in which I have had to remove the
kidney for severe haemorrhage continuing some days after
nephrolithotomy, the bleeding almost invariably took place from a
suture having penetrated into a dilated calyx and either cut and
allowed a vessel to bleed, or having been tied too tight it had torn
through a vessel.
When there is sepsis and dilatation of the kidney, drainage of
the intra-renal cavity is necessary, and this is provided by a rubber
tube of moderate size, which is retained in the kidney cavity by a
catgut stitch passed through the edges of the kidney incision. The
peri-renal space should also be drained.
The treatment of calculous hydronephrosis and pyonephrosis
is discussed elsewhere.
Dangers of Nephrolithotomy. The dangers of nephrolithotomy
are haemorrhage and septic infection.
Cases have been recorded where at the end of the operation of
nephrolithotomy very severe haemorrhage occurred from a large
vessel and necessitated nephrectomy. These cases are, however,
very rare, and there is usually no difficulty in controlling the
haemorrhage by sutures so long as the fibrous capsule is intact. If
the capsule has been stripped from the kidney, the sutures cut out
762 Renal Calculus.
very easily. Bleeding may, however, commence after the operation
and the blood escapes into the pelvis and causes hsematuria. This
post-operative haematuria may assume serious proportions and
clotting may occur in the bladder, or it may persist and cause
profound anaemia and even death.
When post-operative hasmaturia is moderate, treatment by
absolute rest and the application of an icebag together with small
doses of morphia and the administration of calcium lactate (10 to
15 gr. every four hours for two days) may be tried. Should this
fail to arrest the bleeding, operation should not be too long delayed.
And further, if the haemorrhage is alarming from the first, operation
should be performed at once.
The kidney should be rapidly exposed and the previous incision
opened. Usually a quantity of blood escapes under tension. A
stream of hot lotion should be directed into the cavity and then a
medium-sized rubber tube introduced into the renal pelvis.
Around the tube long strips of aseptic gauze are packed.
The patient may be infused on the table and continuous rectal
infusion commenced on returning to bed. This treatment usually
suffices to control the haemorrhage, and after three days the packing
is removed and if necessary renewed.
Rarely it becomes necessary to remove the kidney in order to
control post-operative haemorrhage.
Sepsis may arise from a kidney already infected or may be
introduced at the operation. Septic pyelonephritis sometimes
follows nephrolithotomy, and frequently causes severe haamaturia.
Post-operative haematuria combined with elevation of the
temperature is usually due to this cause. Peri-renal suppuration
may occur. The infection usually subsides, and only very rarely
is there an infection of the lumbar wound, necessitating opening
it up.
Results. The results are influenced by the presence or absence
of sepsis previous to the operation. Some authorities, notably
Morris, regard only such cases as nephrolithotomy in which the
kidney is healthy and there is no infection. Most surgeons look
upon all cases of removal of calculi from the kidney as cases of
nephrolithotomy. The results of nephrolithotomy in cases un-
complicated by sepsis or dilatation show a very small death-
rate. Watson collected 185 such cases with three deaths (2'2 per
cent.).
Rovsing collected 115 cases of neprolithotomy in non-infected
cases with seven deaths (6'08 per cent.).
In infected cases the mortality is high. Schmieden collected 211
Renal Calculus. 763
cases with forty-three deaths (20'3 per cent.), and the statistics of
Kiister show 251 cases with 50 deaths (19'9 per cent.)-
After nephrolithotomy the wound usually heals rapidly even
when mild infection has been present. In infected cases a fistula
may persist, and this is occasionally due to calculi having been left
in the kidney or to ureteral or pelvic obstruction.
In Schmieden's cases (infected) a fistula followed the operation in
22*2 per cent. In Watson's collection (infected and non-infected)
there were 8'1 per cent, of fistula.
Pyelolithotomy. By this is understood the removal of a
calculus through an incision in the pelvis of the kidney.
The posterior wall of the pelvis is incised so that the renal
vessels in relation to the anterior wall are avoided. A posterior
branch of the renal artery and irregular vessels must be avoided.
The kidney is drawn out of. the lumbar wound. The organ is
grasped in the left hand of the operator and turned forwards and
upwards, so that the posterior aspect of the pelvis is
exposed. The fat covering the pelvis is removed with
dissecting forceps. If a stone is felt in the pelvis, it is made
prominent by pressure of the fingers from the front of the pelvis
and a longitudinal incision made upon it through the posterior wall.
The stone is then removed with forceps. If a stone is not felt, the
kidney is given to an assistant to hold and the posterior surface of
the pelvis exposed by dissecting away the fat. A longitudinal
incision is then made in this about three-quarters of an inch in
length and a fine catgut suture passed through each lip and the
wound held open by these. A probe is now introduced and the
pelvis and calyces are explored. If a calculus is felt, the probe is
held in position and a pair of fine forceps slipped along it, the
stone grasped and removed.
After removal of the stone the edges of the wound in the pelvis
are brought together by interrupted stitches of fine catgut. Over
this a row of Lembert's sutures may be inserted.
Since 1905 I have covered all wounds in the renal pelvis with a
flap of the fibrous capsule turned down from the kidney and
stitched in place. This has proved very successful in preventing
the escape of urine and promoting primary healing. A drainage
tube is placed behind the kidney and the lumbar wound closed.
Usually there is no escape of urine, but occasionally some urine
leaks for a few days. Barely this continues for a fortnight or
longer and a urinary fistula may become established.
The cases which are suitable for pyelolithotomy are small
unbranched stones lying in the pelvis.
764 Renal Calculus.
As a method of exploration of the kidney for stone, pyelotorny is
usually considered inferior to nephrotomy. The relative methods
of these operations will be discussed later.
Results. In Schmieden's statistics there are fifty-four cases of
pyelolithotomy, of which thirty-six (66'7 per cent.) were completely
healed, twelve (22*2 per cent.) recovered with a fistula, and six
(ll'l per cent.) died.
These operations were performed only on uncomplicated cases.
The Relative Merits of Nephrolithotomy and Pyeloli-
thotomy. By nephrolithotomy all calculi which are not so
extensive or so fixed as to require nephrectomy can be removed.
Pyelolithotomy can only be performed for small or moderate sized
calculi occupying the renal pelvis or calyces, and it is only in
regard to these cases that the relative merits of the two operations
can be discussed.
In cases where there is a short pedicle and a deep loin pyelo-
lithotomy may be impossible where nephrolithotomy presents no
insuperable difficulty.
In nephrolithotomy the incision through the renal tissue causes
some destruction of renal tissue, and the sutures introduced to
control haemorrhage cause further destruction. Each suture is a
sclerotic centre and fibrosis may extend for some distance around
it. In pyelolithotomy there is no destruction of renal tissue by
incision, tearing or suture.
In nephrolithotomy there is some immediate and remote danger
of haemorrhage ; in pyelolithotomy a retro-pelvic vessel may be
wounded, but there is little probability of severe haemorrhage. In
an exploration of the kidney for stone which cannot be felt in the
pelvis, pyelotomy is looked upon as inferior to nephrotomy. In a
single large pelvis (ampullary pelvis) Legueu looks upon both
operations as being equally efficient.
When there is a branched pelvis (ramified pelvis), nephro-
lithotomy is the better operation, as it is difficult to explore all the
calyces satisfactorily with an instrument and the small calibre
makes the introduction of the finger impossible.
The exploration in nephrotomy is also difficult in many cases.
After incising the kidney the finger may pass through the wound
into the sinus of the kidney without entering the pelvis at all,
and a probe appears at the hilum alongside the pelvis. The
sounding of each calyx with an instrument when the pelvis is much
branched is less likely to be successful through a nephrotomy than
through a pyelotomy wound. In cases where a small radiographic
shadow is present and the stone is not felt in the renal pelvis, and
Renal Calculus. 765
when the kidney can be brought out of the wound, I usually explore
the pelvis first by pyelotomy and thorough sounding with a probe,
and if this fails, open the kidney and explore the calyces through
both incisions simultaneously.
Urinary fistula is stated to occur more frequently after pyeloli-
thotomy than after nephrolithotomy, and the statistics of a number
of cases support this view.
The danger of a fistula following pyelolithotomy has been over-
stated. The probability of post-operative fistula is slight, if care is
taken to remove any obstruction to the flow of urine along the
ureter and with accurate suturing of the pyelotomy wound. In
cases of moderate sized unbranched calculi in the renal pelvis, and
for many small stones concealed in the calyces, pyelolithotomy is
preferable to nephrolithotomy, as it is more easily performed, there
is no danger of haemorrhage, and the kidney is not damaged.
Nephrectomy. It is an indispensable preliminary to
nephrectomy that the presence and functional activity of the
second kidney should be proved before the operation.
Primary nephrectomy is rarely practised for calculus. Under
the following conditions it may become necessary : (1) Severe un-
controllable haemorrhage during nephrolithotomy ; (2) when the
kidney is atrophied or destroyed by suppuration or dilatation;
(3) when calculi are so numerous and large that they cannot be
removed without destroying the kidney ; (4) a malignant growth
has been found with renal calculi and necessitated nephrectomy.
Secondary nephrectomy may be called for : (1) When there is
urinary fistula causing great discomfort irremediable by other
means ; (2) recurrence of stone with an atrophied kidney ; (3) pro-
longed renal suppuration.
The operation may be very difficult on account of extensive
adhesions to the peritoneum, colon, liver, aorta and vena cava.
An intra-capsular operation is often impossible from the adhesion
of the kidney to the capsule, or a portion of the kidney may
be shelled out, while the rest of the organ is firmly adherent.
Watson collected the following statistics : Primary nephrectomy,
136 cases, forty-one died (30*1 per cent.); secondary nephrectomy,
thirty-three cases, six died (18'1 per cent.).
Bilateral Calculi. It is unwise to remove the stones from
both kidneys at the same operation. The best kidney should first
be operated on in case it may become necessary to perform
nephrectomy on the second kidney later. Nephrolithotomy should
be performed on both sides whenever possible.
Kuster collected twenty double operations, and found ten
766 Renal Calculus.
successful cases, three recovered with fistulas and seven died, the
fatal result being usually caused by uraemia.
Calculus in a Solitary Kidney. A conservative operation is
here a necessity. Pyelolithotomy is preferred to nephrolithotomy
whenever possible. Both operations have been successfully
practised. The same limitation applies to calculus in a horseshoe
kidney.
J. W. THOMSON WALKER.
7 6y
RENAL AND PERI-RENAL FISTUL/E.
PERI-RENAL FISTULA may be connected with the kidney or ureter,
or arise apart from the" urinary organs.
Those unconnected with urinary organs take origin in a peri-
nephritic abscess, which may be secondary to an empyema, to an
appendix abscess or some other cause.
Urinary fistulee are spontaneous or post-operative.
Spontaneous urinary Jistuhe may result from the rupture of an
untreated pyonephrosis on the surface of the body, or into a
bronchus, the stomach or elsewhere.
Post-operative Jistuhe open in the lumbar region. The fistula
may be intentionally produced, as in the operation of nephrostomy,
or it may follow the operations of nephrolithotomy, nephrotomy,
pyelotorny, or nephrectomy.
Before operating upon a fistula in the lumbar region it is
necessary to obtain the following information :
(1) What is the origin of the fistula, and is it connected with the
urinary tract ?
The history of the case will point either to a renal origin or to
an empyema or appendix abscess. The absence of changes in the
urine and the presence of a healthy kidney on the fistulous side is
shown by cystoscopy, and the examination of the urine drawn from
the kidney by the ureteral catheter will show that the fistula is not
urinary. The discharge from the fistula should also be examined
for urea, which can be detected if even a small quantity of urine is
present.
After an mtra-muscular injection of methylene blue the discharge
will be tinged with blue if the fistula is urinary.
By injecting a solution or emulsion of bismuth into the fistula
and obtaining a radiograph the course of the track can be followed,
and a cavity in the thorax or elsewhere may be demonstrated.
There is frequently a peri-renal cavity which is not necessarily
connected with disease in the kidney.
(2) In a urinary fistula is the ureter patent ?
This information is obtained by catheterisation of the ureter.
(3) What is the functional power of the fistulous kidney ?
The urine from both kidneys is withdrawn by catheter, examined
and compared, and the discharge from the fistula is also
y68
Fistulae, Renal and Peri-Renal.
examined. The phloridzin and methylene blue tests of the renal
function should be used.
Treatment. In non-urinary peri-renal fistulae extensive
operations may be required, such as the exploration of the peri-
nephritic tissue, the search for a diseased retro-caecal appendix, or
the obliteration of a cavity in the pleura by resection of ribs.
When a permanent renal fistula is intentionally produced, the
treatment will consist in the provision of an efficient apparatus
Flo. 1. Drainage apparatus for renal fistula.
to collect the urine discharged and prevent it from soaking the
clothes.
A modification of Irving' s supra-pubic drainage apparatus is the
best for this purpose (Fig. 1). It consists of a shallow celluloid
cup with rolled-over edge, and a flat detachable bottom which is
perforated. A rubber drain opens on the dependent part of the
wall and leads to a receptacle. The apparatus is held in position
by rubber bands which pass round the body.
When a lumbar fistula follows nephrectomy, the cause is usually
a septic ligature. The fistula usually penetrates deeply to the
renal pedicle. It may be scraped and cleaned out by means of a
plug of gauze rolled round sinus forceps. If it persists, the track
should be dissected out and pockets opened up.
Fistulas, Renal and Peri-Renal. 769
In urinary fistula, when the ureter is patent, Albarran recom-
mends drainage by a catheter en demeure in the ureter.
In order to get a large catheter into the ureter he introduces by
means of a cystoscope a large stilette (70 centimetres), which is
flexible for the first 6 centimetres. Over this stilette a catheter with
a terminal eye is passed, and ascends the ureter to the renal pelvis.
The catheter is held in place and the stilette removed. The
catheter is left in the ureter for four or five days, and then changed
after passing the stilette as a guide. Eventually a No. 13 F.
catheter may thus be passed. The renal pelvis is washed daily with
silver nitrate solution (1 in 1,000). This continuous catheterisation
is maintained for three weeks.
Should this fail or be impracticable, a plastic operation should
be performed upon the renal pelvis.
If the ureter is impassable and the kidney has been shown to
retain a considerable proportion of its function, a plastic operation
on the renal pelvis is necessary ; but should the functional value
of the kidney be low and that of the second kidney adequate,
nephrectomy should be performed.
J. W. THOMSON WALKER.
S.T. VOL. II. 49
770
HYDRONEPHROSIS.
THE following points are important in the treatment of hydro-
nephrosis :
(1) Unilateral hydronephrosis is usually due to obstruction at
the upper end of the ureter, but occasionally a stone, new growth,
stricture, or other cause of obstruction may be situated at the
lower end of the ureter or at some intermediate part.
(2) Obstruction at the uretero-pelvic junction may be due to
stone, valves, stricture, pressure of an aberrant vessel, to kinking
from undue mobility of the kidney.
(3) The removal of a stone may not relieve the obstruction, for a
stricture may co-exist.
(4) The presence of an aberrant renal artery in a case of
hydronephrosis cannot be accepted without further evidence, as
the cause of the hydronephrosis.
(5) The seat of the obstruction may be above or below the level
of crossing of the aberrant artery, in which case the artery is
unconnected with the obstruction.
(6) If the artery crosses the ureter at the level of obstruction, it
may be accepted as the primary cause, but there may also be
stenosis at this level.
(7) Hydronephrosis in a movable kidney may be due to kinking of
the ureter, but there may be a valve or stenosis at the junction of
the pelvis and ureter, which is the true cause of the obstruction.
(8) In intermittent hydronephrosis the kidney and renal pelvis
do not contract and return to the normal conditions between the
attacks of distension. They form a slack, partly filled sac, which
is too soft to be felt on abdominal palpation.
(9) The obstruction is usually incomplete even in the largest
hydronephroses. The urinary tension never, except in the latest
stages, becomes so great that the renal secretion is entirely
abolished.
Until a late stage there is polyuria on the obstructed side. I
have observed the following differences in the quantity of urine
secreted in the two sides during the same time :
Diseased Side. Healthy Side.
Case I. Early stage . . . 82'6 c.c. 68*4 c.c.
,, IL Advanced stage . . 45 c.c. 213 c.c.
,, III. Complete block . . No urine. 158'5 c.c.
,, IV. No urine. 150 c.c.
Hydronephrosis. 771
(10) After relief of the obstruction the kidney does not return
to normal. In the early 'stage of- hydronephrosis the damage is
slight and the functional value of the organ is little impaired. In
the later stages the kidney tissue is extensively destroyed and the
functional value is much reduced.
(11) Permanent relief of the obstruction is followed by con-
siderable improvement in the function of the kidney.
(12) The functional value of a hydronephrotic kidney is usually
much greater than would be supposed on examining the thickness
of the hydronephrotic sac. The renal tissue, although present in a
thin layer and much damaged by interstitial nephritis, is spread
over a large area.
(13) The work of a hydronephrotic kidney may form a large
proportion of the total renal function.
(14) The renal tissue is already much damaged when the kidney
can be felt as a hydronephrosis on abdominal palpation.
(15) In order to make an early diagnosis of renal retention the
capacity of the renal pelvis should be measured by means of the
ureteric catheter, and the injection of a known quantity of fluid,
by radiography after the injection of a non- irritating fluid opaque
to the X-rays and by measurement of the size of the radiographic
shadow of the kidney.
By these means distension of the kidney can be recognised
before enlargement of the organ can be detected on abdominal
palpation.
(16) Bilateral hydronephrosis is usually due to ureteral or vesical
disease or to pressure on the ureter within the bony pelvis. It
may be due to bilateral renal or ureteral calculus.
Before he commences treatment for hydronephrosis the following
information must be in the possession of the surgeon :
(1) Is the hydronephrosis unilateral or bilateral, and what is the
seat of the obstruction ?
Obstruction in the lower urinary organs or from some growth or
other condition in the bony pelvis must be excluded.
(2) What is the condition of the second kidney when one is
hydronephrotic ?
This information is obtained by radiography, the examination of
urine drawn from this kidney by the ureteric catheter, and the use
of the tests for the renal function.
If the case is one of calculus hydronephrosis, the radiogram will
show the position of the obstructing calculus.
The passage of a ureteric catheter will show the position of the
obstruction.
492
77 2 Hydronephrosis.
The question as to whether the hydronephrosis is unilateral or
bilateral is settled by the history of the case, by abdominal
palpation, by catheterisation of the ureters, and, if necessary, by
pyelography.
(3) What is the cause of the obstruction ? A careful radio-
graphic examination should be made of the whole urinary tract.
A ureteral calculus may be felt from the vagina or rectum.
A movable-kidney may be present, and have existed for some
years. Beyond these points no further information is likely to be
obtained in regard to the cause before operation.
Congenital Hydronephrosis. Hydronephrosis in the new-
born and infant is more frequently of interest to the obstetrician
than to the surgeon on account of the difficulty in parturition
to which it may give rise. The condition is frequently associated
with congenital malformations, such as harelip, imperforate anus,
etc., and the child seldom survives birth for more than a few
hours, occasionally a few months, and very rarely four or five
years. Morris performed bilateral nephrotomy on a male child
within twenty-four hours of its birth, and the child survived
ninety-four days.
Hydronephrosis due to Obstruction in the Urethra, Bladder,
or Bony Pelvis. In cases of urethral obstruction from stricture
or enlarged prostate, operations will be undertaken for the relief
of these conditions. The presence of dilatation of the kidneys
in these cases and in cases of growths of the pelvic organs, such as
uterine and ovarian tumours, greatly increases gravity of such
operations.
In growths of the bladder which involve one ureter causing a
moderate degree of hydronephrosis, but which are in other respects
suitable for operation, removal of the growths with transplantation
of the ureter to some other part of the bladder should be under-
taken. No direct operative treatment of the hydronephrosis will
be necessary in these cases.
In nearly all these cases the formation of a hydronephrosis can
be prevented by early operation, and this is especially true in cases
of urethral obstruction and of bladder growth.
Movable Kidney with Hydronephrosis. In cases where
hydronephrosis is combined with undue mobility of the kidney, the
mobility is not always, at the time of operation, the cause of the
obstruction ; strictures, valves and adhesions may be found, the
removal of which is necessary for the relief of the obstruction.
But in many cases the mobility is the direct cause of the
ureteric obstruction. In cases of movable kidney hollowing of the
Hydronephrosis.
773
organ with slight distension of the pelvis is frequently discovered.
In these cases nephropexy will be sufficient to cure the hydrone-
phrosis.
The early diagnosis of these cases is possible by the methods
described, and early operation should be insisted upon in order to
prevent destruction of the kidney 'tissue.
In more advanced cases, even when no sign of narrowing or
adhesion or permanent kinking is found on exposure of the
kidney, the renal pelvis must be opened and the patency of the
outlet and the ureter examined.
When a plastic operation has been found necessary in such
cases nephropexy must afterwards be performed.
Hydronephrosis with Calculus. - When calculus in the
ureter or renal pelvis
is combined with hydro-
nephrosis the distension
of the kidney has fre-
quently arisen from this
cause, but in many cases
strictures of the ureter
are present, and have
either preceded the for-
mation of calculus or
developed secondarily.
In addition to the
removal of the calculus,
the ureter must there-
fore be examined for the
presence of stricture.
Hydronephrosis
with Aberrant Vessels. In cases where an aberrant vessel is
found, which bears no close relation to the point of obstruction,
it need only be divided, if it interferes with the plastic operation
for the relief of the obstruction. In other cases it lies in close
relation to the point of obstruction, and is evidently the cause of
the obstruction.
If it is an unimportant vessel passing to the hilum or to the
peri-renal tissues or an additional vessel arising from the aorta, it
should be divided between two ligatures and the patency of the
ureter then examined, and, if necessary, a plastic operation per-
formed. If, however, the aberrant vessel is an important artery
passing to the lower pole of the kidney, and it is not proposed to
perform nephrectomy, the vessel should be preserved and some
FIG. 1. Pyeloplication.
774
Hydronephrosis.
form of plastic operation carried out which will circumvent the
obstruction caused by it.
Operations for Congenital and Acquired Malformations of
the Ureter. - - (1) Operations which modify the form of the renal
pelvis :
(a) Nephropexy in intermittent hydronephrosis. The kidney is
not only raised and fixed, but the pelvis resumes its old form,
provided that the distension has not been too long established and
led to a weakening and sagging of the sac wall.
(6) To remove the pouching Israel introduced an operation
FlO. 2. Resection of renal
pelvis. Triangular por-
tion thrown down.
FIG. 3. Resection of renal pelvis. Triangular
portion removed, stitching wall of reduced
pelvis.
" pyeloplication," by which the redundant part of the wall is folded
inwards after emptying the sac by puncture. A row of Lernbert
sutures fix the fold. In addition, an operation may be performed
to correct any malformation of the uretero-pelvic junction (Fig. 1).
(c) The writer resects a large triangular portion of the renal
pelvis, the apex of the triangle being at the uretero-peivic junction,
and the base at the margin of the kidney. A plastic operation for
relief of any malformation of the uretero-pelvic junction is then
performed, and the wound closed by Lembert's sutures. A flap of
renal capsule is reflected and stitched over the pelvic wound, the
kidney drained through a nephrotomy wound and fixed to the
posterior abdominal wall (Figs. 2, 3, 4, 5).
Hydronephrosis.
775
(d) " Orthopaedic resection " or capitonnage. Albarran removes
the pouch consisting of the portion of the pelvis and kidney
FIG. 4. Resection of renal pelvis.
Pelvic wound closed, flap of renal
capsule marked by dotted line.
FIG. 5. Resection of renal pelvis. Flap
of renal capsule stitched over pelvic
wound and nephrotomy wound closed.
which lies below the level of the outlet of the pelvis, and sutures
the opening (Figs. 6, 7).
(2) Pyelo-ureteral A nastoinosis : (a) Lateral anastomosis. This is
FIG. 6. Orthopaedic resection,
incision.
Line of
FIG. 7. Orthopaedic resection. Pouch
removed, closing wound by inter-
rupted sutures.
the oldest plastic operation for hydronephrosis, and was performed
by Trendelenberg in 1886 (Fig. 8). The ureter is split longitudi-
nally on a level with the lowest part of the hydronephrotic sac and
Hydronephrosis.
a transverse incision is made in the sac wall. The edges of these
wounds are sutured and the kidney is drained and fixed (Fig. 9).
FIG. 8. Lateral anastomosis of kidney FIG. 9. Detail of stitching in lateral
and ureter. anastomosis of kidney and ureter.
(b) Transplantation of the ureter into the lowest part of the sac
(uretero-pyelo-neostomy) (Fig. 10).
The ureter is cut across transversely or obliquely and in addition
FIG. 10. Uretero-pyelo-neostomy.
FlG. 11. Detail of stitching in uretero-
pyelo-neostomy.
it may be split longitudinally to prevent stenosis. An incision is
made into the lowest part of the sac, a small triangular portion
excised and the ureteral mucous membrane is sutured to the pelvic
mucous membrane (Fig. 11).
Hydronephrosis.
777
(c) Nephro-cysto- anastomosis : This is the direct anastomosis of
a hydronephrotic sac with a bladder, and has been performed in
cases of displaced hydronephrotic solitary kidney. The operation
is performed intra-peritonealiy. The sac is emptied by puncture and
the peritoneum over its lowest part incised and brought into contact
with an incision in the upper posterior peritoneal surface of the
bladder and the edges sutured.
(3) Plastic Operations on Strictures and Valves : (a) Incision of
a valve. This is performed through a nephrotomy wound or a large
opening in the posterior wall of the dilated sac. The pyelo-ureteral
opening is found and one blade of a pair of scissors introduced into
it. The valve is then cut downw r ards. If it is thin and formed
FIG. 12. Operation for pyelo-ureteral
valve. Incision in posterior wall of
pelvis.
FIG. 13. Operation for pyelo-ureteral
valve. Scissors in position for cutting
valve.
only of mucous membrane, this will suffice ; usually, however, the
thickness of the pelvic and ureteral walls are cut through and these
are sutured to each other (Figs. 12, 13, 14, 15).
(b) Uretero-pyeloplasty : This consists in making a longitudinal
incision through a stricture at the uretero-pelvic junction and
uniting the edges of the wound transversely (Fig. 16).
General Observations. (1) These operations are performed on
aseptic or on mildly infected hydronephrotic sacs.
(2) When infection is present, a preliminary nephrotomy with
drainage for some weeks should be carried out.
(3) The lumbar extra -peritoneal route is used in all except
nephro-cystostomy.
(4) Adhesions of the hydronephrotic sac and ureter should be
removed before commencing the plastic operations.
778
Hydronephrosis.
(5) Operations on the renal pelvis are performed on the posterior
surface. The renal vessels are usually adherent to and stretched
over the anterior surface.
(6) Before commencing the operation a catheter should be passed
FIG. 14. Operation for pyelo-ureteral
valve. Valve cut, stitching of edges
of ureter and pelvis commenced.
FIG. 15. Operation for pyelo-ureteral
valve. Stitching completed.
up the ureter from the bladder to ascertain the position of the
obstruction and assist in the operative measures.
(7) The pelvic outlet may be examined through a nephrotomy or
pyelotomy wound and the examination is rendered simpler by
everting this part of the sac through the wound.
(8) The sac should be drained through a nephrotomy wound.
FIG. 16. Uretero-pyeloplasty. a. Longitudinal incision through stricture.
b, c. Edges united transversely.
Some surgeons leave a ureteric catheter in situ, but this is not
necessary and may be a source of irritation.
(9) Nephropexy is an important part of many of these opera-
tions.
(10) Catgut should be used as a suture material.
Hydronephrosis.
779
Nephrostomy. Incision and drainage of the sac without any
attempt to overcome the cause of. the obstruction is sometimes
performed. This has been followed in between 30 and 45 per cent,
of cases by re-establishment of the flow of the urine through the
ureter and healing of the nephrotomy wound. In the remaining
cases a fistula persisted.
Results of Plastic Operations. Schloffer collected eighty-six
operations, with the following results :
Operations.
Deaths.
Failures.
Section of valves .
12
1
3
Uretero-pyeloplasty
18
1
4
Uretero-pyelo-neostomy
Lateral anastomosis
19
13
2
2
6
3
Plastic operations on renal
pelvis
1
1
Pyelopli cation
4
Orthopaedic resection .
Combined operations .
8
11
1
Total
86
7
17
To this I can add three personal cases treated by my method, with
two successes and one failure due to haemorrhage into the resected
pelvis. This patient was submitted to nephrectorny and recovered.
I also had a successful result in a case of pyelo-ureteral anastomosis.
Nephrectomy. Primary nephrectorny is only indicated when
the sac is very large and its wall so thin and fibrous that no
renal tissue is present, and only in cases when it can be proved
that a second kidney is present and efficient.
Secondary nephrectorny is required when nephrotomy and plastic
operations have failed.
J. W. THOMSON WALKER.
780
INJURIES OF THE KIDNEY.
INJURIES OF THE KIDNEY WITHOUT EXTERNAL WOUND.
IN eases of slight and moderately severe uncomplicated rupture
of the kidney the treatment is non-operative. The side is strapped
with adhesive plaster reaching to the middle line in front and
behind to prevent movement, and a broad bandage is applied over
this to give pressure. Ice-bags should be placed over and under
the loin, and the patient kept absolutely quiet in the recumbent
position. The food should be fluid. Haemostatics are of little
value, and those which raise the blood-pressure, such as ergot, are
harmful. Calcium lactate in doses of 10 to 15 gr. every four hours
may be tried. It should not be continued longer than forty-eight
hours. Morphia should be given hypodermically, and serves the
double purpose of relieving pain and quieting the circulation.
Shock, if not profound, should not be too energetically treated
lest bleeding be encouraged. Warmth to the extremities and the
recumbent position will usually suffice. If the patient cannot pass
water, the bladder should be emptied by catheter under the most
rigid aseptic precautions. Clots, if numerous, may be washed out.
If the bladder is distended,. and on passing a catheter only a little
bloody urine is drawn, there is an accumulation or clot in the
bladder which cannot be removed by catheter. An attempt may
be made by means of a large evacuating cannula and bulb, such as
is used after the operation of lithotrity, to remove the clots by
suction ; but this method should not be persisted in if it is not
quickly successful. The bladder should, in case of failure, be
opened supra-pubically, the clots cleared out, and a large rubber
drainage tube introduced. The operation should be rapidly carried
out. Should no such complications supervene, the patient should
be kept in bed for a fortnight after the haemorrhage has ceased
and all local tenderness and swelling have disappeared.
Operative interference may be required for the following
conditions : (1) Immediate severe haemorrhage ; (2) delayed severe
haemorrhage ; (3) suppuration of the injured kidney ; (4) septic
peritonitis ; (5) hydronephrosis, pyonephrosis. When there is a
rapidly increased swelling in the region of the kidney or free fluid in
the peritoneum or severe persistent hasmaturia, and especially when
there is progressive ansemia, operation is necessary to control the
Injuries of the Kidney. 781
bleeding. An oblique lumbar incision should be made and the
damaged kidney exposed ; clots are cleared away and a careful
search made for the bleeding point. It may be necessary, when
the haemorrhage is free, to compress the renal pedicle with the
thumb and fingers. A single tear in the kidney substance should
be closed by catgut sutures passed through the substance of the
kidney. If one or several portions are partly detached by a number
of lacerations, packing with strips of sterilised gauze should be
resorted to, and will successfully control the bleeding.
When a large branch of the renal artery is the source of haemor-
rhage it should, if possible, be picked up in long artery forceps and
tied with a silk ligature. It may be necessary to underrun the
vessel with a curved needle and silk in order to tie it securely.
A distended renal pelvis should be incised and the clots turned
out. If this is followed by considerable haemorrhage, the pelvis
may be packed with gauze.
Detached portions and shreds of kidney tissue should be removed,
and rents repaired as far as possible.
When the kidney is injured so that repair does not appear
possible, primary nephrectomy should be performed.
All operative measures should be carried out with the utmost
despatch, and when the haemorrhage has been controlled, rectal
and intra- venous infusion of glucose solution (2^ per cent.) should
be given.
When there is free fluid in the peritoneum and the diagnosis of
injury to the kidney is clearly established, the kidney should first
be exposed and dealt with, and the peritoneal cavity cleared of clots
and blood by an extension of the lumbar incision. When the
diagnosis of injury to the kidney is uncertain, an exploratory
laparotomy will be necessary, the abdomen being opened in the
middle line.
Nephrectomy is called for when there are recurrent attacks of
haemorrhage after injury to the kidney.
Suppuration of the damaged kidney necessitates lumbar explora-
tion. Free incision, irrigation and drainage may be all that is
necessary, but nephrectomy should be performed if there is
extensive destruction of the kidney tissue.
Laparotomy and drainage of the peritoneal cavity will become
necessary if septic peritonitis supervenes.
Persistent anuria should be treated by nephrotomy and packing.
The treatment of hydronephrosis and pyonephrosis are discussed
under their proper headings.
Results. Prognosis is chiefly affected by haemorrhage and
782 Injuries of the Kidney.
injury to other organs. Recovery takes place in 70 per cent, of
uncomplicated cases. Grawitz found that fifty-eight out of 108
cases of injury to the kidney recovered.
The fatal result in fifty cases was caused by injury to other vital
organs in eighteen, immediate haemorrhage in fourteen, delayed
haemorrhage in eight, suppuration in seven, and failure of the renal
function in three. The mortality is much higher in children than
in adults, owing to the greater frequency with which the peritoneum
is ruptured.
The results of operative treatment in injuries of the kidney
have greatly improved in recent years since the necessity of early
aseptic operation has been recognised.
Of thirteen cases of nephrectomy performed on account of
dangerous haemorrhage only four died, and the six patients operated
on most recently all recovered (Guterbock). Willis collected
fourteen cases of nephrectomy for injury to the kidney, with nine
recoveries and five deaths.
Albarran knows of six cases of operation in which packing of the
injured kidney was resorted to, and all recovered.
The operative interference in septic complications is frequently
postponed until too late and the already exhausted patient succumbs.
In seven nephrectomies of this nature, four resulted fatally.
Nephrotomy has also a high mortality ; of eight cases four died
after the operation, and another after a second nephrotomy
(Guterbock).
The following general statistics may be quoted from Eiese :
Of 490 cases of uncomplicated subcutaneous injuries to the
kidney, ninety-three (18'9 per cent.) died. There were 327 treated
by expectant treatment, and of these sixty-nine (21*1 per cent.)
died, forty of the deaths being due to haemorrhage. In eighty-five
cases a conservative operation was performed (forty-six times on
account of bleeding), and ten died (11'7 per cent.). In seventy-eight
cases nephrectomy was performed (fifty-four on account of bleeding)
and fourteen died (17'9 per cent.).
INJURIES TO THE KIDNEY WITH EXTERNAL WOUND.
The external wound may lie in the loin or on the anterior
surface of the abdomen or over the ribs, and according to the
site and direction of the wound the intestine, liver, spleen, or
pleura may be wounded.
Any part of the organ may be affected, and portions may be
detached by bullet wounds. In the older forms of bullet, the ball
and portions of clothing might be embedded in the organ and
Injuries of the Kidney. 783
remain for considerable periods. A bullet may have a bursting
action on the kidney and cause extensive destruction of its
substance.
The blood escapes by the external wound, and if the calices or
the pelvis of the kidney are wounded, urine escapes along with it.
There is no peri-renal accumulation of blood, unless in rare cases
when the wound is a long sinuous track.
The kidney may partly prolapse from a large wound.
The wound is almost invariably infected, so that primary union
is very rare, and prolonged suppuration is common.
Urinary fistulas occur, but seldom persist.
External haemorrhage from stab wounds may be severe and
rapidly fatal. In bullet wounds the haemorrhage is seldom severe,
but it may be intermittent, recommencing after an interval of
several days.
The escape of urine seldom takes place at first. It usually
appears when the bleeding is diminishing, after a few days.
Septic complications occur about the fourth or fifth day.
Treatment. If the external haemorrhage is moderate and dimi-
nishing, it will suffice to clean and dress the wound. A careful
watch is kept for recurrent haemorrhage and septic complications.
If there is any reason to suspect that a foreign body is lodged
in the wound, the track should be freely opened up and the kidney
exposed and examined.
If the haemorrhage is severe and persistent, the kidney should be
exposed by an oblique lumbar incision. A single wound in the
kidney may be closed with catgut sutures. Detached portions of
the kidney may require removal, or if the kidney is extensively
lacerated, nephrectomy may be necessary.
When a large vessel is wounded at the hilum it may be very
difficult to control the haemorrhage, and clamps must be placed
upon the pedicle. If the blood-supply of the kidney is entirely
cut off in this way, it will be necessary to remove the kidney.
Kiister advises that, when a doubt exists as to the blood-supply
being sufficient to nourish the kidney, the clamps be left on for a
day, and then be removed on the operating table.
If the kidney now bleeds when it is pricked, it may be left
and packed with gauze. If it fails to bleed, nephrectomy is
performed.
A kidney prolapsed into a large lumbar wound is cleansed,
examined and replaced, fixing it in position by means of catgut
stitches. The wound is then cleansed and partly closed, and a
large drainage tube inserted.
784 Injuries of the Kidney.
In complicated cases, when it is probable that other organs are
wounded, an exploratory laparotomy will be necessary.
Results, In wounds of the kidney the prognosis is compara-
tively good, and operation is frequently undertaken with success.
Wounds of other organs increase the gravity of the prognosis.
Tuffier found in thirty-one cases eight died, and in six of these the
fatal result was due to complicating injuries.
The mortality of incised wounds of the kidney is as low as
15 per cent. (Albarran) ; but bullet wounds have a high mortality,
namely, 53 per cent. (Kiister).
The mortality of bullet and other wounds of the kidney in the
American Civil War was 66'2 per cent.
The statistics are all compiled from cases treated before the
development of aseptic wound treatment and abdominal surgery.
The duration of healing varies from three weeks to three months ;
rarely it may be prolonged to two years.
After healing of the wound, sequelae, such as inflammation in the
urinary track, fistulae, etc., may cause chronic invalidism. In
fifty-two recently healed wounds of the kidney, Tuffier found
twenty-two with sequelae.
Primary union is very rare, and prolonged suppuration is
common. Urinary fistulae occur, but seldom persist. In the
American Civil War there was only one permanent fistula in
seventy-four cases of bullet wounds of the kidney.
When healing has taken place the kidney is usually extensively
destroyed, and presents irregular depressed scars and extensive
adhesions to neighbouring parts.
J. W. THOMSON WALKER.
785
MOVABLE KIDNEY.
THE following points are important in considering the treatment
of movable kidney :
(1) Dilatation of the renal pelvis and kidney develops in varying
degree in the majority of movable kidneys from kinking of the
ureter or pressure upon it of bands, or from other causes.
(2) When the hydronephrosis can be detected by palpation,
either as intermittent or permanent enlargement of the kidney,
the destruction of secreting tissue of the kidney is already extensive,
and although considerable functional activity may remain, the kidney
is permanently damaged.
(3) If the undue mobility is relieved in the early stage, the
destruction of kidney tissue is arrested or prevented.
(4) The early symptoms of obstruction in movable kidney are
insignificant, and are likely to be overlooked.
(5) Dilatation of the kidney in the early stage may be diagnosed
by estimating the capacity of the renal pelvis after catheterisation
of the ureters, by radiography after filling the renal pelvis with
an opaque fluid, such as collargol (pyelography) , and by measure-
ment of the kidney shadow on a radiographic plate (proportional
renal mensuration). These methods are harmless in the hands of
an expert urinary surgeon.
(6) Some other disease, such as stone or tuberculosis, may be
present in addition to the abnormal mobility of the kidney.
(7) When the movable kidney is hydronephrotic, the obstruction
may be due to some condition, such as stenosis of the ureter, or the
pressure of an aberrant vessel, which is not relieved by nephropexy.
The Selection of Cases. The careful selection of cases for the
different methods of treatment is the only means of obtaining satis-
factory results. In cases where no symptoms are present, and there
does not appear to be any change taking place in the kidney itself,
as shown by enlargement or tenderness of the organ, or changes
in the urine, it will only be necessary to limit violent exercises,
such as horse-riding, and to warn the patient against lifting
heavy weights. The bowels should be carefully regulated. Should
symptoms appear, active treatment of the condition will become
necessary. In cases where symptoms are present a choice will have
to be made between palliative and operative treatment.
S.T. VOL. ii. 50
786 Movable Kidney.
In certain cases palliative treatment is contra-indicated, and
operative treatment is imperative :
(1) Where there are signs that the mobility is causing disease of
the kidney. This includes cases where the kidney is tender or
enlarged, cases of intermittent hydronephrosis, cases where haerna-
turia or albuminuria are present or there are tube casts in the
urine, or where slight or severe attacks of torsion of the renal pedicle
have occurred.
(2) Where the kidney is exerting harmful traction upon other
organs. This includes cases where there are gastric and intestinal
crises, and attacks of jaundice.
(3) Where the kidney lies below the waist line, and is un-
controlled by any mechanical apparatus, and when the use of a
mechanical apparatus causes pain and aggravates the symptoms.
(4) When the patient is going to reside in tropical or uncivilised
countries.
(5) When the patient has to perform manual labour, and the
expense of maintaining an apparatus in good order cannot be
borne.
In all other cases palliative treatment may be tried before
resorting to operation.
In cei'tain cases operative treatment is doomed to failure, and is
therefore contra-indicated :
(1) When general enteroptosis is present.
(2) When severe neurasthenia is present, and no symptoms can
be referred to the kidney.
In a few cases of movable kidney with neurasthenia, control of
the renal movements by a mechanical apparatus will alleviate or
cure the neurasthenia, and in these cases also fixation of the
kidney by operation will be followed by a similar result. This
view is generally held, but a few writers go further and advo-
cate operation in all cases of neurasthenia with movable kidney.
Palliative Treatment. (1) Treatment by rest and increasing
the body fat. It is claimed by a very few writers that this method
can bring about a cure of the renal mobility. They hope by
increasing the general fat of the body to produce a simultaneous
deposit around the kidney which will fix it in position. Such a
result is not obtained in practice. The method is, however, useful
in treating cases of movable kidney when neurasthenic symptoms
are present. In these cases a " rest cure " should be the first
resort, and an operation the last.
The patient is strictly confined to bed, and in severe cases full
Weir-Mitchell isolation should be exacted. The bowels are carefully
Movable Kidney.
787
regulated, and the food given with the view of increasing the body
weight. Milk is given in large quantities, graduated according to
the digestive powers. General massage is practised, but the kidney
areas are not subjected to manipulation. The treatment will extend
over a month or six weeks.
This is a useful preliminary to treatment by means of a mecha-
nical apparatus.
(2) Treatment by mechanical apparatus. Treatment by this
means is specially indicated when enteroptosis is present. It is
ERNST,
FIG. 1. Ernst's Kidney Truss.
suitable for any case of movable kidney, with the exceptions already
mentioned.
I shall describe three forms of apparatus :
(a) KIDNEY TRUSS. Ernst makes the truss, of which the follow-
ing is a description (Treves, Practitioner, January, 1905) : This
instrument consists of a thin, carefully -padded metal plate, which
exercises pressure upon the abdominal wall by means of two springs.
The pressure concerns the lower and inner margins of the plate, so
that the kidney is forced upwards and outwards (Fig. 1). It must
of necessity be applied when the patient is lying down. The truss
must be very carefully fitted, and the patient trained and practised
in its proper adjustment.
502
y88
Movable Kidney.
Treves found that the truss proved absolutely efficient in 90 per
cent, of cases. The kidney was kept in place and the symptoms
disappeared. The patient was able to take active exercise.
(b) KIDNEY BELT. A kidney belt is an abdominal belt which is
specially adapted for the relief of movable kidney (Fig. 2).
The belt consists of a broad band of jean or cotil, which surrounds
the waist and comes down over the iliac crests and is accurately
moulded to the hips. The lower border follows the curve of the
groin along Poupart's ligament, and in the middle line in front it
slightly overlaps the pubic bones. The upper border is about the
level of the umbilicus. The belt is stiffened by whalebone or
light steel busks. It is laced in front and behind. At each side
FIG. 2. Kidney Belt.
FIG. 3. Pad for Kidney Belt.
there is a broad inset of silk elastic. There are two perineal straps
to prevent the belt from riding upwards.
A kidney pad (Fig. 3) is added with the view of exerting pressure
upon the movable kidney and retaining it in place. This may be
horseshoe-shaped or oval. The pad may be fixed in the lining of
the belt, and consist of a rubber bag with a fine tube, which pierces
the belt and has a turncock ; or the pad may be a closed air sac or a
rubber bag containing glycerine, and fits into a pocket in the lining
of the belt. The belt must be put on when the patient is lying
down, and is worn over a silk or fine woollen undervest.
A belt of similar construction can be fitted to the lower part of
a corset, and by this means the perineal straps which are irksome
become unnecessary.
The pads which are used in these belts do not control the move-
ments of the kidney; were they sufficiently large and firm to do so,
they would exert injurious pressure upon the bowel. Their use
appears, however, to give a feeling of security to the wearer, and
for this reason they may be worn.
Movable Kidney. 789
(c) CORSET FOR MOVABLE KIDNEY (GALLANT). The corset is
made from measurements taken from each patient. At the bottom
the front steels must overlap the upper half-inch of the symphysis
pubes and fit very snugly over the hips, stretching tightly from one
to the other to flatten and reduce the hypogastrium. The circum-
ference must be equal to the natural waist, but there must be well-
marked incurving of the sides, so that the clothing is supported,
the corset prevented from slipping upward, and a fashionable
outline afforded to the figure. At the back and sides the upper
portion must accurately fit the thorax, while in front ample room
must be provided for the replaced stomach. Below the waist the
corset must be inflexible and inelastic, and the portion above the
waist must permit free play to the motions of the trunk and
thoracic walls. If the hips are poorly developed, pads should be
stitched inside the lower part of the corset to give rotundity to the
figure and avoid painful pressure on the iliac 'crests and anterior
spines. One lace begins at the eyelet above the waist-line, and
is continued down to the bottom of the corset. In the upper
part a thin, flat, hat-elastic is loosely threaded so as to keep the
corset in contact with the thorax, ;but not so tight as to cause
pressure.
The following directions must be followed in putting on the
corset : The lower lacing is freely loosened and the corset applied
to the body over a fine woollen or silk vest. The patient lies on
her back on a bed, and the legs are flexed to a right angle.
The abdomen is massaged by stroking upwards for ten minutes.
The corset is then drawn well down over the hips and fastened
in front, beginning with the lowest hook. Without lowering the
thighs the lace behind is drawn as tight as possible and tied.
The corset must not be drawn down after the front has been
fastened.
The lower part above the pubes must fit so snugly that the fingers
can barely be inserted between the corset and the pubes when lying
down. On rising, sitting, or walking the corset should not slip
upwards.
Gallant holds that from 90 to 95 per cent, of movable kidneys
with symptoms are cured of the symptoms by wearing this
corset.
Operative Treatment. The usual incision is an oblique incision,
extending from the angle of the last rib and the erector spinse
muscle downwards and forwards towards the anterior superior iliac
spine. A vertical posterior incision along the outer border of the
erector spinae muscle is used by Edebohls, and has the advantage
7QO Movable Kidney.
of slight disturbance of the muscles. A disadvantage is that the
exposure is limited. An anterior incision has been used by some
surgeons (Harlan, Stanmore Bishop). The incision runs from
the anterior edge of the latissimus dorsi forwards for 4 inches
parallel with the costal margin.
The great majority of operations are extra-peritoneal. The fatty
tissue around the kidney is carefully removed. The kidney is fixed
by sutures of catgut, silk, kangaroo tendon or a strip of tendon
from the erector spinae muscle of the patient. Strong catgut and
kangaroo tendon are the best. The sutures may be passed through
the fibrous capsule of the kidney alone or through the kidney
substance, or the fibrous capsule may be stripped and clipped away,
leaving the denuded organ in contact with the muscles of the
posterior abdominal wall. After decortication the capsule, instead
of being clipped away, may be used to sling the kidney by sutures
passed through it and then through the parietes. If nephrotomy
has been performed, I close the nephrotomy wound with thick
catgut sutures passed through the kidney substance, and then
decapsulate the kidney, leaving an area of capsule round the
nephrotomy wound to prevent the stitches cutting out. The stitches
which close the nephrotomy wound are then used to fix the
kidney.
In place of suturing, a fibrous sling may be formed at the lower
end of the kidney by packing the wound with strips of gauze
placed below the lower pole of the kidney, and thus promoting
granulation.
Stanmore Bishop forms a shelf of peritoneum by exposing the
kidney by an anterior incision through the peritoneum, and passing
sutures through the peritoneum below and internal to the lower
pole. The sutures pass through the muscles of the posterior
abdominal wall, and are tied behind after division of the skin.
Watson Cheyne exposes the kidney by an anterior incision and
pushes aside the peritoneum. Flaps of capsule are stripped from
the lower pole and stitched to the muscles, so that a shelf of fibrous
capsule is formed below the kidney.
Results. The operative mortality is stated at 1 per cent., but it
is lower than this in the practice of most surgeons. The statistics in
regard to the success of operation vary. Keen found that in 116 cases
examined, not less than three months after operation 57'8 per cent,
were cured, 12*9 per cent, improved and 19'8 per cent, failed.
Failure may be shown by recurrence of the mobility or persistence
of pain. In forty-two cases examined by Me Williams twenty-two were
cured, eight greatly benefited, seven somewhat relieved, and five
Movable Kidney. 791
unrelieved of symptoms. Improvement in many cases was only
seen some months after the operation. There were 48 per
cent, of cures where parenchymatous sutures were employed.
Wilson and Howell examined forty-one cases after nephrotomy
had been performed at St. Bartholomew's Hospital, and found twelve
cured, eight greatly improved, twelve improved, and nine unaffected
by the operation.
J. W. THOMSON WALKER.
792
ACUTE NEPHRITIS (ACUTE BRIGHT'S DISEASE).
THIS is seldom primary except as a sequela of an acute fever,
such as scarlatina. Most cases so labelled are exacerbations of a
chronic condition.
The patient should be in bed. So long as the urine is scanty, and
hsematuria with lumbar pain persists, or any fever is present, the
diet should be of milk and farinaceous food. The presence of
hsematuria alone does not forbid a richer diet. It often persists for
a long time.
No drugs directly influence renal congestion or inflammation.
The point is to keep the patient in the condition most favourable
to its subsidence.
The chief symptoms that need attention are in the usual order
of their occurrence, oliguria, haematuria, alUuminuria, nausea and
vomiting, dropsy and uraBmia.
The diminution of urine sometimes amounts to complete
suppression. Occasionally, when slight, a milk diet is sufficient
to relieve it. If not recourse must be had to diuretics. These are
of three kinds. The first are the organic salts of the alkalies
(Pot. citrat., Pot. tartr. ac., Pot. acet., Sod. bicarb., Sod. citrat.,
Liq. ammon. acetatis), which are gentle stimulants of the renal cells.
Their excess in the blood leads to their excretion by the epithelium
of the tubules, and they draw with them a certain amount of water.
A good method of using them is the Imperial drink, a lemonade
made with a drachm of acid tartrate of potash to the pint. When,
as sometimes happens, the situation is partly due to cardiac
weakness, tonics of the digitalis group are needed (Tr. digitalis,
strophanthi [U.S.P., irtl to 3] , vel convallariae, ni5 to 15 ; Infus.
digitalis, jij to 5iv [U.S. P., 5j to 5ij] ; Sulphate of sparteine, gr.
to 1 ; Nativelle's crystalline digitaline, gr. aio)- I think myself the
infusion of digitalis acts best. A third class of diuretics is formed
by the alkaloids caffein and theobrornin, with their salts and
preparations (Caffein. citrat., gr. 5 to 10 ; Theobrornin., gr. 1 to 5 ;
Agurin=Theobr. sod. acet., gr. 5 to 15; Diuretin =Theobr.
sod. salicylat., gr. 5 to 15 ; Theocin. sod. acet., gr. 2 to 4), which
act on both kidneys and heart. I always use diuretin of these
drugs, and combine it with digitalis (Infus. digit., 5iv [U.S.P., 5ij] ;
Diuretin, gr. 10 ex. Aq.). Caffein is not so good a diuretic. It is
Acute Nephritis. 793
better not to use these, which are stronger stimulants than the
alkalies, unless the latter fail.
At the same time the kidneys may be relieved by acting on the
bowels or on the skin. For the latter purpose hot baths, hot air
baths, hot packs, and injections of pilocarpin nitrate may be given.
The latter should not be given in doses greater than gr,, as it
may produce collapse and diminish the secretion of urine (for
hot air bath see Uraemia).
But if oliguria is very severe it is advisable to deplete the kidney
locally. I have known half a dozen leeches to each loin completely
relieve a case of suppression. Cupping is a similar but less effective
method. Mr. Reginald Harrison recommended, when symptoms
pointed to extreme congestion, to cut down upon the kidney and
relieve internal pressure by splitting the capsule open. I have
never had to do this, but it seems reasonable. Edebohls has
practised complete removal of the capsule. That is in my opinion
unreasonable.
Hsematuria usually clears up spontaneously ; but it occasionally
persists though the other symptoms improve. If the blood is in
large quantity leeches to the loin sometimes stop it altogether.
More often it is slight in amount. I have never found iron or gallic
or tannic acid of any use. Hamamelis is recommended, but I have
not used it, and as its action is only due to the gallic acid it
contains I should not expect it to be useful. I have known ergot
effective, and once or twice, when other drugs failed, I have given
oil of turpentine in 10 or 15 min. doses successfully.
Albuminuria is due chiefly to the damaged glomeruli. It decreases
as the inflammation subsides, but hardly ever disappears if the
patient is past childhood. No drugs seem to affect it. The impor-
tant thing to remember is that its presence does not contra-
indicate a flesh diet. Repeated analysis has shown me that it
is not increased by a change from milk to fish diet, or from fish
to meat. A temporary increase may appear with any change of
diet, even if in the reverse direction, but it is transient.
Nausea and vomiting can be treated with ordinary bitters and
alkalies. Sometimes minim doses of Tr. iodi, given hourly, succeed
if these fail. Cerium oxalate was at one time recommended, but
I have never known it useful. A good formula is Acid, hydrocyan.
dil., irj.iv ; Sod. bicarb., gr. 5 ; ex. Aq. ; given at short intervals for
a few doses.
Dropsy is discussed under chronic diffuse nephritis and uraemia
under its own heading.
W. P. HERRINGHAM.
794
CHRONIC INTERSTITIAL NEPHRITIS.
THIS is common after forty years of age. Probably more than
a third of all patients over this age show some renal fibrosis. It
is generally accompanied by sclerosis of the arteries.
At first it produces no symptoms. Systematic examination with
the microscope of kidneys from the 'post-mortem room proves this.
Later the symptoms are chiefly due to cardiac dilatation, hyper-
trophy and eventual failure, which result rather from the arterial
than from the renal disease.
But many such cases are complicated with parenchymatous
changes as well. Either a parenchymatous nephritis has developed
fibrosis, or a kidney in which interstitial changes have been at
first uncomplicated, has been subsequently affected by parenchy-
matous inflammation (see Chronic Diffuse Nephritis).
In many cases the patient complains chiefly of shortness of
breath. On examination the lungs are found to be normal, and
the symptoms are clearly due to changes in the heart and arteries
(see Arterial Sclerosis), in the course of which the heart has become
unequal to its work. The first indication is to lessen its labour
by rest. Such patients should be put to bed for a time, and when
allowed to get up must be warned that any effort which produces
either shortness of breath or palpitation is a strain upon the heart,
which it is unsafe to allow. Digitalis is seldom of much use
in this condition, probably because it increases the peripheral
resistance as much as it increases the stroke of the heart. But
convallaria, strophanthus and sparteine, though they belong to the
same group, are said to act more on the heart than on the arteries,
and to be better, in this condition, than digitalis.
In some cases a pure milk diet relieves symptoms rapidly. A
patient of this kind has been in my wards occasionally during the
last three years, and has each time been relieved by this treatment.
He has no albuminuria, and is a thin, florid man, with extreme
arterial degeneration. A woman of the same build and with the
same symptoms, seen in consultation, has been much less subject
to attacks of dyspnoea and palpitation since taking tablets of
alkaline salts (Sod. Chlorid., gr. 150 ; Sod. Sulph., gr. 15 ; Sod.
Garb., gr. 6 ; Sod. Phosph., gr. 5 ; Magnes. Phosph., gr. 6 ; Calc.
Glycero-phosph., gr. 5 ; make 25 tablets ; dose, two tablets, thrice
Chronic Interstitial Nephritis. 795
daily) made in imitation of Trunesek's " inorganic serum." The
effect may be due to suggestion. Bleeding may be necessary in
some cases.
In the intervals between the attacks the diet of these patients
must be light and digestible, for any mechanical interference with
the heart, such as indigestion may produce, will bring on an
attack at once. The bowels for the same reason must be well
regulated. But there is not the same urgent need for diminu-
tion of the food as in cases complicated with parenchymatous
change. Indeed, as the symptoms are due chiefly to cardiac weak-
ness, a physician hesitates to reduce the food to a low level. It is
better to try to treat the patient like a man in training, giving
him a fair amount of plain proteid food and using exercises
with passive resistance, and general massage to take the place of
ordinary muscular work. Some of these patients declare them-
selves better after a course of Nauheim baths. Later uraemia may
appear (see Uraemia).
W. P. HERRINGHAM.
796
CHRONIC DIFFUSE PARENCHYMATOUS NEPHRITIS.
PRIMARY acute nephritis is rare. Most cases of nephritis begin
insidiously. But they are liable to fresh attacks of inflammation
with haematuria, lumbar pain and oliguria. These furnish most
of the cases of what is called acute nephritis, and their treatment
is discussed under that heading.
In the mildest form the chronic disease produces slight albu-
minuria, anaemia and a trace of oedema. For these the chief aim of
treatment is (1) to cure the anaemia ; (2) to prevent the inflamma-
tion spreading or recurring.
(1) For the anaemia the lighter forms of iron are the best, such
as the tartrate or the citrate of iron and quinine. When digestion
is not affected the perchloride or the sulphate can be given.
(2) The chief part of the treatment is preventive.
(a) Chill must be avoided. Many of these patients are young,
and for them the chief danger is chill after sweating. Exercise
does not hurt them, but they must not stand about when hot, as,
for instance, after a game of lawn tennis. Dancing is never safe.
Clothing should be warm. I think loose cotton fabrics are better
than flannel. Damp cold is dangerous. A dry climate, even if
cold, allows evaporation through the skin and relieves the kidneys.
In the Riviera or North Africa special care should be taken to
escape the sunset chill and cold winds. The Grand Canary and
Southern India are the two best winter climates that I know.
(b) The kidneys are permanently damaged, for albuminuria
rarely disappears if the patient has passed childhood, and therefore
must be spared as much as possible. This is almost entirely a
question of diet, and especially of the proteid intake. The work of
the kidney consists chiefly in the excretion of proteid products and
of salts. These latter, again, are contained in large amount in the
proteids. The amount of proteid in the standard diet of an ordinary
man is about 120 grammes. Many eat a great deal more. It has
been shown by Chittenden that about half this amount is sufficient
to preserve health and strength. In making up a diet it may be
remembered that
Milk contains about 3'5 per cent, of proteid.
Meat, fish or poultry 20'0
Bread 6'5
Macaroni lO'O
Oatmeal 14'0
An egg 3'6 grammes ,,
Chronic Diffuse Parenchymatous Nephritis. 797
Therefore a pint of milk (= 600 grammes = 21 grammes
proteid) +8 oz. of meat, fish or poultry (= 90 grammes = 18
grammes proteid) + 6 ozs. of bread (= 180 grammes 12
grammes proteid) contain 51 grammes of proteid, to which can be
added vegetables, fruit, jams, farinaceous puddings, cream, butter,
bacon and other fats, without much increasing the renal labour.
Alcohol and condiments are renal irritants. Salt should be
taken sparingly.
With care such patients live for many years. But in cases
which are neglected the disease progresses in one of two directions :
(1) By fibrosis to the contracted kidney, which ends in
uraemia (q.r.).
(2) By epithelial degeneration to the large white kidney which
ends in general dropsy, oedema of the lungs, and cardiac failure.
In this form it is almost impossible, owing to the state of the
kidneys, to increase the amount of urine, either by renal or cardiac
stimulation, but both should be tried. Sometimes dropsy can
be relieved to some extent by sweating or purging, but most often
it must be drained directly by tapping. All these methods are
described under Acute Nephritis (p. 792).
W. P. HERRINGHAM.
798
SURGICAL TREATMENT OF NON-SUPPURATIVE
NEPHRITIS.
Acute Nephritis. In 1896 Reginald Harrison suggested
operative interference in certain cases of acute nephritis. He
operated on cases of scarlatinal nephritis, nephritis complicating
influenza, traumatic nephritis, and nephritis which had followed
a chill. The operations were undertaken on account of one or
more of the following symptoms : Diminished secretion of urine,
pain, haematuria.
He recommended operation in cases of acute nephritis where
convalescence was delayed, and albumen and casts did not disappear
from the urine; also in cases, such as the malignant type of
scarlatinal nephritis, where suppression occurred ; and, lastly,
where cardiac and circulatory complications were present. The
operation was performed with the object of setting aside 'the
dangerous symptoms, and also of preventing the sequence of
chronic nephritis.
Harrison suggested incision of the renal capsule and puncture of
the kidney to relieve the renal tension in these cases. Other
observers (Pel and Rosenstein) recommend nephrotomy in acute
nephritis when oliguria is present and medical treatment has
failed. Confusion in regard to statistics has been caused by the
publication of cases of suppurative nephritis under the same
category as those referred to above.
All Harrison's cases recovered, but the after-history is un-
recorded.
Chronic Bright's Disease. (1) Acute Exacerbations in Chronic
Bright's Disease. Edebohls, Pousson, Casper and others have
treated the acute exacerbations of chronic Bright's disease by
surgical operation. In these cases surgical interference is supple-
mentary to medical treatment. Where there are symptoms of
uraemia, diminished secretion of urine and oedema, operation may
be of service when medical treatment has failed. Cases where
advanced car dio- vascular changes and pulmonary complications are
present are unsuitable for operation.
Decapsulation and nephrotomy are the operations recommended.
Except in the rare cases when the disease can be proved to be
unilateral, decapsulation should be rapidly performed on both
Surgical Treatment of Chronic Nephritis. 799
sides. Pousson recommends that nephrotomy should be performed
on one side and only decapsulation on the other.
The immediate results give a mortality of 25 per cent. (Pousson)
some part of which is due to the patient being moribund when the
operation was performed.
Of ninety-two patients who survived the operation, eight are
considered as cured. The others died after a temporary relief,
lasting from' some months to one or two years in a few cases.
In the writer's experience of decapsulation, and nephrotomy in
these cases and in large white kidney, very striking improvement
may be observed ; but this is temporary, and relapse soon occurs.
(2) Chronic Interstitial \e)>liriti# irith Hd-maturia. There is
a class of cases where the symptoms of chronic nephritis are
insignificant, and intermittent profuse haernaturia occurs. These
cases have been classed under the heading of " Essential
Haematuria," along with other conditions which give rise to
renal haematuria without other symptoms, and without gross
changes in the kidneys. The haematuria is accidental, and is due
to pressure of a patch of sclerosis on a vein. Nephrotomy is
followed by disappearance of the haematuria, which does not recur,
except in the rarest instances.
(3) Chronic \e)>hritia irith Pain. Legueu described these
cases under neuralgia of the kidney. In a few cases the renal
condition is that of chronic Bright's disease, but in many cases
there has been a renal calculus at some previous date, while in
others there is a history of trauniatism.
The kidney shows chronic nephritis, and there is thickening and
adhesion of the fibrous capsule and fibrosis of the fatty envelope.
The pain may be localised to the kidney, and may be spontaneous,
constant, and unaffected by movement, or there may be attacks of
renal colic. There may be a trace of albumen with hyaline and
granular casts.
Nephrectomy, nephrotomy, capsulotoniy, decapsulation or simple
freeing of the kidney from surrounding adhesions have been practised.
The great majority of patients have been relieved by operation,
and the relief is known to have lasted for some years. If there
has been a diminution in the quantity of urine and albuminuria
these symptoms disappear.
The operation, like that for haematuria in chronic nephritis,
usually takes the form of an exploratory nephrotomy, and to this
decapsulation may be added.
(4) Treatment of Oinmic Briyltt's Disease by Decapsulation.
In 1899 Edebohls suggested nephrotomy as a method of
8oo Surgical Treatment of Chronic Nephritis.
treatment of chronic nephritis in cases of chronic nephritis in
movable kidney. Newman, of Glasgow, had previously treated
two cases of this nature by nephropexy.
In 1901 Edebohls proposed decapsulation of the kidney with
the object of curing chronic Bright's disease. He held that
the thickened fibrous capsule prevented the establishment of a
collateral circulation, and if this barrier were removed a free flow of
blood through the kidney, which the diseased vessels were unable
to supply, was provided by anastomosis with the parietal vessels.
By this means the increased interstitial tissue would be absorbed,
pressure on the tubules removed, and a regeneration of renal
epithelium would take place.
Experimental enquiry into this hypothesis has shown that no
damage is done to the kidney by decapsulation, and that, although
the fibrous capsule invariably re-forms in a few weeks, the new
capsule is composed of loose connective tissue which does not
compress the kidney. A parietal anastomosis has actually been
observed which was not strangled by contraction of the new capsule.
The kidney has also been transplanted into the peritoneal cavity
and formed adhesions with the serous membrane or with the
omentum. Conflicting statements have been made in regard to the
results, found post-mortem, after decapsulation in human beings.
Results. Pousson gives a mortality of 5 per cent. Of fifty-five
cases, thirty-six survived more than three months after the
operation.
Of ten cases of nephritis withnephroptosis, there were nine greatly
improved, three of which were said to be cured ; while of sixteen
cases of nephritis without nephroptosis, three were improved, four
much improved, four greatly improved, and five cured. The five
cases of cure were under observation for eleven years, six and a half
years, five and one-third years, two years, and one year.
It will be seen, therefore, that, although the course of the disease
is uninfluenced in a considerable proportion of cases, improvement
is undoubted in some, and it is possible that a cure may be brought
about in a few cases. The cases of movable kidney with albumi-
nuria and tube casts should be carefully separated from the others,
for the prognosis without operation is very different from that of
chronic Bright's disease, and the effect of nephropexy alone is to
cure most of these cases.
In cases of chronic Bright's disease the results might be
improved by operation performed at an earlier date than is usually
the case.
). W. THOMSON WALKER,
8oi
PERINEPHRITIC ABSCESS.
PRIMARY PERINEPHRITIC ABSCESS may follow injury to the kidney,
suppuration occurring immediately or after months or years, or
it develops during the course of some fever, such as typhoid,
scarlatina, measles, or pneumonia, or when the patient is suffer-
ing from tonsillitis or boils.
Secondary perinephritic abscess complicates suppuration in
some neighbouring organ, such as the kidney (25 per cent.), liver,
gall-bladder, appendix, pelvic organs or vertebrae.
Tuberculous perinephritic abscess is usually found with tuber-
culous disease of the vertebrae ; very rarely with tuberculosis of
the kidney. Pus from an empyema or an abscess of the lung may
track through the costo-lumbar hiatus of the diaphragm, and form
a perinephritic abscess.
Early operation is the only successful method of treatment.
The kidney is exposed by an oblique incision and the abscess
drained. The cavity should be explored in all directions, so that
no pockets are left undrained. Subphrenic collections of pus and
those in the iliac fossa are searched for and opened up. Counter-
openings may be necessary in the loin or elsewhere to ensure free
drainage. If the kidney is the seat of abscess, pyelonephritis, or
pyonephrosis, it should be freely incised and drained. If
nephrectomy is necessary, it should be postponed to a later
date.
When the abscess has originated in an empyema, this also should
be drained.
In old-standing cases when sinuses have persisted, a diseased
kidney or an imperfectly drained empyema may necessitate
nephrectomy, resection of portions of ribs, or other secondary
operations.
Results. Good results are obtained by prompt operation .in
primary cases. The longer the operation is delayed, the worse the
prognosis. The prognosis in secondary perinephritic abscess
depends upon the original cause. Kiister collected 230 cases at a
period when the importance of early operation was imperfectly
understood, and found 151 (65'6 per cent.) recovered. Fistula?
persisted in six of these cases.
S.T. VOL. ii. 51
802 Perinephritic Abscess.
Watson compared two series of cases where perinephritic
suppuration had followed injuries to the kidney.
In twenty-one cases treated without operation, seventeen died
(80 per cent.), while in twenty-eight cases treated by operation,
two died (7'1 per cent.).
J. W. THOMSON WALKER.
8o 3
PYELITIS.
THE intimate relation between the kidney and its pelvis makes it
impossible for severe inflammation to be wholly confined to one or
the other. At the same time, there are cases when the brunt of
the inflammation falls upon the pelvis and the kidney is but
slightly involved. These are cases of mild subacute or chronic
inflammation, which may either follow upon an acute attack of
pyelonephritis or arise de novo.
Diseases of the lower urinary organs which cause obstruction
and inflammation, such as enlarged prostate, stricture, stone in the
bladder, gonorrheea, bladder growths, etc., are the most frequent
causes.
In some cases a calculus is present in the renal pelvis which may
either be the cause or the result of the pyelitis.
Diagnosis. (1) In a case of cystitis from any cause, is pyelitis
present ?
When the signs of pyelitis are overshadowed by cystitis, the
diagnosis "depends upon the observation of a cloudy efflux from the
ureteric orifice, the appearance of the orifice and the 'examination
of the urine of each kidney obtained from the ureteric catheter.
(2) Is the kidney involved ?
The history of a severe acute onset points to renal inflammation,
and so do tenderness and enlargement of the organ, an excessive
quantity of albumen, the presence of tube casts and proofs of an
inadequate renal function shown by the methylene blue and
phloridzin tests.
(3) Is there a calculus in the renal pelvis ?
A calculus is readily discovered by the X-rays, but this method
of examination may not be used, for there may be no pain or
haBmaturia and no history of stone, and the possibility of stone
being present may not be suspected. It should be a rule, there-
fore, that all cases of persistent pyelitis should be examined by the
X-rays.
The first indication for treatment is to remove any local irritant
in the renal pelvis or any cause of back pressure or sepsis in the
lower urinary organs.
The removal of a calculus from the renal pelvis may suffice to
cure the pyelitis.
51 2
804 Pyelitis.
Enlarged prostate and stricture must be treated. If the pyelitis
is of long standing, and there is reason to suspect that the kidney
is involved, it may be necessary to drain the bladder by supra-
pubic cystotomy for a fortnight or more before proceeding to the
operation for radical cure of the prostatic obstruction.
The treatment of the pyelitis consists in the administration of
urinary antiseptics (urotropine, hetraline, helmitol, metramine, etc.)
and diuretics (Contrexeville, Evian, Vittel, and other alkaline
diuretic waters).
Vaccine treatment should be tried in chronic cases (see
Pyelonephritis).
Installations of argyrol and other silver preparations have been
made through a ureteric catheter. The method is not free from
the danger of obstruction resulting from swelling of the mucous
membrane at the outlet of the pelvis, and should be practised with
the utmost caution, and should not be used if there is any
elevation of the temperature. Kelly and Casper have used this
method in cases of gonorrhceal pyelitis with success. They used
instillations of 10 to 15 cubic centimetres of silver nitrate solution
(1 or 2 per cent.), or washed the pelvis with silver nitrate solu-
tion (1 in 500 to 1 in 1000). Stockmann recommended the use of
this method in chronic pyelitis of any origin. Albarran dilated
the ureter in order to introduce larger ureteral catheters.
Should these methods fail, in severe cases the kidney may be
exposed and the pelvis washed out and drained through a nephro-
tomy or a pyelotomy wound. I have used this method, tying in
a small rubber tube in the renal pelvis through a nephrotomy
wound and washing the pelvis daily with silver nitrate solution
for ten days, and then allowing the wound to close. This was
successful where other measures had failed.
J. W. THOMSON WALKER.
8o 5
PYELITIS OF INFANCY AND CHILDHOOD.
A FORM of acute pyelitis occurs in infants and children.
Constipation is frequently present, or there may be attacks of
diarrhoea.
There is a tendency to spontaneous recovery, but the condition
sometimes ends fatally. The cases improve rapidly under treat-
ment. Bacteria may, however, persist in the urine.
Treatment. The acidity of the urine is reduced by the adminis-
tration of alkalies, and the urine is kept neutral. Citrate of potash
is given in doses of 24 gr., or in severe cases 36 to 48 gr. per day in
infusion of digitalis, and continued till danger of a relapse is past.
Urotropine (5 to 10 gr. daily) and salol may be given in addition
to the alkaline treatment.
The nurses should be warned not to wipe soiled diapers against
the urethra.
Operative measures are very rarely necessary. If the child is
steadily losing ground under medicinal treatment and the symptoms
are unilateral, nephrotoniy may be performed.
J. W. THOMSON WALKER.
8o6
PYELITIS (PYELONEPHRITIS) OF PREGNANCY.
WHEN pyelonephritis is already present, the effect of pregnancy
is to aggravate the disease. Pyelonephritis may however commence
during pregnancy, and in such cases the pregnancy is the predis-
posing cause of the disease. The bacillus coli is present in 82 per
cent, of cases. In some cases the disease follows the passage of a
catheter, but it also occurs apart from instrumentation. Premature
labour occurs in 25 per cent, of cases. If the infection occurs late
in pregnancy, there is usually fever during the puerperium. If the
pregnancy is interrupted, the child dies in one-third of cases.
If the attack occurs late and the pregnancy goes on to full term,
the child is usually healthy.
After parturition the pyelonephritis may subside and the urine
become sterile, but bacilluria usually persists and pyelonephritis
recurs during succeeding pregnancies.
Treatment. Prophylaxis consists in careful asepsis in catheter-
isation, and in the treatment of constipation during pregnancy.
If bacilluria exists, or there has been a previous attack of pyelo-
nephritis, this should be energetically treated and the patient
warned of the danger of becoming pregnant.
The production of abortion or the induction of premature labour
is seldom necessary, but it may be called for in a severe case.
Urinary antiseptics are not likely to influence the course of the
disease.
Operative Treatment. Nephrotomy has given good results, and
according to Legueu is specially indicated when the pyelonephritis
is unilateral. In bilateral pyelonephritis premature labour should
be induced. Nephrectomy is a more severe operation, but does not
affect the course of the pregnancy in most cases.
Cova collected twenty-one cases of nephrectomy, and found that
the pregnancy went on to term in fifteen, and was five times inter-
rupted spontaneously and once artificially. The mortality is 9*5
per cent. According to this observer, nephrectomy is well borne in
the early months of pregnancy, but less so after the fifth month.
J. W. THOMSON WALKER.
807
PYELONEPHRITIS (INFECTIVE),
IN infective pyelonephritis there is acute or chronic inflammation
of the kidney and renal pelvis.
There are two forms of the disease, namely, primary and
secondary.
Primary or haematogenous pyelonephritis occurs without any
previous disease of the lower urinary tract, and is due to blood-
borne bacteria.
Secondary or ascending pyelonephritis is a complication of
disease of the lower urinary tract. The treatment of these two
forms will be described separately.
PRIMARY OR HAEMATOGENOUS PYELONEPHRITIS.
Haematogenous pyelonephritis occurs in three degrees :
(1) Hyperacute or fulminating. (2) Acute. (3) Chronic.
In fulminating pyelonephritis there is sudden profound toxaemia,
with scanty bacterial urine or complete anuria. The diagnosis
must be made from other acute infections, such as infective
endocarditis, acute influenza, lobar pneumonia, or malaria. In
acute pyelonephritis the attack may be mild or severe. There are
symptoms of septic absorption with signs of acute inflammation in
one kidney, and the urine contains bacteria, pus, blood and casts.
Bacteria may be found in the blood, and there is leucocytosis. In
chronic pyelonephritis the renal symptoms are insignificant.
There are symptoms of cystitis with polyuria and acid pyuria.
There may be oliguria and intermittent attacks of anuria. The
diagnosis is made by the cystoscope and by catheterisation of the
ureters. Chronic pyelonephritis may be complicated by the
presence of stone in the kidney. The lesion is usually unilateral
in haematogenous pyelonephritis.
The bacillus coli communis is the most common cause of renal
infection. The next most frequent bacteria are the staphylococcus,
streptococcus, proteus, and the bacillus pyocyaneus. The bacillus
coli is usually found in pure culture, but occasionally in a mixed
infection.
Prognosis. In mild cases of acute pyelonephritis the prognosis
is good. Recovery without operation is the rule. Recurrent
attacks occur, however, and in a large percentage of cases bacilluria
8o8 Pyelonephritis (Infective).
and slight chronic pyelitis or pyelonephritis persist. This may
disappear or it may continue for many years, and may be the cause
of an acute attack ten or twelve years after the first.
In acute cases the prognosis is very grave, and operation will
frequently be necessary. In fulminating cases the issue is
frequently fatal. If the diagnosis has been made, early operation
gives a more hopeful outlook. Chronic pyelonephritis persists for
many years and eventually destroys the kidney. There is the
danger of secondary stone formation in the kidney and bladder and
of ascending pyelonephritis of the second kidney.
The treatment is medicinal, serum and vaccine, or operative.
Medicinal Treatment consists in confining the patient to bed
and applying hot fomentations to relieve pain, and turpentine stupes
or dry cupping over the loins to relieve congestion. Urinary
antiseptics should be given, such as urotropine, metramine,
hetraline, or helmitol (in doses of 5 or 10 gr. every four
hours). Alkalies and diuretics should be freely administered,
such as potassium citrate (in doses of 50 or 60 gr. daily),
Contrexeville water and distilled water. The bowels should be
freely opened, and calomel (in doses of ^ to ^ gr. daily)
administered. This treatment is suitable for mild cases
and the early stage of acute cases. If bacteria persist in the
urine when the acute symptoms have subsided, urinary antiseptic
treatment should be continued and vaccine treatment adopted.
Serum Treatment. This consists in the injection of anti-toxin
serum, usually anti-colon bacillus serum, since the infection is due
to the bacillus coli in the great majority of cases. A dose of 25 cubic
centimetres is injected hypodermically each day for three days, and
at the same time calcium lactate (in doses of 20 gr. thrice daily) is
given by the mouth, in order to prevent the joint pains and rashes
which may result from the serum. Should no effect be produced
in three days, the treatment should be abandoned.
Dudgeon obtained satisfactory results in most instances by this
treatment in twelve cases of acute pyelonephritis. In five of these
cases the effect was rapid and permanent, in four there was
considerable benefit, and in three no benefit. In chronic cases the
treatment has no effect.
Vaccine Treatment. This consists in injecting graduated
doses of dead bacteria obtained from cultures of the patient's urine,
or of a stock vaccine should there not be time for the preparation
of an auto-vaccine. Small doses of 2 or 3 millions of bacillus coli
should be used at first, and repeated in four or five days, rising
rapidly to 10, 15, 20, 25, 30 millions, and so on to 100 millions, then
Pyelonephritis (Infective).
809
150 for six doses, then 200 for six or twelve doses. The injection
should then he made once a week, and should any reaction (shown
by a rise of temperature, malaise and headache) occur, the dose
should be reduced and a longer interval allowed. The opsonic
index has not proved a reliable guide to dosage.
In acute cases the results of the vaccine treatment have been
unsatisfactory. In ten cases only one showed a change in tem-
perature (Williamson) ; in a large number of patients treated by
Dudgeon there was " no material improvement except in a very
few instances."
In chronic cases, with or without acute exacerbations, where no
complication, such as growth or stone, is present, the treatment
may be of great service, and bring about a cure when all other
methods have failed. The treatment is a long and tedious one, and
may last for six months or a year, or even longer.
The doses must be carefully graduated, and a sudden large
increase of dose avoided, as an overdose is frequently followed by a
recurrence of symptoms, and the vaccine appears to have less effect
if this has occurred. In several cases under the writer's care
the urine has been rendered sterile after six or twelve months'
treatment.
Operative Treatment. The following operations have been
performed : Nephrotomy, decapsulation and opening of surface
abscesses, partial resection and nephrectorny, but only nephrotomy
and nephrectomy need be considered.
I have collected forty cases of operation in acute haematogenous
pyelonephritis from the literature with the following results :
Operation.
Cases.
Recovered .
No change.
Died.
Nephrotomy ......
Decapsulation and opening of surface
12
3
2
7
abscesses ....
6
6
Partial resection
2
2
- .
Nephrectomy ....
17
17
HU'tfcral operations :
Nephrotomy
2
2
Nephrectomy and nephrotomy
1
1
~-
40
31
2
7
The results of nephrotomy are not quite so unsatisfactory as this
table suggests. I have performed the operation twice in the acute
8io Pyelonephritis (Infective).
stage, and seen three cases in which it had previously been
performed. All these patients survived. This makes twenty cases
of nephrotomy, with seven deaths. The after-results of nephro-
tomy are unsatisfactory. Chronic pyelonephritis persists, and
nephrectomy may be required at a later date.
The best results in acute cases have been obtained by nephrec-
tomy. This should not be too long delayed. If at the end of five
or seven days the acute symptoms persist, and the patient is
beginning to lose ground, nephrectomy should be performed.
In chronic cases, operation will be called for on account of
recurrent exacerbations of acute inflammation, or of persistent
cystitis, or of secondary calculus, or sometimes for anuria. If the
second kidney is shown to be healthy by examination of its urine,
nephrectomy should be performed. I have found nephrotomy
sufficient when reflex oliguria and attacks of anuria were caused by
chronic unilateral pyelonephritis.
SECONDARY OR ASCENDING PYELONEPHRITIS.
This disease occurs as the result of extension of infection from
the lower urinary organs. It is the last phase of many chronic
diseases of the bladder and urethra, such as malignant growths,
stone, enlarged prostate, stricture. It frequently follows surgical
interference in the bladder or urethra, such as the passage of
instruments, operations for stone, etc., and has for this reason been
termed " surgical kidney."
Ascending pyelonephritis usually attacks kidneys which are
already the seat of chronic aseptic pyelonephritis, due to obstruction
in the lower urinary tract.
Ascending pyelonephritis is always bilateral in chronic cases,
and usually in acute cases ; but in acute cases the symptoms
frequently point to one kidney being affected alone, or one
kidney being severely affected while the disease in the other is
slight.
The disease may be acute or chronic. In acute ascending
pyelonephritis there is the sudden onset of symptoms of septic
absorption, with local signs of inflammation of the kidney, and
partial or complete suppression of urine.
Chronic pyelonephritis may follow an acute attack, but the
onset is frequently insidious. The condition known as " chronic
urinary septicaemia " develops. This may be interrupted by acute
attacks.
Prognosis. Many patients die during the acute attack of
ascending pyelonephritis, and of those that recover the majority
Pyelonephritis (Infective). 811
suffer from chronic pyelonephritis. Should the urinary obstruc-
tion be removed, the further progress of the disease will probably
be arrested, but the kidneys are permanently damaged.
Chronic ascending pyelonephritis is usually slowly progressive,
and is eventually fatal after some years.
Acute Ascending Pyelonephritis. - - Prophylactic measures
include the sterilisation of all urethral instruments and of all basins,
syringes, lotions, etc., and cleansing of the surgeon's hands and the
patient.
They consist also in practising the utmost gentleness in all
manipulations. Roughness means bruising and laceration, and
this, together with the damage produced by obstruction, paves the
way for sepsis.
Non-operative treatment consists in dry cupping, hot fomenta-
tions, turpentine stupes, or poultices applied to the loin to relieve
the renal congestion. A hot pack or hot vapour bath or radiant
heat-bath should be given to induce sweating. Pilocarpin may be
injected hypodermically, but should be carefully watched. It is
important to get the bowels opened, and to relieve the abdominal
distension. A large dose of castor oil or a strong saline purge
should be given, but it is frequently returned if the patient has
commenced vomiting. Turpentine and soap-and-water enemata, to
which 20 min. of oil of rue are added, help to bring away flatus,
and a rectal tube should be introduced high up in the rectum.
If the patient is able to keep fluids down, large draughts of
warm Contrexeville water should be given, and may be combined
with theocin sodium acetate, 3 to 8 gr. every four hours, or
theo-bromine sodiosalicylate (diuretin), 10 or 15 gr. every four
hours. Glucose solution should be introduced into the subcutaneous
tissues in large quantities, several pints being injected slowly.
Infusion of glucose solution into a vein (median basilic) is the
most rapid and powerful means of re-establishing the renal
secretion.
Operative Treatment. There are two indications for operative
treatment : (1) the relief of urinary obstruction, if present ;
(2) the relief of congestion and drainage of the kidney.
Should the measures detailed above prove ineffectual, and no
improvement be apparent in two or three days, or if the patient
appears to be failing before this, operation will become necessary.
If there is unrelieved urinary obstruction, this should first
receive attention. The operation which is performed for the
relief of the obstruction is not necessarily that which would have
been chosen had no kidney complication developed.
8i2 Pyelonephritis (Infective).
The operation should give the freest drainage with the least
amount of shock. Supra-pubic cystotomy and drainage with a large
tube is the best means of carrying this out. It is a temporary
measure. Operation for the permanent cure of the obstruction can
be performed later, if the patient survives. For relief of the
renal congestion and sepsis, nephrotomy should be performed.
The kidney is freely incised along the convex border, and a
large rubber drain introduced into the pelvis. If there is free
haemorrhage, a mattress stitch may be inserted to control it, and
the rest of the kidney wound left open or packed with antiseptic
gauze. Another large drain is placed outside the kidney before
uniting the edges of the parietal wound.
As a result of this operation the temperature will fall to normal,
and within a few hours the dressings will be flooded with urine. The
temperature may remain normal, and the progress to complete
recovery be uninterrupted, or the temperature may rise again to
100 or 101 for a few days, and then gradually fall. The secretion
of urine, however, is re-established and the crisis is over. It is of
vital importance that these operations should be carried through
with the utmost celerity. The operation for obstruction and that
for relief of the renal congestion and sepsis are done at one sitting.
Glucose infusion, rectal and intra-venous, should be given on the
return from the operation. There is some danger of haemorrhage
from the kidney about the seventh or tenth day after operation.
Should this occur, the tube is removed arid the kidney rapidly
plugged with gauze.
Nephrectomy is not indicated in these cases, since nephrotomy
suffices to tide over the crisis ; the shock is greater, the disease is
not cured by nephrectomy, the second kidney, if it is not acutely
septic, is damaged to an unknown degree by back pressure.
Nephrectomy may, however, be necessary in the hsemorrhagic type
of pyelonephritis on account of the severe and- continuous
haemorrhage.
Chronic Ascending Pyelonephritis. In the majority of
cases chronic ascending pyelonephritis is bilateral, one kidney
being more seriously damaged than the other. The prophylaxis of
chronic ascending pyelonephritis consists in the early removal of
enlarged prostate, the efficient treatment of stricture, the removal
of calculi, and other measures directed against the existence of
chronic obstruction and chronic sepsis in the lower urinary organs.
When chronic pyelonephritis has become established, operative
interference in the bladder and urethra must be undertaken with
the utmost caution. When an operation for enlarged prostate is
Pyelonephritis (Infective). 813
proposed, the bladder should be opened supra-pubically and drained
for a week or more before the prostate is removed. In the case of a
stricture, external urethrotomy with drainage of the bladder would be
preferred to internal urethrotomy or dilatation with instruments.
Urinary antiseptics (see under Chronic Haematogenous Pyelo-
nephritis) and diuretics should be freely administered.
If the disease is proved to be unilateral, and the second kidney
ascertained to be healthy by means of the ureteric catheter and
tests for the renal function, the kidney may after removal of all
lower urinary obstruction be incised or removed. It is seldom,
however, that these circumstances combine to make this possible.
Vaccine treatment has not given encouraging results.
The administration of renal extract has been tried in these cases
and in chronic aseptic pyelonephritis. It does not influence the
cause, or, in the cases I have seen treated by it, modify the
progress of the disease.
J. W. THOMSON WALKER.
PYONEPHROSIS.
THE following information should be in the possession of the
surgeon before operating upon a case of pyonephrosis :
(1) Are calculi present in the kidney or ureter, and, if so, what is
their position and number ?
This information is obtained by the X-rays, and it is essential
that the number of the calculi should be shown in the plate. It is
often" possible to distinguish one stone plugging the upper end of
the ureter, while other shadows are scattered over the renal area.
A stone may be found low down in the ureter and be the cause of
the pyonephrosis. I have operated for and removed a large
calculus from the lower end of the ureter some years after the
corresponding kidney had been removed for pyonephrosis by
another surgeon.
(2) What is the functional value of the pyonephrotic kidney ?
This is ascertained by catheterisation of the ureter. The urine
obtained is examined, the quantitative estimation of urea and
chlorides being most important. The methylene blue and
phloridzin tests for the renal function are employed.
(3) What is the condition of the second kidney ?
Information is necessary in regard to the presence of calculi or
of nephritis or septic pyelonephritis, and it is necessary to estimate
the functional power of this kidney.
This is obtained by the use of the X-rays, the examination of the
urine of this kidney, and the use of the phloridzin and methylene
blue tests. The examination is made simultaneously with that of
the other kidney, so that the X-ray examination includes the whole
urinary tract, and both ureters are catheterised.
The following table shows the information obtained in a case of
calculous pyonephrosis :
Right Kidney Left Kidney,
(pyonephrosis).
Quantity . . 206-5 c.c. 107 c.c.
Specific gravity .
Freezing point (A)
Colour
Urea .
Chlorides .
Methylene blue .
1,004 1,011
0-18 c. 0-76 c.
Pale, limpid Fairly coloured
0-4 per cent. 1 '3 per cent.
0-977 per cent. 0-1112 per cent.
No change Delayed two hours. Small
quantity ; lasted eighteen
hours.
Phloridzin glycosuria . 0-395 gramme 1 '623 grammes
Pyonephrosis. 815
An X-ray examination showed calculi in the right kidney, but
the rest of the urinary tract free from calculi.
From this examination it was inferred that the right kidney was
almost completely destroyed, and that the functional power of the
left kidney was practically normal. Nephrectomy was performed,
and the patient made a good recovery.
The following methods of treatment will be discussed : (1) Drain-
age by ureteral catheter ; (2) Plastic operations ; (3) Nephrotomy ;
(4) Partial nephrectomy ; (5) Nephrectomy.
Drainage by Ureteral Catheter. - - Pawlick and Albarran
have advocated this method in selected cases. The ureter is
catheterised daily, or less often according to whether a reaction
occurs. The pelvis is washed at the same time. The catheter
may be progressively increased in size until a No. 13 F.
is reached. Albarran has left the ureteral catheter in place for
several weeks, changing it when it became blocked. He uses
boracic acid, silver nitrate (1 in 1000) and permanganate of
potash (1 in 4000 to 1 in 500) for washing the kidney. Pawlick
recommends massage of the kidney and the application of a firm
bandage afterwards. He claims a cure in a pyonephrosis of 150 gr.,
and Albarran another in one of 60 gr.
Many circumstances combine to limit the application of this
method : an intolerant bladder, febrile reaction, stricture of the
ureter, subdivision of the pyonephrotic pouch, the presence of
calculi, thick caseous contents, etc., and there can be very few cases
when it will possess an advantage over an open operation.
Plastic Operations. In cases of uro-pyonephrosis plastic opera-
tions have been undertaken with the object of re-establishing the
lumen of the ureter. These operations have been discussed under
Hydronephrosis. It is necessary to ascertain first the nature of
the obstruction and the functional power of the kidney, and in
order to do this a preliminary nephrotomy is necessary. Fre-
quently the functional power is so far destroyed that it is not worth
while doing such an operation, and the choice will lie between
nephrostomy and nephrectomy.
Nephrostomy. Nephrostomy may be only the incision of the
kidney, or there may be an attempt made to re-establish the flow
by the ureter.
The pyonephrotic sac is opened by an oblique lumbar incision.
The contents are evacuated, septa between saccules are broken
down. Careful search is made for interstitial abscesses and the
main cavity, the upper portion of the ureter and the subsidiary
cavities are carefully examined for stone, and the perinephritic
816 Pyonephrosis.
tissue around the kidney, and especially at the upper and lower
poles, should be explored for extra-renal collections of pus.
Guyon recommends that the edge of the sac should be stitched to
the skin, in order to avoid peri-nephritic suppuration. This is not
necessary if free drainage is established by large rubber tubes
placed both inside and outside the kidney.
This operation has the advantages that it is rapid, causes no
shock, and the remains of the secreting tissue are preserved. It
may therefore be performed in the very worst cases, when the
patient is weak from severe or prolonged suppuration, and in cases
where it is impossible to estimate the value of the second kidney,
or where this organ is known to be the seat of advanced disease.
The mortality of this operation is from 17 per cent. (Kiister) to
23-3 per cent. (Tuffier).
After the operation an improvement in the work performed by the
second kidney is usually observed, and is due to the relief of the
depressant reno-renal reflex, and also to the removal of toxins which
were being absorbed and excreted by the second kidney. The
general health for similar reasons greatly improves. In 27
per cent, of cases the wound closes, the sac shrinks, and the patient
is cured (Kiister).
In a certain number of cases septicaemia persists, and the work
of the second kidney is still poorly performed. This is due to the
continued suppuration in a thick, fibrous-walled cavity, to unopened
pouches, to abscesses in the walls and partitions, to stones being
left in the sac (16 per cent, of cases), and to the persistence of the
ureteric block and ureteritis.
A fistula remains in from 45*6 per cent, (calculous pyonephrosis,
34'2 per cent. ; non-calculous, 57'1 per cent.) (Tuffier) to 56 per cent.
(Kiister).
Various means have been adopted to obviate this, or to cure the
fistula when it has developed.
At the nephrotomy Bazy introduced a bougie along the ureter,
and Doyen used a metal sound to dilate the ureter. There is
difficulty, however, in finding the opening of the ureter in a large
multi-locular sac, and Albarran has used the following method :
Before the nephrotomy he passes a catheter up the ureter by means
of the cystoscope. At the operation this is easily found, and to the
end of it is attached a catheter of No. 10 F. size. By withdrawing
the first catheter the No. 10 catheter is drawn down to the bladder.
This second catheter is fixed to the skin of the loin with a thread,
and the nephrotomy is finished in the manner described. The
ureteric catheter is left in place for four or five days and then is
Pyonephrosis. 817
changed. A light, pliable stilet is passed along the catheter, and a
metal conductor attached to the end of it. The catheter is now
withdrawn and replaced by another, which is threaded over the
guide. The ureteral drainage is continued for a month. By this
means the number of post-operative fistulae have decreased.
A fistula may be cured by the removal of its fibrous wall, the
opening up of the sac, removal of calculi, and the establishment of
free drainage. Should this fail, the patient has the choice of
retaining the fistula or having the kidney removed. The presence
of a renal fistula does not of itself necessarily shorten life. Watson
has described a bilateral renal fistula persisting for thirteen years,
and Legueu has known patients become pregnant and parturition
proceed naturally when such fistulae were present.
Secondary nephrectomy is indicated (1) when septicaemia per-
sists, (2) when it is believed, by the inadequate secretion of the
diseased kidney and the absence of disease in the second kidney,
that a depressed renal function in the latter will improve after
nephrectomy, and (3) when the patient is gradually losing ground
from prolonged suppuration.
The mortality of secondary nephrectomy is only 5'9 per cent,
(two in twenty-five operations, eight calculous and seventeen non-
calculous) (Tuffier). If this is added to the mortality of nephrotomy
(23'3 per cent.), the total mortality is 29'2 per cent.
Nephrectomy. (1) Partial nephrectomy is only possible when
there is a partial pyonephrosis with a separate pelvis ; (2) Total
nephrectomy.
Nephrectomy is performed by the lumbar route. The abdominal
route has been abandoned owing to its high mortality (57 per cent.)
(Kiister).
Subcapsular nephrectomy should be performed. The kidney will
usually shell out of the great peri-nephritic fibro-fatty mass with
comparative ease, whereas the removal of the thick, fibro-fatty
capsule with the kidney is fraught with extreme difficulty and some
danger. It may be necessary to puncture a very large pyonephrosis
with a trocar and cannula and to remove a large part of its contents,
so as to deal with the pedicle more easily. The wound should be
protected with pads, and the purulent fluid removed by a rubber
tube attached to the cannula to avoid soiling the wound. The
ureter should be dissected out separately, and as much of it removed
as possible. The mortality of this operation is 17 percent. (Kiister).
Death may take place from shock in patients exhausted by
severe or prolonged suppuration, but the principal danger is the
inadequacy of the second kidney from disease (40 per cent.).
S.T. VOL. II. 52
8i8 Pyonephrosis.
Nephrectomy should not, therefore, be undertaken until the
condition of the second kidney has been ascertained by catheter-
isation of the ureters and the use of the phloridzin or methylene
blue tests. By this means only those cases are submitted to
nephrectorny that have a functionally adequate second kidney, and
the mortality is thereby greatly reduced. In the remaining cases
nephrotorny is performed, and at a later date improvement in
the condition of the second kidney may render nephrectorny
practicable.
J. W. THOMSON WALKER.
819
TUBERCULOSIS OF THE KIDNEY.
THE following points are important in considering the operative
treatment of tuberculous kidney :
(1) Tuberculosis of the kidney is unilateral in the great majority
of cases during the early stage of the disease. It is bilateral in
only 8 or 9 per cent, of cases when the patient comes under the
observation of the surgeon.
In childhood the disease is much more frequently bilateral
(53*3 per cent.).
(2) In the late stage the disease is bilateral in almost 50 per cent,
of cases.
(3) The extent to which the disease has advanced in each kidney
in bilateral tuberculosis differs to a marked degree, and leads to the
view that a considerable interval has intervened between the infec-
tion of the first and the second kidney.
(4) The probability of the healthy kidney becoming tuberculous
increases as the disease progresses in the diseased kidney. The
number of cases where the healthy second kidney becomes tuber-
culous after extirpation of its diseased neighbour is less than that
when the diseased kidney is left unoperated.
(5) One kidney may be destroyed by tuberculous disease without
giving rise to pronounced symptoms, and this kidney may not be
palpable or tender.
(6) The second kidney may be increased to twice the normal size
by hypertrophy without disease.
(7) When tuberculous disease attacks the hypertrophied second
kidney, the patient may be unaware of the disease of the first
kidney, and there is nothing in the clinical history or physical
examination to show that the large, tender, painful kidney is not the
only seat of disease.
(8) Chronic nephritis without tuberculous infection is frequently
present in the second kidney.
(9) Symptoms of cystitis may be present in tuberculosis of the
kidney without disease of the bladder, and are due to reflex irritation
of the bladder (reno-vesical reflex). Symptoms of renal disease
may be absent in these cases.
(10) There is no anatomical proof that tuberculosis of the kidney
ever heals spontaneously or as a result of medical treatment.
522
82O Tuberculosis of the Kidney.
The following information must be in the possession of the surgeon
before he performs an operation upon tuberculous disease of the
kidney :
(1) Is there tuberculous cystitis? The cystoscope is necessary
to distinguish between reflex vesical irritation and tuberculous
cystitis.
(2) The presence of a second kidney must be ascertained, and
information must be obtained in regard to the presence of disease
in this kidney and its functional activity. These data are obtained
by examination of the ureteral orifice and by catheterisation of the
ureter. The tests for the renal function are made, and the urine
examined chemically and bacteriologically.
(3) Are there foci of tuberculous disease in the genital system,
lungs, bones, joints or elsewhere '?
Tuberculin Treatment. Tuberculosis of One Kidney Alone.
It is impossible to speak with certainty in regard to the effect of
tuberculin upon the early stage of renal tuberculosis when one
organ only is affected, for extensive observations on the subject are
wanting.
The tuberculin treatment to have a fair trial must be prolonged
for two years or even longer. In tuberculosis of the kidney, where
the spread under all other non-operative forms of treatment is
known to be progressive, where the second kidney becomes almost
certainly affected after a variable period of time, the length of
which cannot be estimated in any single case, where the results of
nephrectomy in the early stage are extremely good, the surgeon
will hesitate before recommending a form of treatment the results
of which are still uncertain and the period of time over which it
must extend may well exceed the interval of safety during which
the second kidney is still unaffected. It is in cases where
operation has been offered, and fairly discussed and has been
refused, that this treatment must for some time to come find its
application.
An exception may perhaps be made in renal tuberculosis in
children. The frequency with which the disease is bilateral in the
early stage in young children is much greater and the difficulties in
accurate diagnosis by modern methods are more formidable. In
such cases tuberculin may be tried in lieu of operation.
Tuberculosis of the Kidney and Bladder. The indications for
tuberculin treatment are the same as when the kidney alone is
affected.
Nephrectomy is not contra-indicated by the presence of tubercu-
losis of the bladder.
Tuberculosis of the Kidney. 821
In these cases the chief application of tuberculin is the treatment
of the bladder after nephrectomy has been performed.
In some cases the cystitis subsides without further treatment
after removal of the kidney, but in the more severe grades of tuber-
culous cystitis the disease persists. The administration of tuber-
culin is indicated in such cases, and the results obtained by its use
are extremely good.
Tiil><'irnlo*is of l>ot)i Kidneys. In such cases operative inter-
ference is contra-indicated, and tuberculin should be tried.
I have not met with a cure or any case approaching a cure in this
class of cases. There has, however, been undoubted improvement
after the institution of the tuberculin treatment.
When the disease is so extensive, a considerable period of time
might be expected to elapse before the full effect of the tuberculin
is obtained. Such a period, unfortunately, is seldom afforded in
these cases before death takes place from intercurrent infection or
renal failure.
The treatment may be commenced with such doses as J 00
milligramme and carried on with great caution, for there is some
danger of blocking the already obstructed ureters if a reaction and
swelling of the mucous membrane takes place.
If the injections are followed by renal pain or by a rise of tempera-
ture, or an increase of fever already present, they should be stopped
or the dose much reduced.
Tuberculosis of one Kidney, iritJi Tuberculous Foci in other
/V/>-/x A frequent combination is renal and genital tuberculosis.
Tuberculin treatment is often of service in these cases, either in
combination with nephrectomy or apart from operation.
After nephrectomy tuberculin treatment of the genital tubercu-
losis is likely to be successful.
Tuberculosis of the kidney may occur, with active tuberculosis of
the lungs, bones or joints. My experience of tuberculin in these cases
has not been encouraging. There was improvement in the renal
disease in some of the cases, but the extra-renal foci were unaffected
or even appeared to increase under the treatment. When the extra-
renal disease was quiescent, it could be ignored in the treatment of
the renal tuberculosis.
The method of administration of tuberculin is described else-
where. (See Vaccine Therapy, Vol. III.) In renal tuberculosis I
have used dose sconimeucing at ^cfeo or ^oo milligramme (T. R),
and gradually increased the strength to jooo or noo- I have not
found the tuberculo-opsonic index necessary as a routine guide to
dosage. I used it in my earlier cases and found the " negative
822 Tuberculosis of the Kidney.
phase " described by Sir Almroth Wright reproduced in these cases.
This period of depressed resistance lasted two or three days, and
even if severe it completely passed off before the end of a week. The
" negative phase " appeared in all the cases examined for it under
the influence of doses which proved to be of therapeutic value.
An excessive dose was followed by a more profound negative
phase, but it was also accompanied by symptoms of reaction, such as
malaise, depression, " aching all over tfce body, " a slight rise of
temperature and some pain or tenderness in the diseased organ. I
found that the appearance of these symptoms was a sufficient warn-
ing, without the use of the tuberculo-opsonic index, that the thera-
peutic dose had been over-stepped. The converse also held good,
and in the absence of these symptoms of reaction the doses which
were being administered were within the limit of safety.
The treatment must extend over one or several years. A course
of six or eight injections is worthless. I have given tuberculin
both continuously (i.e., weekly or fortnightly for one or more years)
and intermittently in successive courses of two or three months
with intervals of rest of equal duration, the treatment lasting one
or more years. Of the two methods, I am inclined to favour the
intermittent one. Each course must, however, be cautiously intro-
duced with a small dose, and the strength gradually increased.
Progress is measured by the effect upon symptoms : the increase
or decrease of the body- weight, the general feeling of vigour, the
effect on pain, tenderness, enlargement of the kidney, and the re-
currence of attacks of haematuria. Where vesical symptoms are
present the amelioration of these symptoms frequently provides the
most striking demonstration of improvement. The specific gravity
and the pigmentation of the urine increase as the renal condition
improves. The quantity of pus and the presence or absence of
microscopical quantities of blood are also important tests.
The presence and number of tubercle bacilli are the most critical
tests of the progress of the disease.
The operations which may be performed for tuberculosis of the
kidney are partial nephrectomy, nephrotomy, and total nephrec-
tomy.
Partial Nephrectomy. This operation consists in removal of
the diseased part of the kidney. It has been practised in isolated
cases by Israel, Watson, Morris, Godlee and others, and has been
recommended in the early stage of renal tuberculosis.
In practice, however, it is found that at this early stage it is
impossible to make certain how much of the kidney is affected. On
surface inspection the organ may appear normal, or one pole may
Tuberculosis of the Kidney. 823
appear tuberculous and the rest of the kidney healthy when the
disease has already affected both poles.
For this reason partial nephrectomy has not been widely adopted,
and the opinion is practically universal at the present time that
total nephrectomy is the only radical operation that should be
practised for tuberculosis of the kidney.
Nephrectomy. Nephrectomy in the early stage of renal
tuberculosis is the only method by which a cure can be assured,
and the operation is indicated whenever the diagnosis is made.
Nephrotomy is reserved for certain cases that are unsuitable
for nephrectomy, and is a purely palliative operation.
The contra-indieations to nephreetomy are as follows :
(1) Bilateral Tubi'inilosis. When both kidneys are proved to
be tuberculous, nephrectomy cannot be recommended as a curative
operation.
The disease is always more advanced in one kidney than in
the other, and it may be discussed whether the removal of the
organ in which the disease is more advanced will not prolong
life. If we set aside general tuberculosis, which is a very rare
accident in tuberculous disease of the kidney, and is not likely
to be affected by the removal of one of two tuberculous organs, the
dangers to which a patient with bilateral renal tuberculosis is
exposed are two :
(a) Toxaemia due to absorption from the tuberculous foci.
(b) Anuria from destruction of the renal tissue.
In so far as the general health is suffering from the absorption
of toxins from the diseased area considerable benefit will accrue from
the removal of one focus of disease, and it is also certain that the
second and the functionally more active kidney will be relieved of
the irritation caused by the excretion of toxins from the blood. But,
on the other hand, the period of life remaining to the patient is
also measured by the quantity of active renal tissue which he
possesses. By nephreetomy of the most diseased organ some
functional renal tissue is removed even when the tuberculous
inflammation is far advanced. The whole work of secretion is
thus thrown upon the remaining kidney. In some cases the
removal of even this small amount of renal tissue leaves the
patient with too little active secreting tissue, and anuria follows
the operation. In other cases the patient survives the operation,
but after a short period death from anuria takes place.
Unless it is proved by the examination of the urine obtained
by the ureteric catheter, and by the various tests of the renal
function, that the disease of the second kidney is in a very
824 Tuberculosis of the Kidney.
early stage, and unless it is obvious that the health of the patient
is suffering to a marked degree from the absorption of toxins,
nephrectomy of the more diseased kidney in bilateral tuberculosis
is contra-indicated.
(2) Non-tuberculous Nephritis of the Second Kidney. A slight
degree of chronic nephritis is very frequently present in the
second kidney. This is shown by the presence of albumen and
granular and hyaline tube-casts in the urine, and is due to the
excretion of toxins. This does not centra-indicate nephrectomy of
the tuberculous kidney unless the nephritis is advanced. The
urine from this kidney must be examined and the tests of the renal
function carried out in order to ascertain the extent of the renal
disease. Should these prove satisfactory, nephrectomy should be
performed.
(3) Tuberculous Lesions of the Bladder. Tuberculous cystitis
does not centra-indicate nephrectomy if it can be proved that the
second kidney is healthy.
This proof is sometimes very difficult to obtain, for the con-
tracted and irritable state of the bladder interferes with catheterisa-
tion of the ureters. With care and perseverance, however, this can
be carried out by a skilled cystoscopist in all but the most
exceptional cases.
The removal of the tuberculous kidney has usually a most
beneficial effect upon the disease of the bladder. The cystitis
may subside without further local treatment.
The use of tuberculin in these cases has given most satisfactory
results in my hands. When the tuberculous infection has become
mixed with bacterium coli or other bacteria the prognosis is not,
however, so good.
(4) Tuberculous Lesions of other Organs. Obsolete tuberculous
foci, such as Pott's curvature, ankylosed joints, healed tuberculous
disease of bones or glands, etc., do not contra-indicate nephrectomy,
although from anatomical reasons the operation may be rendered
more difficult.
In active tuberculous disease of the genital system, nephrectomy
may be performed if the genital disease is not widespread. In a
case where both epididynies, both seminal vesicles and the prostate
are affected, nephrectomy would be contra-indicated ; but in less
extensive lesions, such as unilateral tuberculous epididymitis,
nephrectomy and epididymectomy may be performed. When renal
tuberculosis is complicated by active spinal caries, psoas abscess,
tuberculous arthritis, pulmonary phthisis and other such serious
lesions, nephrectomy is contra-indicated.
Tuberculosis of the Kidney. 825
(5) The General State of the Patient. It is occasionally
necessary to refuse primary nephrectomy on account of an
enfeebled general state, apart from any of the complications above
described.
Secondary nephrectomy may sometimes be possible in these cases
after nephrotomy.
The Operation. The retro-peritoneal route is invariably chosen
for the removal of a tuberculous kidney. An oblique lumbar
incision gives the most satisfactory access.
The operation is simple or complicated according to the absence
or presence of peri-nephritic inflammation.
Nephrectomy in an early stage of renal tuberculosis before the
peri-nephritic fat has become dense and sclerosed presents no
difficulties or unusual features. On exposing the organ the out-
ward appearance may not suggest that it contains any disease,
and palpation does not detect any change in consistence. In such
a case the value of the previous examination of the urine from
each kidney becomes evident. The kidney is removed without
being incised, and the danger of infecting the wound with tubercle
is avoided.
The ureter is first isolated and carefully examined. Whether it
is thickened or not, it should be cut across between two ligatures
and each end seared with the cautery or touched with pure
carbolic acid. The pedicle is ligatured and the kidney removed.
Legueu recommends that the peri-renal fat should be dissected
away, as there are frequently tuberculous deposits in it. To do
this thoroughly is often difficult and sometimes impossible. In the
early stage of tuberculosis of the kidney, before peri-nephritis has
occurred, there is little difficulty, but in the later stages it is impossible
to dissect away the fibro-lipomatous mass that surrounds the kidney,
and this applies also to the adherent lymphatic glands that are
sometimes found among the structures forming the renal pedicle.
"When there has been peri-nephritis the fatty capsule is transformed
into a thick, firm, adherent fibro- fatty mass, and a sub-capsular
nephrectomy becomes necessary. The kidney is exposed and
stripped from its capsule with the forefinger, great care being
taken not to rupture the tuberculous cysts, the walls of which are
thin and easily torn. If the kidney is converted into a large
pyonephrosis, it may be advisable to tap it, and so reduce the size
and diminish the possibility of rupturing the wall of the sac
during the ermcleation. This is seldom necessary, however, and
if it is done the most stringent precautions must be observed to
prevent soiling of the wound with the escaping tuberculous
826 Tuberculosis of the Kidney.
material. The puncture is made with a trocar and cannula after
protecting the wound with large gauze swabs, and the puncture
wound is closed by pressure forceps over gauze during the
remaining stages of the operation. After removal of the kidney
the cavity must be drained.
When the ureter is normal in appearance it is ligatured and
dropped into the wound. When it is thickened and tuberculous,
one of three courses may be pursued : (1) The upper end may be
fixed in the lumbar wound ; (2) the upper end may be ligatured,
cauterised, and dropped into the retro -peritoneal space after remov-
ing the kidney ; (3) the ureter may be excised.
(1) The upper end of the tuberculous ureter may be fixed in the
lumbar wound. This has been done with a view to ureterectorny
at a later date. A tuberculous sinus results, and in one case in
which I did this the lumbar wound became extensively infected
with tubercle, and only healed after some months.
(2) The upper end is dropped into the retro-peritoneal space
after being ligatured and cauterised. In the majority of cases
the tuberculous process becomes quiescent, and the tube gradually
becomes transformed into a fibrous cord. Zuckerkandl found that
a sinus followed nephrectomy more frequently when the ureter
had been left intact. Occasionally, tuberculous cystitis appears
to be kept up by the persistence of tuberculosis in such a
ureter.
(3) The ureter is excised. In order to do this the oblique
lumbar incision is prolonged forwards beyond the anterior
superior iliac spine, and runs parallel to Poupart's ligament and
about 1 inches above it to about the middle of its extent. The
patient should be placed in the Trendelenberg position in order
to reach the pelvic portion of the ureter. The thick rigid tube is
easily traced down into the pelvis.
The adhesions sometimes give rise to some difficulty in iso-
lating it. In the male subject the ureter can be traced to the
bladder, and then ligatured and cut across. In the female
the pelvic portion of the ureter is concealed in the broad liga-
ment, and the tube must be cut across behind this. Kelly has
removed the lower portion of the tuberculous ureter through the
vagina.
A portion of the bladder-wall around the lower end of a
tuberculous ureter has been excised along with the ureter.
The advisability of performing an extensive operation for the
removal of the ureter at the end of nephrectomy will depend upon
the state of the patient and the duration of the nephrectomy.
Tuberculosis of the Kidney.
827
The ureterectomy should only be performed if the nephrectomy
has passed off smoothly and the patient's strength is well
maintained.
Most authorities are content to remove "as much as possible"
of the ureter, which means that the ureter is traced over the brim
of the pelvis and cut across in the descending part of its pelvic
course, leaving the remaining portion of the pelvic ureter. This
operation occupies less time and necessitates less extensive dissec-
tion than the more complete removal of the ureter ; it protects
the lumbar wound against the possibility of infection from the
ureter, and the small stump does not give rise to any further
trouble. On these grounds it is to be recommended. Secondary
ureterectomy may be required in cases where the ureter has not
been removed at the time of the nephrectomy. The operation is
necessary when a fistula connected with the ureter persists, and when
vesical symptoms persist or increase.
Results of Nephrectomy jor Primary Tuberculosis Immediate
Mortality. The following figures are given by Brongersma :
Surgeon.
Number of
Nephrectomies.
Deaths from
Operatiou.
Per cent.
Albarran
108
3
2-77
Brongersma
58
3
5-17
Casper .
19
2
10-50
Israel .
97
11
11-34
Kronlein
34
2
10-70
Kummel
69
3
4-35
Pousson
20
2
10-00
Rafin .
40
5
12-50
Eovsing
47
3
6-30
Ziickerkandl
23
3
13-05
515
37
7-18
This gives an operative mortality of 7*18 per cent, in 515 cases.
During the last twenty-five years there has been a steady and rapid
decrease in the mortality of nephrectomy for tuberculous disease of
the kidney.
The improvement in the statistics was due in the earlier years to
more perfect asepsis, and to improved methods of treating surgical
shock and more perfect technique, as well as to experience in the
selection of cases suitable for operation.
Recently the great advance in the methods of early diagnosis and
examination of the renal function afforded by catheterisation of
828
Tuberculosis of the Kidney.
the ureters and the use of the phloridzin, methylene blue and
Albarran's experimental polyuria tests have led to still further
reduction of the mortality.
If from the above list only those cases are selected where modern
methods of diagnosis were used, the mortalit} 7 falls to 2'85 per
cent. The following are the figures thus obtained :
Surgeon.
Number of
Nephrectomies.
Deaths.
Per cent.
Albarran
106
1
0-94
Brougersma
57
1
1-75
Casper .
19
2
10-50
Kiimmel
68
2
2-90
Ra6n .
32
2
6-50
JRovsing
33
1
3-38
315
9
2-85
In these cases not one of the nine deaths was due to renal
failures.
After-Results The after-history of 369 patients on whom
nephrectorny was performed for primary tuberculosis shows that
death occurred after a considerable interval in fifty-six cases (15'2
per cent.).
In these cases the interval varied from one or two years to four-
teen or sixteen years. The great majority of these fatal cases died
within the first two years. Thus of 329 cases of nephrectomy,
thirty-five (or 10*6 per cent.) died during the first two years. In
these cases the fatal result would be due to spread of the tubercu-
lous process.
Of 184 cases surviving two years after nephrectomy from
tuberculosis only six (3 - 2 per cent.) died of tuberculosis after that
interval. It may be stated, therefore, that there is a risk
(amounting to 10'6 per cent.) of the patient dying of tuberculosis
during the first two years, and a risk of 3'2 per cent, of a fatal result
from tuberculosis after this.
Nephrotomy. Nephrotomy is a preliminary or a palliative
operation in tuberculosis of the kidney, and is indicated under the
following conditions :
(1) When it is impossible from the condition of the bladder to
catheterise the ureter and obtain information in regard to the state
of the second kidney. After an interval the cystitis subsides
Tuberculosis of the Kidney. 829
and the examination can be carried out. Casper has recommended
that under these very rare circumstances the diseased kidney should
be exposed, its ureter compressed, an injection of indigo carmine
given, and the urine collected from the bladder by a catheter. By
this method the functional power of the second kidney is tested.
(2) As a preliminary operation to nephrectomy when the general
condition of the patient is much enfeebled.
Secondary nephrectomy is performed after some weeks, when
the patient has regained strength.
(3) When both kidneys are tuberculous : (a) to remove a collec-
tion of tuberculous material ; (b) to relieve excessive haemorrhage
or severe pain ; (c) to relieve profound toxemia.
The mortality of nephrotomy is high. Pousson in his personal
statistics found an operative mortality of 27*5 per cent, for
nephrotomy, and 6'54 per cent, for primary nephrectomy.
A fistula persists during the lifetime of the patient.
In a few cases the fistula has closed after the kidney has been
entirely destroyed.
J. W. THOMSON WALKER.
8 3 o
TUMOURS OF THE KIDNEY IN ADULTS.
THE following points are important in regard to operative
treatment of tumours of the kidney in adults :
(1) The results of operation in the early stage of malignant
growths of the kidney are encouraging. Operation in the later
stage is invariably followed by recurrence.
Diagnosis must therefore be made in the early stage.
(2) Haematuria occurs in nearly all cases of renal growth. Israel
found haematuria in 92 per cent, of his cases. In 70 per cent, of
cases hsematuria is the first symptom of new growth of the kidney,
and in the early stage it is the only symptom.
(3) All cases of renal hsematuria without other signs or symptoms
should be explored for renal growth.
(4) The size of the tumour is no contra-indication to operation.
(5) In cases where the peri-renal adipose tissue appears normal
there may be microscopical deposits of cancer cells in it.
(6) The growth may take origin in the suprarenal capsule and
invade the kidney, or nodules of growth may be present in the
suprarenal capsule.
(7) The lymphatic vessels surrounded by adipose tissue pass
from the kidney in a mesentery between the layers of fascia to
glands lying along the inferior vena cava on the right and the aorta
on the left side. These glands are found for the most part below
the level of the renal vessels. In their course the lymphatic vessels
do not communicate with other plexuses.
(8) The ideal operation- should remove the kidney and tumour,
the adipose capsule, the lymphatic vessels and lymph glands and
the adipose tissue in which they are embedded, and the suprarenal
capsule. Gregoire insists that these should be removed in one
piece.
Before embarking upon nephrectomy the following points must
be decided :
(a) Has the growth spread beyond the kidney ?
The disappearance of movement in respiration when the kidney
is still small is an important sign of spread beyond the kidney.
Immobility in a large tumour has not the same significance. The
extent of the growth can best be ascertained after exposure of the
kidney. In all large growths the peritoneum should be opened and
Tumours of the Kidney in Adults. 831
the peritoneal aspect of the tumour examined. I have twice had
to desist from nephrectomy on finding the peritoneum adherent
and nodular over the highest part of the kidney in tumours which
in other respects appeared to be suitable for removal. From the
peritoneal cavity the upper pole of the kidney can be explored in
large growths, whereas it cannot be reached until a late stage of
the operation if approached extra-peritoneally.
The lymph glands lying alongside the aorta or vena cava should
be examined. The most frequent seat of metastatic deposit is the
lungs. A radiograph of the thorax should be obtained in all cases,
and examined for secondary deposits in the mediastinal glands
and lungs. Such deposits may be present and widespread with-
out causing pulmonary symptoms or with only slight signs of
bronchitis. Next in frequency to the lungs, the liver is the seat of
metastatic deposit. This organ should therefore be examined by
palpation, percussion and the X-rays.
(&) What is the condition of the second kidney ?
The presence, health or disease of a second kidney should be
ascertained and its functional activity estimated by catheterisation
of the ureter, examination of the urine thus obtained, and the use
of the tests for the renal function.
Bi-lateral renal growths occur very rarely in adults. At least
90 per cent, are unilateral. The second kidney is frequently the
seat of chronic nephritis. Rarely it is shrunken and atrophied or
absent. The presence of disease such as chronic nephritis or stone
does not centra-indicate operation if the renal function is adequately
performed.
Indications and Centra-indications for Operation. In all
cases of malignant growth confined to one kidney nephrectomy
should be performed if the condition of the patient is considered
sufficiently good and the second kidney capable of carrying on
the renal function.
The operation is contra-indicated when : (1) There is evidence of
invasion of the peri-renal tissues ; (2) enlarged lymph glands in
the abdomen ; (3) evidence of metastatic deposit ; (4) the second
kidney is the seat of growth, of advanced nephritis, or is shrunken
or absent ; (5) the patient is weak and cachectic ; (6) the heart is
dilated and feeble.
Operation. Total nephrectomy is the only radical method of
treatment. Partial nephrectomy is unsuited to the treatment of
malignant growth of the kidney. Nephrectomy may be performed
by the abdominal (transperitoneal) or lumbar (retroperitoneal)
route. In cases where operation is performed before enlargement
832 Tumours of the Kidney in Adults.
of the kidney can be detected, the operation will take the form of
an exploration of the kidney for haematuria, and the discovery of
the growths leads to nephrectomy. These constitute a considerable
proportion of the cases, and are those in which the prognosis
should be most favourable.
In such cases the operation commences as a retroperitoneal ex-
ploration of the kidney, the adipose capsule has been opened and the
kidney has often been incised before the diagnosis is made. The
incision in the kidney should be closed with catgut sutures, and
nephrectomy carried out. The peri-renal adipose tissue should then
be dissected from the surface of the peritoneum and colon as far as
the vena cava or the aorta.
The adipose tissue is also dissected from without inwards from
the muscles of the posterior abdominal wall, leaving them bare.
Near the vena cava or aorta the spermatic vessels will be en-
' countered, and should be preserved. The removal of adipose and
areolar tissue and with them lymphatic vessels and glands should
be carried out with great care as far as the great vessels. The
suprarenal gland should also be removed, and to carry this out
good retraction is necessary.
When the new growth is larger and a diagnosis has been made
before operation, abdominal nephrectomy will give a better
approach, or the growth may be exposed by the lumbar retro-
peritoneal method and the incision extended and the peritoneum
opened to the outer side of the colon.
Gregoire has described an operation which is more thorough
than these methods, and which is to be recommended when a
diagnosis of new growth of the kidney has been made previous to
operation. The object of the operation is to remove in one piece the
kidney, peri-renal adipose tissue, lymphatics, and lymphatic glands.
A firm pillow is placed under the diseased side, and does not
extend further than the vertebral column, so that the body leans to
the healthy side and lies midway between the dorsal and lateral
positions, and is curved backwards.
In the anterior axillary line an incision is made from the costal
margin to the iliac crest. From the upper extremity this is carried
forwards along the costal margin for 4 or 5 centimetres, and from the
lower end the incision is prolonged along the iliac crest for a similar
distance. This is carried through the muscular planes, care being
taken in cutting through the transversalis abdominis not to wound
the peritoneum.
With the index fingers, the peritoneum, colon, and peri-renal
tissues enclosed within the fascia of Zuckerkandl are displaced
Tumours of the Kidney in Adults. 833
forwards and stripped off the muscles of the posterior abdominal
wall, and this is carried as far as the vertebral column.
The reflection of the peritoneum is identified, and about 1
centimetre behind this the fascia of Zuckerkandl is incised. The
peritoneum and colon are now stripped forwards as far as the vena
cava or aorta. Slight traction will detach the kidney at its upper
pole, but with this the suprarenal capsule must be removed by blunt
dissection with the finger.
A large retractor holds back the peritoneum, and the renal
vessels are well exposed and ligatured. The ureter is tied and cut,
and the kidney is now removed so as to obtain better access. The
adipose tissue lymphatics and glands are now dissected along the
vena cava and aorta, preserving the spermatic vessels.
Dangers of Nephrectomy in Renal Growths. The im-
mediate danger is haemorrhage.
The veins of the peri- renal tissues are greatly enlarged when the
new growth has reached a fair size. These veins are easily torn,
and may give rise to free venous haemorrhage, which is difficult to
control. The bleeding ceases when the kidney is removed, but
occasionally may give rise to continuous oozing for some days or
weeks after the operation. Formidable veins may also be met with
at the upper pole, and are difficult to reach. They are controlled
during the operation by packing, and may have ceased to bleed at
the end of the operation. In Gregoire's operation the peri-renal
veins are more likely to escape. The inferior vena cava has been
torn. This should not occur unless considerable force in tearing
away glands, etc., has been exercised. Lateral suture of the vein
has been performed, but the accident has always proved fatal.
The wound may be soiled with carcinomatous tissue. In a large
number of cases recurrence takes place in the operation scar, and
there is no doubt that the growth became implanted during removal
of the kidney. In one of my cases in which a nodule of growth
appeared in the scar I had dissected out a mass of glands extending
from the pillars of the diaphragm to the common iliac artery.
During the removal a large cyst contained in the mass burst and
flooded the wound with cancerous debris.
Heart failure is a serious danger since the heart muscle is
frequently enfeebled by the absorption of toxins. Five out of eight
fatal cases (62 per cent.) in Israel's operations were due to heart
failure.
Pulmonary embolism has been caused by the detachment of a
clot in the renal veins during the operation. (Israel.)
Results. The mortality of nephrectomy for renal growths has
S.T. VOL. n. 53
834 Tumours of the Kidney in Adults.
fallen rapidly during recent years, as the following statistics
demonstrate :
1885 Minges. . . . Mortality, 76 per cent.
1888 Tuffier ... 65 '2
1888 Guillet ... 72
1891 Chevalier ... 58 ,,
1892 Earth .... 42
1898 Heresco ... 24
1902 Albarran and Imbert . 22 ,, ,,
Schmieden collected 329 fully described cases of nephrectomy for
renal growth. Of these 108 died, or 32*8 per cent.
On analysing these results he found that the mortality during
the first ten years of renal surgery was 64 '3 per cent., in the second
ten years 43*0 per cent., and in the third 22'0 per cent, in adults.
The high death-rate in the earlier operations was largely due to
septic infection, and this also accounted for the high mortality of
transperitoneal nephrectomy as compared with the retroperitoneal
operation. In the transperitoneal operation previous to 1890 the
mortality was 50 per cent., according to the statistics of Gross and
Brodeur, while the mortality of the lumbar retroperitoneal opera-
tions was estimated by the same authorities at 37 per cent, and
38 per cent, respectively.
Albarran and Imbert' s statistics of operations performed after
1890 showed a mortality of 23 per cent, for lumbar nephrectomy,
and 21*10 per cent, for transperitoneal.
Death is due in these cases to septic infection, heart failure,
shock, asthenia and anuria from inefficiency of the remaining kidney.
Late Results. Recurrence takes place in 60 per cent, of cases,
and in over 70 per cent, of these it occurs within the first year.
After the first year recurrence is less common, and it is rare after
the third or fourth year. Cases in which recurrence has taken
place after three years are recorded.
Garceau gives the following table of collected cases. Time
between nephrectomy and death from metastasis :
1 year or under . . . . . . . 17
1 to 2 years 8
2 to 3 4
3 to 4 1
4 to 5 -. . 1
7 to 8 . . 1
10 to 11 1
33
Tumours of the Kidney in Adults. 835
The recurrent growth is most frequently found in the scar. It
occurs also in the lymph glands, lungs, and liver, and in these
cases metastasis has almost certainly taken place before the
operation.
Forgue found that twenty-eight cases (7 to 10 per cent.) had
survived at the end of the fourth year without recurrence.
In Wagner's cases, thirty-four remained well from two years to
eighteen years ; but only twenty-one were free from recurrence
from three years and upwards (sixteen adults, five children).
J. W. THOMSON WALKER.
532
8 3 6
TUMOURS OF THE KIDNEY IN CHILDREN.
TUMOURS OF THE KIDNEY in children are invariabty malignant, and
present some peculiarities which are important in view of operative
treatment.
They are bilateral in about 50 per cent, of cases.
Hsematuria occurs in a small number of cases (24 per cent.), and
is rarely present until after an abdominal tumour has been
discovered. Tumour is constant (140 in 142 cases, Walker), and
is the initial symptom in about one-third of cases.
The operations are the same as those practised in the adult.
The mortality is higher, and recurrence is more rapid and certain
than in the adult. Walker places the general mortality from opera-
tions and recurrence at 93*22 per cent. Albarran and Imbert give
the mortality as 25 to 30 per cent., and state that recurrence
takes place in between 67 and 81 per cent, of cases.
Simon collected the following cases of survival for a year or more
after operation :
Israel ........ 5 years.
Doderlein . . . . . . . 4
Schmid ....... 3 ,,
Schend 2|
Eovsing .... . 2J
Malcolm . . . . ... 28 months
Hue ........ \\ years.
Eovsing .... li
Steele 1 year.
Schonstadt ....... 1
The longest survival of which I have definite information is a
case on which Mr. J. D. Malcolm operated in November, 1892. This
was a female child under two years, and the tumour was a
"malignant adenoma." The capsule and some enlarged glands
were removed. Mr. Malcolm informs me that the patient is now
alive and well, eighteen years and three months after the operation
(February, 1911). Abbe, of New York, recorded two cases of
prolonged survival, one for four-and-a-half years, in which the
patient died of new growth in the second kidney, and in the other
the patient was alive and well in 1902, over ten years after the
operation.
J. W. THOMSON WALKER.
837
UREMIA.
THE early symptoms are usually indigestion, nausea, vomiting,
and sometimes diarrhoea. The best diet for the stomach is
light solid food. Something with a taste is less likely to be
vomited. Milk not infrequently disagrees. A little stimulant is
often of service. Bitters and small doses of rhubarb, with magnesia,
Tr. Nuc. Vom., -\r\_5 ; Tr. Rhei, in. 5 ; Magnes. Garb., gr. 10;
Infus. Gent. Co., ad 3]; [U.S.P. Tr. Nuc. Vom., ml2; Tr. Rhei,
ill 2 : Magnes. Garb., gr. 10 ; Infus. Gent. Co., ad 33 ;] or Pulv. Rhei,
gr. 1 ; Bismuth. Garb., Sod. Bicarb., aa gr. 5 ; Pulv. Nuc. Vom.,
gr. \ ; Pulv. Cinnamomi Co., gr. \\ [U.S.P. Pulv. Rhei, gr. 1 ;
Bismuth. Garb., Sod. Bicarb., aa gr. 5; Pulv. Nuc. Vom., gr. \\
Pulv. Cinnam., Pulv. Sem. Cardamomi, Pulv. Zingib., aa gr. ]
should be given in cachets.
For the diarrho3a give Salicylate of Bismuth, gr. 15 ; Pulv. Opii
Co., gr. j. [U.S.P. Bismuth. Salicylat., gr. 15 ; Pulv. Opii, gr. ^;
Pulv. Piper. Nig., gr. ^; Pulv. Zingib., gr. J; Pulv. Carui, gr. ;
Pulv. Tragacanth., gr. ^ H .] Sometimes blood appears in the stools.
This is usually due to thrombosis of a small artery in the intestinal
wall, and ulceration may follow. The food must be as digestible
and leave as little residue as possible. Bismuth and very small
doses of opium are the best drugs. Pulv. Cret. Aromat. C Opio.
[U.S.P. Pulv. Aromatici, 1 part; Pulv. Cretse Co., 9 parts; Pulv.
Opii, J part]. Pulv. Kino Co., [U.S.P. Pulv. Kino, 15 parts ; Pulv.
Opii, 1 part ; Pulv. Cinnam., 4 parts]. Tr. Catechu, [U.S.P. Tinct.
Garnbir Co.]. Decoct. Haematoxyli may also be tried in small and
repeated doses.
At the same time these patients are anaemic. The anaemia should
be treated with light preparations of iron whenever the digestion
can stand it. Beside those of our Pharmacopoeia there are several
organic forms, such as ferratin, liq. ferri albuminati, glycerole of
glycero-phosphates, with or without red bonemarrow, fersan,
haemoglobin extract, Rommel's haeniatogen, and haemaboloid, which
can be used for a change.
The next symptoms will probably be headache and giddiness. The
latter is due to arterial sclerosis. Tincture of nux vomica is some-
times good for it. Headache is sometimes very severe, especially
when the blood pressure is high. It is usually frontal. The best
838 Uraemia.
drug I know for it is cannabis indica, Tr. Cann. Ind., -\i\l5 ; Pot.
Brom., gr. 10; [U.S.P. Tr. Cannab. Ind., m8; Pot. Brom., gr. 10]
quartis horis. It is a variable drug, and some specimens produce
hallucinations ; but it nearly always relieves the fearful pain of
uraemic headache.
These patients commonly become drowsy, and in this condition
begin to have a little twitching of the face or of the hand and arm ;
or without any premonitory symptoms, a violent convulsion may
take place. These symptoms are a sign that the total amount of
poison in the blood is near the lethal dose. It has to be got rid of
somehow. The natural passage for any poison is with the urine,
and the attempt should be made to increase the flow. This
depends upon the rapidity of the blood current in the kidney, and
this upon the blood pressure. In spite, therefore, of the excess of
pressure already present, it is advisable to give digitalis and theo-
bromin, Tr. Digit., n[W; Diuretin, gr. 10; quartis horis. Infusion
of digitalis in 2-drachm [U.S.P. 1 drachm] doses sometimes acts
better than the tincture, as the alkaloids it extracts from the plant
are a little different, for the danger of uraemia is greater, especially
in young patients, than that of cerebral haemorrhage. In addition,
purging and sweating will extract some solids as well as water from
the blood. For the latter the hot bath, the hot air bath, the hot*
pack, or injections of pilocarpine nitrate (^ gr.) are employed. The
hot air bath is made by putting a metal funnel, wide end down-'
wards, over a spirit lamp, and attaching to the small upper end a
tube (metal or flexible), which is carried under the bedclothes. The
latter should be supported on a cradle. A hot pack is best given
by hot dry blankets, with hot water bottles or hot bricks. But if
the fits continue venesection must be done, and \ pint of blood,
or more, taken away. The removal of this amount reduces the
total poison considerably below the lethal dose. It accumulates
again, no doubt, but slowly, and meanwhile the power of tolerance,
which the body possesses, can increase too.
Convulsions are not the only severe symptoms of uraemia. They
are sometimes replaced by dyspnoea. This " uraemic asthma," as
it is called, is not due to organic disease of the lungs, but is nervous
in origin. It is best treated by oxygen inhalation.
In other cases convulsions are replaced by a terrible restlessness,
which is even worse. The patient is usaully half unconscious, will
take nothing, does not sleep, and is in a state of extreme distress,
continuously tossing, turning, pulling the clothes up, down, off, or
trying to get out of bed. Oxygen has been recommended for this
variety of uraemia also. Veronal in 10-gr. doses gave good sleep in
Amyloid Disease of the Kidneys. 839
two cases of the kind. Sedatives, such as the bromides, broinetone,
bromural and sulphate of hyoscyamine should be given, but are
often unsuccessful. Morphine should also be tried, though with
caution.
Occasionally uraemia produces a hemiplegia or a monoplegia like
that of organic disease. No special treatment is needed, and the
cases will hardly be distinguished except by their rapid recovery if
the patient lives, or by the absence of any gross lesion if he dies.
W. P. HERRINGHAM.
AMYLOID DISEASE OF THE KIDNEYS.
THIS is a sequela of chronic suppuration, or tuberculosis, or
syphilis, and occasionally of other chronic diseases, such as
rheumatoid arthritis, and even of rheumatism. The diagnosis is
difficult. It rests upon the presence of albuminuria, the absence of
other symptoms of true nephritis, whether diffuse or interstitial,
and the signs of amyloid enlargement of the liver and spleen.
The treatment is that of the underlying disease. In every case
iodide of potassium should be tried. Anaemia, vomiting and
diarrhoea, must be treated as in ordinary chronic nephritis (5.^.),
except that arsenic may well be added to the iron for anaemia,
which is not advisable in true nephritis. Fresh air, sunshine, and
good food are rather part of the treatment of the original than of
the renal disease.
Dropsy, if present, should be treated as in nephritis. Uraemia is
seldom seen.
W. P. HERRINGHAM.
840
AFFECTIONS OF THE URETER.
WOUNDS OF THE URETER.
WOUNDS OF THE UEETER are rare apart from surgical operation.
They may result from blows on the abdomen, from stabs or bullet
wounds, or from injury caused by the foetal head during
parturition.
The operations in which the greatest danger of wounding the
ureter is incurred are operations upon the uterus and Fallopian
tubes. In rare cases the ureter is partly torn. In such a case a ureteral
catheter should be passed from the bladder up the ureter and
FlG. 1. End-to-end anastomosis
of the ureter.
FIG. 2. End-to-end anastomosis
by invagination.
the edges of the wound sutured over this. The catheter should be
left in position for a week.
If there is an irregular tear of the ureter it is better to resect
a portion of the tube and perform one of the operations for
anastomosis. Complete section of the ureter necessitates immediate
suture. This should be done with fine rounded needles and fine
catgut. Many varieties of ureteral suture have been introduced.
(1) End-to-end anastomosis after transverse (Schopf) or oblique
(Bove"e) section, or by transverse section with longitudinal splitting
of the ends (Tatze). Interrupted sutures are used and penetrate
the whole thickness of the wall (Fig. 1).
(2) End-to-end anastomosis by invagination (Poggi). This is
simplified by making a longitudinal incision in the lower end of
the ureter (D'Antone) (Fig. 2).
(3) End-to-side implantation. One end is ligatured and the
other cut obliquely and invaginated into a lateral incision in the
ligatured segment, and secured by interrupted sutures (Van Hook)
(Fig. 3).
(4) Lateral anastomosis is performed by ligaturing both ends
Wounds of the Ureter.
841
and uniting two longitudinal openings in these in a manner
similar to intestinal anastomosis (Manari) (Fig. 4).
The peritoneum may be closed over the union, but there is a
danger of leakage into the extraperitoneal tissue. The peritoneum
should therefore be sutured outside the junction, which is thus
rendered intraperitoneal and the peritoneal cavity is freely drained.
A graft of omentum may be stitched over the line of union. A
ureteral catheter may be passed up the ureter from the bladder
and retained in the ureter, but it may cause irritation and is not
used by some surgeons on this account. Taddei introduced a
magnesium tube over whicli the ends of the ureter were brought
and invaginated, the object being to render invagination easy, and
to preserve the lumen. The magnesium is dissolved by the urine
in twenty days.
Results. Alksne collected all the published records since 1886.
He found forty-three complete recoveries in sixty cases, nine
FK;. 3. End-to-side implantation.
FIG. 4. Lateral anastomosis.
recoveries after temporary fistulae, and eight deaths (11 '6 per
cent.). The mortality of both the circular and the invagination
methods was the same, namely, 10'3 per cent.
He looks upon the invagination method of Poggi as the best.
This method yielded 12 per cent, of fistulae in twenty-eight cases,
while the circular method gave 24 per cent, of fistulae. When a
portion of the ureter has been torn away, one of several procedures
may be carried out :
(1) If the remaining portion will reach the bladder it should be
implanted in it.
(2) It has been suggested that the ureter should be carried across
the.middle line and implanted into the other ureter. (Bernasconi
and Columbine.)
(3) The ureter may be implanted into the intestine.
(4) The end of the ureter may be brought out on the skin
surface.
(5) Nephrectomy may be performed.
842
FISTULA OF THE URETER..
FISTULA OF THE UEETER occurs under a variety of conditions. A
fistula is rarely caused by stabs or bullet wounds ; more frequently
it may result from injury caused by the foetal head or by
instruments during parturition.
A fistula may follow an operation upon the ureter for stone.
Most frequently it follows gynaecological operations such as vaginal
or abdominal hysterectomy.
The fistulous track may open on the surface of the body or into
the vagina or uterus.
Post-parturition fistulae are situated close to the bladder, and the
bladder itself may be involved so that the opening is a uretero-
vesico-vaginal fistula. Post-operative fistulae lie at some distance
from the bladder, so that there is a short segment (5 centimetres,
Bazy) of ureter below the fistula.
There is always a stricture of the ureter below the fistula.
Above the stricture and fistula the ureter is dilated and the
kidney is also dilated. Infection of the fistula, ureter and kidney
invariably occurs. The fistula very rarely closes spontaneously.
The following information should be obtained before operating
upon a ureteral fistula :
(1) Is the ureter partly or completely severed? On examina-
tion of the bladder with the cystoscope I have found that the
ureteric orifice shows no movement when the ureter is completely
severed, but that rhythmic contraction of the ureteric orifice
takes place on the diseased side if the ureter is only partially
severed.
(2) Is the fistula vesical or ureteral '? This may not be evident
in some post-parturition cases. If on injecting fluid coloured with
methylene blue the blue fluid escapes from the fistula, the fistula
communicates with the bladder. If on the other hand the coloured
fluid does not appear at the fistulous opening, the fistula
communicates with the ureter.
Examination with the cystoscope will show a healthy bladder in
ureteric fistula.
(3) Which ureter is fistulous ? When the fistula has followed
parturition or a gynaecological operation, this may be in doubt.
Cystoscopic examination will show one ureter motionless and
Fistula of the Ureter. 843
without efflux, and chromo-cystoscopy will further demonstrate
the absence of efflux.
(4) What is the position of the fistula ? This is ascertained by
passing a bougie opaque to the X-rays along the ureter. The
bougie is arrested at the stricture on the vesical side of the
fistula, and the distance from the bladder is estimated by observing
the markings on the catheter and also by obtaining a radiogram
with the catheter in position.
Treatment. (1) The introduction of a catheter en demenre.
This is impossible in a large proportion of cases on account of
the stricture of the ureter. In a few cases it has been practised,
but the ultimate result has not been successful. The stricture
re-contracts and the fistula opens after the catheter has bden
removed, or the fistula may heal permanently and the reconstruction
of the stricture brings about atrophy of the kidney.
(2) Suture of the ureter. This is not feasible. The patent
segments of the ureter are widely separated by a mass of fibrous
tissue and it is impossible to approximate them.
(3) Transplantation of the ureter, (a) Implantation into the
bladder. (Uretero-cysto-neostomy.) This may be done by a
transperitoneal operation or by the extraperitoneal route. Legueu
recommends that the abdomen should be opened and the position
of the ureter ascertained. The peritoneum is then closed and the
operation performed extraperitoneally. The urine is invariably septic
in these cases, so that the extraperitoneal route is to be preferred.
The ureter is followed downwards as low as possible and cut
across above the fistula. An opening is made in the most
accessible part of the bladder and the union of the ureter and
bladder made at this point. It is essential that no traction should
be exerted on the newly-formed union, and the ureter and
bladder should be freed to avoid dragging. For this purpose
Ricard sutures the wall of the bladder to the pelvic peritoneum.
On the other hand the ureter must not be stripped too extensively
from its surroundings, lest sloughing from inadequate blood
supply follow.
Many varieties of implantation have been used.
The edges of the ureter transversely or obliquely cut are stitched
to the edges of the bladder wound, and further sutures are placed
on the outside and the union buried by folds of the bladder wall
held by Lembert's sutures.
The end of the ureter may be introduced into the bladder and
project into its lumen for some distance. The end is split and the
flaps turned back as a cuff on the tube itself, and stitched there.
844 Fistula of the Ureter.
The bladder wall is invaginated and stitched by series of sutures
to the ureter. (Bicard.)
The end of the ureter may be split and passed through an
opening in the bladder wall. The two flaps are stitched to the
surface of the vesical mucous membrane by sutures passing
through the thickness of the wall and tied on the outer aspect
of the bladder.
A button has been used to connect the ureter and bladder.
(Baldassari.)
Results of Uretero-cysto-neostomy. Primary union is occasionally
obtained, but frequently there is leakage of urine. This does not
usually persist, and the wound heals. A few cases have been
recorded in which by catheterisation of the implanted ureter a
successful result has been proved after considerable periods.
There are other cases, however, in which the kidney has been found
atrophied post mortem without having given any signs during life.
(b) Implantation into the bowel. On the right side the CEecum
or ascending colon should be selected ; on the left, the pelvic
portion of the colon: The abdomen is opened in the middle line,
the ureter isolated, and the most suitable part of the bowel
selected. The implantation is made into the posterior wall, if
possible extraperitoneally. Interrupted sutures are used, and the
outer coat of the ureter is stitched to the serous covering of the
intestine, the mucous membranes are then united, and the opera-
tion 'continued like an entero-anastomosis. After the union is
complete a third row of sutures may be added which invaginates
the union into the lumen of the bowel. The implantation may be
made obliquely, or a flap of intestinal mucous membrane may be
raised and the ureter implanted below this, so that it is protected
by a kind of valve. Boari uses a button to form the union.
Results of Implantation into the Bowels. Successful results have
been published.
The mucous membrane of the colon does not resent the action of
the urine and the fluid is passed with the faeces. The dangers of
the operation are shock, peritonitis, and ascending pyelonephritis
from infection. Pagini found a mortality from the operation of
58 per cent, when bilateral implantation was performed, and
20 per cent, when one ureter only was implanted. A few cases
have been recorded in which the patient continued in good health,
but many cases die with a comparatively limited period of ascending
pyelonephritis.
(4) When the fistula opens high up in the [vagina an opera-
tion may be performed which turns a small portion of the vagina
Fistula of the Ureter. 845
into the bladder. The fistula is enlarged and an opening made
into the bladder close to it. This part of the vagina is then closed
off so that the fistula and bladder become continuous.
(5) The vagina may be obliterated, after first establishing a large
vesico-vaginal fistula.
(6) Ligature of the ureter with the object of producing atrophy
of the kidney was suggested by Guyon.
(7) Nephrectomy has until recently been resorted to by a large
number of surgeons. It should not be performed until a plastic
operation has been tried or unless septic pyelonephritis is present.
T. W. THOMSON WALKER.
846
STONE IN THE URETER.
THE following points are important in relation to treatment :
(1) A calculus may become arrested in the ureter at any part of its
course, but is most frequently found at the upper end of the ureter,
at the level of the brim of the pelvis, or at the vesical end.
Jeanbrau gives the following statistics :
Lumbar segment of the ureter . . 46, 22 per cent.
Iliac 15, 15
Pelvic ,, 105, 51 ,,
Intravesical ,, ,, ,, 36, 17
(2) Ureteral calculi are solitary in 90 per cent, of cases. In
10 per cent, there are more than one, and there may be as many
as twenty-seven calculi. They are bilateral in only 3'6 per cent,
of cases.
(3) Calculi may be free in the ureter, or impacted or encysted.
(4) Freely movable calculi may travel up a dilated ureter when
the pelvis of the patient is raised.
(5) An impacted stone frequently lies above a stricture of the
ureter.
(6) An encysted calculus may cause rupture of the ureter and
peritonitis.
(7) An impacted calculus increases in size and causes urinary
obstruction, and eventually hydronephrosis.
(8) Infection takes place by way of the blood stream and kidney
in the majority of unrelieved cases. Pyelonephritis or pyonephrosis
results.
(9) A good radiogram will show a shadow in all but pure uric
acid calculi.
(10) It is frequently necessary to obtain a radiogram with an
opaque bougie in the ureter in order to localise a doubtful shadow.
(11) A bougie may be arrested by the calculus, or it may pass
alongside it after a slight hitch.
(12) As short an interval as possible should intervene between
the radiography and the operation, and the bladder should be
examined with the cystoscope immediately before the operation.
These precautions are necessary to avoid performing an operation
on the ureter after the stone has passed into the bladder.
Stone in the Ureter. 847
The following information should be in 2)ossession of the surgeon
before he operates : (1) The presence of a calculus in the ureter and
its exact position. This is ascertained by means of the X-rays,
cystoscopy, and the passage of an opaque ureteric bougie.
(2) The calculus is impacted or encysted. This is shown by the
history, the size and shape of the calculus, and the absence of any
change in position on repeated X-ray examination.
(3) The presence or absence of other calculi in the ureters,
kidneys, or bladder.
(4) The condition of the kidney on the side corresponding to
the stone and that of the opposite kidney. This is obtained by
catheterisation of the ureters and by pyelography.
The treatment of ureteral calculi is medicinal, instrumental, or
operative.
Medicinal Treatment. The cases that are suitable for medi-
cinal treatment are those in which a small stone has recently passed
into the ureter. An oval stone with its long axis in the line of the
ureter is more likely to pass than a round or a long calculus, or one
set obliquely to the line of the uterer.
The patient is subject to attacks of renal colic, and the stone,
when examined at intervals by the X-rays, is found to change
in position. In some cases the patient has passed calculi
previously.
The treatment consists in the administration of diuretics.
Potassium citrate and acetate are given in doses of 15 or 20 gr.
thrice daily, and theocin sodium acetate, 3 to 8 gr., in cachet.
Diuretic mineral waters, such as Contrexeville (Pavilion) and
Yittel, should be taken fasting. The best effect is obtained by
taking a large draught of the diuretic water in the early morning,
and a very light breakfast of tea and a roll, a full meal at midday,
and another large draught of the water about five in the afternoon,
and a meal at eight o'clock. With the diuretic medicine anti-
spasmodics, such as atropine and belladonna, may be prescribed
in the hope of relieving any ureteric spasm that may be grasping
the stone.
This treatment should not be continued indefinitely. A period
of from four to six months should be placed upon it, and at the end
of this time operative interference should be recommended.
Should signs of dilatation of the kidney or infection appear,
operation should be performed at once.
Instrumental Treatment. The passage of a bougie up the
ureter is sometimes followed by the expulsion of a stone. With-
out recommending this as a routine method of treatment, I believe
848 Stone in the Ureter.
it is worthy of trial in stones which appear likely, from their size
and shape, to pass.
The injection of sterilised oil into the ureter has been said to
assist the expulsion of the calculus.
Nitze injected several cubic centimetres of eucaine ('2 per cent.)
into the ureter with the object of relieving spasm. He also intro-
duced a ureteral catheter (catheter occlusir) near the distal end of
which is a fine membranous balloon, which could be distended
with fluid. With this he proposed to dilate the ureter below the
calculus. Jahr has used a modification of this apparatus with
success in one case.
Operative Treatment. Operation is indicated (1) when
anuria has supervened; (2) when medicinal and instrumental
treatment have failed ; (3) when infection has taken place ;
(4) when there are signs of dilatation of the kidney.
The operative treatment of calculous anuria has already been
discussed. The operation is performed to relieve the anuria, and
the removal of the stone may be deferred to a later date.
In all other cases the object of the operation is to remove the
calculus.
(1) When the calculus is impacted at the junction of the pelvis
and ureter, the treatment has already been discussed under " renal
calculus."
(2) Calculus in the lumbar portion of the ureter is exposed by
an oblique lumbar incision, and the duct found at the lower end of
the kidney and traced downwards. The stone is easily felt, and is
removed by an incision made directly upon it in the long axis of
the ureter.
If the urine is septic, a ureteral compressor may be placed above
the stone before incising the ureter to prevent contamination of the
wound. A large rubber drainage tube is left in the lumbar wound.
(3) Calculus at the brim of the pelvis. This is exposed by a
curved incision commencing above the level of the anterior
superior iliac spine, and passing downwards and inwards parallel
to Poupart's ligament, and about 2 inches above it, and carried
inwards as far as the outer edge of the sheath of the rectus.
The peritoneum is reflected along the external iliac vessels, and the
ureter is found adhering to it at the bifurcation of the common
iliac artery. The patient should be placed in the Trendelenberg
position, the calculus removed, and the ureter sutured. Great care
must be exercised in this operation and in the extra-peritoneal
removal of stones in the pelvic portion of the ureter that the
rubber drainage tube does not lie in contact with the iliac vessels.
Stone in the Ureter. 849
Several cases of ulceration through the external iliac artery from
this cause have been recorded. -I place a large tube in the iliac
fossa well away from the vessels and raise the lower end of the bed
on blocks.
(4) Calculus in the pelvic portion of the ureter : (a) Extra-
peritoneal removal by the iliac route. The incision is similar to
that already described. The ureter is traced over the pelvic brim
into the pelvis. Jhe stone can usually be detected with the finger.
If it is small and movable, a small incision should be made in the
ureter above the iliac vessels. A fine scoop (Fig. 1), which I have
introduced, with a soft silver handle, which may be bent to the
required angle, is passed along the lumen, and with the finger out-
side the ureter the stone is extracted. The wound is then sutured.
When the stone is large and fixed, the ureter is carefully incised
over it and sutured after its removal.
(1>) Extra-peritoneal removal by the sacral route. This operation
was first performed by Morris and has been advocated by Rigby.
An incision is made parallel to the sacral spines and 2 inches from
J. H. MONTAGUE. LONDON
FK;. 1. Thomson Walker's pliable ureteral scoop.
the middle line from the third sacral spine to 1 inches beyond the
tip of the coccyx. The gluteus maximus muscle and great sacro-
sciatic ligament are divided and the ureter found alongside the
rectum. The advantages claimed for this method are the absence
of haemorrhage, the patient is spared an abdominal incision, and
dependent drainage is obtained. The disadvantage is an extremely
narrow field of operation.
(c) Trans-peritoneal route. The peritoneum is opened in the
middle line and the patient placed in the Trendelenberg position.
The ureter is exposed by incision of the peritoneum over it and the
stone removed. The ureter and peritoneum are thus carefully
sutured and the laparotomy wound drained. This operation entails
a risk of infection of the peritoneum.
(d) Vaginal route. A stone which can be felt from the vagina
may be removed by an incision in the vaginal wall.
(<.') Calculus in the intra-mural portion of the ureter. These
calculi are best removed from within the bladder after cystotomy.
After all operations upon the ureter for stone the lumen of the
duct should be examined by passing a bougie downwards into the
bladder.
S.T. VOL. ii. 54
850 Stone in the Ureter.
If a stricture is present it should be incised in the long axis of the
ureter. If the lumen is much contracted it may be necessary to
perform a plastic operation for relief of the stenosis. This may be
a longitudinal incision with transverse suture of the wound, or a
lateral, or end-to-end, or end-to-side anastomosis. After removing
the stone, the ureter should be sutured with fine catgut, the stitches
penetrating only the outer and muscular coats. I have not found
any harm result when a catgut suture penetrates the whole thick-
ness of the wall, but if silk is used a concretion forms upon the
suture. Silk sutures should on this account be avoided. Suture of
the ureter is not absolutely necessary in order to obtain healing of
the ureteral wound, for some surgeons have obtained good results
without it. The ureter heals more rapidly, however, if its wall is
sutured, and in several cases I have obtained healing by first
intention without the escape of any urine. In some operations on
stones in the pelvic segment of the ureter it is difficult or impossible
to suture the ureter accurately, and the wound must be left open.
In suturing the ureter it is an advantage to place a ureteric catheter
in the duct, so that the lumen is not narrowed by the sutures. The
catheter is withdrawn before the last suture is tied. All manipu-
lations of the ureter should be carried out in the most delicate
manner. Stripping of long segments from the peritoneum, pinching
the duct with dissecting and pressure forceps, tearing and dragging
on the tube during the removal of the calculus and the subsequent
passage of a bougie must be avoided, since damage to the blood
supply or walls of the duct will lead to sloughing and contraction
of the wall and to stricture and fistula.
Results. Apart from cases of calculous anuria and when other
operations, such as nephrolithotomy, have not been combined with
ureterolithotomy, the operative mortality is under 2 per cent, in
extra-peritoneal ureterolithotomy. Jeanbrau collected sixty cases
with one death a mortality of 1'66 per cent.
When other operations are combined with ureterolithotomy, the
mortality rises to 13*11 per cent.
Trans-peritoneal ureterolithotomy has a mortality of 5'5 per cent.
Late Results. Urinary fistula following ureterolithotomy results
from stenosis of the duct or damage to the wall of the ureter at
the operation. The number of cases in which it occurs is small.
A temporary fistula has been recorded in about 5 per cent, of cases,
but in only 3 per cent, does it become permanent. With the
knowledge that stricture may complicate stone in the ureter, and
the possibility of dealing with the stenosis surgically, the frequency
with which fistula occurs will still further diminish. Stenosis may
Stone in the Ureter. 851
also occur from rough handling of the ureter, and all manipulations
must be delicately performed.
The symptoms from which the patient suffered are relieved by
the operation. Patients upon whom I have operated by extra-
peritoneal ureterolithotomy are well seven years, five years, and
three years after the operation, and others more recently operated
upon enjoy perfect health.
In the early stage of dilatation of the kidney the organ may
completely or almost completely recover, so that no difference can
be detected in the functional power of the two kidneys. When
dilatation of the kidney has been well established, even although
the enlargement of the organ is not so advanced as to be detected
by palpation, repair is not complete, and the dilated pelvis does not
shrink to its normal proportions.
I examined a case in which I had removed a calculus from the
ureter at the brim of the pelvis a year previously, and found on
injecting Collargol and radiographing the patient, that a large,
dense shadow was obtained, having the form of a hydronephrosis,
with a capacity of a little over 2 oz.
Eecurrence of stone in the same ureter is rare. In a case in
which I removed a calculus weighing 7 gr. from the ureter at the
brim of the pelvis I stitched the ureter with four strands of fine silk.
The patient subsequently passed two stones at intervals of six
months. In the first stone was embedded one silk ligature, and in
the second the remaining three. The patient has since remained
well for six years.
J. W. THOMSON WALKER.
54
8 5 2
DISEASES AND AFFECTIONS OF THE
BLADDER.
CALCULUS OF THE BLADDER.
VESICAL CALCULI are divisible into primary and secondary
varieties. The latter are secondary to inflammation of the urin-
ary tract. The real causation of the former is as yet imperfectly
understood ; predisposing factors, however, may be both general
and local. The general predisposing factor is the presence of
some diathesis, such as the uric-acid diathesis, oxaluria, phos-
phaturia, or cystinuria. Local factors are obstruction to the
outflow of urine (stricture and enlarged prostate), and stagnation
of urine, such as occurs with diseases of the nervous system or the
presence of a sacculus.
Of the utmost importance for diagnostic purposes is cysto-
scopy. It is performed with local anaesthesia applied to the
urethra, and causes less discomfort to the patient than rectal
examination or examination with the sound. Its one disadvantage
is that, being a skilled method of diagnosis, it cannot be carried
out by all. Its advantages are that it enables us to differentiate
stone from other conditions producing the same symptoms. If
stone is present it informs us of its size, shape, composition, and
whether one or more are present. It informs us also of its position,
whether free, situated in a sacculus, or projecting from a ureter.
It informs us, lastly, whether intra-vesical projection of the
prostate or sacculation of the bladder is present. All these
points influence us in deciding the correct treatment for each
individual case.
Failing cystoscopy, the sound may give us positive informa-
tion. This examination is conducted with the patient in a
horizontal position ; the pelvis should be raised upon a cushion
or sand-bag. A moderate distension of the bladder should be
used in order to obliterate all folds. The sound is introduced,
and the most dependent part of the bladder examined first.
This is done by -elevating the handle so that the instrument comes
to lie almost vertically. If a stone is not felt in this situation
the beak is rotated and the rest of the bladder carefully explored.
There are various sources of error, however : a stone may be
missed because it is small, covered with mucus or blood clot, or
Calculus of the Bladder. 853
hidden behind an enlarged prostate or in a sacculus. An ulcer
or growth with a phosphatic deposit upon it may be mistaken for
a stone. In a young patient the sound must not be used until
urinary tuberculosis has first been excluded.
X-ray examination may also help diagnosis. Oxalate stones
cast a dense shadow, and phosphatic ones a slight one. A pure
uric-acid stone gives no shadow at all. The whole of the urinary
tract should be skiagraphed, as it is important to know whether
further stones exist in the kidneys or ureters.
It is scarcely necessary to say that there is no palliative
treatment. Spontaneous fracture of stone sometimes occurs,
and has been known to follow a diuresis induced by the copious
drinking of mineral waters. The fracture appears to be due to
the swelling of the colloid framework of the stone, produced by
urine of lowered specific gravity. Spa treatment may alleviate
symptoms by relieving concomitant cystitis.
Preventive treatment of stone is directed to those conditions
which we know favour stone formation. Thus urinary obstruc-
tion is removed and cystitis treated. With regard to the gouty
or uric-acid diathesis we are unable, in the present state of know-
ledge, to influence the endogenous production of uric acid, but
we can eliminate from the diet those foods which are the source
of the exogenous uric acid. These are the nuclein-containing
foods, viz., the highly cellular organs, such as liver, kidney and
pancreas. With these patients attention should be paid to
general hygiene, and regular exercise taken. Those drugs are
prescribed which will render the urine alkaline and keep the uric
acid in solution. Such drugs are potassium citrate, lithium
carbonate, lithium citrate, urodonal, etc. In the same way
diuresis and flushing of the urinary tract are encouraged by the
use of the alkaline mineral waters. Phosphaturia is corrected
by prescribing acid sodium phosphate or the dilute mineral acids.
These drugs increase the acidity of the urine and so keep the
phosphates in solution. Patients suffering from oxaluria should
diminish as far as possible the intake of both the oxalates and the
calcium salts. Foods rich in oxalates are : Rhubarb, spinach,
strawberries, tea and cocoa. Foods rich in calcium are : Milk
and eggs, cabbage, asparagus, radishes, etc. The oxalates are
kept in solution in normal urine by magnesium and sodium
phosphate. These salts, or waters containing them (such as
Hunyadi), should be prescribed therefore. The diluent waters
should also be used freely, preferably those with but small calcium
content (Vichy and Contrexeville).
854 Calculus of the Bladder.
OPERATIONS FOR VESICAL CALCULUS.
(1) Litholapaxy.
(2) Supra-pubic lithotomy.
(3) Median perineal lithotomy.
Litholapaxy is the operation of choice. Its advantages are
that there is no wound, and the convalescent period, therefore, is
only a matter of one or two days. In skilled hands it has a lower
mortality than the other operations, but where opportunity to
acquire this special skill has not been forthcoming, supra-pubio
operation is the safest proceeding. In St. Peter's Hospital during
1909 and 1910 there were performed ninety-six litholapaxies with
two deaths, i.e., mortality of 2'08 per cent. ; and eleven supra-
pubic lithotomies with one death, i.e., mortality of 9'09 per cent.
Recurrence is not more common after a properly performed
litholapaxy than after cutting operations ; it is due, not to
retention of fragments, but to the persistence of the conditions
which gave rise to the original stone. When disease of the lungs,
heart or kidneys is present and .general anaesthesia is deemed
inadvisable, litholapaxy can be efficiently and painlessly per-
formed with local anaesthesia.
The contra-indications to litholapaxy are :
(1) Inexperience in this operation on the part of the surgeon.
(2) The presence of acquired sacculation of the bladder. This
condition is recognised by the cystoscope, and litholapaxy is
never justifiable unless a cystoscopic examination has been made.
It occurs in old back-pressure bladders ; the sacculi are hernial
protrusions of the mucous membrane through the muscular
bundles, and their walls are exceedingly thin (mucous membrane
with a thin external fibrous layer). The danger of litholapaxy
is that small fragments may remain behind in a sacculus, and
cause ulceration and perforation of its thin wall. Pelvic cellulitis
or general peritonitis will then ensue.
(3) A urethra too small to admit the instrument. Stricture is
best treated by internal urethrotomy, followed by litholapaxy at
the end of a week. If bad cystitis is present in addition to
stricture, median perineal lithotomy and subsequent drainage of
the bladder is preferable to litholapaxy. It is only available,
however, in the case of small stones. Speaking generally, if
preliminary treatment is adopted in cases of cystitis, litholapaxy
can be performed. In children litholapaxy is inadvisable under
the age of three. In expert hands stones can be crushed in
children even younger than this. It must be remembered,
Calculus of the Bladder. 855
however, that the bladders are small and thin-walled, and we
regard supra-pubic lithotomy as the safer proceeding.
(4) Large stones. Stones above 1| to 2 oz. should be removed
by the supra-pubic method.
(5) Hard stones, though more difficult, are no bar in skilled
hands to litholapaxy.
(6) Encysted stones should be dealt with by supra-pubic cysto-
tomy. Some can then be crushed in situ, others can be delivered
after small " nicks " have been made in the mouth of the sacculus
in several places. If this manoeuvre fails, the stone must be split
by means of a chisel and mallet while the assistant steadies it by
means of a finger in the rectum.
(7) When sufficient enlargement of the prostate is present to
render litholapaxy difficult, supra-pubic operation should be per-
formed ; the prostate can be removed at the same time or later.
Litholapaxy in these cases is unwise, as retention of urine, some-
times permanent, is a not uncommon sequel.
The Operation of Litfwlapaxy. The patient is placed
horizontally upon his back with the legs separated. A catheter
is passed and the bladder washed with some mild antiseptic
solution ; 3 to 6 oz. are then left in the bladder and the catheter
withdrawn. Small stones can be evacuated without crushing.
If too large for simple evacuation the lithotrite is introduced, and
the handle elevated so that the instrument lies at an angle of
45 degs. with the horizontal. The beak of the instrument is now
pressed gently against the floor of the bladder, so that it comes to
be situated at the most dependent part of that organ. The beak
is opened, and the stone, which in obedience to the law of gravity
is also situated at the most dependent part of the bladder, drops
upon the female blade. The male blade is now closed upon the
stone and locked. The stone is then crushed. This manoeuvre
is repeated until the larger fragments have been dealt with.
During the whole operation the female blade is not moved, but is
kept in contact with the floor of the bladder. Before withdraw-
ing the lithotrite the beak is rotated and the sides of the bladder
base gently explored for large fragments by opening and closing
the blades. The soft bladder wall is easily distinguished from
the more resistent stone. If doubt arises, the blades are rotated
to the centre of the bladder before the instrument is locked, and
if there is any resistance, such as is felt when the bladder wall is
grasped, the blades are again separated. If no more fragments
are felt the evacuating tube is now introduced, the pump attached,
and the fragments evacuated. When most of the dtbris has been
856 Calculus of the Bladder.
withdrawn the beak of the evacuating tube is rotated downwards,
the bulb of the pump squeezed, and the beak of the tube rapidly
rotated upwards again. By this manoeuvre any debris lying on
the base of the bladder is set into motion and evacuated while in
suspension. Should a fragment too large for evacuation be
caught in the eye of the tube, it is recognised by a characteristic
click ; it is dislodged by means of a stylet. The lithotrite must be
introduced again, however, and the fragment crushed. A click
is also heard if the bladder wall is sucked into the eye of the tube,
but it gives rise to a different sensation both to the ear and to the
fingers grasping the instrument. This difference cannot be
described, but is readily recognised after very little practice.
After-treatment. Should any difficulty in micturition, or bad
cystitis, exist before operation, a soft catheter is tied in for
twenty-four hours. The patient is allowed up as soon as the
urine is free from blood. Before his discharge cystoscopy is
again performed, and if any small fragments are present they
are evacuated.
Supra- pubic Lithotomy. The advantages of this over the
perineal operation are that the mortality is less, that the surgeon
can see what he is doing, that larger stones can be removed and
primary union obtained in clean cases. In addition there is no
risk of incontinence or damage to the genital apparatus, as some-
times occurs with perineal lithotomy. The indications for the
operation have been discussed already in dealing with litholapaxy.
No detailed description of this operation is necessary. The
bladder is opened supra-pubically and the stones removed with
scoop or forceps.
Median Perineal Lithotomy. Practically the only indication
for this operation is the presence of a small stone associated with
severe cystitis, or with severe cystitis and stricture. Its advan-
tage over the supra-pubic operation is that the convalescent
period is shorter. Larger stones are sometimes crushed by
introducing the lithotrite through the perineal wound. This
we consider inferior to supra-pubic lithotomy.
The operation of median perineal lithotomy is performed as
follows : A grooved staff is passed into the bladder ; the patient
is then placed in the lithotomy position. The staff is cut down
upon and the urethra opened immediately behind the bulb.
The edges of the urethra are grasped with catch forceps, and a
gorget is passed along the grooved staff into the bladder. The
staff is now withdrawn. Next the finger is passed into the
urethra and the gorget withdrawn. The finger is now pushed
Calculus of the Bladder. 857
onwards into the bladder, dilating as it goes the posterior urethra
and the meatus. Stone forceps can now be passed ; with these
the stone is seized and withdrawn. Drainage of the bladder is
secured by introduction of a soft rubber tube, which is stitched
to the skin.
In the female two additional methods of dealing with vesical
stone should be mentioned. Firstly, small stones (up to | inch
in diameter) may be removed by dilating the urethra ; this
method is liable to be followed by incontinence. Secondly,
vaginal lithotomy is recommended by some surgeons ; we
consider it inferior to both litholapaxy and supra-pubic lithotomy.
It carries in addition the danger of vesico-vaginal fistula.
SYDNEY G. MACDONALD.
8 5 8
CYSTITIS.
THIS is due to a combination of causes, which may be divided
into : (1) The exciting cause. (2) The predisposing causes.
The exciting cause is the presence of bacteria. The mere
presence of bacteria in the bladder is not sufficient in itself to
produce inflammation of that organ. Injection of organisms into
a healthy bladder does not produce cystitis, except in the case of
organisms (such as those of the proteus group) which have the
power of decomposing urea.
The predisposing causes are, firstly, injury to the bladder, such
as that produced by calculus, new growth, foreign bodies, or
parasites such as the bilharzia ; and, secondly, stagnation of
urine. The latter may be produced by obstruction, such as the
presence of an enlarged prostate or stricture, or by inability to
empty the bladder, as in disease of the nervous system, or the
presence of a sacculus.
Acute Cystitis. All grades of inflammation are met with,
from a simple catarrh to a more deeply seated infection involving
the submucous and even the muscular coats. Ulceration is not
uncommon. Rarely a gangrenous form of cystitis is met with,
in which sloughs and actual casts of the mucous membrane are
passed. This sometimes occurs in diabetics.
The patient must rest in bed. The diet at first should con-
sist mainly of milk, the ordinary diet being resumed gradually
as improvement occurs. All irritating substances, such as
seasoned foods, spices, tea, coffee, and alcohol, are rigidly
withheld as long as any cystitis remains. Copious alkaline
waters (Contrexeville, Evian, Vichy) are taken ; these help to
flush out the bladder and, by diluting the urine, render it less
irritating. The bowels are kept freely open. Pain and strangury
are best relieved by hot fomentations or hot baths. Hot rectal
infusions often give relief. Failing these measures morphia and
belladonna are given in suppositories or hypodermically. With
regard to drugs, the most satisfactory are the alkalies, combined
with hyoscyamus and buchu. Urotropine is more useful in the
subacute and chronic cases. The balsams are avoided in the
Cystitis. 859
acute stage, as they are ill tolerated both by stomach and kidneys .
When the acuter symptoms have subsided local treatment (lavage)
may be considered. The most comforting lotions in this stage
are the mildly astringent ones, as potassium permanganate
(1 in 6,000), protargol (| per cent.), or silver nitrate (1 in 10,000).
Before instrumentation, however, bacteriological examination
should be made and the tubercle bacillus excluded. Cystoscopic
examination is important in all cases of spontaneous cystitis (in
most of these the primary disease is in the kidney), and in cases
in which pyuria persists. By this means, for example, we can
distinguish pyelitis from cystitis, or recognise that the condition
is a tuberculous one. All cases of cystitis associated with fever
and severe constitutional symptoms must be regarded as cases of
renal infection. When pyelitis is present stone must be excluded
by X-ray examination.
Chronic Cystitis. This may result from an acute cystitis
or it may be chronic from the start. All the symptoms met with
in acute cystitis may be present ; they differ only in degree. On
the other hand, there may be no symptom beyond pyuria.
Treatment is directed to the cause (e.g., stricture, enlarged pro-
state, stone, or pyelitis). Rest in bed is unnecessary, mild exercise
is allowed, fresh air and general tonic treatment are important.
A normal diet is allowed, but all irritating substances are avoided
as in acute cystitis. The diuretic mineral waters should be
freely taken. Of drugs, the urinary antiseptics are prescribed :
the best are urotropine and helmitol ; these are of most help when
the urine is alkaline. When they are not well tolerated they
should be substituted by ammonium benzoate or boric acid.
When the cystitis is an acid one more relief is obtained from
alkalies. In every case of chronic cystitis, cystoscopy is of the
utmost importance in regard to future treatment. Apart from
establishing the source of the pus, it may reveal the presence of
unsuspected growth, ulceration, stone, sacculus, vesico-intestinal
fistula, etc.
In chronic cystitis lavage is essential. Solutions of silver
nitrate (1 in 10,000) or hydrogen peroxide (1 to 2 oz. of 20 volumes
solution to the pint) are amongst the most useful. Better results
are obtained with weak than with strong solutions. Ulceration
when present can often be advantageously treated by direct
applications through an endoscopic tube. Under certain con-
ditions the advisability of surgical interference has to be con-
sidered. In the gangrenous form cystotomy is essential ; it is
also advisable in resistent cases where pain and frequency are
86o Cystitis.
marked features. It is by cystotomy alone that absolute rest to
the bladder can be obtained. Drainage is inadvisable in cases of
colon infection ; though temporary relief is obtained, relapse
always occurs. Supra-pubic cystotomy is the operation of
choice. Though affording less satisfactory drainage than the
perineal operation, it is more comfortable for the patient. In
the latter operation the drainage tube lies upon the inflamed
trigone, and every movement of the patient is associated with
pain.
Vaccine Therapy in Cystitis. This can be summed up in a
few words as follows : In acute cases it is useless. In sub-
acute cases it is valuable, provided the autogenous vaccine be
used. In chronic cases (and this applies mainly to colon infec-
tions) it is a valuable prophylactic agent (as already stated under
BaciUuria), and patients can be kept free from symptoms
although organisms may abound in the urine.
SYDNEY G. MACDONALD.
86 1
TUBERCULOUS CYSTITIS.
THIS may be primary or secondary.
The vast majority of cases of vesical tuberculosis are secondary
to similar diseases of the kidney, a smaller number to tuberculosis
of the genital organs. When secondary to renal tuberculosis the
vesical infection occurs by direct spread of the tuberculous
process down the ureter (i.e., by continuity of tissues), and the
vesical lesion is limited in the early stage to the tissues imme-
diately surrounding the corresponding ureteric orifice. When
secondary to disease of the testis the earliest lesion in the bladder
is found to the inner side of the ureteric orifice of the same side,
infection having occurred at the point where the vas deferens
and ureter cross. When secondary to tuberculosis of the prostate
the vesical lesion begins in the trigonal region, but this is a rare
condition.
Given a young patient with frequency of micturition and
pyuria, one has to determine :
(1) Whether cystitis is actually present.
(2) If so, whether it is tuberculous in nature.
(3) The primary source of infection.
(1) Is Cystitis Present? The same train of symptoms is
found in the early stages of renal tuberculosis, without any vesical
lesion. Painful micturition does not necessarily mean disease
of the bladder. It may be due entirely to prostatic disease or
to disease of the lower end of the ureter. This question can be
decided, firstly, by ascertaining whether distension of the bladder
evokes pain, and, secondly, by cystoscopy.
(2) Is the Cystitis Tuberculous ? The history of the case
will enable one to exclude a cystitis of urethral origin. Bacterio-
logical examination will show the presence or absence of tubercle
bacilli. If the latter examination is negative, but strong suspicion
exists that the disease is tuberculous, the biological test must be
made (viz., inoculation of a guinea-pig).
(3) The Primary Source of Infection. Routine examination
of the genital organs will enable one to say whether they are
definitely tuberculous. Palpation of the kidneys will give only
negative information in the majority of cases. The most impor-
tant examination is the cystoscopic one, since on this examination
treatment depends. It informs us of the extent of disease in the
862 Tuberculous Cystitis.
bladder, whether it is primary, or whether renal tuberculosis is
also present, and, if so, whether one kidney or both kidneys are
involved.
The treatment of vesical tuberculosis resolves itself into the
treatment of the primary organ infected, and will be discussed
when tuberculosis of these organs is being considered.
In the majority of cases the proper treatment of tuberculosis
of the bladder is nephrectomy. When this has been performed in
suitable cases it is surprising how rapidly the vesical symptoms
disappear. Apart from this, however, there are certain conditions
to be considered :
(1) The extension of the tuberculous process to the bladder
is often signalised by the onset of acute vesical symptoms.
Cystoscopy in this stage is exceedingly painful and difficult, and,
beyond showing the presence of an intense and generalised
cystitis, gives little information. This stage must be treated by
absolute rest in bed. Food must be of the lightest nature, all
irritating substances, such as alcohol, spices, coffee, etc., must be
avoided. Of drugs, sandalwood, taken in capsules, gives the
most relief. Suppositories of belladonna and morphia may be
necessary. No local treatment is permissible owing to the in-
creased danger of producing a secondary infection. Under this
strict regime these acute symptoms subside in a few weeks, and
enable the all-important cystoscopy to be made.
(2) We have yet to consider the treatment of primary vesical
tuberculosis and secondary tuberculosis after nephrectomy (or
orchidectomy, etc.) has been carried out. This resolves itself
into general tonic treatment rest, forced feeding, fresh air in
the country or at the seaside (when this is possible), combined
with tuberculin injections. There is no type of tuberculosis which
yields such excellent results with tuberculin as vesical tuberculosis
in this stage. Koch's new tuberculin (T.B.) is injected . sub-
cutaneously every tenth day (this ensures the injection during
the positive phase). It is not necessary to know the opsonic
index ; dosage is controlled entirely by the clinical manifestations.
An initial dose of 5^5^ milligramme may be given ; if there is
increase in the pain and frequency of micturition, the size of the
next dose must be reduced. If no reaction occurs, the next dose
given is 30*00 milligramme, and so on. The correct dose is the
maximum dose which produces no increase in the symptoms ; this
dose increases, however, from time to time so long as improve-
ment is maintained. The maximum dosage may reach, but rarely
exceeds, 5^0 milligramme.
Tuberculous Cystitis. 863
Bladder lavage is best avoided ; it is only justifiable when a
secondary pyogenic infection has already occurred. In the latter
case the appropriate vaccine is combined with the tuberculin.
Other forms of local treatment are usually unnecessary, though
strongly advocated by various Continental surgeons. Rovsing
recommends injection into the bladder of 50 cubic centimetres
of 5 per cent, carbolic. This is left in for three minutes and
then washed out. The process is repeated at weekly intervals.
Luys is a strong advocate of silver nitrate ; the individual lesions
are touched directly with solid silver nitrate by means of a
direct-vision cystoscope. Instillations of various substances, such
as sublimate or iodoform emulsion, have also been recommended,
lonisation has also been tried. These various forms of local
treatment possess this one common disadvantage, that they
produce pain and irritation, and necessitate that the patient
should remain in bed.
Cystotomy with a view to curettage, etc., is to be condemned.
It is unnecessary and futile, and is followed by tuberculous
infection of the wound. There is one class of case in which
cystotomy may be considered, however, viz., when a solitary
ulcer persists in spite of treatment, or gives rise to serious haemor-
rhage or pain. In such cases recovery may be hastened by clean
excision of the ulcer, followed by suture and closure of the bladder.
When extensive genital and urinary tuberculosis are combined,
extensive operations (such as excision of prostate and vesicles
combined with nephrectomy) cannot be advised. In addition to
the high immediate mortality the danger of dissemination and
general miliary tuberculosis is great.
REFERENCES.
Fenwick, " Clinical Cystoscopy." Twenty-fourth German Congress of
Surgery.
SYDNEY G. MACDONALD.
864
DIVERTICULA AND SACCULI OF THE BLADDER.
DIVERTICTJLA or sacculi of the bladder may be congenital or
acquired. In the acquired form, which is due to urinary obstruc-
tion, the sacculi consist of hernial protrusions of the mucous
membrane through the muscle bundles. They are multiple and
rarely attain a large size. They occur more commonly in males
after middle life (rarely in females), and are invariably associated
with marked trabeculation of the bladder and other back pressure
signs.
The congenital sacculi are more commonly single, and may
attain a large size (they may be as large as the bladder itself).
They are situated at the apex of the bladder, or to the outer side
and in front of the ureteric orifices. They may give rise to
symptoms at any age ; there is no urinary obstruction present,
and no trabeculation of the bladder.
Any of the symptoms may call for relief . Catheterisation and
lavage are only palliative measures, and, owing to the difficulty
in washing the sacculus itself, fail to cure the cystitis.
Drainage, supra-pubic or perineal, is also only a temporary or
palliative measure ; it may be called for when severe cystitis is
present, either as a preliminary step to excision, to remove a
stone, or to give relief in cases that are too bad for more radical
treatment. In either case, in addition to the cystostomy tube,
a tube should be passed right into the sacculus, so that efficient
lavage can be carried out subsequently.
Other palliative operations that have been performed are :
Simple enlargement of the opening of the sacculus ; division and
suture of the septum between it and the bladder ; or the estab-
lishment of a new anastomotic opening between the sacculus and
the bladder, with the object of securing better drainage of the
sacculus. The two latter operations may be the only methods
available in cases when a large sacculus is situated low down in
the pelvis, or is too adherent to important structures to permit
complete excision. The objection to these operations is that
inability to empty the bladder still remains, since the walls of the
sacculus are non-contractile, either because they are fibrotic or
because they are adherent to surrounding structures.
Diverticula and Sacculi of the Bladder. 865
The operation of choice is excision of the sacculus. It is avail-
able in cases where the sacculus is situated at the apex, or at the
lateral aspect of the bladder. The operation is performed as
follows : The bladder is washed and distended, and then exposed
supra-pubically. If the sacculus is situated at the side, the
rectus muscle on that side is divided. The limits of the sacculus
are then examined and the peritoneum stripped upwards. The
bladder is next opened and the position of the ureters ascer-
tained, if this was impossible from the cystoscopy. The opera-
tion is facilitated by using the Trendelenberg position. The
sacculus is defined, freed and excised. In separating it from
the bladder the whole of the fibrous opening between it and the
bladder must be excised. The wound thus left in the bladder is
sutured with through-and-through catgut sutures. A large
drainage tube is stitched into the bladder, the extra-peritoneal
space from which the sacculus was removed and the supra-pubic
space are also drained.
When the sacculus is adherent to the rectum, large vessels,
pelvis, etc., it should be shelled out, leaving the fibrous capsule
behind (Young). This obviates the danger of damage to these
structures and lessens haemorrhage. If the opening of the ureter
is situated in the sacculus, the ureter is carefully dissected down
to the point at which it disappears into the sacculus ; the portion
of sacculus bearing the ureteric orifice is then separated as a flap
from the rest of the sacculus. This flap is subsequently turned
in to the bladder and sutured. This method, which was used by
Young, is preferable to transplantation of the ureter, as it obviates
the danger of stricture and lessens that of ascending renal
infection.
SYDNEY G. MACDONALD,
REFERENCE.
" Annals of Surgery," 1906.
S.T. VOL. ii. 55
866
ECTOPIA
THIS is a condition in which the mucous membrane of the
bladder and urethra, from the urachus above to the meatus below,
is spread out on the surface of the hypogastrium. At the margins
the mucous membrane becomes continuous with the skin of the
belly wall. It is often stated, in descriptions of this condition,
that the anterior wall of the bladder is absent. This is not so.
The whole of the bladder is present.
Ectopia vesicse is more common in males than females, in the
ratio of 3 to 1. In female specimens the only difference from the
above description is that the clitoris is completely cleft.
Operations for relief of ectopia vesicae are divisible into two
classes. In the first class the object is to effect a plastic closure
of the bladder, in the second group the urinary stream is diverted
into the intestine.
(1) Plastic Closure of the Bladder. This has been effected
both by skin and intestinal flaps. The great objections to this
type of operation are that, as there is no sphincter, incontinence
of urine continues. In addition, fistulse generally result, as also
calculus formation from the presence of hairs. The latter feature
may be obviated by using sliding flaps, so that the hairy skin
surface remains external. Trendelenberg, by dividing the
sacro-iliac joints and bringing the pubic bones together, was
enabled to freshen the bladder edges and unite these directly.
(2) Diversion of the Urinary Stream. The original opera-
tion consisted in the transplantation of the ureters into the
rectum. The result, however, was death from ascending renal
infection. Maydl, therefore, transplanted the trigone into the
sigmoid colon. By leaving the valvular orifices of the ureters
intact the risk of ascending renal infection is diminished. He,
moreover, considered risk of infection to be less if he utilised the
comparatively empty sigmoid instead of the rectum. This is
probably a fallacy, however, as the faeces do not remain in the
rectum, they merely pass through it during defsecation. The
operation was performed as follows : The trigone was carefully
freed and the wound cleansed. The abdomen was then opened
in the mid-line and a loop of sigmoid drawn up. A longitudinal
incision was made in the latter, the trigone was then rotated so
Ectopia Vesicae. 867
that the ureteric orifices lay one above the other, instead of side
by side, and sutured to the margins of the incision in the colon.
Two rows of sutures were used, the first uniting all the coats, and
being then covered by a row of Lembert sutures. The wound
was then completely closed.
This operation has been modified in various ways. For instance,
the bowel has been divided at the junction of the sigmoid and
rectum, the trigone implanted into the upper end of the rectum,
and the sigmoid anastomosed to the rectum lower down. This
adds to the severity of the operation ; however, the advantage
claimed is that the liability of ascending renal infection is
diminished.
Moynihan has successfully transplanted the whole of the
bladder into the rectum, thus increasing the capacity of the latter
and allowing a longer retention of urine (three to four hours).
His operation has the additional advantage in the male that it is
an extra-peritoneal operation. In the female, however, the opera-
tion is intra-peritoneal, and the uterus and appendages must first
be removed. Moynihan' s operation was performed as follows :
The ureters were catheterised, an incision was then made
all round the margin of bladder mucous membrane and skin, and
the bladder carefully dissected up. The whole bladder was thus
isolated with a pedicle consisting of the two ureters. The peri-
toneal covering of the rectum (which organ was lying at the
bottom of the wound) was then stripped upwards from . its
anterior surface for 4 or 5 inches. An incision 3| inches in length
was made in the outer surface of the rectum, the bladder was
turned upside down, so that its former lower border now became the
upper border and its former anterior surface now became posterior.
It was then sutured to the opening in the rectum by a continuous
suture, including all coats with the exception of the mucous
membrane. The toilet of the wound was then performed and the
skin edges brought together as far as possible.
In addition to these operations ectopia vesicse has been treated
by making an anastomosis between the bladder and rectum and
then closing the parietal wound. The only objection to this
operation is that the closure of the bladder fails.
The best age for operation is about four or five. By this time
the parts are sufficiently large for manipulation and the risk of
shock less than in younger children. Before operation the con-
dition of the kidneys must be ascertained by ureteral catheterisa-
tion.
SYDNEY G. MACDONALD.
552
868
INJURIES OF THE BLADDER,
RUPTURE OF THE BLADDER.
THIS is a rare injury owing to the deep situation of this organ
in the pelvis. Most commonly the bladder is full at the time of
injury. Rupture is produced by direct injury to the hypo-
gastrium, such as by a kick from a horse, or a blow, or by com-
pression of the lower part of the abdomen as in buffer accidents,
or by the passage of a vehicle wheel over the body. Under the
latter conditions rupture of the bladder may complicate fracture
of the pelvis. Rupture of the bladder may also occur during
parturition, and cases of pathological rupture, due to carcino-
matous or tuberculous ulceration, etc., have been described.
Traumatic rupture may be completely intra-peritoneal or com-
pletely extra-peritoneal, or the rent may involve both intra- and
extra-peritoneal portions of the bladder. The commonest type
is the intra-peritoneal one. When occurring with fracture of the
pelvis, the rupture is nearly always extra-peritoneal. Prognosis
is always serious ; the best results following operation show a
mortality of nearly 30 per cent. An important point to take into
consideration here is whether the urine is septic or aseptic.
Treatment. In cases which are seen early and in which there
is a strong suspicion that rupture has occurred, the only safe
treatment is exploration. A vertical supra-pubic incision is made
and the anterior wall of the bladder explored extra-peritoneally.
If extra-peritoneal rupture is present, blood and urine are found
in the pre-vesical tissues. If the urine is aseptic, the edges of the
bladder rent are trimmed and the latter closed by a single row of
through-and-through catgut sutures. Pre-vesical drainage is
employed. If the urine is septic or the rent cannot be sutured,
drainage of the bladder by means of a large tube is adopted ; the
pre-vesical space is also drained.
If the rupture is an intra-peritoneal one, the incision is extended
and the peritoneal cavity opened. The latter is cleaned with dry
abdominal swabs, and the rent sutured by a row of interrupted
through-and-through catgut sutures (including serous coat and
mucosa) ; this is buried by a second row of sutures, taking up
peritoneum only. The abdominal cavity is closed without drain-
age. This operation is facilitated by adopting the Trendelenberg
Injuries of the Bladder. 869
position. When the urine is septic the pelvis should be drained
by means of a tube applied either through the abdominal wound
or through the rectum. In the female the pouch of Douglas
can be drained through the vagina.
If the rupture involves both intra- and extra-peritoneal portions
of the bladder, the intra-peritoneal portion is first sutured, then the
extra-peritoneal portion.
Some doubt may exist as to whether the case is one of rupture
of the bladder or rupture of the deep urethra. The latter injury
is always associated with fracture of the pelvis, and is best treated
by supra-pubic operation. Rupture of the membranous or
bulbous portion of the urethra is always accompanied by perineal
signs.
After-treatment. When the bladder has been closed, a soft
catheter must be tied in for three or four days. The catheter is
changed daily, and the bladder washed morning and evening with
some antiseptic lotion, such as oxycyanide or perchloride of
mercury (1 in 6,000). Urotropine, or some other urinary anti-
septic, is also prescribed. After the catheter has been left out
regular catheterisation is carried out until the eighth or tenth day,
when the patient is allowed to pass water naturally.
WOUNDS OF THE BLADDER.
These may occur from gunshot wounds, or from the penetration
of some sharp body, e.g., a fall upon a spike. In these cases the
wound must be explored and the injury to the bladder dealt with
as already described under Rupture of the Bladder.
SYDNEY G. MACDONALD.
8yo
TUMOURS OF THE BLADDER.
GROWTHS of the bladder are found more often in males than
females. They are more commonly malignant than benign.
They are uncommon below the age of thirty, and rare in children.
In adults up to the age of forty the benign papilloma is the
commonest growth, after forty malignant growths are the
commonest.
It cannot be emphasised too strongly that haematuria is an
urgent indication for cystoscopy. Should the haemorrhage be
too profuse to allow of this, it may be controlled pending
cystoscopy by absolute rest in bed. The patient should drink
copiously the mineral waters, such as Contrexeville, and ergot
( 1 drachm doses of the liquid extract) combined with urotropine
should be prescribed. Lavage with dilute solutions of silver
nitrate (1 in 10,000) is the best method of producing local
haemostasis. Should clot retention occur, the clots should be
evacuated by means of the litholapaxy evacuator.
A Single Papilloma should be removed by supra-pubic cysto-
tomy. This is the only safe method of treatment, because we
may be unable to tell with the cystoscope whether it is benign or
malignant, and also because if not excised death from haemorrhage
will ultimately result. The pedicle of the papilloma is grasped
with clamp forceps, and an incision made around this, including
a wide area of mucous membrane and submucous tissue. A
ligature of catgut is then placed round the pedicle, the growth is
removed, and the mucous membrane brought together with one
or two catgut sutures. If absolute haemostasis has been obtained,
the bladder may be safely closed, drainage being secured by a
catheter, which is retained for five days. Otherwise supra-pubic
drainage is employed. In either event the bladder must be
washed twice daily until the urine is clear. Owing to the local
infectivity of many of these growths the utmost care must be
taken during operation to avoid breaking the tumour, and also
to avoid contact between it and the vesical walls. Thomson
Walker advocates lavage of the bladder with a strong solution of
formalin (1 in 500) immediately after completion of the opera-
tion.
On account also of this local infectivity piecemeal operations
Tumours of the Bladder. 871
by means of the operating cystoscope must be strongly
condemned.
The patient should be urged to return for cystoscopy every few
months at first, so that any local recurrence may be dealt with
at once.
The treatment of multiple papillomata is a very difficult
question, and one upon which the last word has not yet been
said. The tumours may be removed individually, but in addition
to these tumours one commonly finds large areas of the mucous
membrane in a condition of villosis. All these areas of mucous
membrane must be carefully dissected away. This is a long and
tedious task, and under the best conditions is but a palliative
measure. It is an open question whether it would not be better
in the early stages to transplant the trigone into the rectum and
excise the rest of the bladder in toto. Rovsing 1 holds strongly
the opinion that cure can be looked for only by performing a
preliminary bilateral ureterostomy and then excising the bladder
unopened.
In considering whether radical cure should be attempted
in a case of Carcinoma the cystoscope is of prime importance.
Thus the extent of involvement of the mucous membrane
and the situation of the growth are ascertained. Growths
occupying the upper zone of the bladder give the best prog-
nosis ; they are more easily accessible and a wider area of
bladder can be removed. Those occupying the middle zone are
less satisfactory, and in those springing from the base prognosis
is worst in them dissemination is rapid and operation advisable
only in the earliest stages. Induration of the bladder base or
palpable glands felt per rectum are centra-indications to surgical
interference. With the cystoscope it is impossible to tell how
much infiltration of the deeper layers of the bladder has already
occurred ; this instrument may show only a small involvement
of the mucous membrane in growths which have infiltrated the.
muscular walls or invaded the peri-vesical tissues too extensively
to allow operation. In all doubtful cases a supra-pubic incision
should be made and the external aspect of the bladder palpated.
If the growth proves too extensive for excision the incision is
closed without opening the bladder. When the growth is situated
at the apex of the bladder the peritoneal cavity should be opened
and the bladder examined from the peritoneal aspect. Extensive
involvement of the peritoneum means also extensive lymphatic
involvement, and though partial resection of the bladder may
give relief, it will not prevent dissemination of the growth. If
872 Tumours of the Bladder.
intestine or omentum is adherent to the bladder heroic opera-
tions are useless.
The types of operation employed are as follows : If the growth
is situated at the apex the bladder is opened and the limits of
the growth determined. The patient is then placed in the
Trendelenberg position and the peritoneal cavity opened. The
peritoneal area which corresponds to the portion of bladder to be
resected is marked out by a circular incision. If any puckering
of the peritoneum is present a margin of at least 1 inch is allowed.
The peritoneal cavity is then closed and the growth, with at least
1 inch margin of the whole thickness of healthy bladder wall, is
excised. The raw surfaces of the bladder wall are then brought
together by means of a single row of catgut sutures including all
the coats. The supra-pubic space is drained and the wound other-
wise closed. The bladder is drained by means of a catheter.
If cystitis is present the bladder should be drained by means of
a supra-pubic tube. Another method, applicable more for growths
of the middle zone and some of those of the basal zone, is to split
the bladder from the original incision right down to the growth.
The peritoneum, when necessary, is first separated, partly by
stripping, partly by dissection. An oval portion of the whole
thickness of the bladder wall is then excised, consisting of the
growth surrounded by a wide margin of healthy tissue. At each
snip of the scissors spurting vessels are clamped and through-
and-through traction sutures of catgut placed in each side alter-
nately, but not tied. When the portion of bladder has been
resected each suture is threaded through the opposite side and
tied, thus bringing the cut surfaces of bladder together.
Growths of the basal zone can also be removed by this method,
the peritoneum having been stripped back. Smaller growths in
the region of the base should be excised as follows : A fixation
stitch is passed through the mucous membrane 1| inches below
.the lowest limit of the growth ; the latter is then surrounded by
an oval incision cutting through all layers of the bladder wall.
With each cut stitches are placed through one side of the gap left
in the bladder. After removal of the tumour these stitches are
threaded through the opposite cut surface and tied ; the gap in
the bladder wall is thus closed.
If the growth is situated in the region of the ureteric orifice,
the ureter must be transplanted. It is best done at the time of
excision of the growth. The ureter is first catheterised, the area
of bladder wall carrying the ureteric orifice and the growth are
then excised as above, the ureter is picked up in the retro-vesical
Tumours of the Bladder. 873
tissue at its point of entry into the bladder and fastened by one
or two catgut stitches into the upper part of the wound. Drainage
of the retro-vesical cellular tissue is obtained by means of a small
tube which is secured by a catgut stitch just below the trans-
planted ureter. Thus one end of this tube lies in the retro-vesical
tissues, the other passes through the bladder and out through the
supra-pubic wound.
Palliative Operations. When the growth is too extensive
for partial cystectomy, total cystectomy is, in the majority of
cases, contra-indicated also. The general condition of the patient
at this stage is too feeble and the immediate mortality high. In
addition to this it is an open question whether the patient is any
better off than he would be by simple drainage of the bladder.
Cystostomy as a means of relief (by affording permanent
drainage of the bladder) is indicated in inoperable cases when
serious hemorrhage or clot retention occur and when the internal
meatus becomes blocked with growth and micturition accordingly
difficult and painful. It is also indicated when vesical spasm is
a marked feature of the case ; the spasm and pain caused thereby
are thus checked. In cases in which the bladder is full of soft car-
cinomatous growth some months' respite from pain and obstruc-
tion can be obtained by curettage of the bladder. The bladder is
packed with gauze for forty-eight hours to check haemorrhage.
The gauze itself acts as a sufficient drain, after curettage, for the
urine. The danger of this form of treatment, however, is that
the growth may fungate through the wound and prevent its
closure. When the symptoms in this type of case demand surgical
relief, it is perhaps better to perform a bilateral nephrostomy or
ureterostomy. In the latter operation the ureters are brought
out upon the loins and the urine collected in some suitable
apparatus, such as that of Rovsing.
SYDNEY G. MACDONALD.
REFERENCE.
1 Transactions, Second Congress of " Association International de Urologie."
8 7 4
DISEASES AND AFFECTIONS OF THE PENIS.
BALANITIS AND POSTHITIS.
INFLAMMATION of the glans and prepuce is nearly always
associated with a long prepuce, dirt, or venereal disease. In some
cases the fixed and adherent prepuce renders the inspection of the
glans impossible, and one is unable to ascertain with certainty the
condition beneath until this fold of skin can be withdrawn. In
all such cases the possibility of syphilis being present must be taken
into consideration.
In mild cases a large fomentation (boracic) should be applied ;
the patient should be instructed to syringe some weak antiseptic
(1 in 200 carbolic) beneath the swollen prepuce. In a short time
the inflammation subsides ; the prepuce can be retracted, the
diagnosis confirmed, and local remedies can be applied.
In the more severe types this is not sufficient, and in order to
gain access to the hidden region the swollen foreskin must be
divided in the middle line, as in the operation for circumcision, so
that the inflamed glans is thoroughly exposed, or even the complete
operation of circumcision may be performed. This latter procedure
as a routine is not to be advised ; mere division of the prepuce,
allowing it to contract, is sufficient for the moment. The operation
of circumcision should be completed when the active inflammation
has subsided.
Sometimes an active phagedeiiic ulceration complicates matters,
and requires special treatment.
IVOR BACK.
CAVERNOSITIS.
FIBROUS SCLEROSIS of the cavernous bodies and corpus spongio-
surn does not yield to treatment. Iodide of potassium in 10-gr.
doses should be tried.
IVOR BACK.
75
CONGENITAL MALFORMATIONS OF THE PENIS.
THE plastic operations required for the repair of these defects lie
essentially in the domain of the specialist, and ought only to be
undertaken by a surgeon who has frequent opportunities of
perfecting his technique ; so that only the simplest outlines of
treatment will be given here.
Hypospadias. Here operation is demanded for two reasons :
(1) Fertile coitus is impossible owing to the opening of the urethra
in some abnormal position ; and (2) the malformed penis is
usually bent in such a way that the urine is sprayed out and the
scrotum is constantly wet, and therefore liable to eczema. Two
main varieties are met with : (1) That in which the urethra opens
at the base of the glans penis ; and (2) that in which it opens at the
junction of the scrotum and the penis. The former is the simpler,
and is usually not associated with incurvation of the penis. In this
case, if there is a redundant preputial hood, the best treatment is
to make an incision into it, push the glans penis through, and
repair the urethra by means of the preputial skin which now lies
on the under-surface of the penis. If the prepuce is not redundant,
attempts may be made to repair the urethra by cutting up lateral
flaps of skin and bringing them together in "the middle line over a
catheter. In the second class of case, where the urethra opens at
the back, the penis is usually markedly curved downwards. Before
any satisfactory operation can be undertaken the penis must be
straightened. This is best done by making a series of transverse
nicks with a tenotome in one or more places until the organ can be
made to lie flat upon the abdominal wall. In order to prevent
re-contraction it is best to cover in these incisions by minute
Tiersch's skin-grafts. This will prevent granulation.
Most of the operations which have been described for the restora-
tion of a complete hypospadias are theoretically excellent, but fail
in practice. The best method is the one advocated by Mr. Bucknall.
It consists essentially of using a portion of scrotal skin in the
line of the median raphe to complete the urethra. The steps of the
operation are exceedingly complicated, and the reader is referred to
the original article for the details of its technique. 1
Epispadias. This is a condition in which the urethra is
deficient on the dorsal surface of the penis, and is usually associated
876 Injuries of the Penis.
with a more or less complete ectopia vesicae. The object of the
operation is to restore a channel for the passage of urine along the
penis. This has heen done by making lateral incisions, depressing
the floor of the urethra into the centre of the penis, and bringing
the edges of the lateral incisions together over a catheter. But
if there is any degree of ectopia vesicae present it must be
remembered that the normal sphincter of the bladder is absent,
and that, even if the operation is successful, the patient will
afterwards have to wear a portable urinal.
IVOR BACK,
KEFERENCE.
1 Lancet, 1907, II., p. 887.
INJURIES OF THE PENIS.
Bruises and Lacerations of the penis are treated on ordinary
surgical lines ; local cleanliness and the application of a cooling
lotion or surgical dressing are all that is required.
An accident which may give rise to copious and even alarming
haemorrhage is rupture of the fraenal artery during coitus. The
artery should be ligated, but as this is sometimes difficult to effect,
it may be underrun by a curved needle carrying a ligature, the
haemorrhage being efficiently checked by this means.
IVOR BACK.
8 77
MALIGNANT DISEASE OF THE PENIS.
SARCOMA is exceedingly rare. Carcinoma is met with in two
forms : (1) A squamous-celled variety, which arises from the
epithelium of the glans penis ; and (2) a columnar-celled form,
which derives its origin from the epithelium lining the glands
of Tyson. There is little doubt that chronic irritation predis-
poses to the condition, and the most important factor in pro-
ducing this is the retention of the sniegma behind a long
prepuce. This is one of the reasons, and not the least cogent
one, for performing the operation of circumcision for phimosis
in children, for it is said that epithelioma of the penis is almost,
if not quite, unknown amongst circumcised persons. The lym-
phatic glands are involved early. The inguinal glands drain
the skin of the penis and are enlarged when the prepuce is
attacked ; but when the body of the penis is enlarged, secondary
deposits are found in the lumbar glands. If the disease is recog-
nised early, amputation of the penis through the body is indicated.
In this case there is some hope that removal of the diseased
portion, if associated with eradication of the inguinal glands, will
cure the disease. The operation in itself is not difficult. A
straight bougie is introduced into the urethra and the penis held
up vertically. A flap, whose length is equal to the circumference
of the penis, is then marked out and reflected from the skin of the
under-surface. It is better to fashion the flap from this surface
than from the dorsal one, so that the urine does not tend to dribble
over the surface of the wound during the process of healing. The
flap, which consists only of skin and subcutaneous tissue, is raised
from the penis, and a straight incision made round the dorsum at
the base of the flap. The corpora cavernosa are now cut through
at the level of the base of the flap. The corpus spongiosum,
however, is divided at a point about ^ inch distal to this. The
bougie is then withdrawn. A small opening is now made in
the skin flap, and the protruding | inch of corpus spongiosum
is drawn through this. The flap is fixed over the end of the
penis with fine silk sutures, and the orifice of the urethra sutured
to the margins of the aperture in the skin flap, after slitting
it up vertically for about inch on each side. This prevents
contraction during healing. In all cases the inguinal glands
878 Malignant Disease of the Penis.
on either side should be removed, whether there is any macro-
scopic evidence of disease or not. If the disease when first seen
has involved the corpora cavernosa and the lymphatic glands,
radical extirpation of the penis is necessary. The operation is
performed as follows : The patient is placed in the lithotomy
position and a bougie introduced into the urethra. An incision
is made along the whole length of the middle line of the
scrotum. This is carried back until the urethra is exposed. The
corpus spongiosum is divided about 2 inches in front of the
triangular ligament, and the proximal portion of it isolated. The
incision in the scrotum is then carried round the dorsum of the
penis, and the whole organ is removed, the crura being detached
from the rami of the pubes with a periosteum elevator. The
urethra is fixed in the posterior angle of the wound, and the two
cut edges of the scrotum are united. As in the former case, the
inguinal glands should always be removed. It is no use attempting
to remove enlarged lumbar glands by laparotomy, since, if these
are so large as to be palpable through the abdominal wall, the
prognosis is hopeless. If when the case is first seen the disease is
in a hopelessly advanced state and there is no chance of a radical
operation being successful, the end of the penis may be amputated
as a palliative measure. This will at any rate rid the patient of
the fungating mass, which is a source of great discomfort to him.
IVOR BACK.
79
PAPILLOMATA OF THE PENIS.
PAPILLOMATA are fairly common, usually in connection with
gonorrhoea. They may disappear spontaneously. In recent cases
lactic acid is almost a specific. In advanced cases circumcision will
be required. The warts should be destroyed by the actual cautery.
Cleanliness is essential.
IVOR BACK.
PARAPHIMOSIS.
THIS condition may be treated in the following way : The penis
is seized behind the corona glandis between the interlocked index
and middle fingers of both hands and an attempt made to reduce
the glans by firm pressure with both thumbs. The attempt is more
likely to be successful if an anaesthetic is given. If the condition
has been present for twenty-four hours or more before advice has
been sought, there is always much swelling and cedema of the
retracted prepuce, and it is nearly always necessary to divide the
constricting band along the dorsuin under anaesthesia before
reduction can be effected.
IVOR BACK.
88o
PHIMOSIS.
IF the prepuce is abnormally long, and can only be retracted with
difficulty owing to its tightness or actual adhesion between the
prepuce and the glans, active treatment is required in order to
prevent many of the troublesome complications associated with
this condition. In the slighter forms of phimosis in children it is
sufficient to press the prepuce back gently, and to instruct the
nurse to perform the same action daily, until the fold of the skin is
sufficiently stretched to allow free exposure of the glans penis.
In the more advanced cases circumcision should be performed,
and the surgeon should be very ready to perform this excellent and
advisable operation.
Circumcision. There are many different ways of performing
this operation. The best method is as follows : The skin of the
penis having been carefully cleansed, the prepuce is seized with
Spencer Wells' or catch forceps on either side of the middle line of
the dorsum. A probe or a director is introduced beneath the fore-
skin, between it and the glans, to separate any adhesions that
may be there ; and then the prepuce is divided in the middle
line between the forceps with scissors, down to the junction of the
mucous membrane with the corona.
In this way two flaps of prepuce will be formed, consisting of
double layers of the cutaneous mucosa. These are now carefully
trimmed away with scissors, following the line of the corona to
the fraenum below ; about % inch of the mucous layer should be left
to form, as it were, a little frill round the coronal margin. If
too much of this layer is left, it is apt to swell up afterwards
and cause some trouble. Care must also be taken to see that
too much of the cutaneous layer is not removed, as it is quite
easy to " flay " the penis of a small child. Bleeding is checked by
pressure forceps and fine catgut ligatures, and the cut edges of
the mucous and cutaneous surfaces are accurately approximated
with fine catgut stitches. If catgut is used, it softens in a few days,
and does not require deliberate removal.
In this method the fraenal artery is not divided. When the fore-
skin is very long, the above method is rarely sufficient, as it
leaves a long pendulous mass of tissue beneath the frsenum, which
swells up and becomes cedematous. In such cases it is better to
free the cutaneous completely from the mucous layer, suturing the
Phimosis. 88 1
latter across the region of the fraenum, and securing the fraenal
artery. A small triangular flap is fashioned from the central
portion of the cutaneous layer, and this is adjusted to the
triangular raw surface left at the frsenal region. This modification
gives a much better result.
After-treatment consists in applying regularly cooling antiseptic
dressings. In very young children a pad of gauze soaked in
boracic acid is placed over the penis (not round it) and frequently
changed. In adults the following plan is useful : After the operation
is concluded a small huckaback towel is taken, and a hole is
cut in its centre, through which the penis is drawn. A piece of
oiled silk or waterproof is placed over this, with a similar aperture
in its centre. The organ is now loosely wrapped in a strip of gauze
or lint soaked in lotio plumbi c opio. This acts as an antiseptic
sedative styptic dressing. It should be changed every three or four
hours. The patient can be instructed to clean his hands, soak the
lint, and apply it himself. This dressing never becomes adherent.
For the first few nights a draught of 30 gr. of bromide of
potassium and 10 gr. of chloral hydrate should be given. If
priapism causes trouble, the bowels should be thoroughly opened,
and the bedclothes reduced to a minimum. In this way the comfort
of the patient is ensured. He should remain in bed for four or
five days, after which he may get up, but the penis should be kept
up in contact with the abdominal wall by means of a triangular
badge or a pair of " bathing drawers" until healing is complete.
IVOR BACK.
S.T. VOL. II. 0<!
882
DISEASES AND AFFECTIONS OF THE
URETHRA.
INJURIES OF THE URETHRA.
THE chief injuries to which the urethra is liable are abrasion or
perforation from the misuse of catheters or other instruments, and
rupture as the result of blows or falls upon the perineum.
Occasionally in acute gonorrhoea there may be very severe
haemorrhage from the canal, which will require active measures to
secure its cessation (see Gonorrhoea).
The treatment of the minor injuries is simple. Haemorrhage, if
profuse, should be checked by the injection of a few drachms of
adrenalin solution (1 in 10,000), and a cooling lotion (lotio plumbi
subacetatis c opio) should be applied to the organ if there is pain
and swelling. False passages, if present, should be allowed to heal,
and if there is no urgency from retention of urine or other con-
dition, no instruments should be passed for several days. Wounds
of the urethra heal rapidly, on the whole. In the more severe
cases special attention has to be paid to the condition of the
perineum with a view to ascertaining whether the urine is escaping
into the cellular tissue outside the urethra.
Blows or Falls on the Perineum may produce several forms
of injury.
(1) There is bruising and laceration of the urethra, and
haemorrhage into the cavernous tissue ; the fibrous sheath, however,
remains intact.
(2) With the above there is considerable extravasation of blood
into the perineal tissues.
(3) The urethra is lacerated and ruptured, so that urine as it
passes along the canal is extravasated, the fibrous sheath of the
corpus spongiosum being torn.
The routine treatment of all such cases is as follows. If there is
evidence of urethralinjury obtainable from the history, or from the
presence of blood at the meatus, or from the patient's inability to
micturate, the case should from the first be regarded as one of
possible urethral rupture. The patient must on no account
attempt to pass water until the extent of the injury has been
ascertained.
Injuries of the Urethra. 883
A catheter should be passed, preferably a gum-elastic or a rubber
instrument which has been thoroughly sterilised. If this passes
without difficulty it is safe to assume that there is slight laceration
only, and the patient may be allowed to micturate as he desires,
but the perineum should be watched in case there has been any
leakage of urine through a minute opening in the canal.
If the catheter passes with difficulty, catching frequently at a,
point of obvious rupture, the passage of the instrument causing
free bleeding, the instrument should be tied in for forty-eight
hours, a careful watch being kept on the perineum as before.
If a soft instrument cannot be passed, a metal instrument may
be used, but it will frequently fail, and is very unpleasant to
the patient if it has to be retained ; in most cases where its use is
necessary there will be sufficient evidence of urethral injury present
to render a perineal section advisable.
If a perineal haematoma is present, its size must determine the
need for surgical interference. Small collections of blood may well
be left alone, but the larger extravasation should be dealt with by
incision and drainage, since if left alone they may become iniected,
and further, by exerting pressure on the urethra they interfere
with micturition.
In cases where no doubt exists as to extensive urethral rupture,
or in those where no instrument can be passed, or where after a
time signs of urinary extravasation make their appearance, a
perineal section should be performed. The operation may be simple
or difficult, according to the extent of the injury and its duration.
In cases where much extravasation of urine is present, free drainage
of the perineum, with catheter drainage of the bladder, will be
indicated; in more recent cases an attempt may be made to suture
the wounded urethra, a catheter being left in situ, and the perineal
opening drained. It is imperative to attempt this in cases of com-
plete transverse rupture of the canal owing to the trouble which
ensues from the development of a traumatic stricture, one of the
most difficult varieties of urinary obstruction.
The procedure is as follows : The patient is placed in the
lithotomy position, and a Wheelhouse staff, or, if this is not at
hand, a large gum-elastic catheter, is passed down to the site of the
rupture. The perineum, having been carefully cleansed and shaved,
is incised freely for two or three inches, strictly in the middle line.
This incision is deepened until the end of the staff or catheter is
exposed at the distal torn end of the urethra. Clots are now washed
away with an irrigator, and a search is made for the proximal end
of the ruptured canal. Sometimes extreme difficulty will be
562
884 Injuries of the Urethra.
encountered at this stage, the torn end may have retracted so
deeply into the bruised perineal tissues that its identification is by
no means easy. Pressure on the bladder above the pubes may
assist the operator in causing urine to flow through the torn
proximal end, but in cases of extreme difficulty it may be advisable
to open the bladder above the pubes and pass a catheter from the
bladder through the internal urinary meatus, out through the torn
proximal end of the canal, a procedure termed retrograde
catheterisation. This step is certainly a serious one, but it is justified
by the superior results that are obtained if the torn ends of the tube
can be approximated.
The rent of the. two ends being identified, they are carefully
sutured together with fine catgut; silk must not be used. The
bruised and lacerated edges should be accurately trimmed, and the
corpus spongiosum in which the urethra lies may be mobilised by
dissection from the corpora cavernosa, so that there is no tension
on the line of suture. Accurate suture may be a matter of great
difficulty if the rupture lies deep, but upon it depends the patient's
subsequent comfort to such an extent that every effort must be made
to secure a firm junction. A rubber catheter should be tied into
the bladder, and the perineal wound should be freely drained.
There is usually some leakage of urine along the suture line :
this is provided for by the perineal drainage, but the extensive
stricture which often develops in such cases is prevented. Regular
instrumentation, at the time and for some period subsequently, are
required to bring the case to a successful issue.
Foreign Bodies in the Urethra. Foreign bodies in this canal
are of two main kinds, those that descend from above, i.e., from the
bladder, and those that are introduced from without, pencils,
stones, cinders, pins, etc. The first variety comprises urethral
calculi, which, in the majority of cases, are expelled by the bladder
along the urethra, becoming impacted in some part of the tube,
either near the triangular ligament or the fossa navicularis. More
rarely calculi may form in the urethra itself, and in such cases they
are often of considerable size and only removable by incision of the
urethal wall. If a calculus is impacted deeply in the urethra, an
attempt may be made to extract it with the special urethral forceps
devised by Thompson, but the nianoauvre will generally fail ; in such
a case the stone must be gently pushed back into the bladder and
crushed.
It is well to lear in mind tJtdt in cases of impacted calculus a second
or tliinl (<!< may Represent in the bladder.
If the calculus lies near the anterior part of the canal, it can
Injuries of the Urethra. 885
usually be extracted with forceps, especially if the meatus is incised
so as to give the necessary freedom of access. If any great diffi-
culty is experienced, the attempt should be abandoned, and the
operation of external urethrotomy should be performed. This
treatment is also suitable to large stationary urethral calculi, and
for the removal of foreign bodies of extraneous origin which are not
amenable to manipulation. In no case should any attempt be
made to force such a body back into the bladder.
Operation. The patient is placed in the lithotomy position, and
an incision is made down to the urethra in the middle line the
exact position of the foreign body has been previously ascertained
accurately by means of a sound. The urethra is incised, and the
stone or foreign body is extracted with as little bruising of the
edges of the incision as possible. If no urinary infection is present,
the edges of the incision should be closed with fine catgut sutures,
a catheter being tied in for a few days to accelerate healing. In
cases with much bruising, ulceration, or infection, this step should
be omitted, the wound being allowed to close gradually, and the
canal being kept patent with bougies.
Large-headed pins introduced head first into the canal may be
extracted by the method of Poulet: " The head of the pin is fixed
by the thumb and finger of the left hand to prevent it slipping : the
penis is next bent at the part of the urethra against which the
point of the pin is lying ; as a consequence the point can be pro-
truded through the wall of the canal : the point is grasped and the
pin withdrawn until the head is in contact with the floor of the
urethra. The shaft of the pin is now drawn down to the root of
the penis, and then by pushing upwards the head of the pin
emerges from the meatus and is withdrawn. If the object is a hair-
pin, both portions are made to protrude, one is then cut off with
pliers, and the same manoeuvre is undertaken."
IVOR BACK.
886
STRICTURE.
STRICTURE of the urethra consists in a replacement of the uurmal
muscular and elastic walls by fibrous tissue. Organic strictures
are, in the great majority of cases, due to gonorrhcea. A small
number, however, result from injury. The object of treatment is
to restore the lumen of the canal, and, what is extremely important,
to do this without introducing a septic element, and thus infecting
the urethra or bladder.
The treatment of Uncomplicated Strictures is usually carried
out by means of dilatation. Dilatation is performed by passing
instruments of gradually increasing size at intervals of a week.
It is a mistake to pass instruments more frequently than this.
Instrumentation always bruises the stricture somewhat, so that
there is a slight reaction and swelling in the urethra for a few
days. The following instruments are necessary : (1) Filiform
bougies, preferably made of whalebone ; (2) gum-elastic bougies
with olivary heads and pronounced necks; the shaft should be
fairly rigid : the best pattern is the French one made by Dela-
rnotte ; (3) curved steel bougies. It is important to know how
these instruments may be properly sterilised. Steel bougies, of
course, can be readily sterilised by boiling. But this method
is not applicable to gum-elastic bougies. At the same time
it is a mistake to suppose that gum-elastic bougies cannot be boiled
at all. The best varieties made to-day will stand boiling for some
time, though even now they are gradually destroyed by the process.
A convenient method of sterilising gum- elastic bougies is to place
them in a long glass tube, which is closed by a hollow rubber
stopper. Tho base of the stopper is made of metal which is per-
forated, and the hollow receptacle is filled with paraforrn granules
which emit a continuous formalin vapour. After a bougie has been
placed for thirty-six hours in such a medium it is completely
sterile. When only an occasional bougie is required it is best,
after use, to wash the instrument thoroughly and then boil it for
about a minute, afterwards placing it in the glass cylinder for
future use.
Supposing that from the patient's history a tentative diagnosis
of stricture has been made, it remains to examine the urethra and
confirm the diagnosis. For this purpose the urethroscope gives
Stricture. 887
invaluable information. The largest tube which can be introduced
readily should be passed as far back -as the bulb, if possible. By its
means the constriction is easily seen, its calibre roughly estimated,
and the condition of the rest of the urethra made out. It is most
useful in locating the orifice of a very small stricture, and in the
diagnosis of multiple strictures. A word of warning must be intro-
duced here about a danger of instrumentation, and that is the
occurrence of what is known as urethral shock. Certain patients
who have never had an instrument passed before are profoundly
shocked by the manoeuvre. In passing an instrument for the first
time it is therefore wise to put the patient to bed, preferably in a
nursing home, where for twenty-four hours he can be kept under
observation. The risk of shock is diminished by the previous
injection into the urethra of a 2 per cent, solution of eucaine
lactate with an ordinary stylographic pen-filler. This is especially
indicated if the patient is nervous. He should lie on his back with
the pelvis slightly raised and the knees flexed. The surgeon stands
on his right. The glans and prepuce must be thoroughly cleaned
before instrumentation, and if there is any urethral discharge the
canal must be flushed out with an antiseptic solution. Ordinarily,
micturition is sufficient to cleanse the urethra. The instrument
selected for the first attempt should be a medium-sized gum elastic
bougie, about a No. 12 French. The instrument, well sterilised
and lubricated, is passed down the urethra, which is kept on the
stretch without torsion by the fingers of the left hand placed behind
the glans. By trying successive sizes an instrument will eventually
be found which will just pass the stricture. This is sufficient for
the first occasion. A week later this instrument may be passed
again, and larger sizes then introduced until one is found which
is just gripped by the stricture. It is most important that no force
should ever be used. If this is done the stricture will be torn
rather than dilated, and the healing of the tear will cause it to con-
tract down instead of to dilate. The time occupied in dilating the
stricture by such means varies within wide limits. In a recent
soft local stricture it may be complete in two or three weeks. But
in an old extensive fibrous stricture one may have to be content
with very slow progress. Dilatation should be continued with
bougies until a No. 20 French can be introduced with ease.
After this steel instruments should be passed, starting with a
No. 9 to 11 English. The technique of passing this instrument is
somewhat different from that of the gum-elastic bougie. The penis
should be held in the line of the right Poupart's ligament. When
about 4 inches of the bougie has passed, the handle is swung to the
888 Stricture.
mid-line, being still pushed gently onwards ; and, finally, when the
point is judged to be under the symphysis, the handle is depressed
until the point enters the bladder almost by the weight of the
bougie alone. The commonest mistakes that are made are depres-
sion of the handle before the point has got well under the sym-
physis, failure to keep the urethra on the stretch, and torsion of
the urethra. If any difficulty is met with at the bulb it may often
be overcome by manipulating the point of the bougie past this
place with the finger of the other hand in the perineum. As the
size of the steel bougie which can be passed increases, the period
between each dilatation may be lengthened, so that when a No. 14 to
16 had been passed it is only necessary to dilate the stricture once in
every six months. Dilatation twice a year with a bougie of this
size should continue throughout the patient's life, and he should be
warned that if he stops treatment the stricture is likely to close
down again. In certain cases the stricture, when the patient is
first seen, is so small as to be permeable by no ordinary bougie.
Recourse must then be had to the filiform whalebone bougie, which
may be bent into a bayonet shape. This will often succeed where
a straight bougie has failed, because the orifice of the stricture is
rarely in the middle line of the urethra. In these cases it is well
to put the patient to bed for two or three days, and tie in the
filiform bougie. It will be found at the end of this time that the
stricture has dilated to such a size that a small French bougie is
easily introduced, and interrupted dilatation can be proceeded with,
as already described.
Two common difficulties are caused by multiple strictures, and
by false passages. Multiple strictures may be very troublesome.
The orifices of the various strictures are frequently not in the same
line, and so the point of the bougie is diverted from the axis of the
urethra. And again, the more superficial stricture may grasp the
bougie so tightly that it has not the necessary mobility to enter into
the deeper strictures. The obvious way to avoid this is to dilate
the superficial strictures first and the deeper later. But multiple
strictures often do better if treated at the outset by a cutting
operation. A false passage may be known to exist by a constant
obstruction at a definite point to an instrument finer than the
calibre of the stricture. When there is a definite false passage, it
is best to use a whip bougie. The point of this can be manipulated
past the false passage without difficulty, and the stricture may be
dilated by pushing it in as far as it will go readily. This gives the
false passage time to heal, while the orifice of the stricture is kept
regularly open, and subsequently there should be no difficulty in
Stricture. 889
continuing the dilatation with the steel bougies, as described above.
AVhile instruments are being passed it is well to give an occasional
purge and a urinary antiseptic ; urotropiue is undoubtedly the best.
Besides the grave catastrophe of infection and the occurrence of
urethral shock, other and more immediate accidents may occur from
the passage of instruments: (1) A slight amount of haemorrhage
is not uncommon. It can usually be arrested by placing the patient
in the recumbent position for half-an-hour or more. More severe
liu'inorrhage may be checked by the application of adrenalin.
Occasionally, if a steel bougie has been forcibly passed into the
bladder through a false passage in the deep urethra, intra-vesical
haemorrhage with clot may occur and lead to clot retention. In
this case it may be necessary to pass a catheter with a large eye,
or even to remove the clots from the bladder with Bigelow's
evacuator ; (2) Catheter fever. This is not a good name, since it
implies a septic element, whereas, as a matter of fact, what is
known as catheter fever may follow on the passage of an absolutely
aseptic instrument. It is characterised by a suddeii rise of tem-
perature within twelve hours of the passage of the instrument, and
one or more rigors. In graver cases there may be suppression of
urine without pyrexia, which may lead to delirium, and even death.
The treatment, when the condition arises, should consist in rest,
low diet, urinary antiseptics, the administration of quinine or
salicylates, and the temporary cessation of local treatment.
Certain classes of stricture may prove resistant to intermittent
dilatation. Such are those of very long standing, with almost
cartilaginous walls, multiple strictures, resilient strictures, which
habitually relapse, and strictures in those who are intolerant of
instrumentation. These cases are best treated by internal
wetkrotomy, particularly the cartilaginous variety, in which it is
found that interrupted dilatation is successful to a point, say, the
passage of a No. 1'2 French, but week after week it is impossible to
dilate the stricture further than this.
Many instruments have been devised for internal urethrotomy ;
of these the Maisonneuve is one of the best. It consists of a
line flexible guide, a grooved director, and a triangular knife on
a long handle, which fits into the groove of the director. The
Maisonneuve cuts the stricture from before backwards. The guide
is passed and tied in beforehand, or, if this cannot be done, it is
passed under the anaesthetic. The director is then screwed on to
the end of the guide, and passed through the stricture into the
bladder. The knife is inserted into the groove, and firmly pressed
through the stricture. In all ordinary cases the director is grooved
890 Stricture. .
along its concavity, so that the stricture is cut on its dorsal surface.
It is best to pass the knife twice through the stricture, so as to be
certain that all fibrous tissue is divided. After the withdrawal of
the urethrotorne a full-sized steel bougie is passed, to make sure of
complete division, and, finally, a full-sized catheter is tied in. The
catheter is tied in to prevent the urine, which may be septic, from
coming into contact with the wound for a day or two. It is removed
in forty-eight hours, and after three days the patient is allowed to
get up. It will often be found that after removal of the catheter
there is a slight rise of temperature. This is due to the fact that
the urine is now allowed to get in contact with the surface of the
wound, but the pyrexia is usually temporary, and of no importance.
Afterwards, large steel bougies must be passed at intervals, exactly
in the same manner as in ordinary interrupted dilatation.
Acute Retention of Urine is a complication of stricture. It is
caused by the gradual narrowing of the stricture to such a point
that urine will no longer pass. The acute onset is generally pre-
cipitated by an excess of alcohol. When the condition has advanced
to an extreme degree there is often some dribbling of urine. This
is known as retention incontinence. It is important to know this,
because the presence of retention is sometimes overlooked on
account of this symptom.
The treatment must be conducted in a routine manner. The
patient must be put to bed, and an attempt made to pass a catheter ;
but only a soft rubber one at first, preferably a No. 6 or No. 7.
Sometimes the retention is largely due to spasm, and steady
pressure, even with a soft catheter, may gradually overcome it. If
this is not successful a gum-elastic catheter of successively smaller
sizes may be tried, but on no account must force be used. If
gentle manipulation with a gum-elastic catheter fails, no further
attempt to pass an instrument should be made at the moment.
An enema should be given, and 15 gr. of pulv. ipecac, co.
[U.S.P. pulvis ipecacuanhas et opii.] administered by the mouth.
The patient should then be immersed in a bath as hot as he
can bear. These measures often relax the spasm, and he may
be able to pass some urine in the bath ; and afterwards it may
be found possible to pass an instrument where it could not
be done before. If, in spite of this treatment, no urine is still
passed and no instrument can be introduced, the bladder should
be aspirated supra-pubically. This must be done with careful
antiseptic precautions. The pubes must be shaved and made
aseptic, and the trocar and cannula must be boiled. The trocar
is inserted in the middle line, about 1 inch above the pubes,
Stricture. 891
with a slight inclination downwards and backwards. The cannula
should be a small one, so that the 'urine can be withdrawn from
the bladder gradually ; to let it out suddenly is to run the
risk of causing a certain degree of shock. When the bladder is
empty, the cannula is removed and the small wound covered with
gauze and collodion. After supra-pubic aspiration it is sometimes
found that the patient can pass his urine per vias naturales, or a
small catheter can be introduced. If this can be done, it should
be tied in for twenty-four hours. This will cause the stricture to
dilate, so that when the instrument is removed, one, two, or three
sizes larger can be introduced on the next day without much
difficulty, and the stricture can then be dilated interruptedly in the
manner already described. But if, after trying all palliative
measures, including aspiration, no instrument can be passed, '
an external urctlirotoiny must be performed. Of the various
methods which have been advocated, Wheelhouse's is the only one
which is available in the case of acute retention. The patient is
placed in the lithotomy position, Wheelhouse's staff, which has a
hooked end, is passed down the urethra as far as the stricture, and
an incision about 1 or 2 inches long is made in the middle
line of the perineum, between the anus and the posterior border
of the scrotum. The incision is gradually deepened, and the
hooked end of the staff carefully felt for. The main responsi-
bility falls upon the assistant, for it is his duty to see that the
patient lies flat upon his back, and to hold the staff exactly in the
middle line. If this precaution is not observed, it may be extremely
difficult to find the urethra, in spite of the presence of the staff in
it. When the urethra is found, an incision is made through its
lower wall distal to the stricture, and the end of the staff pushed
through. The hook is then made to catch in the angle of the
incision in the urethra, which is held on the stretch. The stricture
is incised from before backwards along its lower border. A Pridgen
Teale probe-pointed gorget is passed along the proximal portion of
the urethra into the bladder and the urine is evacuated. A large
gum-elastic catheter is passed into the bladder per urethram, the
point being directed into the proximal urethra through the wound.
The wound need not be sewn up. The catheter is fixed in by
means of tape, tied round it with a clove hitch, and strapped to the
penis. The catheter should be allowed to remain in situ as long as
possible, being merely turned round once daily. After a few days
a discharge will be seen oozing from between the catheter and the
lips of the meatus. This is an indication that it must be changed.
On the first occasion it is well to give an anaesthetic, but afterwards,
892 Stricture.
when a new urethra is more or less formed, it may be changed
without this. The wound in the perineum should heal in ahout ten
days, and the patient may be allowed to get up in a fortnight. But
afterwards he must attend for the periodical passage of a steel
bougie, since the new urethra formed by the operation shows a great
tendency to contract ; and he must be warned that if he does not
persevere in the after-treatment he may suffer from another attack
of acute retention.
IVOR BACK.
93
EXTRAVASATION OF URINE.
As a result of softening behind a stricture, or as the result of
rupture, the urine may be exlravasated into the cellular tissues very
widely. The extent of this extravasation is limited by certain
anatomical boundaries. If the leak in the canal lies, as is usually
the case, distal to the superficial layer of the triangular ligament
in the penile portion of the canal, the urine passes up beneath
the membranous fascia of Colles and Scarpa, distending the
superficial tissues of the penis, scrotum, and perineum. It does
not pass down into the thighs, but tracks up along the abdominal
wall to the axilla.
The longer the duration of the extravasation before the patient
comes under treatment, the worse is the prognosis ; and this is also
markedly affected by the cause of the extravasation. In cases of
stricture the urine is more likely to be offensive and infected, and
so acts as a deadly poison on the tissues, producing early a form
of gangrenous cellulitis ; while the sufferer from a stricture of
long standing is usually in an unhealthy state, and his kidneys
may be extensively diseased. On the other hand, in extravasa-
tion from rupture, the general condition of the patient is entirely
different.
Treatment consists in making free incisions into the swollen
cedematous areas. Two mistakes are often made. The incisions
are too small, and are not made sufficiency deep. In the abdominal
wall they must go down to the aponeurosis of the external oblique.
One special large and deep incision must be made into the perineum
down to the urethra, and if the urine is not foul there is no need to
introduce a catheter or tube; but this must, of course, be done if
severe cystitis is present.
In a few cases of rupture from injury it may be wise to attempt
to repair the canal in the manner already described.
Further treatment consists in supporting the patient's strength
with stimulants. Since in cases of long-standing stricture the
general condition of the patient is bad, he is very liable to die from
septic absorption.
The wounds must be fomented, or, if it is possible, the patient
should sit in a solution of warm boracic acid for a couple of hours
during the day.
894 Fistulae of the Urethra.
In some cases of injury the urethra may give way behind the
triangular ligament, the escaping urine thus being extravasated into
the cellular tissue of the pelvis and abdomen. Such cases closely
simulate extra-peritoneal rupture of the bladder, and the general
lines of treatment are to make free incisions wherever the fluid
tends to accumulate, to pass a catheter into the bladder, aided, if
need be, by a supra-pubic incision, and to provide in this way
drainage of the viscus for some time. In many cases a section
of the perineum will be required as well.
IVOR BACK.
FISTULA OF THE URETHRA.
FISTULJE occur as the result of the gradual giving way of the
urethra behind a stricture. The commonest situation is the
perineum, because the commonest situation of a stricture is
the bulb. But they also occur in the anterior urethra, where they
are known as penile.
In the treatment of fistula the first thing to do is to cure the
stricture by dilatation, if possible. In some cases the fistula will
then close of its own accord. But, unfortunately, this does not
usually happen. In the case of perineal fistulre it is generally
necessary to do an external urethrotomy in the manner already
described, and to cut' out the fistulous tract at the time of the
operation.
The repair of a penile fistula is undertaken as follows. The edges
of the skin are freed all round the fistula, and the excess of granu-
lation tissue cut away. The edges of the orifice of the urethra
should then be brought together with fine catgut sutures, so that
the line of sutures is at right angles to the axis of the urethra.
The edges of the skin are united over this with horsehair or fine
silkworm gut. It is advisable to keep a catheter in the urethra for
a day or two.
IVOR BACK.
95
PERI-URETHRAL ABSCESS.
AN abscess in the cellular tissues of the perineum may be the
direct result of laceration or disease of the urethra, and will require,
in many cases, an external urethrotomy for its proper treatment ;
but there are other conditions which may produce the same
formation without any appreciable breach of continuity in the
urethra which necessitates its section.
The common causes are as follows :
(1) Gonorrhoea, producing suppuration in the glands of Cowper,
or local follicular abscesses, which may track along the perineum,
and are important in that they may be a cause of retention of
urine.
They are treated by free incision, without any interference with
the urethra, beyond that which may be required for the treatment
of the gonorrhoea.
(2) Prostatic abscess, either from acute gonorrhoeal infections or
infections subsequent to the formation of calculi, may point down
in the perineum and form a peri-urethral abscess. It is also
treated by perineal incision ; and it is not necessary to encroach on
the urethra, the walls of which occasionally remain intact across a
prostatic abscess cavity.
(3) Infection of a perineal haematoma. This has been considered
already. Free incision alone is necessary.
(4) Peri-urethral abscess from stricture or laceration of the
urethra.
Peri-urethral abscess from stricture may be of very slow develop-
ment, and is easily overlooked. There may be no marked urinary
obstruction, but the abscess arises from a process of infection and
softening behind a stricture of long standing. The urine may be
perfectly clear and free from pus and albumen.
At first a peri-urethral abscess occurs as a hard, indurated nodule
in the line of the urethra. There is no redness, fluctuation cannot
be obtained, and tenderness may not be marked. It spreads, and
gradually the whole perineal region, together with the scrotum,
becomes osdematous, and finally as the pus approaches the surface
the skin becomes reddened. If neglected the process may spread as
an extravasation along the planes of cellular tissue, reaching even
as high as the axilla.
896 Peri-Urethral Abscess.
A free incision should be made into the abscess, the contents of
which are exceedingly foul, a finger should be introduced to break
down the partitions of the various loculi, and free drainage should
be provided. Fomentations and boracic baths are necessary
to diminish the fcetor. There is no need to interfere with the
urethra at this juncture, unless the urine is very foul. Many of
these cases heal readily and well, and the stricture can be dealt
with by subsequent dilatation. If the urethra is opened into this
septic cavity, acute infection may spread to the bladder.
If, on the other hand, the bladder is already infected, and the
urine foul and ammoniacal, external urethrotomy should be per-
formed, and the stricture should be incised. A metal perineal
tube should be introduced into the bladder along the urethra from
the wound ; the organ should be drained until it recovers ; urethral
drainage by means of a catheter passed along the whole canal
from the meatus is inadequate in a bad case. As soon as the
wound has begun to granulate healthily, and the cystitis has cleared
up, the perineal tube should be left out, and instruments should
be passed daily along the urethra, to preserve its calibre and to
accelerate healing of the perineal wound. A gum-elastic instrument
may be tied in for twenty-four to forty- eight hours, to facilitate the
process of healing in the later stages. So long as any stricture is
left in such a case the perineal wound will fail to close..
Peri-urethral abscess from laceration usually develops more rapidly,
but it requires the same treatment. At an early stage it may be
feasible to identify and suture the torn ends of the urethra, but
such a proceeding is rarety successful in the presence of suppuration.
Drainage of the bladder will not be required, and is even likely to be
injurious; but instruments should be passed daily per urctltrnni as
soon as the abscess cavity has become healthy.
IVOR BACK.
8 9 y
CHRONIC URETHRITIS (GLEET).
BEFORE commencing the treatment of any case of gleet it is
essential to discover whether the discharge is coming from the
anterior or posterior part of the urethra or from both. To ascertain
this, the anterior urethra must be freely irrigated with cold boiled
water : cold fluid is used in preference to warm, since the latter may
cause relaxation of the compressor and permit the fluid to enter
and cleanse the posterior urethra. The washings from the anterior
urethra should be carefully inspected for shreds or epithelial debris.
The patient is then told to pass his water : clear urine indicates
that the anterior urethra alone is affected ; cloudy urine which does
not clear with acetic acid shows that the posterior urethra is
affected ; the presence of prostatic threads indicates a prostatic
infection. This method is to be preferred to the old " two-glass "
method, which is fallacious.
When chronic anterior urethritis is present, the penis should
be examined for a constriction of the external meatus, since
this is a fairly common cause of persistent discharge, the purulent
secretion being dammed up behind the meatus and causing
chronic inflammation or ulceration of the fossa navicularis. If a
contracted meatus is found, it should be dilated by the passage of
graduated straight bougies until a No. 14 English passes easily.
For the same reasons a gleet associated with a stricture demands
immediate treatment of the stricture, preferably by the method of
intermittent dilatation.
Next, the urethra itself must be examined : this is best done by
some form of urethroscope, preferably of a pattern allowing of the
inflation of the urethra with air, since by this means the folds of
the mucous membrane are obliterated. In using the urethroscope
the tube used should be the largest which can be passed without diffi-
culty, and it should be passed at once as far into the urethra as
possible ; any fluid present, e.g., lubricant or urine, is then
carefully removed by means of cotton-wool swabs securely
mounted on long holders. After adjusting the lamp to the
tube the urethra is gently inflated with air and examined from
behind forwards by slowly withdrawing the tube. The special
points to be looked for are the presence of infected follicles, patches
of ulceration or evidence of submucous infiltration. If no urethro-
scope is available the passage of an acorn-headed bougie will often
S.T. VOL. u. 57
898 Chronic Urethritis (Gleet).
give valuable information, the patient complaining of pain when
the head of the bougie passes any ulcerated area. If definite
granular patches are seen they may be treated locally by the
application through the urethroscope tube of 20 per cent, silver
nitrate solution on a wool swab. Frequently the granular patches
are multiple ; if this is so, or if no urethroscope is available, the
anterior urethra should be dilated by the passage of straight steel
bougies or by a Kollrnann's anterior urethra dilator, which consists
of a straight sound, the shaft of which can be made to expand by
turning a handle at the end. After dilatation the urethra should
be irrigated with one of the following solutions : 5 per cent,
argyrol, 3 per cent, protargol, or silver nitrate 10 gr. to 1 pint of
distilled water. Irrigation may be carried out with a back-flow
catheter attached to a 4-oz. syringe, or, better still, with a glass
urethral nozzle (Wyndham Powell's or Janet's) connected to a glass
tank containing the solution. This treatment should be carried
out once or twice a week according to the severity of the case.
If, however, the discharge does not entirely disappear, the applica-
tion of stronger silver solutions (such as protargol, 10 to 15 per cent. ;
argyrol, up to 20 per cent. ; or silver nitrate, 5 to 8 gr. to 1 oz.) by
means of the back-flow catheter and syringe should be tried. This
must only be done by the surgeon, never by the patient himself.
If the strong solutions are used, the patient must be warned that
lor a day or two after the injection the discharge will be more
profuse.
In the interval between the injections the patient should be
instructed to use a weak injection of per cent, argyrol ; but these
injections must be suspended for a day or so after the use of the
stronger injections described above, and it must be remembered
that the constant use of irritating injections may in itself be a
cause of persistent discharge from irritation.
The time necessary for a cure depends to a large degree on the
duration of the original discharge ; but treatment on these lines will
usually succeed, if patiently persisted in.
The treatment of a gleet due to an affection of the posterior
urethra depends largely on whether the prostate is also infected
or not. When there is no evidence of any prostatic infection,
simple irrigation is the best form of treatment to adopt. For
irrigation the following apparatus is required : A glass urethral
nozzle (Maiocchi's, the best : Wyndham Powell's or Janet's), a tank
to hold the solution (this should be suspended about 8 feet from
the ground), and 6 feet of rubber tubing with a tap or clip to con-
nect the tank to the nozzle. The patient must first pass his water,
Chronic Urethritis (Gleet). 899
the glans penis be cleansed by running some of the solution over
it, and the anterior urethra then thoroughly irrigated. The nozzle
of the irrigator is then firmly inserted into the rneatus, the outflow
orifice being closed, if the Maiocchi nozzle is used, and the solution
is thus allowed to flow into the bladder. Usually there is no diffi-
culty in passing the compressor, but if there is much spasm a few
drops of 2 per cent, novocaine may first be injected. Three irriga-
tions of about pint should be used at each sitting, the patient
emptying his bladder after each irrigation. The following solutions
may be used : Permanganate of potash, 1 in 5,000, increasing to
1 in 2,000 ; argyrol, 1 per cent. ; or silver nitrate, 2 gr. to 1 pint.
If these injections do not succeed, the instillation into the
posterior urethra of silver nitrate (5 gr. to 1 oz.) by means of
a Guyon's syringe is often useful.
When there is definite evidence of a prostatic infection it is
necessary to remove the infected secretion of the prostate as far as
possible, so as to allow the irrigating fluid to reach the infected
area. This may be effected in the following ways : (1) By the
passage of a large steel sound ; this method is usually valueless,
since no sound which will pass the external meatus is large enough
to dilate the prostatic urethra : (2) by the use of Kollmann's
posterior urethral dilator, an instrument similar to the anterior
dilator, except that it is curved like a sound and has the dilating
portion at the curved end only : (3) by massage of the prostate
per rectum.
The latter two methods are of the most value if used in combina-
tion. Whichever method is chosen, the dilatation and massage is
preceded and followed by irrigation with one of the fluids mentioned
above. A small quantity of the solution is left in the bladder after
the first irrigation ; this is passed after the dilatation or massage,
and prevents the infected secretions being carried into the bladder.
This treatment should be carried out once or twice a week, the
patient taking urotropine or some other urinary antiseptic in the
interval. Deep instillation of silver nitrate (5 gr. to 1 oz.) is
also useful, the Guyon syringe being used for this purpose.
It must be remembered that these cases are extremely chronic,
and that long and persistent treatment is necessary. In some cases
vaccines are useful, a stock gonococcus vaccine being used if
gonococci are present, but, as is often the case, cannot be cultivated.
Vaccines prepared from any other organisms found in the discharge
may also prove valuable.
C. H. S. FRANKAU.
572
QOO
DISEASES AND AFFECTIONS OF THE
SCROTUM.
Wounds of the Scrotum must be treated on ordinary anti-
septic lines, and sewn up. If, however, the wound becomes septic,
cellulitis may ensue, and owing to the lax condition of this part it
is apt to be of a violent nature. The whole scrotum may become
red and oedematous, and abscess formation may occur. In such
a case free incisions into the osdematous area are demanded,
followed by the application of a fomentation. Weak biniodide
lotion is more efficacious than boracic. Most often the inflamma-
tion subsides, but occasionally, especially in infants, the whole
scrotum may slough off.
Haematoma of the Scrotum may result from blows, but is
more commonly post-operative. It is, therefore, exceedingly
important in operations in this region to see that every bleeding
point has been ligatured before the wound is sewn up. It is best
treated by supporting the scrotum in the manner already described,
and applying lotio plumbi cum opio. It may take some weeks
before the effusion is completely absorbed, and until this happens
the patient should wear a suspender.
Epithelioma of the Scrotum may appear in the form of
warty growths or of an excavated ulcer. In either case the treat-
ment is the same. The whole of the affected area should be excised,
the line of the incision being at least 1 inch from the edge of the
growth. Owing to the nature of the scrotal skin there is usually
no difficulty in getting the edges together, however big the growth
has been. The inguinal glands on both sides should be extirpated
at the same time.
IVOR BACK.
901
DISEASES AND AFFECTIONS OF THE
TESTICLE.
HERNIA TESTIS.
A HERNIA of the testis may result from a penetrating wound
which has become septic, or from tuberculous or gummatous
abscesses which have involved the skin of the scrotum and
made their way to the surface. In order that an operation
may be successful it is essential that any septic infection must
be got rid of first. The testis should therefore be dressed with
a compress of biniodide of mercury (1 in 4,000) for a week or
more, and when the wound is comparatively clean an operation
may be undertaken. An elliptical incision should be made in the
scrotum, surrounding the hernia, and the edges freed. The whole
of the diseased area should then be cut out, and the edges of the
tunica albuginea united with catgut sutures. The wound in the
scrotum is sewn up with fine silkworm gut. Before undertaking
such an operation it must, of course, be made certain that the
fungating mass which protrudes from the testis is not an outlying
portion of malignant disease of the organ.
IVOR BACK.
902
IMPERFECT DESCENT OF THE TESTIS.
THE testis may be retained in some part of its normal descent
(retained testis) or it may be in a completely abnormal position
(ectopia testis). Arrests in the normal course of development may
be subdivided according to the position in which the testis lies.
Thus it may be retained in the abdominal cavity, in which it may
be fixed, or float freely : or it may descend as far as the internal
abdominal ring, and remain there without entering the inguinal
canal : or, again, it may be retained actually in the inguinal
canal : and, lastly, it may rest in a position under the skin, at the
junction of the scrotum and the abdominal wall.
For these conditions no palliative measures are of any avail.
Reliance on the application of a special truss, designed more or less
in the shape of a horseshoe, so that the testis can be brought down
into the scrotum and retained there without pressure on the con-
stituents of the cord, is not to be advocated. It is only in rare
cases that a retained testis can be thus manipulated into the scrotum,
and even if it can, the apparatus does not effect a cure, for as soon
as the truss is removed the testis is again drawn up. In fact, it is
less harmful to leave things as they are than to employ this form
of truss, the use of which has been known to cause atrophy of the
testis from pressure. It has therefore been superseded by operative
methods.
The operative procedures available are : (1) Orchidopexy, or
fixing the testis in the scrotum ; (2) re-position of the testis in the
abdomen ; and (3) castration.
If the testis is completely retained within the abdomen, the con-
dition may cause no pain nor inconvenience, and in this case it is
wise to leave things as they are. The only danger in doing so is
that if an acute orchitis supervenes upon an attack of gonorrhoea,
peritonitis may result ; and though this is extremely rare, the
patient should be warned of the danger of exposing himself to
infection. The argument that the retained testis is more liable to
malignant disease than one in the normal situation, and should
therefore be removed at all costs, is not convincing. The statistics
of malignant disease of the testicle rest upon such a small number
of cases that there is not enough evidence to justify the removal of
any retained testis upon this suspicion.
Imperfect Descent of the Testis. 903
In 96 per cent, of cases of retention of the testis there is co-
existent a congenital hernia, which demands a radical cure. When
the parts are exposed for this, a decision can be come to as to the
most suitable method of dealing with the testis.
Orchidopexy is only possible if the testis has already come down
as far as the external abdominal ring, and if the vas is long enough
to permit of the testis being brought down to the bottom of the
scrotum.
The early stages of the operation are identical with those of the
operation for the radical cure of an inguinal hernia. As soon as
the testis and the structures of the cord are found and isolated, the
first thing to do is to separate the hernial sac and ligature it at its
upper extremity, near the internal abdominal ring. The sac is
nearly always congenital in type, and its lower attachment should
be cut through as near as possible to the testis. It is not necessary
to suture the remains together and so form a false tunica vaginalis.
The sac should then be removed. Now comes the all-important
question : are the structures of the cord long enough to allow the
testis to come down into the scrotum? Ee-position of the testis in
the scrotum is rarely, if ever, resisted by shortness of the vas
itself. It is the vessels of the cord which cause the trouble. But
these may safely be cut without any fear that the testis will have an
insufficient blood-supply ; the vessels which surround the vas itself
will be quite adequate to carry on its circulation.
Another difficulty is due to the fact that the corresponding half of
the scrotum is ill-developed, and often incapable of accommodating
a testis to whose presence it has been unaccustomed. A bed for the
testis must therefore be made by thrusting the index finger through
from the wound down into the bottom of the scrotum. This gives
sufficient room for the testis to be inserted, but it will not remain
there unless some method of mechanically fixing it in its new posi-
tion be employed. This may be done by passing silk sutures
through the tunica albuginea and through the scrotum, and then
either fixing them to the skin of the thigh, or to a wire frame which
has been specially devised by Sir Watson Cheyne to fit the front of
the thigh, and which is incorporated in the dressings. The sutures
may be removed after about twenty days, when it will be found
that there is no immediate tendency on the part of the testis to
retract. Some authorities say that the testis may begin to undergo
development in its new surroundings, while others assert that the
manipulation required to bring the testis down into the scrotum
may determine the onset of degenerative changes.
I am so convinced of the unsatisfactory nature of the late results
904 Imperfect Descent of the Testis.
of orchidopexy that I have adopted the following practice as a
routine when I have performed an operation for the radical cure of
the congenital hernia.
If the testis has descended through the external abdominal ring,
it is best left alone ; but if it lies in the inguinal canal or against
the internal abdominal ring, I replace it in the abdomen and close
the abdominal ring. The testicle is pushed well into the abdomen,
so that it lies retro-peritoneally upon the iliacus muscle at some
distance from the internal abdominal ring. The inguinal canal
is then closed with kangaroo-tendon sutures. I have not yet seen a
case of peritonitis arising from inflammation in a testicle so
replaced, though I am aware, as has been already mentioned, that
such a complication has been recorded. But the risk must be an
exceedingly small one.
The testicle should on no account be removed entirely unless it
is obviously diseased. The fact that it is atrophic and apparently
functionless is not a sufficient indication. Such testes have before
now been removed, and have been proved on histological examina-
tion to have been capable of producing active spermatozoa,
and further, a testis which is genitally functionless produces a very
important internal secretion. If, however, the testis is obviously
diseased, e.g., if it is the seat of carcinoma or of tuberculosis, or if
it is becoming gangrenous from acute torsion of the cord, there
should, of course, be no hesitation in performing castration
forthwith.
If, as not infrequently is the case, the condition is bilateral, it is
still more difficult to decide on the best line of treatment. In such
cases it is usually best to do nothing ; but should an operation be
demanded by any of the complications already mentioned, one side
only should be done in the first instance, and a long interval
allowed to elapse before the second testis is submitted to surgical
interference ; and then this must only be done if the result of the
first operation proves satisfactory.
The operation should be done for preference between the sixth
and tenth years. Before this it is difficult to perform a satisfac-
tory radical cure, and after puberty orchidopexy is rendered difficult
by the retraction of the cord and re-position in the abdomen by the
size of the testis.
In Ectopia the testis may be found in the perineum behind the
scrotum, in the pubic region at the base of the penis, or below
Poupart's ligament, having passed through the crural canal. The
decision as to whether any operation shall be performed in these
cases must be influenced by the liability of the testicle to injury in
Imperfect Descent of the Testis. 905
its abnormal position, and by the condition of the one on the
opposite side. If there be a history, of pain and attacks of inflam-
mation in the ectopic testicle, castration should be performed, and
in the case of femoral ectopia a radical cure done if a femoral
hernia co-exists. But in the absence of any definite symptoms it
is better to leave these cases alone.
To sum up, the principal argument in favour of performing
an operation in these cases is, that the congenital hernia which
nearly always co-exists can be subjected to a radical cure. In my
opinion, the procedure which will generally give the most satisfac-
tory results is to replace the testicle within the abdomen. I am
not in favour of orchidopexy as a routine operation, for the reasons
which have already been put forward, and castration is only
indicated by some secondary change in the testicle in its abnormal
position.
IVOR BACK.
906
INFLAMMATION OF THE TESTIS.
Acute Orchitis and Epididymitis will be considered together,
since one rarely occurs absolutely independently of the other. In
the great majority of cases this condition results from gonorrhrea
(see under Gonorrhea). But it may also result from the passage
of an instrument which is not aseptic, or in acute infective
diseases, such as mumps and typhoid, or an infection may spread
from small abscesses round prostatic calculi.
The treatment is somewhat similar to that of traumatic orchitis,
already mentioned. The patient must be put to bed, the scrotum
elevated, and lotio plumbi cum opio applied to it. Adequate
purgation is extremely important. In severe cases, with extreme
enlargement, venesection may be necessary. Leeches should not
be applied to the scrotum, because the wounds which they produce
do not heal readily. It is better to open one or more vessels with a
scalpel. In a favourable case the inflammation will subside in a
week or ten days. The scrotum should be supported in a suspender
for another fortnight, and then, if resolution is not complete,
strapping may be resorted to. In other cases the disease does
not pursue such a favourable course. Abscess formation may
occur, as evidenced by the appearance of a soft fluctuating area
at some spot in the testicle or epididymis. This must be imme-
diately incised and its contents evacuated, and a fomentation
applied. More rarely the whole organ becomes the seat of
multiple abscesses, and in this case the testicle must be removed.
IVOR BACK.
9 oy
INJURIES OF THE TESTIS.
THE testis, from its position, is peculiarly liable to blows,
squeezes and contusions. These, if severe, give rise to sickening
pain, and after a time the whole organ becomes enlarged and
inflamed. The patient must be put to bed, and the scrotum
elevated on a pad which is crescentic in shape and covered with
jaconet. It is placed under the scrotum and kept in position by
tapes, which come from either angle and are attached to a bandage
round the waist. The application of lotio plumbi cum opio fomenta-
tions is efficacious and soothing. In most cases the inflammation
will subside in a week or ten days under this treatment. If at the
end of this time the testis still remains somewhat enlarged and
hard, it may with advantage be strapped for another week or two.
Penetrating Wounds of the testis should be sewn up, with the
usual antiseptic precautions. As a rule they heal readily.
IVOR BACK.
SYPHILITIC DISEASE OF THE TESTIS.
SYPHILIS may attack the testis in the secondary stage, causing
an enlargement of the epididymis, with a concomitant hydrocele.
But this is uncommon. Tertiary syphilitic disease of the testis, on
the other hand, is frequently met with. It should be treated
with the usual anti-syphilitic remedies. Surgical interference is
only required when a small gummatous abscess makes its way to
the surface and causes a hernia testis. (See Hernia Testis.)
IVOR BACK.
TORSION OF THE TESTIS.
i
THIS condition occurs as a result of acute twisting of the cord.
In a remarkably short time the organ undergoes necrosis, because
it is completely deprived of its blood-supply. Castration is almost
always necessary, although one or two cases have been recorded in
which the testis has survived after the cord has been untwisted by
operation. This, however, can only be done if the condition is seen
and recognised in the very earliest stages.
IVOR BACK.
TUBERCULOUS DISEASE OF THE TESTIS.
TUBEKCULOUS disease of the testis may be divided into two
varieties, acute and chronic. In the acute form the course of
the disease is extremely rapid, and the early formation of abscess
is a characteristic sign. The accessory organs, the vas deferens
and the vesiculae seminales, and even the prostate, are attacked
with astonishing rapidity. As soon as the diagnosis has been
definitely made, the testis should be removed at the earliest
possible opportunity, with as much of the cord as is possible.
No palliative measures hold out any hope of success. The
very nature of the process is proof that the patient has no resist-
ance to the tubercle bacillus, and delay will only result in the whole
genital apparatus becoming progressively involved. In the chronic
form the epididymis is first attacked, and the body of the testis is
involved later, if at all. On examination the epididymis will be felt
to be hard and nodular, and the organ tender on pressure. In the
earliest stages the disease may be cured by the general measures with
which we combat tuberculosis, with a view to improving the resistance
of the patient. He should be instructed to lead a quiet life, to live in
the fresh air as much as possible, and to take a generous diet, with
an excess of fatty foods. In addition to this, tuberculin may be
administered, starting with a small dose, e.g., 1 /40,000th of a milli-
gramme of tuberculin (T.K.). If the patient improves after the first
dose, it may be increased in a fortnight to l/20,000th, and so on
until that dose is experimentally found which produces in him the
most beneficial effect. Under this treatment some cases undergo
spontaneous resolution ; but if in spite of it the testis and epididymis
become progressively larger, some form of operative treatment must
be undertaken, and the question arises as to whether the testis
itself can be saved. It is extremely important to do this whenever
it is possible, because the testis is the source of an internal secretion
which is of value to the individual. If, therefore, the epididymis alone
is involved and there is no evidence of a central abscess in the body
of the testis, the operation of epididymectomy should be performed.
An incision is made extending from the inguinal canal on the
affected side, down the scrotum, of such a length that the swollen
organ may be conveniently delivered through it. An incision is
then made through the tunica on either side of the epididymis, and
Tuberculous Disease of the Testis. 909
this structure carefully separated from the testis. The important
point in the operation is to avoid damage to the vessels which lie
on the inner side of the epididymis. If these are injured, the blood-
supply to the testis will be interfered with and necrosis will ensue
necessitating castration later. The epididymis is separated from
the testis from below, starting at the globus minor, and it is
removed with as much of the vas deferens as can be isolated. At
the time of the operation the body of the testis should be examined
for the presence of any tuberculous foci. To facilitate this,
Mr. Burghard advocates opening the testis from behind for one-
third of its depth. If it is not diseased, it may be sewn up again,
but if any little abscess is found it should be scraped out. In this
way one can be sure that one has removed the whole of the tuber-
culous disease. In a fair proportion of cases this procedure results
in a permanent cure.
If the body of the testis is already involved and is the seat of one
or more abscesses, the outlook is not so hopeful. But unless it is
hopelessly disorganised and a source of inconvenience to the
patient, it should not even then be removed, but the abscess or
abscesses opened and scraped on the chance that after the removal
of the main foci the disease will subsequently undergo a spon-
taneous cure. Unfortunately it is necessary to admit that this
rarely occurs, and the usual termination of such a case is castra-
tion. Castration as performed for tuberculous disease does not
differ from the set operation, except that it is necessary to remove
as much of the cord and vas deferens as can be isolated. If a high
incision is made over the inguinal canal, this can be done as far
up as the internal ring. If at the time of operation an abscess
has come to the surface and involved the scrotum, the affected
portion of this must be included in the incision and removed. Some
surgeons have advocated an even more radical operation by means
of two incisions, scrotal and perineal, through which the whole cord
of the affected side, including the vesicula seminalis, can be taken
away. But this is not a sound surgical procedure. The perineum
should only be opened when it is certain that there is a definite
tuberculous abscess in the vesicula seminalis.
IVOR BACK.
9io
TUMOURS OF THE TESTIS.
Innocent Growths of the testis are rare. The only one which
is commonly met with is fibro- cystic disease (also known as
adenoma testis and cystic sarcocele). The affected organ should
be removed, because the growth deprives it of its function, and
there is the further danger that, if left, the disease may
become malignant. Carcinoma and sarcoma occur in about
equal proportions. Castration should be performed as soon as
the diagnosis is made, but even then the outlook is extremely
gloomy, because in this position malignant disease is peculiarly
virulent, and the lumbar glands are involved at a very earl}'
stage. The steps of the operation are as follows : An incision
is made which extends from the upper border of the inguinal canal
to a point half-way down the scrotum. The testicle is delivered
through this. In order to make the diagnosis absolute it is as well
to make a preliminary incision into the testis. If the growth is
malignant, a large Spencer Wells forceps should be put upon the
structures of the cord and the testis removed forthwith, for fear of
infecting the neighbouring tissues. All the structures of the cord
should then be isolated as far as possible, that is to say, as far as,
or possibly beyond, the internal abdominal ring, and ligatured and
removed. The wound is then sewn up. Mr. Bland Button has
published an account of an operation for malignant disease of the
testis, in which he extirpated the glands at the same time as he
removed the organ. He did this by means of an incision through
the linea semilunaris, which extended from the costal arch to the
inguinal canal, and the infected abdominal and lumbar glands were
removed by stripping up the whole of the lateral aspect of the
peritoneum. If the malignant disease has invaded the scrotum at
any point, it goes without saying that the inguinal glands must also
be thoroughly extirpated.
IVOR BACK.
IMPOTENCE.
IMPOTENCE may be due to physical defects in the organs of
generation, may be symptomatic of other morbid conditions, or
may be of nervous origin, so that three varieties of impotence are
described, viz., physical, symptomatic and nervous or psychical.
The Physical Causes of impotence are malformations and cur-
vatures of the penis ; varix of the dorsal vein of the penis ;
cryptorchidism ; atrophy of the testes ; large inguinal hernise,
hydrocele and elephantiasis scroti. Some of these conditions,
such as congenital malformations of the penis or the scrotal
tumours, will yield to appropriate surgical measures such as plastic
operations, radical treatment of the hernia or hydrocele, or removal
of the affected tissue in elephantiasis scroti ; but, in bilateral
atrophy of the testes due to gonorrhoea, syphilis or mumps,
treatment is of but little avail.
Symptomatic Impotence may be caused by the prolonged use
of drugs, such as bromide or iodide of potassium, the salicylates,
conium, opium, morphia, and by alcoholism and excessive smoking ;
by diseases such as phthisis, Bright's disease or diabetes, and by
injuries to the brain and spinal cord. Here the treatment must be
dependent on the cause, and in cases of the drug habit, alcoholism
or tobacco poisoning the condition is capable of great improvement.
Psychical Impotence is caused by sexual excesses, by per-
verted sexual impulses, by mental shock or strain, and may be
associated with varicocele, chronic prostatitis, prostatorrhoea and
spermatorrho3a, all of which are accompanied with severe mental
depression and morbid sensitiveness, and which give rise to the
condition known as sexual neurasthenia.
The treatment of these forms of impotence is one of the most
difficult problems the practitioner may be called upon to face, as
these patients are timid, distrustful, and are unable to detach their
thoughts from their condition, which they believe to be incurable.
The first object is to obtain the confidence of the patient by a
sympathetic manner and by taking a friendly interest in his case,
assuring him that his condition is susceptible of improvement if
not of complete cure. A cold morning bath and cold sponging of
the perineum and scrotum will act as a tonic to the genital organs,
which may also be stimulated by electricity in the form of the
constant current, one electrode being applied to the lumbar region
of the spinal column and the other to the perineum, scrotum and
912 Impotence.
dorsum of the penis. Efforts should be made to distract the
attention of the patient from his sexual disabilities by a routine of
exercise and diversions which will prevent him from brooding on
his condition. His diet must be plain and nourishing, the last
meal should be taken at least three hours before going to bed, and
stimulants must be administered sparingly and with discretion
according to the past history and present requirements of the
individual. To prescribe total abstention from alcohol to those
who have hitherto been accustomed to it may tend to increase the
mental depression, and to such patients a strictly limited allowance
of mild alcoholic beverages, such as hock, moselle or claret, may be
permitted at meal-times ; no liquids should be taken after the
evening meal, as an accumulation of urine in the bladder at night-
time may lead to excitation of the sexual organs and possibly to
nocturnal emissions. Constipation and the consequent straining
during defaecation must be avoided, since that condition may lead
to the escape of some seminal or prostatic secretion, the presence of
which is calculated further to distress the patient. He should sleep
on a hard bed and be covered with a minimum amount of bedclothes,
and if there is a tendency to nocturnal emissions he should be in-
structed to empty the bladder if he wakes in the course of the night.
In cases of sexual hypochondriasis due to chronic prostatitis,
prostatorrhoea, spermatorrho3a, incomplete erection and premature
ejaculation, a large sound should be passed once a week, and
applications of solutions of nitrate of silver (10 to 30 gr. ad 33)
should be made to the prostatic urethra ; sexual intercourse and
even association with the opposite sex should be prohibited. In
cases in which the genital centre of the spinal cord is deemed to be
in an irritable condition, sedatives, such as bromide of potassium,
hyoscyamus, camphor, conium, hyoscine and the liquid extract of
salix niger, may be prescribed. If the spinal centre has been
rendered inactive, either by prolonged abstention from sexual
intercourse or from excesses in that direction, aphrodisiacal drugs
may be of benefit, e.g., phosphorus in pills of T Q to J$ gr., or
preparations such as the syrupus glycerophosphatum co. or the
syrupus hypophosphitum co. ; muiracethin pills, composed of
extract of muira-puama wood and lecithin, four pills to be taken
daily ; sol. yohimbine hydrochlor. (1 per cent. 5 to 15 min.), three
times a day ; testicular extracts, such as spermin, administered by
the mouth or subcutaneously, or a pill such as the following:
^ . Phosphori, gr. T ^ ad ^; Extract. Nucis Voni., gr. ^; Ext.
Damianae, gr. 2 ; Jit. pit ; t.d.s.
). ERNEST LANE.
DISEASES AND AFFECTIONS OF THE
TUNICA VAGINALIS.
H^MATOCELE.
THIS is an effusion of blood into the tunica vaginalis. Like
a hydrocele, it may be connected with disease of the testis
itself; but the typical hsematocele is independent of this, and
is in most cases the direct result of injury. The treatment will
depend upon whether the haematocele is recent or of old stand-
ing. A recent haematocele which is definitely traumatic in origin
should be treated with complete rest, suspension of the scrotum,
and the application of an ice-bag or evaporating lotion to
the part. The following evaporating lotion will be found extremely
efficacious : Ammonium Chloride, 1 oz. ; Dilute Acetic Acid,
2 drachms ; Rectified Spirit, 2 oz. ; Distilled Water, to 1 pint.
If the swelling is not absorbed, a small incision should be made
and the blood evacuated. Rigid asepsis is essential. Nothing
is more easily infected with pathogenic micro-organisms than a
collection of effused blood, and in scrotal cases the risk is doubly
great. In old-standing haematoceles with thick walls it is hopeless
to expect a cure by merely incising them and turning out the con-
tained blood-clot. The cavity will merely refill. Nothing short of
complete excision of the whole parietal layer of the tunica vaginalis
is of any avail. Great care must be taken not to injure the vas.
In the altered condition of the part it may be difficult to recognise.
If the wall is calcareous, as sometimes happens in cases of very
long standing, it is probably best to perform castration, since the
pressure of the swelling on the testis has probably been sufficient to
render that organ functionless.
IVOR BACK.
S.T. VOL. II. 58
9H
HYDROCELE.
BY hydrocele we mean a collection of fluid in the tunica
vaginalis itself, or in a sac connected with it. This may be
associated with disease of the testis itself, or may be independent
of this, the so-called idiopathic hydrocele. Of the latter we
recognise four varieties : (1) Vaginal hydrocele proper, in which
the tunica vaginalis alone is distended with fluid ; (2) congenital
hydrocele, in which the tunica vaginalis contains fluid, but the
cavity opens at its upper extremity into that of the peritoneum ;
(3) infantile hydrocele, in which not only the tunica vaginalis, but the
funicular process also is distended with fluid ; this is shut off from
the peritoneum by a constriction at some point on the cord,
generally at the external abdominal ring ; (4) hydrocele in the
tunica of a retained testis.
The treatment is either palliative or radical.
The palliative treatment consists of periodically removing the
contents of the hydrocele with a trocar and cannula. After
removal of the fluid the hydrocele refills in from three to six
months ; and for this reason, and because operative treatment
gives such good results, tapping is falling into disuse. Inasmuch,
however, as there are patients who refuse radical treatment, or
whose general condition centra-indicates operation, its technique
will be shortly described.
The patient should be seated on the edge of a chair in front of
the surgeon, who himself occupies another one. A hydrocele
should never be tapped with the patient in the standing position ; for
two reasons: (1) In case, as sometimes happens, the patient faints from
the pain of the puncture ; (2) in order that the patient shall be unable to
draw himself away from the surgeon when he feels the point of the
trocar. The scrotum should be grasped with the left hand, and the
skin over it made tense, while the right hand holds the trocar,
the end of the right index finger being held about 1 inch from
the point, to prevent the instrument being pushed in too far. A
position on the surface is chosen which is free from veins, and the
trocar is pushed in rapidly, in a direction backwards and slightly
upwards. The trocar itself is now withdrawn, leaving the cannula
in position ; through this all the fluid drains away. When the
hydrocele is quite emptied the cannula is withdrawn, and the site
Hydrocele. 915
of the puncture covered over with a small piece of gauze and
collodion. The scrotum should be supported for a day or two with
a suspender or bandage. Asepsis is, of course, essential ; otherwise
cellulitis or gangrene of the scrotum and testis may result. Another
important point is that the position of the testis must be accurately
denned, before tapping, by means of trans-illumination. It some-
times lies in front of, instead of behind, the hydrocele as in a
normal case, and the results of driving the trocar into the testis are
sickening pain, and possibly the supervention of a hernia testis.
This method hardly ever leads to a permanent cure of a hydrocele.
Very few such authentic cases have been recorded, and several
modifications have therefore been devised with this object. The
commonest is the introduction into the sac of the hydrocele, after
the removal of the fluid with a trocar and cannula, of an irritant
fluid, which causes a low form of inflammation of the sac wall, so
that its surfaces adhere together. The fluids generally relied on to
produce this result are iodine or carbolic acid. If iodine is used, the
hydrocele should be completely emptied, exactly as in the palliative
operation, but before the cannula is withdrawn from 2 to 4 drachms of
the Edinburgh tincture of iodine [U.S. P. 1 of iodine in 16 of alcohol]
are inserted with a syringe. The scrotum is then manipulated so
that the iodine comes into contact with the entire tunica vaginalis.
After this about half the iodine is allowed to escape, the cannula is
carefully withdrawn, and gauze and collodion applied. The
reaction to the fluid generally occurs in a few hours, and it is well
to keep the patient in bed with the scrotum suspended for a day or
two. After about four days the inflammation begins to subside,
and the patient may begin to walk about ; but the scrotum should
be strapped for two or three weeks. At the end of this time the
inflammation should have subsided completely. Carbolic acid is
employed in exactly the same way. From | to 1 drachm of
glycerine, which is saturated with carbolic acid, is injected.
These methods must never be used in hydroceles in infants. In
the first place, the hydrocele is nearly always of the congenital
variety, and communicates with the peritoneum, although the
opening may be so small that the fluid cannot be reduced by
manipulation (the proof of this is, that if the child lies up, the
hydrocele often disappears temporarily) ; and secondly, the tissues
are unable to stand strong irritants, as are those of adults, and
there is a grave danger of sloughing of the whole scrotum if they
are employed. Hydrocele in an infant can very often be cured by
keeping the child on his back and applying an evaporating lotion.
If this fails, the hydrocele should be punctured in a number of
582
9i 6 Hydrocele.
places with a sterilised needle, so that the fluid can run away into
the tissues of the scrotum. If it recurs, recourse should be had to
an open operation, in which the sac of the hydrocele is dissected
out and removed.
Radical Cure by Open Operation. The ideal form of treat-
ment for vaginal hydrocele, which is now slowly but surely
supplanting all other methods, is the removal of the whole parietal
portion of the tunica vaginalis by open operation. A small incision
is made over the external abdominal ring of the corresponding side,
so as to expose the upper pole of the hydrocele by pressing it up
into the wound. The fluid is then evacuated with a trocar and
cannula. The testis and collapsed hydrocele can now be delivered
out of quite a small wound. The sac of the hydrocele is opened
with scissors, and the whole of the parietal portion removed by
cutting it round half an inch from the testis. A large number of
small vessels bleed in the cut edge. These must be carefully
tied, it being very important that all haemorrhage should be arrested
before the testis is returned to the scrotum. If this precaution is
not taken, a scrotal hsematoma may easily result. It is impossible
that there can be any recurrence after this operation, because the
whole secreting wall of the sac is removed. It is much preferable
to incising the tunica, completely inverting it round the testis, and
bringing its edges together with catgut ; or to partial excision of the
parietal layer, and suture of the portions left, so that a new tunica
vaginalis is formed.
The radical operation which has just been described is applicable
to all the other forms of idiopathic hydrocele which have been
mentioned.
The treatment of hydrocele as it occurs in connection with
with disease of the testis itself will be considered under the
separate headings of testicular disease.
IVOR BACK.
DISEASES AND AFFECTIONS OF THE CORD.
H^EMATOMA.
H^MATOMA of the cord may result from blows or, more rarely,
from a spasm of the cremaster muscle. An elongated swelling is
found in the position of the cord, which is usually somewhat
tender. Resolution commonly occurs as the result of rest in bed,
and the application of an evaporating lotion. Occasionally, if the
condition resists this treatment, it may be necessary to make
a small incision and let out the effused blood.
IVOR BACK.
ENCYSTED HYDROCELE.
ENCYSTED hydrocele of the cord is a dilatation of a portion of
the processus vaginalis. which does not communicate either with
the testis or with the peritoneal cavity. The only satisfactory
treatment is to make an incision over the external abdominal ring,
and dissect out the hydrocele completely.
IVOR BACK.
VARICOCELE.
See Affections of Veins, Vol. I., p. 1323.
918
DISEASES AND AFFECTIONS OF THE
PROSTATE GLAND.
CALCULI OF THE PROSTATE.
STONES in the substance of the prostate must be distinguished
from stones in the prostatic urethra.
Multiple small calculi are of extremely common occurrence in
adenomatous prostates. They are not usually found deep in
the substance of the adenomatous tumour, but most frequently
either just below the mucous membrane of the urethra or at the
periphery of the gland. As a rule they give rise to very little
trouble, and are commonly only detected during the examination
of a patient with symptoms of enlarged prostate, or during the
operation upon such a case.
These stones can be quite easily removed through a median
perineal incision made upon a grooved staff in the urethra. The
staff is removed and the finger is passed into the prostatic urethra.
The mucous membrane is scratched through by the finger-nail,
and the stones removed by a suitable scoop or forceps, their
removal being assisted by a finger of the left hand in the rectum.
A large soft perineal tube should be inserted and tied in for a
few days, after which it is removed and a catheter is passed the
whole length of the urethra, and tied in for a week or so to
facilitate the closure of the perineal incision.
It is occasionally necessary to remove prostatic calculi when of
larger size through the same incision in the perineum as is recom-
mended for prostatic abscess (vide suprafto avoid undue laceration
of the urethra. Such large stones in the substance of the prostate
are extremely rare.
Phosphatic calculi form in the cavity left after removal of an
adenomatous prostate. This subject is dealt with in the section
devoted to Adenoma of the Prostate (see p. 940).
JOHN PAR DOE.
919
INJURIES OF THE PROSTATE.
INJURIES of the prostate may be inflicted from without or
from within, the former being of extremely rare occurrence, the
latter taking place frequently.
(1) Injuries from without may be caused by falls upon some
sharp object, by wounds from bullets, and, exceedingly rarely,
from severe injuries to the pelvic girdle of bones. In the last-
mentioned cases rupture of the bladder above, or of the urethra
below the prostate is much more common, but the writer has
seen the prostate lacerated by sharp fragments of bone driven
in by a crushing accident.
Simple contusions and blows upon the perineum do not directly
injure the prostate, though they may start an inflammation of that
organ, causing so much swelling as to lead to retention of urine.
(2) Injuries from within are exceedingly common in the act
of passing instruments along the urethra into the bladder,
especially when the prostate is much enlarged, and particularly
when the enlargement takes the form of a median projection from
one or other lateral lobe.
The treatment of injuries to the prostate depends upon
the severity of the injury, the presence or absence of sepsis,
and the amount of obstruction to micturition which may result.
In the simple lacerations and contusions nothing more is
needed than rest in bed, hot hip-baths and the administration of
such urinary antiseptics as urotropine, helmitol, cystamine, and
the like, to minimise the risk of sepsis. In the cases of injury
involving rupture of the prostatic urethra or bladder the treat-
ment is directed to secure free drainage of the bladder by a supra-
pubic cystostomy and the insertion of drainage tubes by the side
of the bladder to the bottom of the pelvis, upon exactly the same
lines as are adopted for the treatment of extra-peritoneal ruptures
of the bladder.
In cases in which the injury to the prostate is produced by
instrumentation the damage is usually done during an attempt
to pass a catheter, and the treatment is generally that for the
relief of the condition for which the catheter was passed. In
these cases, if possible, a flexible silk web or gum-elastic catheter
should be passed and tied in ; but if this is impossible the bladder
should be opened and drained above the pubes, the enlarged
prostate being removed at once or at a subsequent operation.
JOHN PARDOE.
920
ACUTE PROSTATITIS.
THE most common cause of this condition is infection from
without by the gonococcus, associated with a purulent urethritis.
The onset of this condition is signalled by increasing pain,
difficulty and frequency of micturition, with a feeling of tenesmus
and a sensation of heaviness and weight about the perineum and
rectum. The urethral discharge is very commonly much
diminished at the onset of acute prostatitis, and very frequently
the urine is scanty and slightly bloodstained. There is little or
no rise of temperature unless an abscess forms, when very com-
monly a rigor occurs and the temperature follows the course
usual in the case of acute pus formation under pressure.
It must not be forgotten that acute prostatitis may be caused
by other organisms than the gonococcus. It is not uncommonly
the first symptom of an acute infection by a bacillus of the colon
group, accompanied, followed, or not attended by a purulent
urethral discharge. No opinion should therefore be expressed
as to the nature of the disease until after a bacteriological examina-
tion has been made of any pus obtainable, or in the absence of
pus, of the centrifuged deposit from the urine. The writer has
seen several cases where a too hasty expression of opinion has
given rise to doubts of the patient's chastity, doubts quite unjus-
tified as the cases proved to be acute bacillus coli infections.
Treatment. In the earlier stages of acute prostatic inflam-
mation rest in bed is essential. Hot hip-baths should be given
twice a day, and it is often exceedingly comforting to the patient
to employ hot lavage of the rectum. This should be carried out
by means of a double tube, which can be easily extemporised by
using two Jacques' rubber catheters, the inlet catheter being of
No. 12 calibre and the outlet tube of No. 14 or 16 calibre.
The tubes are well smeared with vaseline and gently introduced
into the rectum, the inlet tube being introduced about 5 or
6 inches and the outlet tube pushed just above the internal
sphincter. The inlet tube is attached to an irrigator tank holding
at least 1 quart suspended about 1 foot above the patient's body,
which should rest upon one side, the buttocks being brought close
to the edge of the bed, the outlet tube hangs down over the
edge into a receiver. By means of a suitable clip upon the
Acute Prostatitis. 921
irrigator tube, or a small vulcanite tap, the flow can be regulated
to any desired speed. The fluid should be kept at a temperature
of 105 to 110 F., and the flow should not be too fast or con-
traction of the rectum will result and the tubes will be forced out.
When the irrigation is over, a suppository should be introduced
of the f ollowing formula : R^ . Extracti Conii, gr. 1 ; Extracti
Belladonna, gr. | ; Olei Theobromatis, q.s. [U.S.P., ty. Extracti
Conii, gr. 1 ; Extracti Belladonnae Foliorum, gr. ; Olei Theo-
bromatis, q.s.]. M. ft. supposit.
The bowels must be regularly emptied by the use of simple
laxatives. If pain is severe it may be relieved and sleep induced
by the use of suppositories containing from | to | gr. of morphia,
added to the ingredients given above. The more popular modern
urinary antiseptics are not of much avail in this condition, but
a free flow of urine should be induced by means of diuretics such
as acetate of ammonium, spirit of nitrous ether, and the diuretic
waters of Vichy, Contrexeville or Vittel. In some cases sandal-
wood oil proves of value as a sedative to the prostatic mucous
membrane and that of the neck of the bladder, which always shares
in this condition. It can be given in capsules, but is much more
active if administered in the form of an emulsion with the follow-
ing formula : R. Ol. Santal. Flav. Puriss., T^IO ; Potass. Bicarb.,
gr. 20 ; Pulv. Acaciae, gr. 30 ; Spt. Menth. Pip., 111 3 ; Aq., ad ^j.
Ft. emuls. Sig. : 1 oz. to be taken three or four times a day.
Complete retention of urine may occur during an attack of
acute prostatitis, and opinion is much divided as to the use of the
catheter or resort to supra-pubic aspiration of the bladder,
especially in cases due to gonococcal infection. The objection
that is urged to the use of the catheter in these cases is the risk
of introducing gonococci into the bladder ; but when it is under-
stood that in these cases the infection invariably reaches the
neck of the bladder, the validity of this objection is much
diminished.
The writer never hesitates to use a flexible catheter after
thoroughly irrigating the bulbo-penile urethra with a solution of
permanganate of potassium (1 in 5,000) and injecting 30 to 40
minims of a 2 per cent, solution of novocaine. When the bladder
has been emptied it should be washed out with a weak solution
of nitrate of silver (1 in 5,000), and a little of this solution should
be allowed to remain after the catheter is withdrawn.
Prostatic Abscess. If the abscess does not rupture into the
urethra either spontaneously or from pressure of a ringer in the
rectum, it must be opened.
922 Acute Prostatitis.
Two warnings must be given : Firstly, the abscess should never
be opened from the rectum. When the abscess is large and
projecting backwards it is exceedingly tempting and very easy
to pass a guarded bistoury or a trocar into the abscess through the
anterior wall of the rectum, but the temptation should be resisted,
for in the first place the pus often re-accumulates, and, also,
there is great danger of a chronic and persistent recto-prostatic
fistula forming. Secondly, the abscess should not be opened by
an incision into the urethra as for median or lateral lithotomy.
It is quite unnecessary to open the urethra, and by so doing
convalescence is unnecessarily protracted.
The Operation. The patient is placed in the lithotomy position,
and a transverse incision 1| inches in length is made half-way
between the anus and the bulb of the urethra. The incision
should be slightly curved with the convexity towards the bulb.
As soon as the skin has been incised, the median raphe of
the perineum is exposed, and is picked up in forceps and
divided by a snip with a pair of scissors. The pre-rectal fat
bulges immediately, and no more cutting instruments are now
required.
The forefinger of the left hand is passed into the rectum and
touches the anterior wall over the abscess. A pair of long
Spencer Wells sinus forceps is now pushed through the wound
into the fatty space in front of the rectum, and is deliberately
pushed onwards in front of the rectum, guided by the finger in that
cavity, until the capsule of the prostate is reached. The resist-
ance encountered here gives way suddenly under steady pressure
of the point of the closed forceps, the blades are widely separated
and the pus escapes along them. The right forefinger is then
introduced along the forceps into the abscess cavity, and all septa
and bands are broken down. This is a most important step in the
operation, as these abscesses are often loculated, and if the septa
are not broken down, convalescence may be tedious. A rubber
drainage tube is introduced alongside the forceps, and these are
now withdrawn. The tube is stitched to the edges of the wound,
which is closed by a few points of suture. A pad of gauze and
a T bandage complete the operation.
After Treatment. The cavity should be syringed with a
solution of peroxide of hydrogen in water (1 oz. of the 20 volume
solution of hydrogen peroxide to 10 oz. of water) once a day for
three or four days. The tube should then be removed and the
opening allowed to close. Complete healing usually occurs in
from ten to fourteen days.
Acute Prostatitis. 923
Recto-Urethral Fistula. Very rarely the prostatic abscess
bursts into the rectum before the patient is brought to the
surgeon, or the abscess is improperly opened through the rectum.
In either case a recto-prostatic fistula results, which may be slow
in healing or may communicate with the urethra.
If no leakage of urine into the rectum takes place, the sphincter
should be dilated as for an operation for haemorrhoids. A bi-valve
speculum should be inserted, the opening in the anterior wall of
the rectum localised and thoroughly scraped with a sharp spoon.
The cavity should be swabbed out with a solution of chloride of
zinc (20 gr. to 1 oz. of water), or nitrate of silver (20 to 30 gr. to
1 oz.), and packed loosely with gauze.
If a recto-urethral fistula of long standing is present, the opera-
tion for its cure may prove to be a somewhat delicate and
difficult one.
The same incision is made in the perineum as for opening a
prostatic abscess. A solid curved staff is then passed along the
urethra into the bladder, and held in position by an assistant.
The incision is then deepened carefully by blunt dissection,
until a probe can be felt which has been passed from the rectum
into the prostatic urethra, impinging upon the metal staff in that
canal. The fistulous track is then divided between the rectum
and the prostate. There is often very little tissue here available
for splitting, as the anterior wall of the rectum is firmly adherent
to the capsule of the prostate. After the division has been
accomplished a hole remains in the anterior wall of the rectum
which must be closed by two layers of catgut sutures.
The prostatic side of the fistula must now be thoroughly scraped
with a sharp spoon. The space between the rectum and the
prostate is lightly packed with gauze, the metal staff is with-
drawn from the urethra, and a silk web catheter introduced in its
place and tied in for a week or ten days. The gauze packing is
removed after forty -eight hours and the cavity allowed to heal by
granulation.
JOHN PARDOE.
924
CHRONIC PROSTATITIS.
CHRONIC inflammation of the prostate is most commonly a
sequel of acute gonorrhoea, in which the infection has penetrated
to the membrano-prostatic urethra and thence to the follicles of
the prostate. It may be one of the most intractable and
obstinate affections, and is often attended by a mental depression
quite out of proportion to the gravity of the symptoms.
As a rule but little physical inconvenience is suffered by the
patient beyond some perineal and rectal discomfort off and on,
occasional discomfort during and at the close of micturition, and
a little undue frequency of desire to pass urine.
In a small proportion of cases, however, the pain occasioned by
the condition is more severe, affecting the sciatic and obturator
nerves, and whilst present really unfitting the patient for his
usual occupations.
As already stated, chronic prostatitis is most often an aftermath
of gonorrhoea. The gonococcus does sometimes linger in the
prostatic follicles for months and even years after the acute
attack has passed away, but usually the infection in acute
gonorrhoea is a mixed one, a variety of other organisms being
found in the discharge, and long after the acute stage is passed
and all gonococci have disappeared the secondary infection may
persist and remain' the cause of a chronic inflammation of the
prostate.
It must also be stated most definitely that chronic prostatitis,
with its usual accompaniment of " gleet," may be due to infection
by numerous organisms other than the gonococcus ab initio.
The writer has met with various kinds of staphylococcf, strep-
tococci, bacillus pyocyaneus, bacillus faecalis, and various members
of the " coliform " group of organisms as the active causes of a
chronic prostatitis.
The treatment of chronic prostatitis falls more naturally to
be dealt with in the section upon diseases of the urethra, but
certain considerations must be mentioned here.
The mucous membrane of the prostatic urethra must be treated
as advised in the section dealing with chronic posterior urethritis.
In treating infection of the gland substance the first essential
is to empty the follicles of their infected contents. This is
Chronic Prostatitis. 925
effected by means of prostatic massage, with the patient in the
knee-elbow position. At the first two or three sittings the
massage must be done with gentleness, but gradually more pres-
sure can be employed, and the follicles can thus be emptied quite
thoroughly. When the massage is completed, the urethra should
be thoroughly irrigated by means of Janet's method of posterior
irrigation. This is given in the following way :
The patient is placed in the recumbent position with the legs
apart and the clothes drawn down below the knees. At the first
two or three sittings it is well to inject into the anterior urethra
by means of a small syringe a 4 to 5 per cent, solution of novo-
caine. Twenty to thirty minims is sufficient. This solution is
" stripped " down into the bulb by milking the urethra backwards,
and then firm backward pressure along the urethra in the perineum
forces the solution into the membrano-prostatic urethra. By this
method the resistance of the compressor urethras is overcome if
the solution is allowed to remain for four or five minutes before
f the irrigation is commenced.
An irrigator tank containing 1 quart of solution is suspended
5 or 6 feet above the recumbent patient. The tube leading from
the tank is fitted with a suitable urethral nozzle and shield to
protect patient and surgeon from splashing.
The meatus is blocked by the conical nozzle and the solution
allowed to gently flow into the urethra, which is felt to balloon
under the fingers of the left hand. The pressure is gradually
increased until the fluid forces the compressor urethras and passes
into the bladder (the sphincter offers no resistance), a thrill being
communicated to the fingers holding the penis. When the
patient feels that the bladder is full, he is allowed to stand and
pass the solution into a receiver.
By this method the whole urethra and bladder is irrigated under
pressure without the introduction of a catheter.
This massage and irrigation should not be given more than
once in every three days, and any sign of irritation should be taken
as a signal to increase the intervals between treatments.
A variety of solutions may be employed, of which perhaps the
best are the following :
Permanganate of potassium (1 in 5,000 to 1 in 2,000) ; or
nitrate of silver (1 in 5,000 to 1 in 2,000) ; or oxycyanide of
mercury (1 in 10,000 to 1 in 2,000) [this must be used with caution,
as some urethrse are very intolerant of any form of mercury] ; or
lysol (5| to 5J to Oj). Protargol, argyrol and other silver salts find
supporters, but it is unnecessary to enumerate further solutions.
926 Chronic Prostatitis.
Great assistance is sometimes afforded by performing the
massage upon a full-sized metal bougie, or better still a Koll-
mann's or Oberlander's four or six-blade prostatic dilator. This
instrument is fitted with a screw handle upon which is a dial
registering the amount of dilatation (on the Charriere scale)
which is being employed. The blades only expand in the deep
urethra when the instrument is in position, an obvious advantage
when large dilatation of the anterior urethra is not required.
Vaccine therapy is of great assistance in many cases of chronic
prostatitis. If the gonococcus is present, a stock gonococcus
vaccine should be combined with an autogenous vaccine made
from cultures of the patient's own bacteria.
JOHN PARDOE.
GOUTY PROSTATITIS.
CONSIDERABLE swelling of the prostate not infrequently com-
plicates an attack of gout, but we have not seen deposits of urate
of soda in the substance of the prostate such as occur in joints,
cartilages, and in the corpora cavernosa of the penis.
The treatment of such swellings follows the lines of general
treatment of the gout and of acute prostatitis.
The prostates which suffer in this manner are almost invariably
adenomatous, and require treatment for that condition sooner or
later.
JOHN PARDOE.
927
ONANITIC PROSTATITIS.
A CLASS of case which should be better recognised than it is at
present is the bulky congestion due to onanism on the one hand,
and excessive sexual intercourse on the other.
It can hardly be called an inflammation of the gland, as it is not
due to infection by micro-organisms.
The prostate is very large, tender to the touch, and causes
increased and much too easily aroused sexual excitement, thus
leading in a vicious circle to the very cause which produced it.
Treatment is simple, consisting in an immediate cessation of
the causative factors, combined with a very simple diet, rest
and prohibition of alcohol.
JOHN PARDOE.
SYPHILIS OF THE PROSTATE.
SYPHILIS of the prostate is met with in two forms. A diffuse
swelling of the gland is sometimes observed in the secondary stage
of acquired syphilis. The symptoms resemble those of a subacute
prostatitis, namely, a little urgency, frequency and discomfort
on micturating, and some sensations of perineal and rectal dis-
comfort between the acts of passing urine. The prostate feels
large to the examining finger, and is a little tender on pressure.
This condition quickly yields to specific treatment.
Gumma of the prostate is very rare, but occurs sufficiently
often to make it a recognisable condition. Fortunately there are
tell-tale signs about the patient as a rule which assist the diagnosis.
All the cases which the writer has seen have quickly yielded to
treatment by iodide of potassium and mercury, no local treatment
being required.
JOHN PARDOE.
928
TUBERCULOUS PROSTATITIS.
TUBERCULOSIS of the prostate is almost invariably a secondary
infection from the urinary tract, or from some other portion of
the genital tract. The latter mode of origin is by far the more
common, as is only to be expected from a consideration of the
anatomical relationship of the vasa deferentia, common ejacula-
tory ducts, and the prostate. The strongest argument for early
extirpation of a tuberculous epididymis is the rapidity with which
infection of the corresponding vas deferens, seminal vesicle and
prostate takes place.
Infection from a primarily tuberculous kidney, ureter, and
bladder is much more uncommon, but it undoubtedly occurs in
some few cases where there is no evidence whatever of' tuber-
culosis of other parts of the genital system. Primary tuberculosis
of the prostate is exceedingly rare.
Treatment. The treatment of this condition is usually only
a part of the general treatment applied to the original infection
of bladder, kidneys, or epididymis.
There can be no question that thorough removal of the source
of the infection, such as is gained by castration, or in less severe
cases epididymectomy with vasectomy, by cutting off the supply
of infective material, is often followed by a cure of the prostatic
trouble. In the same way the removal of a grossly infected
kidney which is acting as the source and fount of infection of the
bladder is followed by a remarkable improvement, if not cure of
the vesical and prostatic tuberculosis secondary to it. In the
writer's opinion active surgical interference with a tuberculous
prostate should be limited to those cases where caseous masses
have broken down into an abscess which is unable to discharge
its contents by way of the urethra. In such cases the abscess
should be approached from the perineum by the same transverse
incision as has been recommended for acute abscess of the gland,
but with more deliberation, a careful blunt dissection being made
up to the capsule of the prostate, and the cavity opened and
scraped out under the guidance of the eye and not of touch alone.
On no consideration should the urethra be opened if it is possible
to avoid doing so, as a most troublesome and persistent fistula is
sure to result.
Tuberculous Prostatitis. 929
The general treatment of such cases must follow the lines laid
down for dealing with vesical tuberculosis.
As already indicated, however, these tuberculous abscesses
are usually met with in cases of advanced general tuberculosis
of the genito-urinary system, and surgical treatment is palliative
rather than curative.
JOHN PARDOE.
S.T. VOL. II. 59
930
TUMOURS OF THE PROSTATE.
IT will tend to a much clearer understanding of enlargement
of the prostate if it is once and for all understood that this condi-
tion, setting aside inflammatory changes, is always due to some
form or other of neoplasm. The old term " hypertrophy " is an
absolute misnomer, for the writer has failed to find a single in-
stance of true hypertrophy of this organ in an examination of
many hundreds of cases. The constituents of the gland are never
enlarged each in their relative proportion to the whole, but the
enlargement is due to an increase either of the epithelial or of
the connective tissue elements at the expense of the rest of the
organ.
A convenient classification of these enlargements is into innocent
and malignant types.
,' . j i Sarcoma
T Adenoma \
Innocent __.. Malignant . Carcinoma
( Flbroma ' Endothelioma
Whatever the nature of the enlargement the obstructive
symptoms are common to them all. The treatment, however, is
widely different, and it will be well, therefore, to examine first some
general considerations before passing on to a discussion of the
best methods of dealing with innocent and malignant enlarge-
ments respectively.
Obstruction to micturition due to permanent enlargement
of the Prostate. With very few exceptions the onset of obstruc-
tive symptoms is very gradual, although the final development of
complete obstruction may be very acute. The development of
obstruction in its early stages is often so insidious that the
patient takes little or no notice of it, or if he does occasionally
think that all is not as it used to be he attributes it to his age,
there being a very widespread impression among the public that
the power of retention and expulsion of urine undergo a natural
diminution as age advances. Needless to say, this is not the pase
unless an abnormal condition is present.
As time goes on and the gland enlarges, a little difficulty is
experienced in starting the stream ; a little dribbling and failure
of the final expulsive jet is noticed at the conclusion. Gradually
the force of the stream diminishes, until there is little or no force
Tumours of the Prostate. 931
at all and the urine drops from the end of the urethra. Coin-
cidently the bladder fails to completely empty itself, and a gradu-
ally increasing quantity of " residual urine " accumulates. The
bladder muscle usually hypertrophies in an attempt to overcome
the resistance ; but the fight is an unequal one, and gradually the
muscle gives way and the bladder distends.
Should this gradual back pressure be long continued, the
sphincters at the orifices of the ureters gradually give way, the
ureters distend, the pelves of the kidneys distend, and eventually
the kidneys may be converted into large thin-walled sacs, the
cortical substance showing marked changes of interstitial nephritis.
These backward pressure changes are attended by a typical
series of symptoms denoting renal inadequacy.
The urine is secreted in great abundance, and the total excretion
may be very large notwithstanding the difficulty with which it
is voided. It is pale, of very low specific gravity (1002 to 1005),
very deficient in solids, particularly in urea, and showing a very
small trace of albumen.
The symptoms are backache, often called lumbago, general
malaise and loss of appetite, marked thirst, a dry mouth and
tongue, cessation of sweating, and progressive loss of weight.
The patient frequently lays stress upon these symptoms and never
mentions his urinary difficulties, which seem to him of slight im-
portance, so that it is very common for such cases to be treated as
dyspepsia, diabetes mellitus, and chronic interstitial nephritis, the
true cause being often overlooked, especially in stout individuals,
where the marked distension of the bladder is not apparent. This
distension is sometimes enormous, even up to the ensiform carti-
lage ; but it must not be forgotten that the back pressure upon the
kidneys sometimes takes place with a very moderate degree of
vesical distension, the ureteric sphincters giving way although the
rest of the bladder muscle succeeds in partially resisting the
pressure.
In some cases even of extreme distension, frequency of micturi-
tion is not very marked, the bladder apparently tolerating the
presence of an enormous quantity of urine. This, however, is
only the case so long as the urine remains aseptic. The introduc-
tion of sepsis immediately causes greatly increased frequency of
micturition, with other much more serious symptoms. In quite
a large number of cases, however, this increasing difficulty of
micturition, does not result in backward pressure changes, and
here the condition is not nearly so serious though the discomfort
may be greater. In some of these cases the vesical sphincter and
592
932 Malignant Tumours of the Prostate.
the compressor urethras give way to a certain extent, and a
condition of false incontinence is produced, the patient being
constantly wet in addition to the small amount of urine that he
passes by voluntary expulsive efforts. This condition is known as
retention with overflow, and is not peculiar to cases of prostatic
obstruction, for it is seen in disease of the central nervous system
and some cases of stricture, sometimes it is associated with vesical
calculus, and it is observed in cases of retention due to the pressure
of a retro verted gravid uterus or of uterine fibroids.
Serious danger commences for the patient when the ureteric
sphincters give way and the backward pressure dilates them and
the kidneys. It is then that the train of symptoms above described
is made manifest, and there are definite and unmistakable indica-
tions of the necessity of extreme caution in dealing with such
cases.
It should be laid down as a hard-and-fast rule in all treatises
upon surgery that in cases of this nature the bladder should never
be suddenly emptied, but the urine should be drawn off very slowly,
very aseptically, and with the patient at absolute rest in bed.
The best method of emptying these bladders is by tying in a
small silk web catheter fitted with a small vulcanite or metal
tap, which is turned on to such a point that the urine only escapes
a little quicker than it is secreted. At least twenty-four hours
should be taken to complete the evacuation, and it is wise to take
even longer.
The strictest asepsis should be observed, as an acute infection
with a coliform organism is only too common. Even with every
precaution an infection from within cannot be avoided in some
cases, and in such cases the patient frequently loses his life or
only escapes after a most desperate illness, for the infection attacks
the whole urinary tract with the greatest severity.
Severe haemorrhage from both bladder and kidneys often
follows a sudden emptying of these bladders ; whilst in other cases,
if neither haemorrhage nor sepsis occur, the patient passes into a
condition of uraemia, with gradually decreasing excretion of urine
and ultimate suppression and death. These calamitous results
are avoided or minimised by very slow evacuation of the urine
combined with a rigid asepsis.
MALIGNANT TUMOURS OF THE PROSTATE.
Sarcoma and Endothelioma of the prostate are at present
the pale of curative surgery.
The bladder must be emptied by the catheter so long as that
Carcinoma of the Prostate. 933
is possible, and when it becomes impossible by reason of difficulty,
pain or haemorrhage, a simple supra-pubic drainage should be
done.
The Operation. The pubes and abdomen are shaved and pre-
pared in the usual manner. The bladder is thoroughly washed
out with sterile warm water through a large catheter, and is then
filled to its utmost capacity.
A straight median incision is made, 2 to 4 inches in length
according to the obesity or thinness of the patient, commencing
just above the pubes. The sheath of the recti muscles is opened
in the mid-line and the muscles separated by the ringer or the
handle of the scalpel. In this situation there is no posterior
sheath to the recti, so the pre-vesical fat immediately appears.
This is cleared from the front of the bladder, and the attachment
of the peritoneum to the bladder is identified and pushed upwards.
The bladder wall is easily recognised by the appearance of the
muscle and the larger veins crossing over it.
It is now w r ise to take a grip of the bladder wall with catch
forceps and empty it of lotion by means of the catheter. In this
way septic infection of the abdominal wound is avoided. The
bladder is then opened by a small incision, and, if clean, a
No. 12 or 14 (English scale) soft rubber catheter is inserted and
stitched in by a purse-string suture passing through the catheter
and the bladder wall. This suture should be of catgut, as it is
not desirable that it should remain in position too long, and it is
difficult to remove if of silk. Two catgut sutures are passed
through the wall of the bladder on either side, piercing the muscular
coat only, and are then passed through the sheath of the rectus
and tied on either side, thus stitching the bladder to the abdominal
wall. The abdominal wound is then closed around the catheter
after bringing the sheath of the rectus together with a few catgut
sutures. This operation is only applicable to cases where the
urine is clear and the bladder aseptic. When purulent cystitis
is present it is better to insert a large tube into the bladder of
from | to 1 inch in diameter, through which the bladder can be
thoroughly irrigated. This tube is removed in a few days and
a smaller one substituted, the wound gradually healing by
granulation. As in these cases the operation is only resorted to
as a last resource, no attempt need be made to establish a valvular
opening and to dispense eventually with a drainage tube.
Carcinoma of the Prostate. In the writer's experience
carcinoma of the prostate is always of the hard scirrhus type
(columnar carcinoma), very slow in growth, and with a most
934
Carcinoma of the Prostate.
insidious onset. Unhappily it is of far more frequent occurrence
than has been commonly supposed. Of one hundred cases of diffi-
cult micturition or retention of urine due to enlargement of the
prostate the writer found fourteen cases definitely carcinomatous.
In these cases difficulty of micturition is by no means always the
earliest symptom. Sensations of perineal and rectal uneasiness,
pain referred to the sciatic or obturator nerves, and possibly
some hesitancy or lack of power in the expulsion of urine are
far more common
early symptoms than
is great difficulty in
ejaculation. Even
when the malignant
growth is quite large,
it is remarkable how
completely sortie
patients are able to
empty the bladder.
This is due to the fact
that in most cases the
growth tends to spread
in the direction of the
common ejaculatory
ducts and up the base
of, and therefore out-
side, the bladder.
Intra-vesical projec-
tion of the prostate is
very rare until the
last stages are reached,
whereas in the case
of adenoma of the prostate intravesical projection is often an
early feature and very common.
From the insidiousness of its onset and early development it
is generally the case that carcinoma of the prostate appears before
the surgeon when no hope remains of a curative operation. But
occasionally a very early diagnosis can be made, and then the
whole prostate, together with the base of the bladder and the
common ejaculatory ducts with the seminal vesicles, can be
removed in one portion, as is advised and practised by Professor
Hugh Young, of Baltimore. The following description of the
operation and illustrations are from the Johns Hopkins Hospital
Reports for 1906, Vol. XIV.
FIG. 1. After transverse section of urethra. (From
Johns Hopkins Hospital Reports, Vol. XIV.,
1906.)
Carcinoma of the Prostate.
935
" An inverted V cutaneous incision was made in the perineum
as in the operation employed by me for simple hypertrophy of
the prostate, each branch of the incision being about 2 inches
long. By blunt dissection the end of the bulb and central tendon
were exposed and the latter divided, exposing in turn the recto-
urethralis muscle, the division of which gave free access to the
membranous urethra behind the triangular ligament. Urethro-
tomy upon a grooved staff was followed by introduction of the
prostatic tractor, which was opened out after it reached the
bladder. While traction was made upon this instrument, the
rectum was carefully
separated from the
prqstatic capsule by
blunt dissection until
the entire posterior
surface of the prostate
was brought into
view. Up to this
point the operator
proceeded exactly as
in the usual prosta-
tectomy operation.
The tissues around
the prostate were
more haemorrhagic
and the wall of the
rectum more closely
adherent to the cap-
sule of the prostate
than usual. Examina-
tion of the prostate
then showed much greater induration than I had ever encoun-
tered in a benign prostate. The rectum and the peri-prostatic
tissues were free from invasion. Complete excision was carried
out as follows : The handle of the tractor was depressed, thus
exposing the membranous urethra anterior to it, where it was
easily divided transversely with a scalpel, leaving a small stump
of the membranous urethra protruding from the posterior -surf ace
of the triangular ligament. By further depressing the handle of
the tractor the pubo-prostatic ligament was exposed, and, being
very tautly drawn, easily divided by scissors, thus completely
severing the prostate from all important attachments (except pos-
teriorly), as shown in Fig. 1. The lateral attachments, which
FIG. 2. Exposure and division of trigone. (From
the Johns Hopkins Hospital Reports, XIV.,
1906.)
936
Carcinoma of the Prostate.
are slight, were easily separated by the finger. The posterior
surface of the seminal vesicles were then freed by blunt dissection,
the now mobile prostate being drawn well out of the wound.
' The next step was to expose the anterior surface of the
bladder, which was easily done by depressing the tractor and
making strong traction. By this procedure the bladder was
drawn down so close to the skin wound that it was easily
incised at a point in the middle line about 1 centimetre above the
prostate- vesical juncture. By means of scissors the division was
continued on each
side until the trigone
was exposed (Fig. 2).
After swabbing away
the blood and urine
the ureters were easily
found, and the line of
incision carried across
the trigone with the
scalpel so as to pass
about 1 centimetre in
front of the ureteral
orifices.
"Whilst still mak-
ing traction upon the
prostate, the base
of the bladder was
pushed up with the
handle of the scal-
pel, thus exposing the
anterior surface of
the seminal vesicles
and the adjacent vasa
deferentia (Fig. 3), all of which were carefully freed by blunt
dissection with the finger as high up as possible, so as to remove
with the vesicles as much circumjacent fat and areolar tissue
as possible on account of the lymphatics which they contained.
The vasa deferentia, after being drawn down as far as possible,
were picked up on a small blunt hook and divided with scissors
high up, care being exercised to see that the ureters were not in
danger. After division of the vasa the seminal vesicles were
found to come down more readily, and the deep adhesions were
finally divided and the mass removed.
' There now remained a large defect to be repaired. The vesical
FIG. 3. -Final separation of seminal vesicles and
division of vasa. (From the Johns Hopkins
Hospital Reports, Vol. XIV., 1906.)
Carcinoma of the Prostate.
937
opening was about 8 centimetres in diameter and had sunk far back
into the depths. The stump of membranous urethra had been
obliterated by the compression of the anterior retractor, so that
it was necessary to insert a soft rubber catheter through the
urethra from the meatus to discover it. The anterior wall of the
vesical opening was then caught with forceps, and with no great
traction I was surprised to find how easily it could be drawn down
to the membranous urethra, where an anastomosis was readily
made. The first suture was placed by inserting the needle into
the triangular ligament above the urethra and out through the
anterior wall of the membran-
ous urethra, then through the
anterior wall of the bladder in
the median line, from within
out, care being taken to include
only the submucosa and muscle.
When this suture was tied the
median line of the anterior wall
of the bladder was drawn to
meet the median line of the roof
of the remaining membranous
urethra, the knot being outside
and the thread left long. Fig. 4
shows diagrammatically the
plan of vesico-urethral anasto-
mosis described above.
" Lateral sutures, similarly
placed (including the peri-
Fig. 4. Diagram showing plan of vesico-
urethral anastomosis. (From the
Johns Hopkins Hospital Reports,
Vol. XIV., 1906.)
urethral muscular structures
below), and two posterior
sutures completed the anasto-
mosis of the membranous urethra, with a small ring into which
the anterior portion of the margin of the vesical wound had been
fashioned by the tying of the sutures. The remainder of the
vesical wound now presented as a longitudinal opening, which
was easily closed by sutures, thus completely closing the defect
and replacing the prostatic urethra with a funnel-shaped process
in a do from the bladder wall.
" The sutures used were silk, one end of each being left long and
brought out of the wound so that they could be extracted later
(since then I have found alternate sutures of catgut and silkworm
gut, also left long, the best). After light gauze packing had been
placed in various portions of the wound, the levator ani muscles
938 Carcinoma of the Prostate.
were drawn together with catgut (two sutures) in front of the
rectum, and the skin wound closed on each side with interrupted
catgut sutures, leaving only a small portion open at the angle
in front for exit of the gauze drainage.
" The retained rubber catheter (which was of considerable
service in making the anastomosis of the urethra and bladder)
FIG. 5. Author's operation, showing supra-pubic scar and valvular fistula.
was fastened in place by adhesive plaster around the penis, and
the patient was returned to the ward."
The operation, described above by Professor Young, undoubtedly
completely extirpates the primary growth in early cases, but
unfortunately recurrence in the pelvic cellular tissue is only too
liable to- occur, and the operation has other drawbacks. Fistulous
tracks sometimes remain which are exceedingly difficult to close.
Complete incontinence, which is permanent, has occurred in
several cases.
The operation is very difficult to perform and is one of great
gravity, especially when the advanced age of most of the patients
is considered.
Carcinoma of the Prostate.
939
Permanent Supra-pubic Drainage. In advanced cases where
there can be no hope of complete removal of the disease, permanent
supra-pubic drainage should be done, when catheterism fails owing
either to difficulty, pain, or haemorrhage in the use of the catheter.
The following operation devised by the writer and used in
Fio. 6. The same with catheter in situ.
twelve cases has given some excellent results in a good proportion
of cases :
The abdomen is opened in the middle line by vertical incision
3 inches in length immediately above the pubes. The recti
are separated and the anterior wall of the bladder is exposed. It
is advisable to place the patient in the Trendelenburg position, as
this much facilitates the operation.
The loose lateral ligaments of the bladder are snipped through
by scissors, and the peritoneum is detached and pushed back as
far as possible. The bladder is now loose and free.
94-Q Adenoma of the Prostate.
The skin is undercut and retracted over the right or left rectus,
exposing the anterior sheath of the muscle, in which a small
vertical incision is made about 2 inches from the middle line.
The muscle is then split from the mid-line out to the small vertical
incision in the sheath. As large a cone of bladder as can be
obtained is then pushed through the split muscle and brought out
through the small vertical incision in the sheath, to the edges of
which it is firmly stitched by several sutures of catgut. The
cone which now projects should be of sufficient size to pull easily
through a small vertical incision in the skin corresponding to the
vertical incision in the rectus sheath. The cone of bladder is now
stitched to the skin. An opening is made in the cone just large
enough to admit a No. 12 or 14 (English scale) Pezzer self-retaining
catheter, which is passed into the bladder. The recti and skin are
now closed in the mid-line and a collodion dressing is applied.
It will be seen that this operation is an adaptation to the
bladder of Frank's method of gastrostomy.
The results are excellent. The self-retaining catheter can be
removed in a few days, and thereafter a soft rubber catheter is
passed through the opening as occasion requires.
After a lew weeks the new meatus is represented by a puckered
dimple in the skin. If a little urine leaks through the orifice, it
can easily be checked by applying a light truss fitted with a small
rubber or artificial ivory pad.
This operation is not applicable to very contracted bladders.
The best results are obtained in those bladders distended by
long-continued back pressure.
Conclusions. (1) It is justifiable to offer the chance of cure
by a radical operation to those patients in whom the disease is
diagnosed very early. Even if the operation fails, it is no bar to
permanent supra-pubic drainage later on.
(2) An " enucleation " by the supra-pubic method as advised
for adenoma of the prostate should never be attempted. Recur-
rence is certain.
(3) It is best in more advanced cases to practise aseptic
catheterism until that becomes impossible owing to pain, difficulty
or the incidence of severe haemorrhages dependent upon the use
of the catheter, when a permanent drainage by the method
described above should be done.
ADENOMA OF THE PROSTATE.
Adenoma of the prostate is the condition to which the term
" hypertrophy " of the prostate is commonly applied. As
Adenoma of the Prostate. 941
already stated, it is a new growth of the prostate and in no sense
a true hypertrophy. It forms by far the largest proportion of
enlargements of the prostate, giving rise to obstruction of
micturition.
Palliative Treatment. This involves the habitual use of the
catheter, and though it cannot be denied that quite a number of
patients arrive at a degree of tolerance of catheterism quite
astonishing to observe, it must be admitted by all who have had
a considerable experience of patients with prostatic obstruction
that sooner or later the habitual use of the catheter, however
skilfully applied, is attended by a greater or less degree of infection
of the urinary system, with its coincident dangers and distresses,
such as cystitis, epididymitis, pyelitis, and haemorrhage from the
inflamed and irritated adenomatous prostate. In a considerable
number of cases self-catheterism is difficult or impossible owing
to the size of the gland, the tortuousness of the prostatic urethra,
and not uncommonly the nervousness or personal inaptitude of
the patient.
In the case of extremely aged men who have used the catheter
for some years, and are still using it with perfect success, it is quite
justifiable to permit them to continue in this manner.
In such cases transient attacks of cystitis should be treated by
irrigation of the bladder with mild antiseptic solutions, such as
have already been suggested in the section devoted to cystitis ;
by the use of urinary antiseptics by the mouth, such as urotropine,
benzoate of ammonium or sodium, cystamin, helmitol, or salol ;
by a wise regulation of the mode of life, with particular regard
to a simple diet, abstinence from alcohol, and avoidance of
exposure to extremes of heat and cold, and undue exertion and
fatigue.
But in those cases where there is a considerable expectation of
life apart from the prostatic trouble, we now consider it to be the
duty of the surgeon to advise removal of the obstruction at as
early a stage of the case as possible, before the use of the catheter
has led to those complications, most of them due to sepsis ; which
have been already indicated.
Restoration of function can be promised emphatically. Recur-
rence of the growth is absolutely unknown if the operation is
properly performed, and the risk in cases uncomplicated by sepsis
and its results, is, in the case of an otherwise healthy man, scarcely
to be considered.
The prostate can be approached and removed either by the
supra-pubic or by the perineal route.
942 Adenoma of the Prostate.
Supra-pubic Prostatectomy. The bladder is first thoroughly
washed out with sterile warm water or normal saline solution and
is then filled to its maximum capacity. The abdomen is opened
in the median line above the pubes, the length of the incision
depending upon the thinness or obesity of the patient. In very
stout patients, especially when the pelvis is very deep, it is some-
times necessary to insert the whole hand into the pelvis, the fore-
finger only passing through the incision in the bladder to perform
the enucleation. In thin patients with flaccid muscles a very
small incision will suffice, as the forefinger is all that need be
inserted, the clenched fingers of the hand pushing the wall of the
belly down into the pelvis.
The pre-vesical fat and peritoneum are stripped upwards by
blunt dissection and the anterior wall of the bladder is exposed.
An incision is now made in the bladder, either vertical or trans-
verse, and the fluid allowed to escape.
Marion, of Paris, recommends that the bladder should be filled
with air rather than water, as he considers the peri-vesical tissues
are less liable to be infected when the bladder is opened. The
writer prefers to catch the wall of the bladder in forceps, then to
empty it by the catheter, and make the incision in the anterior
wall when it is empty.
The bladder is now carefully explored with the finger, and any
calculi which may be present are removed with scoop or forceps.
It is now easy to feel whether or no there is any intra-vesical
projection of the prostate. If the projection is marked, the prostate
in that situation is covered only by mucous membrane, as this
so-called middle lobe has " pushed " upwards through the vesical
sphincter, widely stretching the orifice of the bladder. It is in
this situation that the enucleation of the gland should be com-
menced, by scratching through the mucous membrane with the
forefinger nail. It is quite unnecessary to use knife or scissors
to incise the mucous membrane. It gives way quite easily to the
pressure of the finger. Immediately the mucous membrane is
penetrated the finger is in the proper plane of cleavage to perform
the enucleation. It is immaterial in which direction this is carried
out, as, if the finger is pushed steadily onwards, the adenomatous
gland shells out exactly as encapsuled adenomata do in other
situations. The stripping process is continued all round the
gland until it is left hanging by the urethra in front, very much
like an apple on its stalk. The finger is then hooked under the
urethra and it is torn through. The prostate is now lying loose
in its cavity, and is pulled out by suitably shaped forceps. This
Adenoma of the Prostate.
943
manoeuvre is often much assisted by starting strong irrigation
through the catheter. Sometimes . the prostate is so large in
proportion to the opening from the bladder that it must be broken
into two or three pieces prior to removal. In a few cases where
there is no median projection, the two lateral lobes can be
removed separately, being stripped off the urethra, which, how-
ever, is always more or less torn in this operation. If the haemor-
rhage is slight the writer does not employ irrigation after the
enucleation, but if the bleeding is profuse irrigation with sterile
FIG. 7. Showing Hamilton Ir\ing's " box " applied.
water at 120F suffices in most cases to stop the loss. In a very
few cases the haemorrhage is so profuse that it is necessary to
pack the cavity with a long strip of sterile gauze, the end of which
is brought out through the abdominal wound. This gauze can
be safely and easily withdrawn thirty-six to forty-eight hours
after operation.
The writer always stitches the edges of the bladder incision to
the sheath of the rectus on either side by a strong catgut suture.
A large drainage tube is then introduced (f to 1 inch in diameter),
and the edges of the rectus, sheath brought together by two or three
944 Adenoma of the Prostate.
catgut sutures. The skin wound is then closed by interrupted
salmon-gut sutures.
The dressing to be employed has been very much discussed,
but after prolonged trial of various methods the writer at present
finds the following method most satisfactory :
For the first twenty-four hours the urine is allowed to drain into
pads of woodwool or of cellulose, which are frequently changed. At
the end of that time most of the clots have been discharged, and a
Hamilton Irving's box is applied. This box is made of celluloid
and fits close to the skin all round the wound. From the lower
part of it two rubber tubes convey the urine into an ordinary
glass urine bottle lying between the patient's thighs.
The box is kept in position by means of an elastic belt round
the waist, and two perineal tapes passing round each thigh
prevent the box slipping up upon the abdomen. The box is
removed once or twice a day for cleansing. Before applying the
box the whole wound and the skin around are thickly coated with
an ointment composed of 30 gr. of zinc oxide to 1 oz. of sterile
lanoline. If this is applied twice a day the skin is kept in per-
fectly good condition, notwithstanding the fact that urine is in
contact with it until the supra-pubic wound closes. The wound
must be stitched tightly and the stitches must not be removed
until the wound is quite solid, or the pressure of the box will
cause some gaping, and healing will be a little delayed.
A little care and attention should be exercised in fitting the
box to the patient. If this is done, the patient is kept perfectly
dry and comfortable throughout the whole period of convalescence.
The bladder should be thoroughly irrigated by passing a large
catheter down the supra-pubic tube. The writer prefers, if possible,
not to pass a catheter through the urethra until ten to fourteen
days have elapsed. The danger of epididymitis is thus lessened.
Complications. (1) Cystitis. If a very purulent cystitis is
present it is wise to do the operation in two stages. A median
supra-pubic cystotomy is performed and a large tube is inserted,
no attempt being made to remove the prostate. Through this
tube the bladder is thoroughly irrigated two or three times a day,
urinary antiseptics being given by the mouth, and forced hydro-
therapy instituted by causing the patient to drink large quantities
of water, barley-water, milk and soda-water, and so forth.
It is surprising how marked is the improvement in both the
local and general conditions in a very short time after the drainage
has been performed. It gives rest to the bladder. The patient
is not disturbed at night by innumerable calls to micturate either
Adenoma of the Prostate. 945
in forced driblets naturally or by the catheter. He sleeps, eats,
and feels a different man. In ten days or a fortnight the wound
in the wall of the abdomen has consolidated around the central
fistula, and through this orifice, which only needs dilatation by
the finger, the enucleation of the prostate can be carried out.
Many seemingly desperate cases can be converted by this pre-
liminary drainage and hydrotherapy into quite favourable cases
for prostatectomy.
Very few cases need now be refused prostatectomy, however
septic they may appear, provided this preliminary treatment is
carried out and one feels satisfied that pyelonephritis is not
present. We are satisfied that this procedure has reduced the
mortality of the operation by at least 5 per cent.
(2) Haemorrhage. Severe bleeding occurring during or at the
close of the operation has already been dealt with. In a small pro-
portion of cases secondary haemorrhage occurring from a few days
to a week or ten days after operation is an alarming complication.
If it cannot be stopped without much delay by the use of copious
hot irrigation and the hypodermic administration of T ^Q gr. of
ergotin, together with raising the foot of the bed on high blocks,
the prostatic cavity should be packed with gauze, as already
described. This can be rapidly performed either under nitrous-
oxide gas anaesthesia, or even without an anaesthetic. The gauze
is removed in twenty-four to forty-eight hours. The writer has
never known a recurrence of the haemorrhage.
(3) Failure of Closure of the Supra-pubic Fistula. If the
enucleation has been complete the fistula very rarely fails to
close. In over four hundred cases the writer has only found
occasion in two cases to excise the wound and stitch the bladder
and abdominal wall.
In a small proportion of cases, where the general vitality is low
and powers of healing are bad, it will be found necessary to pass
a catheter into the bladder by the urethra and tie it in for a few
days, so as to drain the bladder by that channel and keep the
fistula dry. The fistula can be stimulated by the application of
solid silver nitrate.
(4) Epididymitis occurs in about 10 per cent, of all cases. It
very rarely goes on to suppuration, and should be treated by sus-
pension of the testicles and the application of the usual remedies.
(5) Formation of Calculus in the Bed of the Prostate.
Phosphatic calculi sometimes form in the cavity left by the
removal of the prostate. They can be removed either by
re-opening the bladder through the supra-pubic scar, or by a
S.T. VOL. n. 60
946 Adenoma of the Prostate.
median perinea! lithotomy (see section on Vesical Calculus). If
the latter method is employed, great care must be taken to injure
the compressor urethras as little as possible, for after supra-pubic
prostatectomy this muscle is practically the only sphincter that
the bladder possesses.
Prognosis. Prognosis as regards restoration of function is
extremely good. If the operation is properly performed (i.e., if
enucleation is complete), an absolute dependence upon the catheter
for from ten to twenty years before operation is followed by easy
and natural and complete emptying of the bladder. The objection
that the bladder muscle lost its tone as the result of long-continued
catheterism has thus been completely disproved.
Advanced age is no bar to operation ; if it were, the operation
would be seldom performed. Aged men who are otherwise
healthy bear the operation remarkably well. In the writer's
practice the earliest age at which the operation was performed
was forty-nine and the oldest ninety-four.
The death-rate of the operation may now be said to be about
stationary. In 352 cases operated upon at St. Peter's Hospital in the
past five years the mortality fairly attributable to the operation
has been 7'9 per cent. These cases were in no sense " selected."
Many of them were in an excessively feeble and septic condition,
worn out by years of suffering. If none but selected cases were
taken the mortality would be less than 2 per cent.
Perineal Prostatectomy. Prostatectomy by the perineal
route has -been a favourite operation upon the Continent and in
the United States of America for many years, but it has never
gained any great measure of support in this country. The
operation is undeniably a very successful procedure, but it demands
much greater skill and the possession of more surgical technique
than supra-pubic prostatectomy. Many different methods of per-
forming the operation have been employed, but the operation now
to be described combines the best features of various procedures,
and with the exception of a few trifling technicalities favoured by
various operators it may be considered the standard perineal
prostatectomy now in vogue.
The Operation. The patient is placed in the exaggerated litho-
tomy position, and a solid metal staff is introduced into the bladder.
An inverted V incision is made in the perineum, the apex of the
V lying just behind the bulb, and the two limbs extending backwards
on either side to a point midway between the anus and the tuber
ischii on either side. When the wound gapes the perineal raphe
is seen passing from the anus behind to the bulb in front. This
Adenoma of the Prostate. 947
raphe contains some bundles of muscles known as the recto-
urethralis. It is picked up in forceps and divided with scissors.
The pre-rectal fat immediately bulges in the wound, and the
space between the rectum and the prostate is opened up. This is
called by the French the espece decollable, a very apt description,
as it can be cleared by the finger and forceps, no cutting being
required. The fat is now cleared away from the membranous
urethra and the capsule of the prostate, great care being taken to
avoid injuring the rectum. A suitable broad retractor can be
placed in front of the rectum, pulling it back towards the sacrum.
A small incision is now made in the urethra just behind the bulb,
through which Young's prostatic tractor is introduced into the
bladder, and the blades widely opened. By pulling upon the
tractor the prostate can be dragged almost up to the level of the
perineum. The capsule is now carefully cleaned of fat, and large
veins are pushed out of the way. Two incisions are made through
the capsule, one on either side of the middle line, converging from
above downwards. Hugh Young advises this mode of incision to
avoid injuring the common ejaculatory ducts which pierce the
prostate, converging to empty into the sinus pocularis on the
floor of the prostatic urethra. The two lateral lobes of the
prostate are then enucleated by the finger, aided by the handle
of the scapel or a periosteal elevator. An attempt is made to
avoid injuring the urethra, but the writer must confess that he
has never been able to satisfy himself that in cases where the
growth is large it is possible to avoid tearing through the mucous
membrane. When there is a large intra-vesical projection, he
believes it to be an impossibility.
The enucleation being complete, the cavity is well flushed with
hot saline solution, the tractor is withdrawn, and a larger soft
catheter introduced through the wound of the urethra into the
bladder and stitched in. This tube must have a large lumen or
it will be blocked by blood clot. The small incision in the
urethra just behind the bulb is now closed by two or three catgut
sutures. The cavity whence the prostate has been removed is
lightly packed with gauze and the skin closed by salmon-gut
sutures, but not tightly, as some drainage is to be expected.
Ajtcr-tn'iitiin'nt. The after-treatment is very simple. The
bladder should be washed out once or twice a day with mild
antiseptic lotions.
The gauze plugging is removed in forty-eight hours, and the
cavity re-plugged less and less firmly each day until it has con-
tracted and closed by granulation.
602
948 Adenoma of the Prostate.
Hugh Young uses a two-way tube, and employs continuous
saline irrigation of the bladder for thirty-six to forty-eight hours.
The gauze packing is removed on the second day and no more
applied, and the tubes are removed also within forty-eight hours.
No sounds are passed, and the patient can usually be placed in a
chair within four days of operation.
Plenty of fluid should be given by the mouth, and urotropin
should be given from the start.
Most of the urine is passed by the perineal wound for some days,
and absolute incontinence is often present for some days also.
Permanent incontinence is a danger if great care is not taken to
avoid injury of the compressor urethras muscle.
Complications. Injury to the rectum with formation of a
rectal fistula is the most dangerous complication. It should be
avoided if great care is taken to pull the rectum well back and to
identify all parts of the field of operation before commencing the
enucleation. A careful examination of the anterior wall of the
rectum should be made before the wound is closed, and if any
tear is detected it should be closed immediately by catgut sutures.
The gauze packing of the cavities should be done deliberately,
and should not press on the rectum in the recto-prostatic
space.
Haemorrhage. Bleeding is usually free but easily controlled.
If secondary haemorrhage occurs it can be controlled by replacing
with gauze.
Advantages of the Operation. This operation possesses two
great attractions. Firstly, all drainage conforms to the usual
requirements of surgery, being in the dependent position.
Secondly, the patients can be got out of bed very much earlier
than in the case of supra-pubic prostatectomy.
Disadvantages of the Operation. Firstly, it takes con-
siderably longer to perform than the supra-pubic operation.
Secondly, the technique required is of a much higher order, and
more difficult to acquire. Thirdly, in the case of very large
prostates, it is impossible, in the writer's opinion, to avoid serious
damage to the neck of the bladder and to the compressor urethrae,
resulting in a small proportion of cases in permanent incon-
tinence.
Conclusions. - The mortality of the two operations being
about equal in skilled hands, this point need not trouble us in
making our choice. For all adenomata of large size the* writer
unhesitatingly recommends supra-pubic prostatectomy. For
moderate-sized growths it may very well be left to the personal
Adenoma of the Prostate. 949
preference of the operating surgeon. For small adenomata the
writer believes that the supra-pubic route will be found the better,
as it is much easier to be quite certain that no growth is left
behind than by the perineal operation.
JOHN PARDOE.
950
FIBROUS ENLARGEMENT OF THE PROSTATE.
THERE is found, in a small proportion of cases of difficult mic-
turition and retention of urine, a form of enlargement of the
prostate which is hardly in the nature of a new growth. To this
the term fibrous enlargement is given.
The prostate, when examined per rectum, is not very large ; it
is firm, smooth, and painless.
The cystoscope shows a slight, collar-like elevation of the
internal meatus all round its circumference, and the lumen of
the prostatic urethra is often so much narrowed that it is difficult
to pass any but a small catheter. These are the cases in which the
operation of Bottini or of Freudenberg, where cuts are made in
the neck of the bladder by means of the galvano-cautery pros-
tatome, met with much success.
This operation has been practically abandoned as considerable
mortality attended it, and quite equally good results can be
obtained by much safer methods.
Three operations are now chiefly practised : (1) Supra-pubic
prostatectomy ; (2) perineal prostatectomy ; (3) perineal pros-
tatotomy.
The first two operations follow the lines of the procedures
already described ; but enucleation is impossible, and a piecemeal
excision must be done.
In attempting to enucleate these prostates with the finger
supra-pubically the writer has seen much damage done to the
neck of the bladder, resulting in stricture and great trouble in
after-life.
Perineal Prostatotomy. In the writer's opinion this is the
operation of choice for this limited class of case.
A median grooved staff is passed into the bladder with the
patient in the lithotomy position, and a small median perineal
incision is made into the urethra immediately behind the bulb.
A long gorget is then run along the groove of the staff into the
bladder, dilating the compressor and the prostatic urethra. The
staff is withdrawn and the finger introduced along the gorget.
Very considerable force is often required to introduce the finger
in these cases, as the neck of the bladder is so tightly contracted.
The gorget is now withdrawn and the forefinger of the left hand
Fibrous Enlargement of the Prostate. 951
is passed into the rectum. The mucous membrane on the floor
of the prostatic urethra is split by the finger-nail, and the whole
ring of the prostate is then split in a backward direction by the
finger in the urethra working against the finger in the rectum until
the neck of the bladder is quite free and loose and the finger
passes in and out quite easily. As large a perineal drainage tube
as the passage will take easily is now stitched in and the patient
returned to bed. The tube can be removed in two or three days,
and the patient can then be allowed to get up and move about
freely.
Very often there is complete incontinence for some days after
the removal of the tube ; but this soon ceases, and the patient not
only retains but is also able to void his urine completely. The
permanence of this operation is beyond doubt, for the writer has
patients now alive and well who were operated upon by this
method more than ten years ago, being then in a condition
requiring the constant and frequent use of the catheter.
JOHN PARDOE.
952
DISEASES AND AFFECTIONS OF THE
BREAST.
CYSTS.
MAMMARY cysts may be divided into the following' groups :
(1) Simple solitary cysts, irritation acinous cysts, serous inter-
acinous cysts ; (2) multiple cysts associated with chronic interstitial
mastitis, so-called involution cysts; (3) galactoceles ; (4) hydatid
cysts; (5) cystic tumours, cyst-adenoma, "cystic sarcoma," cysts
connected with duct papilloma and duct carcinoma.
Simple Cysts. The most satisfactory treatment is excision of
the cyst, for although tapping and injection with pure carbolic
may bring about a cure, the result is uncertain. Moreover, an
apparently simple cyst may be associated with a growth.
The incision is made directly over the cyst, which is then
enucleated, if this can be done easily. Should there be any
difficulty in separating the cyst from the glandular tissue, a portion
of the latter should be excised with the cyst, for otherwise the cyst
is liable to be opened and a part of its wall may be left behind.
The walls of the cavity resulting from removal of the cyst are
brought into apposition by buried catgut sutures, the skin edges
are stitched, and a drainage tube is inserted for twenty -four hours.
In all cases the walls of the cyst and the surrounding mammary
tissue should be examined microscopically.
If for any reason excision of the cyst is impossible, a cure may
be attempted by withdrawing the fluid from the cyst and allowing
3 or 4 drops of pure carbolic acid to run in ; the swelling is then
gently massaged and a firm bandage is applied. The inflammation
excited by the carbolic acid may be sufficient to cause obliteration
of the cyst, but the method is uncertain and recurrence is common.
Multiple Cystic Disease. This disease often affects both
breasts, and is the result of chronic interstitial mastitis, usually in
patients over forty years of age.
Clinically a single cyst only may be apparent, and it is important
to warn the patient that other cysts may be discovered which
will necessitate removal of the main part of the breast ; permission
should be obtained to do whatever may be found necessary.
Operation should always be recommended in these cases for the
Cysts of the Breast. 953
following reasons : (1) There must always be an element of doubt
as to the diagnosis ; carcinoma may co-exist with cysts ; (2) the
disease is usually progressive until the breast becomes a mass of
cystic swellings and a cause of anxiety to the patient, which must
tell on her general health ; (3) some authorities believe that carci-
noma is more likely to develop in a cystic breast than in a
normal breast : this is a matter of doubt, but doubt is an argument
in favour of operation.
Operation. An incision is made over the cyst, which is then
excised with a layer of the surrounding breast tissue ; the latter
will be noticed to be unusually hard but of uniform consistence,
which is quite distinct from the consistence of growth. The cyst
is usually recognisable as such from its blue surface, and incision
into it is unnecessary. The surrounding breast tissue is carefully
examined, and in many cases one or more other cysts become
apparent ; in these cases the wisest course is to remove the main
mass of breast tissue. This can be done through a comparatively
small incision ; the nipple is, of course, left undisturbed, and the
periphery of the breast, which very rarely develops cysts, is also
untouched. Bleeding should be arrested as far as possible, and
a drainage tube is inserted for twenty-four to thirty-six hours ; firm
pressure is applied, and this is most effectually done by the use of
elastic-cotton bandages. Sometimes it is wise to approximate the
cut surfaces of the gland with catgut sutures.
In my experience this proceeding will remove the whole of the
cystic area, and the results are excellent ; comparatively little
deformity is left, especially compared with that of the ordinary
formal amputation.
If open operation is contra-indicated or is refused by the patient,
the cysts may be tapped and injected as they arise. This proceeding
is unsatisfactory ; it has to be repeated from time to time, and there
is no sense of security or cure.
Complete amputation of the breast may be necessary when the
whole of the breast is extensively involved.
Galactocele. A galactocele is a cyst containing inspissated
milk, which arises during lactation and occasionally during
pregnancy. Treatment should not be instituted until lactation has
ceased.
If the cyst is small, it may be treated by gentle massage daily,
after which the breast is firmly bandaged. In all other cases
excision is the most satisfactory treatment, and usually the cyst
shells out quite easily. Tapping and injection rarely do any good.
An alternative but less satisfactory method of treatment is to lay
954 Duct Papilloma.
the cyst freely open, scrape its walls thoroughly, and stuff the cavity
with gauze.
A suppurating galactocele should be treated as an ordinary
abscess.
Hydatid Cysts are rare in this country ; they should be treated
by excision.
Cysts with Intra-cystic Growths. These cysts are of the
nature of cystic adenomata and duct papillomata, and should be
treated as such. Excision of the breast is usually advisable, and if
there is any suspicion of infiltration of the cyst wall by the growth,
the radical operation should be performed.
T. CRISP ENGLISH.
DUCT PAPILLOMA.
A SMALL duct papilloma may be excised locally, care being taken
that the incisions are carried well free of the growth.
In the majority of cases it is wiser to amputate the breast, for
this tumour must be regarded as a pre-cancerous condition, and the
full operation will ensure a certain cure. Amputation of the breast
for innocent tumours is a simple operation.
T. CRISP ENGLISH.
955
FIBRO-ADENOMATA OF THE BREASTS.
VEKY small fibre-adenomata may be left undisturbed if giving rise
to no symptoms. Otherwise removal of these tumours should be
recommended for the following reasons : (1) Neuralgic pain
develops in connection with most of the tumours, and this,
combined with the knowledge of the presence of a tumour, may
materially affect the patient's general health ; (2) if the patient
marries and becomes pregnant, considerable increase in the size
of the tumour occurs during pregnancy and lactation ; (3) slow
but steady growth, unaffected by any treatment, is th'e rule in these
cases, and ultimately visible deformity may result ; (4) occasionally
a tumour, thought to be an innocent fibro-adenoma, proves to be an
early sarcoma or carcinoma: I have seen two such cases in patients
under thirty years of age ; in elderly patients the difficulty of
positive diagnosis is obviously greater ; (5) it is possible that in the
course of time a fibro-adenoma may prove the starting-point of a
malignant growth.
For these reasons, if a patient discovers that she has a mammary
tumour, it is for her best interests that the tumour should be
removed, and that she should understand that the tumour is
innocent and non-recurring. Both breasts should be carefully
examined, for other small tumours may be present, in addition
to the one to which attention has been drawn ; if so, these should
be removed at the same time.
Outward applications, X-rays and the administration of drugs
have not the slightest effect on fibro-adenomata.
Operation. A full general anaesthetic should be given, unless
contra-indicated ; attempts to remove the tumour under nitrous
oxide often result in hurried and imperfect operations. Local
anaesthesia may be employed, if a general anaesthetic is contra-
indicated.
The incision should usually be made directly over the tumour in
a line radiating from the nipple. If the tumour lies above the
nipple and it is desired to place the scar as low as possible, the
incision may be made 1 inch or more below and to the outer side
of the tumour ; the skin above the incision is dissected up until
the tumour is reached.
AYith a few touches of the knife the tumour is then isolated from
956
Fibro- Adenomata.
the surrounding mammary tissue, care being taken that no small
lobule is left behind, for this would lead to a recurrence. If there is
any difficulty in separating the tumour, it is best to remove a zone of
the surrounding glandular tissue with it. All bleeding points should
be dealt with. The cavity is then carefully closed with sutures
passed deeply, so that it is as far as possible obliterated. When the
tumour is deeply placed in the breast, it is advisable to insert a
small drainage tube, a suture being placed on each side of the tube
and not tied until the removal of the tube twenty-four hours after
the operation (Fig. 1). Unless a tube is inserted, blood clot
tends to collect in the wound and may interfere with healing.
The patient should, if possible, remain in bed for three or four
days, the arm being kept at rest
with a sling. Sutures should
be removed on the sixth or
seventh day. If the wound is
a long one and placed horizon-
tally, it should be supported
with strapping or gauze and
collodion, for otherwise the
weight of the breast may
cause it to gape after the
stitches have been taken out.
Guillard Thomas's operation
was devised for the purpose of avoiding a scar in the
upper part of the breast. A large incision is made in the
submammary fold, and the breast is dissected up from the
pectoral fascia; the tumour is reached by incision through
the breast tissue from its deep aspect. All bleeding is carefully
stopped, and the wound is drained for twenty-four hours ; the
resulting scar lies in the submammary fold and is unnoticeable. In
practice it is found that this procedure often involves a large and
troublesome operation for a small tumour. It is almost always
possible by direct incision from the front to place the scar so that
it does not interfere with the wearing of evening dress.
FIG. i.
T. CRISP ENGLISH.
957
HYPERTROPHY OF THE BREASTS.
THIS affection is usually bilateral. In moderate degrees of the
condition some good may be done by firmly supporting the breasts
with elastic bandaging, by the application of mercurial ointment,
and by the internal administration of full doses of iodides ; under
this treatment the hypertrophy is sometimes arrested, and there
may even be some diminution in the size of the breasts.
Many cases of so-called hypertrophy of the breast are really cases
of diffuse adenomatous tumours, for which the only treatment is
excision ; when the nature of the condition is recognised, it is some-
times possible to remove the tumours without sacrificing the breast.
In marked cases of true hypertrophy of the breast, the only
treatment available is amputation, and this is justifiable when the
enlargement is so great as to cause great discomfort and disfigure-
ment. There is no particular difficulty about the operation as a
rule ; haemorrhage may sometimes be troublesome, especially from
large superficial veins. As far as possible, vessels should be secured
before division.
T. CRISP ENGLISH.
958
INFLAMMATORY AFFECTIONS OF THE BREAST.
PAINFUL engorgement of the breast is not uncommon during the
first few days of lactation, and is usually the result of inefficient
suckling. A large fomentation should be applied to the breast,
which should be firmly supported
by a bandage ; if necessary, the
breast-pump may be used to
relieve the tension, after which
efforts must be made to induce
the infant to efficiently empty
the breast, if suckling is to be
continued.
When inflammatory signs
appear, prompt measures should
be taken to prevent the forma-
tion of an abscess. Any cracks
or fissures of the nipples should
be treated vigorously. Hot
fomentations should be applied
every three hours, and a firm
bandage should support the
breast and fix the arms ; a brisk
purge should be given at once,
and any undue tension in the
breast should be reduced by the use of the breast-pump.
Poultices should not be used, for they make asepsis difficult if an
incision for an abscess becomes necessary.
Mammary Abscess Prophylaxis consists in the proper atten-
tion to the nipples and the breasts, and especially in the thorough
treatment of cracks and fissures of the nipples.
A mammary abscess should be opened as early as possible ; the
results of delay are extensive destruction of breast tissue, the forma-
tion of sinuses, and a tedious convalescence. In the worst cases in
which an abscess has been allowed to burst through the skin
amputation of the breast often becomes necessary.
There may be some difficulty in deciding whether an acute
mastitis has led to the formation of pus. The following symptoms
FIG. 1.
Inflammatory Affections of the Breast. 959
indicate the presence of pus, and justify incision : (1) Insomnia ; (2)
fixation or cedema of the skin over the inflamed area ; (3) continued
rise of temperature ; and (4) failure of the inflammation to resolve
under the treatment described for mastitis.
The incision should be free, and should be placed over the lowest
part of the abscess ; if it passes through breast tissue, it should
radiate from the nipple to avoid division of the main ducts. Its
exact position depends upon the situation of the abscess, and the
annexed diagrams show the best
positions for incisions (Figs. 1
and 2).
Most mammary abscesses are
multi-locular ; therefore, as soon
as the abscess is opened, a finger
should be introduced and the
walls between the loculi should be
broken down, so that a single
open cavity is made. This cavity
should not be scraped, rubbed with
gauze, or irrigated. A large
drainage tube is inserted ; one
f inch in diameter is best, but if
this is not available, two smaller
tubes may be used ; tubes are best
retained in position by stitches.
A fomentation of gauze is then
applied. The fomentation is re-
applied two or three hours later,
and should be repeated every three
hours during the first two days ;
after this the dressing is changed two or three times a day according
to the amount of discharge. It is sometimes advisable to excise a
portion of the breast tissue to ensure a free opening into the abscess
cavity, and in neglected cases several incisions may be necessary.
The breast should be well supported by the bandage, and the arm
should be placed in a sling in order to rest the pectoral muscles.
The patient is propped up in bed to encourage free drainage ; diet
should be light and fluids should be restricted. Free action of the
bowels is important, and regular doses of magnesium sulphate
may be given. The tube is gradually shortened as the discharge
diminishes, and later is replaced by a plug of gauze.
During convalescence attention must be paid to the general
health. Good food, plenty of fresh air and tonics are of importance ;
FIG. 2.
960 Inflammatory Affections of the Breast.
iron, quinine, nux vomica and purgatives are useful. If progress
is slow, the patient may be sent to the seaside.
An alternative line of treatment is that by Bier's vacuum cups ; a
comparatively small incision is made into the abscess, and a vacuum
cup is applied to the incision three times a day. It is claimed that
more rapid healing occurs with this proceeding. (For details see
Bier's Treatment by " Hyperaemia," Vol. III.)
Mastitis in Infants. Fomentations should be applied, and an
incision must be made at once if there are signs of suppuration, for
otherwise a general infection is apt to occur.
Mastitis at Puberty. A mild form of mastitis is not uncommon
at puberty, and occasionally terminates in suppuration. It should
be treated on the lines already described. Irritation by corsets or
by brace-buckles should be avoided.
Supra-mammary Abscess. This is usually due to infection of
a superficial lobule of the mammary gland, and should be treated
by free incision.
Infra-mammary Abscess. This affection shows itself by for-
ward projection of the breast, and by oedema or fluctuation at its
periphery, usually at the lower and outer aspect. Most of the
cases are chronic and of tuberculous origin, the result of tuberculosis
of an underlying rib.
An acute abscess should be opened freely from the lower and
outer aspect of the breast; if drainage is efficient, rapid healing
usually follows.
A chronic tuberculous abscess should be approached from the
same region, and should be treated like other tuberculous abscesses.
In most cases drainage must be established, and rest of the neigh-
bouring parts by fixation of the arm and firm support of the breast
is essential. When a rib is diseased, it may be necessary to
excise the affected portion. In this case the incision is enlarged
and the breast is reflected upwards in order to expose the diseased
bone.
Persistent Sinuses. It sometimes happens that sinuses follow
a mammary abscess and show little sign of healing. This is
usually evidence of poor general health, or of inefficient treatment
and drainage of the abscess.
The sinuses should be freely opened up. The walls of each sinus
are then thoroughly scraped or excised, and the parts are swabbed
with pure carbolic, the excess of the acid being washed away with
boracic lotion ; gauze plugging is then firmly inserted.
Treatment of the general health by fresh air, abundance of nutri-
tious food and tonics is essential. Vaccines may help in these cases :
Inflammatory Affections of the Breast. 961
the vaccine should, if possible, he prepared from the actual organisms
found in the sinus.
In long-standing cases, where the sinuses are many and indurated,
amputation of the breast may be necessary. The operation needs
careful performance ; as little skin as possible should be sacrificed,
and free drainage should be established, especially as union of the
skin flaps is often unsatisfactory.
Chronic Lobar Mastitis. This affection involves one or two
lobes of the breast only, and is seen most often after lactation as
the result of imperfect involution. It also follows injuries and the
irritation of ill-fitting corsets.
Treatment consists in the removal of any source of irritation and
the application of a belladonna or mercurial plaster. Rest is also
secured by wearing the arm in a sling. If the condition is very
painful a blister should be applied, and may be repeated if neces-
sary. Attention should always be paid to the patient's general
health. Excision of the affected portion of the breast should be
recommended, if these measures fail to cause improvement.
The effect of ill-fitting corsets in producing a chronic traumatic
mastitis has been drawn attention to by Mr. G. Lenthal Cheatle. 1
In the cases described by him the mastitis was found in the lower and
outer part of the breasts, usually on both sides, and was obviously
due to the irritation of the stay-bones or steels when the patient
bends forward or laterally. This condition may be prevented and
cured by the wearing of properly made corsets.
Chronic Interstitial Mastitis (Chronic Lobular Mastitis).
This form of mastitis occurs chiefly in women between forty and
fifty years of age, and often affects both breasts.
Treatment varies considerably in different cases. In mild cases
it is sufficient to order gentle rubbing with belladonna liniment,
and to see that the breasts are well supported by the corsets.
Ill-fitting corsets are often responsible for the condition. In more
marked cases the breast should be strapped with mecurial plaster,
and iodides and iron should be administered internally. Treatment
by X-rays is recommended by Mr. Sampson Handley. 3
In obstinate cases in which the condition is extensive and causes
the patient much pain and worry, the wisest course is to excise the
affected portion of the breast. This can be done through a 8-inch
incision in the lower part of the breast, the nipple and the periphery
of the breast being spared. Some authorities recommend that the
breast should always be excised in these cases, on the grounds that
the condition is pre-cancerous. It is, however, very doubtful whether
chronic mastitis renders a breast more liable to malignant disease.
S.T. VOL. ii. 61
962 Inflammatory Affections of the Breast.
Chronic Mammary Abscess occurs occasionally during preg-
nancy, and more often during the latter part of lactation or after
weaning. The possibility of a tuberculous, origin should always be
remembered. The abscess cavity should be freely laid open, its
walls thoroughly scraped, and the cavity should be packed with
gauze and be allowed to heal from the bottom.
Convalescence may be considerably shortened by excision of the
walls of the abscess. The resulting cavity is swabbed out with a
1 in 1,000 solution of mercuric chloride or 1 per cent, formalin,
and is freely drained.
T. CRISP ENGLISH.
REFERENCES.
1 Cheatle, G. Lenthal, " Chronic Traumatic Mastitis," Brit. Med. Journ.,
1911, L, p. 492.
2 Handley, W. Sampson, Practitioner, 1910, LXXXIV., p. 463.
963
MALIGNANT DISEASE OF THE BREAST.
INDICATIONS FOR OPERATION.
IN many cases it is at once clear that operation is the only
practicable course ; in others it is equally certain that operation
would be futile or even harmful. But there are a large number of
border-line cases in which it is exceedingly difficult to say whether
or not an operation should be advised.
Operation should always be urged as early as it can be arranged,
unless there is some definite centra-indication in the local or
general condition. Under no circumstances should the medical
attendant consent to a policy of delay or to the trial of any non-
operative measure when operation offers a reasonable chance of
eradicating the disease.
Results of Operative Treatment. About 70 per cent, of the
cases which come under observation are suitable for the radical
operation, and with earlier recognition of the disease this pro-
portion is increasing.
Surgeons who have practised the radical operations are agreed
that permanent cure follows in 40 to 50 per cent, of the cases.
The most careful investigation has been made of the after-results
of the cases operated upon by Professor Halsted in the Johns
Hopkins Hospital. These results emphasise how much can be
done by thorough operating :
Well for
Permanent
Per cent.
Per cent.
Axillary glands not affected microscopically
85
74
Axillary glands affected ......
31
24
Supra-clavicular gland* removed and found affected
10
7
The mortality of the operation in this series of cases was
2 per cent., but in the later cases less than '8 per cent. ; when the
supra-clavicular glands also were removed, the mortality was
3 per cent. Local recurrences after the radical operation were
only met with in 10 per cent, of Professor Halsted's cases, and
were never seen after the lapse of three years.
612
964 Malignant Disease of the Breast.
The prognosis depends upon many factors : the nature, situation
and extent of the growth, the age and physical condition of the
patient. The figures quoted above show that no factor is of more
importance than the condition of the axillary glands ; when they
were unaffected, three patients out of four were cured, but when
they were found to be diseased, only one patient out of four was
saved. There could be no stronger argument than this in favour
of operation at the earliest possible date.
Certain local conditions obviously negative any attempt at a
radical operation. These are : (1) Fixation of the growth to the
chest wall ; (2) extensive implication of the skin, either in the
form of widely scattered nodules, or of extensive brawny infil-
tration "cancer en cuirasse " ; (3) definite lymphatic oedema of
the arm ; (4) implication of the axillary vessels and nerves ;
(5) deposits in the viscera or bones ; (6) extensive involvement of
the supra-clavicular glands.
Enlargement of the Supra-clavicular Glands is usually, but
not necessarily, a contra-indication to the radical operation. As
a rule, when the disease has reached the supra-clavicular glands
and their enlargement is palpable, there is already growth in the
mediastinum or in other inaccessible parts, so that operation is
futile. When the glandular enlargement takes the form of a fixed
mass dipping down behind the sterno-mastoid, operation is quite
useless ; removal of the mass is exceedingly difficult, if possible at
all, and there is always further disease out of reach. On the other
hand, when the glands are only slightly enlarged and are not fixed,
it may be possible to eradicate completely the disease. Eemoval
of these glands often proves quite easy, and it may happen that
there are no other glands involved.
Each case must, therefore, be considered on its merits. It is
obvious that glands are palpable at an earlier date in those who are
naturally thin, whereas palpable glands in those who are very stout
usually mean that the disease in the neck is advanced and
beyond complete removal. It should also be remembered that
the enlargement of glands is not necessarily , malignant ; slightly
enlarged and movable glands often prove to be free of growth.
Atrophic Scirrhus is thought by some surgeons to be unsuit-
able for operation, on the ground that the course of this type of the
disease is usually very slow. The majority of patients with
atrophic scirrhus, however, ultimately die from internal deposits ;
many of them suffer from a great deal of local pain and discom-
fort, and the knowledge that they have a tumour of the breast is a
constant source of mental distress. Moreover, these tumours,
Malignant Disease of the Breast. 965
which are apparently atrophic, may suddenly take on rapid
growth, and they then soon become irremovable.
On the other hand, thorough operation offers these patients a
particularly good chance of permanent cure, and it at once relieves
the local symptoms and mental distress. There may be some
obvious contra-indication to operation, such as visceral disease or
advanced age of the patient, but most of the patients suffering
from atrophic scirrhus would not be considered too old for
operation if the growth were of the ordinary type.
Therefore, cases of atrophic scirrhus should be submitted to
early and thorough operation, unless the patient is very old or
very feeble, or unless there is some other definite contra-indication.
Carcinoma of both Breasts obviously presents a serious
prognosis, but does not necessarily contra-indicate operation. The
question may be decided in the following way : Each breast should
be considered by itself, and a decision should be made as to whether
operation would be advised for the disease in that particular
breast, if the other breast were not affected ; if one can answer in
the affirmative as regards each breast individually, then operation
for both sides should be recommended.
If operation is decided upon, the best plan as a rule is first to
deal with the more seriously affected breast, and then to allow a
fortnight or so to elapse before the other breast is removed ; in this
way a more thdrough and complete removal of the disease is
possible than if both sides are dealt with at once. In fact, it is
doubtful whether, under any circumstances, it is justifiable to
perform the radical operation on both breasts on the same
day.
Pregnancy is a grave complication in mammary cancer, but it
should never be made a reason for postponement of operation. In
considering the question of treatment, two main facts present
themselves : The fearful rapidity with which mammary cancer
grows during pregnancy and lactation, and the risk of miscarriage
after the necessarily extensive operation. The case should be
treated exactly as if the pregnancy did not exist ; delay means rapid
increase in the growth, and probably early death. Moreover, there
is still the liability to miscarriage or non-survival of the child. On
the other hand, the risks of miscarriage after operation are not great.
I have several times operated on these cases without disturbance of
pregnancy. If the patient is in the last month of pregnancy,
labour should be induced at once, and the growth should be removed
a short time after.
The Age of the Patient is a factor of importance. In young
966 Malignant Disease of the Breast.
subjects, the prognosis is grave. As a rule, the growth spreads
rapidly, and visceral deposits are often present when the case first
conies under observation ; for this reason, a very searching
examination is imperative before the complete operation is decided
upon.
In very old patients say those over seventy years of age many
points must be considered before a decision is reached as to the
extent of operation, if any. An estimate should first be made of
the patient's practical age, for a patient is often, for surgical pur-
poses, much younger or older than the actual number of years she
has lived. Therefore, a thorough general examination should be
made, especial attention being paid to the condition of the heart,
lungs, arteries and urine. An estimate should also be made of the
rate at which the tumour is growing, and the length of time which
is likely to elapse before the patient dies if no operation is per-
formed. Accuracy in a matter of this kind is obviously impossible,
but with care and experience an approximate result may be obtained.
Usually, carcinoma grows very slowly in old subjects, and soine T
times it is obvious that the patient is more likely to die from other
causes before the growth is sufficiently advanced to cause more
trouble or to kill her.
In patients over seventy it is usually advisable to perform a
modified operation, limiting its duration to half an hour.
Diabetes was formerly considered a centra-indication to any
extensive operation, owing to the risks of sepsis. Nowadays this
risk should be of little account ; but it is necessary to avoid as far
as possible making extensive skin flaps, as these are likely to slough.
A careful quantitative analysis of the sugar in the urine should be
made, and time should be devoted to the reduction of the amount
as far as possible by rigorous dieting and medical treatment. A
full course of alkalies should also be given, in order to minimise the
risk of coma following the operation. In fact, if possible, it is
advisable to wait until the urine is alkaline before operating.
Chronic Alcoholism and Cirrhosis may contra-indicate
operation. If operation is decided upon, the patient should be
placed under strict medical treatment for at least a fortnight. It is
often wise to modify the extent of the operation. It should be
rapidly performed, and especial care should be taken to secure all
bleeding points before closing the wound.
Chronic Bronchitis is a serious complication in stout subjects.
Acute symptoms are liable to follow the anaesthetic and the inter-
ference with the movements of the chest caused by the wound and
the bandages. Light anaesthesia and quick operating are essential.
Malignant Disease of the Breast. 967
OPERATIONS FOR MAMMARY CANCER.
(1) The Eadical Operation ; (2) Palliative Operations ; (3) Ke-
moval of " Kecurrent " Growths.
The Radical Operation. The term " radical operation " is
applied to the operation in which an attempt is made to produce a
radical cure by the removal of the whole of the disease. In former
days, this expression would scarcely have been admissible in view
of the large number of cases in which recurrence took place, but at
the present time, with more thorough methods of operating, it is
possible in a large proportion of cases completely to remove the
disease and effect a permanent cure.
Preparation of the Patient. Two evenings before the day of
operation the patient is given a hot bath, after which she is
vigorously rubbed down, so that the skin acts freely. On the
following evening the bath is repeated, the axilla is shaved, the
operation area thoroughly prepared, and a large sterilised dressing
is applied. The nurse should be given careful instructions to pre-
pare the skin over a sufficiently wide area, that is to say, from the
neck above to the umbilicus below, from the scapular line to the
opposite breast, and also the whole of the arm. Unless these
directions are given, it is likely that an insufficient area of skin will
be prepared.
The iodine method may be used for the preparation of the skin ;
it presents a special advantage, in that the preparation need not be
started until the morning of the operation, so that the patient, being
free from the discomforts of the dressings and bandages, is more
likely to sleep well during the night before operation. Early in the
morning the axilla is shaved and the dry skin of the operation area
is painted with a 2 per cent, solution of iodine in rectified spirit,
especial attention being paid to the axilla ; a dry sterilised towel is
then applied. As soon as the patient is under the anaesthetic, the
solution is re-applied.
Considerable shock sometimes follows the radical operation in
feeble subjects ; but this is seldom the case if the patient is properly
prepared, and the operation is performed with speed and care. In the
prevention of shock, the following points are of special importance :
(1) It is very desirable that the patient should have a good night's
rest before the operation, and if she is sleeping badly, a hypodermic
injection of morphia and atropine may be given on the night before
the operation ; (2) the body warmth should be carefully main-
tained throughout the operation, for a large surface is exposed ; the
lower half of the trunk and the thighs should be wrapped in wool,
968 Malignant Disease of the Breast.
and the legs should be clad in thick woollen stockings ; the operat-
ing table should be kept heated throughout, hot-water bottles being
used if the table itself cannot be heated ; the temperature of the
operating room must be watched and needless opening of doors
avoided ; (3) haemorrhage should be avoided as far as possible ;
vessels should be secured before division whenever possible, and a
large number of artery forceps should be in readiness : at least two
dozen are necessary.
An&sthetic. The choice of anaesthetic in these cases is specially
discussed in the section on Anaesthetics (see Vol. III.). Particular
care is necessary, for the extensive wound on the chest wall and the
subsequent bandaging are liable to cause pulmonary complications,
especially in stout, elderly women. After the incisions have been
made, very little anaesthetic is required, until the last stage of the
operation when the wound is sutured.
Position. The patient lies with the affected side well over the
margin of the operating table, and with the shoulders moderately
raised by a pillow, and her head turned to the opposite side. The
arm is fixed by a bandage at a right angle to the trunk. This is a
more satisfactory plan than having it held by an assistant, for the
slightest alteration in position produces disturbances in the rela-
tions of the structures in the axilla, and may mislead the operator ;
moreover, hyper-extension may give rise to pressure paralysis.
Exploration of the Tumour. Whenever there is the slightest
doubt as to the nature of the tumour, the first step should be an
exploratory incision into or on to the tumour. It has already been
pointed out that the diagnosis often presents the greatest difficulty,
and that malignant disease may be exactly simulated by innocent
conditions. The study of the records of any hospital will supply
instances of cases in which breasts have been removed for chronic
abscesses, deep-seated cysts and innocent tumours. In all doubtful
cases, therefore, a preliminary incision should be made. This
procedure has been fully discussed above.
There are two small points to remember in connection with this
exploratory incision. In the first place care must be taken to avoid
carrying the incision through the tumour into the deeper parts, for
cancer cells may thus be engrafted into the muscles of the thoracic
wall. Secondly, the knife, instruments and gloves used during the
incision into the tumour must not be employed to continue the
operation ; this seems a very obvious precaution, but is one which
is not infrequently neglected.
When a tumour has been incised and is found to be malignant,
all bleeding points should be secured, and the surface of the wound
Malignant Disease of the Breast. 969
is swabbed over with pure carbolic acid or 1 per cent, formalin ;
after which the skin incision is firmly sutured, and the complete
operation is then undertaken.
The operation may be divided into three stages : (1) The incision ;
(2) the axillary dissection ; and (3) the removal of the breast and
pectoral muscle?. In most cases it is best to dissect away the
axillary fascia arid lymphatics before the breast is removed. This
procedure has many advantages : it deals with the highest point of
possible infection first ; blood-vessels are secured early, so that sub-
sequent bleeding is less ; the large area laid bare by the removal of
FK;. 1. Incisions for radical operation. Shaded area represents position of growth.
the pectorals is exposed for a comparatively short time, and thus
shock and risk of infection are diminished.
(1) Incision. The incision is planned according to the position
of the tumour in the breast, and the annexed diagram (Fig. 1)
shows those most frequently used. The essential point in making
the incision is the inclusion of a wide area of skin in the neighbour-
hood of the growth, and this in view of the fact that otherwise
recurrences are very common in the region of the scar ; free
removal of the skin is imperative, compared with which the closure
of the wound is of quite secondary importance.
The portion of skin removed should be more or less circular, and
970 Malignant Disease of the Breast.
at least 5 inches in diameter. Its centre should correspond with
the position of the growth and not with that of the nipple ; in fact
the nipple should be ignored in the planning of the incisions.
The upper portion of the incision is carried in a curve over the
pectoralis major, so that ready access is obtained to the clavicle
above and to the upper part of the brachial artery below. The
incision should be carried well down on to the abdominal wall, so
that the fat and fascia over the lower ribs and the epigastrium may
be thoroughly removed. Only in recent years has it been recog-
nised that extension of the disease not infrequently occurs in this
direction. This is one further step in the complete operation,
and another argument against the very imperfect operations so
frequently practised.
(2) The Axillary Dissection. As soon as these incisions have
been made, the skin in the upper part is dissected up, to thoroughly
expose the upper part of the pectoralis major and the anterior
aspect of the axilla. The tendinous insertion of the pectoralis
major into the humerus is then divided transversely, a finger
placed under it raising it to avoid injury to the underlying vessels :
the main portion of the muscle is then separated from the clavicular
portion, and the insertion of the pectoralis minor is similarly
divided. Branches of the acromio-thoracic vessels running to the
under-surface of the muscles are secured, and the muscles are then
reflected downwards and inwards.
The highest portion of the axillary vein is then exposed, and the
whole of the axillary fat and fascia with the lymphatics is carefully
dissected off the main vessels from above downwards, branches of
the vessels being systematically secured before division ; a blunt
dissector is very useful at this stage, and Kelly's comb or
a gauze-covered finger is of great assistance. Nerves must be
sacrificed when they cannot be isolated easily, and when their
preservation increases risk of leaving any infected tissue behind ;
the intercosto-humeral is usually divided, but if possible sub-
scapular nerves should be spared.
The dissection includes the tissues around the upper part of the
brachial artery and about the subscapular vessels ; especial care is
needed in removal of prolongations of fascia in front of and behind
the axillary vessels and that lying over the serratus magnus, and
between this muscle and the subscapularis. In many of the more
advanced cases it will be found that infected glands are adherent to
the axillary vein, and in such cases it is useless to attempt to dis-
sect them from the vessel, for this proceeding will certainly fail to
remove the whole of the infected tissue ; a portion of the vein must
Malignant Disease of the Breast. 971
be excised after ligatures have been placed above and below the
involved area.
The dissected axillary tissues are now attached to the mammary
area only, all vessels are tied, and a cloth wrung out of hot saline
solution is inserted in the axilla.
(3) Removal of the Breast and Pectoral Muscles. The skin flaps
are now dissected up below : internally as far as the sternum,
externally to the latissimus dorsi, and below to the middle of the
epigastrium. The mass to be removed is raised, and the inner
attachments of the pectoral muscles are severed ; the perforating
branches of the internal mammary artery are encountered here
and should be secured before division, otherwise they are liable .to
retract and cause some difficulty. The whole mass is then removed,
as large an area as possible of deep fascia being included.
The wound is then flushed out with hot saline solution, and all
bleeding points are tied with fine catgut ; forci-pressure alone should
not be trusted to. Particular care must be taken in ligature of
branches of the axillary vein.
Throughout the operation hot sterilised cloths should cover
those parts of the wound on which the operator is not working at
the time.
I)raina<i<'. Drainage is provided for by an indiarubber tube
(about 2| inches long) inserted through an opening made in the skin
over the lower part of the axilla. Drainage along the line of the
incision is unsatisfactory, and often interferes with the healing of
the wound. The tube should be secured by a silkworm-gut suture.
Some surgeons recommend that drainage should not be used, but
my own experience is decidedly in its favour. When the muscles
have been extensively divided, there is certain to be a considerable
amount of oozing ; well-applied pressure will prevent this under the
thoracic portion of the wound, but it is almost impossible to apply
sufficient pressure to prevent it in the axilla. I have seen several
cases in which extensive collections of blood and serum have formed
under, the skin in cases in which no drainage has been employed.
Suture of the Woiuul. In some cases it is quite impossible to
bring the skin edges into apposition ; in most cases there will be
some difficulty, which can usually be overcome by the use of
tension sutures.
If direct suture of the wound is impossible, the gap may be left
to granulate, or it may be covered with skin-grafts, or some plastic
operation may be employed. Before the sutures are inserted, the
arm should be released and brought nearer to the side ; this
facilitates approximation of the skin edges.
972 Malignant Disease of the Breast.
Dressings. Thick layers of dressings are applied, especially over
the axilla ; sterilised wool should be packed freely over and behind
the drainage tube ; a layer is also placed over the sound breast.
The dressings are firmly fixed with bandages; elastic-cotton
bandaging is especially useful for getting firm, even pressure.
Removal of loth Pectoral Muscles is, I believe, an absolutely
essential part of the complete operation for mammary cancer. In
the first place, it is the only satisfactory way of thoroughly exposing
the upper part of the axilla ; and in the second place, removal of the
muscles means removal of portions of fascia and of small glands,
which are readily overlooked in the less extensive operations. It is
often recommended that, instead of this step being taken, the
superficial portion of the pectoralis major should be dissected off
with the pectoral fascia ; but anyone who has watched this proceed-
ing will know what an unsatisfactory one it is, especially when it is
remembered that many lymphatic vessels pass into the muscle
through the fascia, and that lobules of the mammary gland itself
may exist in the superficial parts of the muscle.
As far as I know, there are no arguments of any importance
against removal of both muscles. It is true that this step adds
somewhat to the severity of the operation ; but in the vast majority
of cases it does not involve any additional danger, which would be
a small matter compared with the importance of complete removal
of the disease. The movements of the arm are scarcely in any way
impaired after the removal of both muscles, if the correct after-
treatment is carried out.
The Axillary Glands should be removed in every case icitJtout
exception. Glands which were not palpable before operation again
and again are found to contain small deposits of growth when
examined after removal ; in stout patients, greatly enlarged glands
may be discovered which were not demonstrable before operation.
Moreover, it sometimes happens that the lower axillary glands
escape, whilst those in the apex of the axilla are infected, and these
glands are only discoverable after removal of the pectoral muscles.
The essential point to remember is that there may be an infection
of the glands which can only be detected by the microscope.
1> it rat ion of Operation. In most cases the complete operation
may be performed in fifty to sixty minutes. The operator should aim
at speed and avoid haste. Particularly should there be no haste
in the clearance of the axilla, for if one particle of disease is over-
looked, the whole operation is rendered futile.
After-tri'dtincnt. As soon as the patient has recovered from the
anaesthetic, she should be set up in bed with 'the arm of the affected
Malignant Disease of the Breast. 973
side fixed on pillows at a right angle to her body. Should there be
much pain, an injection of morphia may be given in the evening,
and be repeated during the night if necessary.
A variable degree of " shock " follows the operation. There is no
doubt that much of the so-called " shock " is dependent upon blood
lost during and after operation ; for this reason, as has been
pointed out above, the loss of blood must be kept to a minimum by
securing vessels before they are divided, and by carefully ligaturing
all bleeding points before the wound is closed.
Owing to the amount of muscular tissue divided, some oozing
must be expected after operation : shock is conservative, in that it
greatly diminishes the amount of oozing. Blood and serum may
soak through the dressing within four or five hours ; the soiled area
on the surface of the dressing should be well dabbed with the 2 per
cent, solution of iodine in rectified spirit, and fresh sterilised wool
firmly bandaged over it.
The drainage tube is removed in twenty-four to thirty-six hours
after operation, the dressing over the main wound not being
disturbed. Stitches are removed between the tenth and the four-
teenth days, by which time healing is usually sound, if complete
approximation of the skin edges has been possible.
For seven days after the operation the patient is kept in bed and
the arm maintained at a right angle to the trunk. After the third
or fourth day gentle movements of the arm are commenced, and after
a fortnight massage and regular movement of the shoulder-joint
are ordered. This treatment should be carried out for at least two
months after operation, and thus painful adhesions about the
axilla and shoulder are avoided.
A course of X-rays should always be given, when possible, as soon
as the wound is firmly healed. It seems highly probable that this
proceeding checks or prevents local recurrences, and in any case it
usually has the definite effect of making the scar more pliable and
painless. Mr. H. M. Rigby and Dr. J. H. Sequeira recommend six
applications, given twice a week over a period of three weeks,
a full dose being given for about ten minutes on the average :
especial care is taken to avoid dermatitis by the use of aluminium
filters.
The patient should be seen at regular intervals, at first every six
weeks, and after the first year every three months, so that any
recurrence may be detected early and promptly dealt with. This
should be insisted upon, for it is quite useless to rely on the watch-
fulness of the patient, her husband, or other relatives.
Palliative Operations. When the extent of the disease
974 Malignant Disease of the Breast.
precludes any attempt at radical operation, it is often possible to
prolong life and to prevent pain by operative means.
Excision of the breast is sometimes indicated as a palliative
proceeding when there is no hope of being able to cure the patient.
This operation is especially called for in eases of rapidly growing
tumours, which are likely to fungate and to cause much pain and
discomfort from constant discharge ; it is often advisable in cases
in which the growth is already fungating, and in which it is possible
to remove the fungating area and the main mass of the breast.
The extent of the operation must depend on circumstances.
Generally speaking, it should approach the radical operation as far
as possible ; the axillary dissection should especially be thorough if
the patient's general condition allows it, for this may do much to
prevent or postpone the pressure symptoms which are so distressing
in advanced cancer.
A point of especial importance in these cases is that the skin
flaps should be so cut that they can be easily brought into appo-
sition ; if the skin is so affected that this is impossible, the operation
may not be worth doing, for recurrence is apt to show itself before
the granulating wound has healed, and the object of the operation
is then defeated.
Treatment of " Recurrent" Growths. Fresh manifestations
of the disease after operation are inaccurately described as " recur-
rences." They represent continued growth in deposits which have
escaped removal by the operation.
Whenever possible they should be at once excised, unless there is
evidence that other deposits render the case hopeless. Superficial
deposits in the neighbourhood of the scar are usually multiple, but
may often be removed successfully : for small isolated nodules, local
anaesthesia is sufficient. Deeper deposits adherent to the sternum
or ribs are usually irremovable, and no good can be done by
attacking them.
Recurrences in the axilla should be dealt with at once. A large
incision is necessary, and the parts should be carefully exposed.
The axillary vein may be involved in scar tissue, and is easily
opened : part of it may have to be excised if the glands are
adherent to it.
If for any reason excision of the nodules is impracticable, treat-
ment by X-rays or radium may be tried.
Recurrence in the Supra-clavicular Glands. Operation may be
indicated for recurrence in this region, especially when there is no
evidence of disease elsewhere, and when moderate size and mobility
of the glands offers a reasonable hope that they are removable :
Malignant Disease of the Breast. 975
a thorough examination of the chest should always be made.
A flap of skin should be turned up, by incisions along the outer
border of the sterno-mastoid muscle and the clavicle. The internal
jugular vein is first exposed, and the lymphatic tissues and fat of
the supra-clavicular triangle are then removed in one piece : special
care is taken to avoid damage to important structures lying in this
space.
Other palliative operations and non-operative methods of treat-
ment of irremovable cancer are fully discussed in the section on
Tumours (Vol. I.).
SARCOMA OF THE BREAST.
About 5 per cent, of breast tumours are sarcornatous. These
tumours in their early stages are apt to be mistaken for fibro-
adenomata.
Sarcoma of the breast should be treated exactly as carcinoma.
A searching examination must be made for secondary deposits in
the viscera, bones and elsewhere, and in the absence of any
centra-indication, the complete radical operation should be per-
formed. There is no justification for less complete operations, for
the patient's only chance lies in early and thorough removal.
In certain cases there is a strong tendency to local recurrences ;
these should be dealt with as early as possible.
T. CRISP ENGLISH.
EEFERENCES.
Kelly, H. A., and Noble, C. P., "Gynaecological and Abdominal Surgery,"
1908, Vol. II.
Rigby, H. M., Practitioner, 1911, LXXXVL, p. 34S.
9/6
NEURALGIA OF THE BREAST.
CASES are met with in which neuralgic pain in the breast is the
leading feature, and local signs are absent or slight.
For successful treatment of the pain it is essential to form an
opinion as to its cause ; the pain is usually associated with one or
more of the following conditions : (1) A small local lesion, such as
a small fibro-adenoma or patch of mastitis, or a congested area ;
(2) pelvic trouble, especially irregularities in menstruation ;
(3) general ill-health, such as ansemia or neurasthenia.
The cause should be treated first. Small fibro-adenomata should
be removed ; patches of mastitis should be dealt with by the
application of mercurial ointment, by X-rays, or by excision.
Pelvic trouble should be inquired into, and any defect in the
general health should be dealt with by appropriate treatment.
Locally, if no definite lesion is discoverable, the pain may be
relieved by the application of a large belladonna plaster, with a hole
cut in its centre for the nipple, or by the application of mercurial
ointment ; the breast should be firmly bandaged, and care should
be taken to see that the corsets do not cause irritation. In obstinate
cases, galvanism often proves effectual.
As regards general treatment, the following measures are of
importance : Fresh air, especially seaside air, plenty of good food,
tonics such as iron and quinine, and carefully regulated exercise.
It is important to remember that patients with neuralgic pains
in the breast usually consult their medical man because they fear
that the pain is a symptom of cancer ; in fact, they come to find
out whether they have cancer. Eeassurance upon this point, when
it can honestly be given, will do much to cure the neuralgia.
T. CRISP ENGLISH.
977
AFFECTIONS OF THE NIPPLES.
Cracks and Fissures of the Nipples are especially apt to form
during lactation after the first pregnancy ; retraction and imperfect
development of the nipples are the chief predisposing causes. These
lesions and their common sequel, mammary abscess, are far less
common now that the importance of care of the nipples during
pregnancy and lactation is recognised.
Prophylaxis. Careful attention should be devoted to the condition
of the nipples during the latter months of pregnancy. Dried
secretion should be regularly washed off with boric lotion, and the
nipples should be dusted with an antiseptic powder ; if they are
tender, they may be smeared with lanolin or " cold cream " each
morning and evening.
Retraction should be treated by gentle manipulation, the nipples
being drawn forwards until they project normally. If there is
difficulty in effecting this, the wearing of a nipple-shield may prove
efficacious, or the use of the breast-pump may be necessary.
During lactation the nipples should be bathed with boric lotion
and carefully dried before and after suckling, and at the same times
the infant's mouth should be swabbed out with boric lotion.
Ineffectual or unsatisfactory suckling is the usual cause of cracked
nipples, and it is the nurse's duty to see that the difficulty is
overcome.
Treatment.' When fissures have formed, they should be treated
promptly, for otherwise they frequently lead to mammary abscess.
Glycerinum Boracis [U.S.P. Sodium Borate, 20 grm. ; Glycerin,
120 c.c.] should be applied every two or three hours, or in more
severe cases, a solution of 1 in 2,000 biniodide of mercury,
or equal parts of glycerinum acidi tannici and 1 in 40 carbolic
acid. The nipple should be well washed with warm water each
time before the breast is used for suckling, and for the first day or
two a shield should be applied.
Obstinate fissures should be dealt with by the application of pure
carbolic acid on a probe, or by a solution of silver nitrate or copper
sulphate.
Simple Eczema should be treated as eczema elsewhere.
Abscess of the Areola occurs chiefly in young girls, and is to
be treated by simple incision.
S.T. VOL. ii. 62
978 Affections of the Nipples.
"Paget's Disease of the Nipple. " This affection is almost
invariably associated with carcinoma of the underlying breast ; in
fact, most authorities consider that the mammary tumour is the
primary lesion, and that the skin affection is a secondary infiltration.
The treatment, therefore, is that of carcinoma of the breast, the
full radical operation being performed unless there is some definite
centra-indication . In early cases the prospects of permanent cure
are good, whereas local treatment affords little or no chance of cure,
for even if the superficial lesion is destroyed, the progress of the
underlying carcinoma is unaffected.
T. CRISP ENGLISH.
979
OPERATIVE DIAGNOSIS OF DOUBTFUL TUMOURS
OF THE BREAST.
IN many cases the surgeon will be in doubt as to whether a
mammary tumour is malignant or not, even after the most careful
examination. In such cases the doubt must be cleared up at once
by the operative examination of the swelling. There can be no
possible justification for delay, or for trying the effect of local
applications and drugs ; those who adopt this course are undertaking
a grave responsibility for which there is no excuse. Doubtful
tumours usually prove to be malignant, and should therefore be
investigated at once.
Patients with mammary swellings are particularly amenable to
reason when matters are carefully and gently explained to them.
Tell the patient plainly that she has a swelling in the breast, of
the nature of which it is impossible to be certain, and that it is
wisest to clear the matter up at once whilst the trouble is still
early, and not to run the risk of allowing a serious trouble to
become more advanced by delay. There is no need to make use of
the word " cancer " when speaking to the patient.
The operative diagnosis of mammary tumours may be made in
one of the following ways :
(1) Incision into or on to the tumour.
(2) Excision of the tumour, and macroscopical examination of the
cut surface.
(3) Excision of the tumour, or a piece of it, and immediate
microscopical examination, whilst the surgeon waits ; the tissue is
handed, as soon as it has been removed, to a pathologist, who
makes fresh sections and gives a report in from five to ten
minutes. If the tumour proves malignant, the operator proceeds to
the full radical operation.
(4) Excision of part or whole of the tumour and microscopical
examination of hardened sections ; in this case three to six days
elapse before a report is made.
(5) Removal of a portion of the tumour under local anaesthesia
for microscopical examination a few days before the proposed
operation.
In practice one finds that the choice of method must depend upon
the circumstances of the case. Personally, I place great reliance in
622
980 Operative Diagnosis of Doubtful Tumours.
the older method of limited incision into the tumour, as being less
liable to cause dissemination of cancer cells than more extensive
proceedings. In at least 90 per cent, of the cases a positive
diagnosis may be made by examination of the cut surface with
the naked eye and the finger, and in many cases it is quite
sufficient to carry the incision only as far as the edge of the tumour
and not into it.
In the 10 per cent, of cases where doubt still exists, the diseased
area should be excised for microscopical examination. This examina-
tion may be made immediately, before the operation is continued,
if an experienced pathologist is available. The method of preparing
frozen sections of the fresh tissues has been fully described by Mr.
Ernest H. Shaw. 1 There are certain cases in which it is very
important that arrangements for this proceeding should be made ;
for instance, cases in which the patient would not consent to a
second operation. If, however, an experienced pathologist is not
available, this method should not be attempted, for it may be
impossible to decide between chronic mastitis and early carcinoma
by examination of fresh sections only ; in fact, many pathologists
are reluctant to make these immediate examinations under any
circumstances.
T. CRISP ENGLISH.
EEFEEENCE.
1 Shaw, Ernest H., " The Immediate Microscopic Diagnosis of Tumours at
the Time of Operation," Lancet, 1910, II., p. 939.
98 1
TUBERCULOSIS OF THE BREAST.
THIS is an uncommon disease. Clinically it presents itself in
many forms, such as chronic ahscess, multiple sinuses, or as solid
masses with caseating centres. The axillary glands are usually
also affected, and sometimes they are apparently the primary focus.
Tuberculosis is often found in other parts of the body.
There is no doubt that in the majority of cases excision of the
affected breast and axillary glands is the wisest course. Investiga-
tion of the subsequent history of cases treated by less complete
operations shows that re-appearance of the disease is very common,
and that many of the patients ultimately die of some form of
tuberculosis.
The chest should be carefully examined before operation is decided
upon. A slight degree of pulmonary tuberculosis would indicate
especial care in the administration of the anaesthetic. More advanced
disease would probably centra-indicate operation.
In excision of the breast all unhealthy skin should be freely
removed, and the incisions are planned to include any sinuses which
may be present. Infected axillary glands are removed, together with
the breast. It is unnecessary to excise any portion of the pectoral
muscle unless it is infiltrated with the disease, but sometimes
division of part of" the muscle is required for the proper clearance
of the axilla. If amputation is contra-indicated, less extensive
procedures may be tried. The diseased segment of the breast may
be excised, or sinuses and localised collections of pus may be freely
laid open, scraped and stuffed with iodoform ribbon gauze.
General treatment is of great importance in all cases, and
should be conducted on the lines of Sanatorium Treatment (see
Vol. I.). Tuberculin may be used when healing is slow after
incomplete operations, and also after the radical operation to
diminish the risk of recurrence (see Vaccine Therapy, Vol. III.).
T. CRISP ENGLISH.
982
DISEASES OF THE NERVOUS SYSTEM.
AFFECTIONS OF OBSCURE ORIGIN.
COMA.
THE treatment of coma is largely that of the causal condition
underlying its production. In order to determine this in any given
case a routine examination should be made. The previous health
and mental condition of the patient should be inquired into,
especially as to the occurrence of fits, headache or vomiting.
Where possible, the mode of onset of the coma, whether gradual or
sudden, and whether attended by any premonitory symptoms,
should be ascertained. Evidence of poisoning, the odour of the
breath or any signs of injury should be noted. The urine should
be examined for indications of acute or chronic renal disease or of
diabetes. Having examined the patient's general state, the nervous
system must then be investigated. The state of the pupils as
regards size, equality, outline and reaction to light must be noted.
Evidence of paralysis should be sought for in asymmetry of the
face, squint, deviation of the head and eyes to one side, or in a
greater degree of flaccidity of the muscles on one side.
All the reflexes must be examined, the tendon reflexes, the plantar
reflexes and superficial abdominal and epigastric reflexes and every
abnormality noted, and in addition to this a careful comparison
should be made of the corresponding reflexes of the two sides of the
body.
Where the paralysis appears to be bi-lateral the temperature
should be taken on both sides. This may be of assistance, as in an
acute cerebral lesion the temperature on the side opposite the lesion
is usually raised one or two degrees above that of the other. In all
cases the fundus should be examined for optic neuritis or renal or
diabetic changes. In cases of toxsemic coma the symptoms are
bi-lateral, and evidence of gross intra-cranial lesions is absent. On
the other hand, in cases due to intra-cranial lesion, evidence of gross
affection of the central nervous system will be obtained.
Uraemic Coma. Treatment is directed to the elimination of the
toxic substances and to the reduction of the increased intra-cranial
pressure which is present in these cases. The bowels should be
freely opened by means of croton oil : 1 or 2 rnin. of the oil
should be added to a little olive oil, and then placed on the back of the
Coma. 983
tongue. Diaphoresis must be encouraged by placing the patient in
a hot-air bath or hot pack, and the action of the heat upon the skin
may be assisted by giving a hypodermic injection of ^ gr. of pilo-
carpine nitrate. If, however, the heart is weak, or there is any
grave danger from hypostatic congestion of the lungs, it is wiser
to withhold the pilocarpine.
Should sweating not take place or prove ineffectual, venesection
should be performed, and 10 to 15 oz. of blood withdrawn from the
arm. The loss of fluid attendant upon diaphoresis or venesection
should be compensated for by intra-veuous or subcutaneous injection
of a warm '85 per cent, solution of sodium chloride.
Inhalations of oxygen have been recommended to diminish the
uraemic intoxication, but in practice their action is not very
obvious.
In all cases lumbar puncture should be performed and 20 cubic
centimetres of cerebro-spinal fluid withdrawn. This procedure is
almost invariably followed by a rapid and striking improvement in
the patient's condition.
Diabetic Coma. The advent of diabetic coma can usually be
predicted by the investigation of the urine and the faeces. Purga-
tion and alkaline treatment, if employed in time, may ward off an
attack. If the patient is suffering from diabetic coma the most
energetic treatment is required. He should be infused immediately
with 2^ pints of a '85 per cent, solution of sodium chloride, to which
8 drachms of sodium bicarbonate has been added. This infusion may
be repeated in the course of twenty-four hours. If the patient
recovers consciousness, he should be given 20 gr. to 40 gr. of sodium
bicarbonate every two hours, by mouth. If constipation exists, free
purgation is necessary, and when it is practicable inhalations of
oxygen may be tried, as they are sometimes of benefit.
In cases where there is evidence of cerebral compression, such as
loss of the superficial abdominal and epigastric reflexes, lumbar
puncture should be performed, and 20 cubic centimetres of cerebro-
spinal fluid withdrawn.
Epileptic Coma. Coma may supervene upon an epileptic attack.
If this occurs after a single fit, the patient should be left quiet as he
will soon come round ; if, on the other hand, he is having repeated
fits and not recovering consciousness between the attacks, he is
suffering from status epilepticus, a most dangerous condition.
Attempts must be made to stop the fits by means of chloroform
inhalations and the administration of large doses of potassium
bromide and chloral by rectal injection. If cardiac failure is
present, venesection and stimulation must be carried out.
984 Coma.
Coma associated with Intra-cranial Tumour or Abscess.
The coma which occurs in cases of intra-cranial tumour or abscess
is due to an excessive rise of intra-cranial pressure. Treatment,
therefore, should be primarily directed to relieving the excessive
intra-cranial tension ; this can be effected radically only by operation.
If the tumour or abscess has been localised accurately, a consider-
able area of bone should be removed over the site of the lesion and
the dura freely incised. In the absence of any precise localising
symptoms the operation should be performed bi-laterally on the infra -
tentorial level. If immediate operation is impossible, the patient
should be given 1 or 2 min. of croton oil mixed with a little olive
oil and placed on the back of the tongue, and lumbar puncture
should be performed, 20 cubic centimetres of cerebro-spinal fluid
being withdrawn. These measures will often restore the patient to
consciousness, and may further enable a correct diagnosis of the
site of the tumour to be made, as the relief of pressure removes all
symptoms of compression which may be giving rise to false localising
signs. In cases where abscess is suspected, any known local source
of infection should be opened at once.
Coma in Cerebral Haemorrhage. For the treatment of this
condition see Cerebral Haemorrhage (p. 1168).
Alcoholic Coma. In alcoholic coma the patient can generally
be aroused. The face is usually flushed, but may be cyanotic. The
pulse is strong and full, respiration deep and slow, and the pupils
dilated. The temperature maybe subnormal. The breath and stomach
contents smell of alcohol ; but the mere fact of the breath smelling
must not be taken as evidence of alcohol poisoning, as most patients
falling into a comatose state are given alcohol by their friends.
When possible the stomach should be washed out, but if no tube
is at hand and the patient cannot swallow, vomiting can be induced
by giving a hypodermic injection of ^ gr. of apomorphine hydro-
chloride. If the patient can swallow, an emetic should be given,
such as warm mustard water (2 drachms to 8 oz. of water) or a large
dose of zinc sulphate.
In cases where the patient has collapsed hot cloths should be
applied, and he should be given hot coffee or aromatic spirits of
ammonia, and, if necessary, hypodermic injections of strychnine.
Coma following Morphia Poisoning. In these cases the
respiration is slow, the skin cold and clammy, the pulse small
and the pupils pin-point in size. Where the patient has
swallowed opium the stomach must be washed out, or, when that is
impossible, vomiting must be induced by the hypodermic injection
of ^ gr. of apomorphine hydrochloride, or by the administration of
Coma. 985
any emetic which can he obtained at once. When possible 8 gr. of
potassium permanganate in half a tumbler of warm water should be
given at once, and after a short interval, the stomach should be
washed out with a warm solution of potassium permanganate.
This lavage may be repeated several times with advantage.
The patient must not be allowed to sink into a state of pro-
found coma ; he should be stimulated by flipping him with wet
towels, administering hot coffee by rectum or stomach tube, and
by the hypodermic injection of ether or atropine (gr. $). If respira-
tion is failing, artificial respiration must be started, and strychnine
and atropine should be injected hypodermically. Once the patient
has been roused from the coma he should be walked about until the
effect of the poison has passed off.
Malarial Coma. In one form of pernicious malaria, coma is the
most, striking manifestation. The patient should be treated at once
by large doses of quinine, either by hypodermic or intra-venous
injection. The following solution should be employed: H. Quininae
II ydrochloridi Acidi, gr. 15 ; Sodii Chloridi, gr. 1 ; Aquae Destillatse,
Further treatment depends upon the condition of the patient in
each individual case.
Coma in Heat Stroke. In this condition there may be a
sudden onset of coma with hyperpyrexia. The patient should be
placed in a cold bath to which ice is added ; if a bath is not avail-
able, he should be wrapped in a cold pack, rubbed with ice and
have ice applied to his head. The rectal temperature should be
tiiken repeatedly, and when it has definitely begun to fall, the
patient should be removed from the pack, as dangerous collapse is
liable to occur. In some cases stimulants may be necessary.
T. GRAINGER STEWART.
9 86
INFANTILE CONVULSIONS,
AT birth the brain is far from fully developed, the latest part to
mature being the cortex of the cerebral hemispheres. The lower
centres are under the control of the cortex, and in the absence of
control are easily excited, and in response to excitation produce
violent muscular movement. Stimulation of the brain may be
effected either directly or through the afferent nerves, and over-
stimulation of any part of the cerebral hemispheres leads to general
convulsions. Thus an irritation, too slight to produce an effect
on an adult, may lead in a baby to muscular twitching or to a
generalised convulsion, with unconsciousness. Infants vary in their
cerebral excitability, and some become convulsed with very slight
causes, while the majority are not disturbed by stimuli which are
comparatively strong. Thus there is a special susceptibility in
certain individuals which may be acquired after birth or be inborn,
and is often found to be hereditary or to run in families. Some
writers even speak of a " spasmophile diathesis," characterised by
increased irritability of the muscles and nerves to mechanical and
electrical stimulation, and often accompanied by spasmodic neuroses,
such as tetany, laryngismus or convulsions. Cerebral irritability
is also increased in certain disorders, of which rickets is the most
striking ; and it is possible that the absorption of toxins from the
intestinal canal may also lead to its augmentation. Anything
which interferes with the flow of well-oxygenated blood through the
cerebral vessels may bring about convulsive attacks and uncon-
sciousness, so that in children convulsions are a common terminal
phenomena in diarrhoea where there is cerebral anaemia, and
in broncho -pneumonia where the blood is insufficiently oxygenated.
A sudden rise of temperature may excite convulsions in a pre-
disposed child, so that a fit may usher in an acute specific disorder,
such as pneumonia or scarlatina. Lastly, inflammatory affections
of the brain or meninges and tumours or other gross defects of the
brain are usually accompanied by convulsive attacks.
The foregoing points have to be remembered when the appro-
priate treatment of the patient is under consideration. A single
convulsion passes away, leaving no defect except a liability to
recurrence, and is in itself of no danger ; but repeated attacks of
convulsions may be followed by marked mental impairment and
Infantile Convulsions. 987
even imbecility, while numerous convulsive fits occurring one
directly after the other cause a condition like the status epilepticus,
in which there is peril of immediate death. Death may also result
from laryngismus in the cases with marked increase of muscular
and nervous irritability. Apart from these urgent cases treatment
has to be directed not so much to the individual fit as to the pre-
vention of recurrence. The parents may be advised in case an
attack supervenes to make use of the traditional hot mustard-bath,
which is harmless, and may be of some slight benefit. The other
traditional treatment of cold applications to the head should be
avoided. For the prevention of further attacks attention has to be
directed to two points : firstly, to the removal of any source of
irritation ; and, secondly, to the lessening, if possible, of the over-
excitability of the central nervous system. The irritants that have
been regarded as responsible for the causation of convulsions are
very numerous, the most frequent being teething, middle-ear
disease, phimosis and the presence of undigested food or ascarides
in the intestines ; but it is probable that the influence of most of
these has been much exaggerated. Still, if there is a source of
irritation it should be attended to, and, if necessary, the membrana
tympani punctured or a circumcision performed. The presence of
unsuitable and undigested food in the intestines has been regarded
as causing convulsions in another way than by acting as a reflex
irritant ; such food ferments in the intestinal canal and toxins are
supposed to be absorbed, which cause the fits by their direct action
on the brain. Thus the diet requires careful regulation. Usually
it is necessary to give the milk more dilute or to reduce the
quantity of proteid in the feeding mixture, and several observers
claim to have stopped convulsive fits solely by such an alteration
of diet. If there is reason to suppose that intestinal fermentation
has any part in causing the convulsions, a mixture containing
ol. ricin. (it5), pot. bicarb, (gr. 2), vin. ipecac. (iri2), aq. carui
(ad 5J) may be prescribed, to which 111^ of tinct. opii should be
added if the motions are frequent ; or small quantities of calomel
(gr. ^) frequently repeated are very useful as an intestinal anti-
septic. To this must be added attention to general hygiene. The
child should get plenty of fresh air both in and out of doors ; it
should be warmly clad, special care being taken to clothe the
abdomen and to keep the extremities warm. If the feet are
chronically cold, it is well to have the legs rubbed from below
upwards for five to ten minutes night and morning. Constipation
is commoner than diarrhoea, and may require a purgative to get
the bowels to act regularly and freely.
988 Infantile Convulsions.
With improvement in the child's general condition it is often
found that the over-excitability of the brain diminishes, and this is
specially the case in rickets. Where there is any evidence of this
disorder its treatment should be carefully carried out as regards
diet, fresh air, and the management of the chronic intestinal
catarrh which is so frequently present. The advocates of the
" spasmophile diathesis " state that the nervous and muscular
excitability is increased by a diet of cow's milk or even whey, but
decreased by human milk. The withdrawal of cow's milk is a
serious step to take with a child under the age of twelve months, and
should not be continued longer than two or three days. If a wet
nurse is available the difficulties are less, and the occurrence of
convulsions in the infant may be regarded as an additional
argument in favour of her employment. The over-excitability can
also be reduced by certain drugs, of which potassium bromide
(1 to 3 gr. for a child of twelve months) is the best for continued
treatment. Phenazone (1 to 2 gr.) may be combined with the
bromide, or may be substituted where the bromide does not seem
to suit the child. Chloral ( to 2 gr.) is not so suitable for
continued administration, as it tends to irritate the gastro-inteslinal
tract. Under this regime, which should be continued for at least
two months after the last fit, the improvement can in some cases be
measured not only by the lessening or cessation of the fits, but also
by the steady diminution of the nervous and muscular irritability to
mechanical stimulation.
Rapidly Repeated Convulsions, which produce a continued
unconsciousness and often a marked degree of fever, require active
and immediate treatment, since life is in imminent danger. As a
rule, the most rapid and convenient method is the inhalation of
chloroform. As soon as the patient is under the influence of the
drug the rectum should be cleared out with a soap-and-water enema,
which usually brings away a quantity of very foul-smelling faeces.
Then 1 to 4 gr. of chloral, with double the quantity of potassium
bromide in an enema of mucilage, should be injected high up into
the bowel : when this begins to act the chloroform may be dis-
continued. In bad cases it may be necessary to repeat the rectal
injection, or to give half the quantity of the chloral and bromide by
the mouth every two to three hours. Other measures which may
be tried are inhalation of amyl nitrite or the hypodermic injection
of morphia (^ to ^ gr.), remembering that the latter must be
used very cautiously in infants under the age of six months. Still
recommends urethane in 2-gr. doses where bromides and chloral
seem to fail. After the fits have ceased the general treatment must
Infantile Convulsions. 989
be carried out with great strictness, and it will probably be necessary
to continue the administration of bromides over several months. A
child that has been brought to death's door by repeated convulsions
is liable for a long time afterwards to similar 'attacks.
ALFRED M. GOSSAGE.
REFERENCE.
Thiemich, M.,'Pfaundler, M., and Schlossmann, A., "Diseases of Children,"
Phila., 1908, Vol. III., p. 285.
990
EPILEPSY.
Introduction. Before giving a detailed account of the treatment
of epilepsy it is necessary to define what is meant by that term
and to mention the clinical forms in which it may reveal itself.
Idiopathic or genuine epilepsy is a chronic disease characterised
clinically by the recurrence of seizures, in which interference with
consciousness is an essential feature, associated either with spasm,
convulsions or transient psychical symptoms, occurring usually in
persons with an hereditary neuropathic predisposition, and in many
cases leading to more or less permanent mental impairment. The
sole feature necessary to establish the diagnosis of epilepsy is
sudden, brief loss or impairment of consciousness.
The following symptoms may be observed as the clinical
expressions of the disease : (1) Transient jerks, jumps or partial
falls ( petit mal moteur), often unattended by loss of consciousness ;
(2) aura sensations, with or without impairment of consciousness ;
(3) incomplete fits (minor epilepsy, or petit mal}; (4) complete
fits (major epilepsy, or grand mal ) ; (5) psychical epilepsy, or
epileptic automatism ; (6) psychical epileptic equivalents.
Epilepsy may be the clinical expression of a number of cerebral
diseases, which may be to a large extent separated from each
other.
(1) Organic cerebral disorders may give rise to epilepsy in no w r ay
distinguishable from the genuine or idiopathic disease. Such are :
(a) Traumatic lesions of the skull, brain or membranes ; (&) focal
organic disease of the brain, such as tumour and thrombosis; (c) in-
fantile cerebral hemiplegia ; (d) degenerative cardio- vascular
disease ; (e) general paralysis of the insane.
(2) Other forms of epilepsy are found in association with :
(a) Intoxications, such as arise from alcohol, absinthe, tobacco and
lead poisoning ; (b) eclamptic conditions, such as uraemia and
puerperal eclampsia.
(3) A variety of epilepsy chiefly characterised by the great
degree of mental impairment, amounting in most cases to imbecility
and in some to idiocy, is found in infancy and early childhood.
This type of the disease is difficult to distinguish from idiopathic
epilepsy, of which it merely forms a variety.
(4) Idiopathic epilepsy. There would appear to be several
Epilepsy. 991
characteristic types of the idiopathic disease. There is a form of
epilepsy in which the whole course of the disease is shown by the
occurrence of a few fits over a limited period of time. As this type
undergoes spontaneous cure it is probable that some case's of
arrested epilepsy are instances of this variety. There is also a
variety of epilepsy whose symptoms consist of infrequent occurrence
of fits associated with little or no mental impairment. This con-
stitutes a favourable and in many cases a curable form when
treated over long periods of time. The majority of cases of epilepsy,
however, are of a kind in which, along with some degree of mental
impairment, there is a greater or less frequency of seizures of
variable types, either major or minor fits (alone or in combina-
tion) psychical attacks (purely psychical or psychomotor) or fits
occurring in series.
The treatment of so multiform and persistent a disease as epilepsy
requires description under several headings, but it is essential to
bear in mind at the outset that it is necessary to treat in every
instance the individual and not solely the disease. The prescribing
of therapeutic and general measures must therefore depend upon
the individual peculiarities and temperament.
TREATMENT OF ASSOCIATED CONDITIONS.
Reflex Epilepsy. Many cases of epilepsy are to some extent
influenced by, and by some writers ascribed to, local irrita-
tion of peripheral structures, more especially the nose, eyes, ears,
teeth and generative organs, although no part or organ of the
body is necessarily exempt. It is therefore desirable to examine
these organs individually in all cases of the disease.
1. The nose ought to be examined for polypi, adenoid growths
and foreign bodies, the last two being not uncommon accompani-
ments of fits, especially in children. The removal of such causes
of nasal irritation and obstruction is not infrequently followed by
temporary, or in some cases permanent, arrest of the seizures.
In all cases, however, treatment by the bromides should be
prescribed and continued.
2. The eyes ought to be investigated for errors of refraction,
which are very common in epileptics. In every case the existing
error should be corrected. There is, however, considerable differ-
ence of opinion as to their influence upon the disease. At the
best the correction of a refractive error will only temporarily
mitigate the seizures, and all cases require treatment by the
bromides.
3. The ears ought to be examined for disease of the external
992 Epilepsy.
and middle ear ; less commonly the labyrinth. The relation of
chronic otorrhoea to epilepsy is uncertain. Appropriate local
as well as general treatment should be carried out in all cases.
4. The teeth ought to be examined for caries, which is notoriously
frequent in epileptics. This requires the necessary attention.
Improvement in the number and severity of fits is not uncommon
after adjustment of suitable artificial means of mastication.
5. The stomach and intestines : Constipation and dyspeptic
disorders are frequent in epilepsy, and require constant attention.
In children the presence of worms should be especially enquired
into. It is, however, not uncommon to find that the fits persist
after the worms have been removed.
6. The genital organs ought to be examined (a) for the presence
of a tight prepuce in boys, which is a well-recognised accompani-
ment of fits ; in these cases circumcision is frequently followed by
great improvement; (6) for abnormal conditions of the pelvic
organs in females. These require the necessary attention. The
old procedure of removing the ovaries or other parts of the female
generative organs was based on an entirely mistaken view of the
nature of epilepsy.
7. Self-abuse is an ascribed cause of epilepsy, but it would seem
to be less a contributory cause of this disease than of some of the
neuroses which appear in later life. As an associated symptom, it
is of frequent occurrence. It may be continued as a habit long
after the disease has become confirmed. Stress should be laid
upon its dangers and any local source of irritation relieved.
In all cases of epilepsy associated with the above-mentioned
abnormal conditions of the peripheral organs suitable medicinal
treatment ought to be carried on even after the correction or
removal of the local disorders.
Epilepsy of Infective Origin. The common infective causes
of epilepsy are scarlet fever, measles, influenza, diphtheria,
pneumonia and typhoid fever. Epilepsy ascribed to one or other of
these diseases arises either during the course of the fever or during
convalescence.
The treatment of epilepsy of infective origin will be described
under the treatment of recent epilepsy (p. 993), as it in no way
differs from the idiopathic disease. Complications, however, of
the infective disorder, such as otorrhosa or album inuria, should
receive appropriate attention. Another aspect of the relation
between epilepsy and the acute specific disorders is a tendency to
remission of the fits, which may be temporarily or even per-
manently brought about. Several cases have been observed in
Epilepsy. 993
which scarlet, typhoid and malarial fevers have brought about a
temporary respite from epileptic attacks.
Epilepsy of Toxic Origin. Auto-intoxication. Toxic influences
arising in connection with the gastro-intestinal tract have
within recent years received considerable attention as possible
causes of epilepsy. There is, however, little evidence as to what
they are or how they act. Treatment directed towards intestinal
antisepsis has not led to any material improvement. In some
cases the onset of the fit or fits is preceded by an increase of
constipation with some furring of the tongue. In these cases a
8 or 5 gr. dose of calomel at bedtime, followed by a dose of salts in
the morning, is desirable and often efficacious. In all cases of
epilepsy, owing to the tendency to constipation and to gastro-
intestinal disturbance, whatever the nature of the medicinal
treatment employed, an occasional dose of calomel is of advantage.
Alcoholic Intoxication, more especially in persons predisposed to
fits, induces epilepsy, sometimes in the form of status epilepticus
associated with delirium tremens. This form of epilepsy the
'true alcoholic epilepsy is rarely followed by the usual chronic
type of the disease, the convulsions passing away when alcohol is
no longer given.
The potent influence of alcohol upon the brains of epileptics
may be referred to here. Alcoholic intoxication may produce serious
and severe relapses of epileptic fits, and sometimes acute maniacal
outbui-sts in these persons. In all cases of epilepsy, therefore,
alcohol should be forbidden except under conditions of collapse,
which will be referred to later.
Tobacco Intoxication, as an exciting cause of epilepsy, is only
of rare occurrence ; but in an epileptic excessive smoking will
occasionally aggravate the disease and lead to frequent and severe
fits. Tobacco smoking need not be prohibited in epilepsy, but the
quantity smoked should be restricted.
EPILEPSY OF RECENT ORIGIN*
The Bromides. There is no single specific remedy in the treat-
ment of epilepsy, although the alkaline salts of bromine come
nearest to this definition. Moreover, the influence of the bromides
upon epileptic convulsions is variable and uncertain.
In the first place, bromide medication may arrest the seizures
immediately or within a short period of its administration,
temporarily or permanently. In this division most of the curable
types of epilepsy are found, cases characterised by the absence of
mental impairment and with fits recurring only at long intervals.
S.T. VOL. n. 63
994 Epilepsy.
If any given case is capable of arrest a satisfactory response will be
apparent within a comparatively short period, usually twelve months,
from the commencement of the bromide treatment.
Secondly, the bromides may induce a lessening in the severity
and frequency of the seizures. This is the common temporary
result of bromide treatment, and is what may be confidently expected
in the majority of cases in the early stages of the disease. Some-
times the change is effected by the arrest of the major seizures, the
minor continuing ; or the bromide may change the time-incidence
of fits, from the waking to the sleeping hours, or vice versa.
Thirdly, the bromides may exert no influence at all upon the
disease, or may even augment the frequency, or severity, of the
seizures.
These observations are in general harmony with those of other
writers on the subject. They point to the fact, admitted by those
who have had much personal experience of the treatment of epilepsy,
that a large percentage of epileptics derive no benefit from the use
of bromides. Only about 50 per cent, of all cases of epilepsy would
seem to be benefited by their use. Notwithstanding the unfavour-
able results of treatment in many cases, it is advisable that all cases
of recent epilepsy should be given the benefit of these drugs for a
time.
The physiological action of the bromide salts consists in lessening
the irritability of the central nervous system and in exerting a
subduing effect upon reflex activity and cerebral function. The
potash salts of bromine also induce a slowing of the pulse and of the
action of the heart. In medium doses (10 to 30 gr.) the bromides
produce muscular fatigue, a slowing of the mental processes, dulling
of the sexual function and of the skin sensibility.
In large doses (150 to 225 gr.) the speech becomes slurred, there
is abolition of the palatal and pharyngeal reflexes, while frontal
headaches and a limitation of the power of thought soon ensue.
Salivation, lowering of the body temperature and of the pulse rate,
catarrh of the stomach and of the respiratory mucous membranes,
are general bodily symptoms, resulting from continual use of
large doses of the bromides. It is therefore obvious that the
prolonged and injudicious use of the bromides may give rise to toxic
symptoms.
Bromifitn. This condition is characterised by a blunting of the
intellectual faculties, impairment of the memory, and a dull and
apathetic state. The speech is slow, the tongue tremulous, the saliva
may flow from the mouth, the gait is staggering, and the movements
of the limbs feeble and infirm. The mucous membranes suffer so that
Epilepsy. 995
the palatal sensibility may be abolished, and nausea, flatulence and
diarrhoea supervene. The action of the heart is slow and feeble,
the respiration shallow and imperfect, arid the extremities blue and
cold. An eruption of acne frequently covers the skin of the face,
neck and back.
Dosage. Bromide treatment should be commenced at the
earliest possible time after the onset of the fits, as there is greater
prospect of arrest or improvement during the early stages of
the disease, although arrest of the seizures may occur after a
duration of twenty years. The administration of the bromides
should be continued for a period the duration of which is to be
determined by the study of each case separately, but should not be
less than two years. The dose usually given is too large. If benefit
does not follow a daily dose of from 45 to 60 gr. of one, or a
combination of the bromide salts, some other remedy or method of
treatment should be sought for and applied. Clouston showed that
no appreciable diminution in the number of fits took place when the
dose of bromide exceeded 75 gr. in twenty-four hours.
The large doses sometimes prescribed, from 100 to 150 gr. daily,
although no doubt suppressing the seizures for a time, induce other
and more serious phenomena, namely, those of bromism already
described. Moreover, the bromides have an accumulative action.
Laudenheimer has shown that an epileptic taking 10 grammes
(150 gr.) of bromide salt daily for eight days only excreted a total
of 35 gr., or less than half the quantity ingested during that period.
He also showed that no result followed its administration until an
equilibrium was established between the intake and the output; this
occurs on saturation of the body and requires about 30 gr. of
bromide to be given daily for three or four weeks. It is also largely
dependent upon the amount of sodium chloride taken in food ; the
deletion of table salt from the dietary being an important modifica-
tion in the treatment of epilepsy.
Most physicians have their own methods of prescribing the
bromides in epilepsy. As already mentioned, large doses are not
necessary, nor are they effectual in their results, both the amount
of the dose and the time of administration being gauged by the
study of individual cases.
The potassium, sodium, strontium and ammonium salts are the
most usually administered. Each is of value, but the sodium salt
is the most efficacious. If the bromides are prescribed in combination,
the dose should not exceed 60 gr. in the twenty-four hours. The
bromide of strontium is less useful, but may be given in 10 gr.
doses in combination with the other salts.
632
996 Epilepsy.
Should the seizures be only nocturnal or occur in the early
morning, one dose of 30 or 40 gr. of the potassium or sodium salt
may be taken in a small tumbler of water at bedtime.
Should the attacks occur at or about the time of rising, which is a
very common time, a full dose may be given at bedtime and a half
dose (15 gr.) before the patient rises from bed. This may be
prescribed along with a cup of weak tea.
Should the attacks occur at irregular hours in the day the medicine
may be given after each meal, in such a way that 45 or even 60 gr.
may be given per diem. The larger dose is preferably given at
bedtime. The omission of the bromides for one day per week is
cften satisfactory.
Combinations of the Bromides with other Remedies. A
combination of the bromides and digitalis has been found very
satisfactory in cases of low arterial tension, irregular action of the
heart, or failing compensation with valvular disease. In similar
cases Bechterew recommends adonis r emails in conjunction with
the bromides. It may be prescribed in 15 min. doses of the tincture
adonis vernalis.
Chloral hydrate, in the form of brornidia, may be given with great
advantage in cases of prolonged serial epilepsy or of the status
eplleptieus.
The bromides and the glycerophosphates form a valuable com-
bination in weak or debilitated cases, more especially in young women
with anaemia or neurasthenic symptoms.
A combination of the bromides and borax has been of service
where the bromides or borax, separately, have been of little use.
A combination of the bromides and bicarbonate of soda has been
recommended on the theory that it is a more efficacious means of
maintaining the blood alkalinity than the bromide salts alone.
Of the combinations of the bromides with other remedies, I have
found GelineaiCs formula the most useful and satisfactory. It is
prescribed in the form of drawees containing 1 gramme of pot. brom.,
% milligramme of picrotoxin, and ^ milligramme of the arseniate
of antimony.
In large doses picrotoxin is a producer of convulsions, leading
to spasms of a tetanic character with death in coma. In small doses
it is theoretically supposed to lessen the tendency to cerebral vaso-
constriction, which is believed by some authors to be a fundamental
factor in the causation of epileptic fits. The arseniate of antimony
would appear to be a more satisfactory remedy than arsenious
acid.
The method of prescribing the drage.es is simple : One dnitjee is
Epilepsy. 997
taken either during or immediately after a meal, thrice daily for a
week, an additional dragee being added weekly until the patient is
taking four, five or six per diem. Four dr ogees daily are usually
sufficient to hold the fits in check, although, according to Gelineau,
as many as ten or twelve daily may be taken.
The bromides may be prescribed alone or in conjunction with
arsenic, nux vomica or gentian. Their taste may be partially
obscured by camphor, chloroform or peppermint water, or the
syrup of Virginian prune may be added as a pleasant medium for
their administration, especially for children.
The treatment of bromide acne requires a few words. As long as
the bromides are being taken it is likely to resist treatment. The
bromides of strontium and sodium tend less to its production than
the potassium salt. Arsenic, as Fowler's solution, may be given
with the bromide solution or separately in pill form. Locally,
sulphur ointment, or mercury in the form of ung. hydrarg.
ammoniat., has been found useful.
New Preparations of Bromine. Many new remedies con-
taining bromine have been recommended with a view to eliminate
the toxic effects of the bromine salts. The chief of these is bromalin
(bromine and formaldehyde derivatives), which may be given in doses
of from 10 to 30 gr. ; broinipin (bromine and sesame oil) is pre-
scribed in doses of from 15 to 60 gr., and bromocarpine (bromine
and pilocarpine) prescribed in oz. doses of the syrup. I have
not found these remedies in any way preferable to the ordinary
bromide salts. Bromipin is difficult to dispense, but bromalin is
stated to cause no skin eruption.
Treatment by Drugs other than the Bromides. Before the
introduction of the salts of bromine in the treatment of epilepsy
many remedies were used, sometimes with marked success, as may
be seen from the satisfactory results obtained by Herpin, Eeynolds
and others. On account of the not infrequent failure of the
bromides to arrest or even to ameliorate epileptic attacks, it will be
found necessary to prescribe some other medicinal remedy, and
a large number have been from time to time advocated and
employed. Perhaps the drug most frequently used as a substitute
for, or as an adjuvant to, the bromides, more particularly in
England, is borax (sodium biborate). Introduced by Gowers many
years ago as an antispasmodic, it has met with considerable favour
in cases where the bromides have been of little service. It would
seem to be of most use in combination with a salt of bromine. It
may be given in doses of from 10 to 20 gr., thrice daily, but is apt
to induce troublesome gastro-intestinal symptoms. If continued
998 Epilepsy.
over long periods it may lead to cutaneous eruptions of a psoriasis-
like character.
Belladonna was the chief anti-epileptic remedy of the pre-bromide
days, and is still used in some cases with marked benefit when the
bromides or other remedies have proved unsuccessful. It formed
the chief remedy of Trousseau, Huf eland, Herpin, Reynolds and
others, and in the hands of the first named was mainly used in those
cases complicated with nocturnal incontinence of urine. A com-
bination of bromide and belladonna may be found useful in cases
of otherwise intractable combined seizure types. It is by preference
prescribed as the tincture in doses of 5 or 10 min. [U.S. P., 7 or
14 min.].
The zinc salts (valerianate, 1 3 gr., and lactate, 10 15 gr.) are
old established, and were occasionally successful remedies in the
hands of the French physicians.
Opium is now only used in the opium bromide method recom-
mended by Flechsig. My experience of the treatment has not
been such as to encourage further trial.
Strychnine has been recommended from time to time and used with
considerable success by some physicians. In doses of ^ to j^ gr.
daily, it may be continued over considerable periods. Its -modus
operandi is probably that of a nerve tonic, although it may have
some influence in strengthening the tone of the vasomotor centres.
Strychnine finds its most useful application* in the treatment of
nocturnal epilepsy, especially when there is reason to suppose that
the blood pressure is materially lowered.
Solatium Caiolinense, or horse nettle, is recommended by American
physicians as of use in some cases. It may be prescribed in
1 drachm doses of the liquid extract.
Duration of Treatment. The question as to how long bromide
or any other form of medicinal treatment should be kept up is not
one upon which any rigid statement can be made. Some autho-
rities maintain that treatment should be continuous for a period
of at least two years after the last seizure. In my opinion, the
bromides should not be stopped under a period of five years in
those whose fits are arrested. On the other hand, many persons
in whom the disease has been arrested after a year or two of
bromide treatment remain free from attacks without the aid of any
medicinal remedy. The important practical point in this connec-
tion is, that those patients who take bromide well, and in whom the
fits are thereby kept in subjection, ought to persevere with the
remedy and not to stop it. It is just when the fits have been satis-
factorily controlled that further treatment is of most use. The
Epilepsy. 999
withdrawal of medicinal treatment in those in whom the fits have
been arrested should be carried out gradually. Under no cir-
cumstances should bromides be withdrawn suddenly, after their
prolonged use, owing to the tendency towards the onset of status
(.'pilepticus.
Miscellaneous Methods of Treatment. It may be useful to
refer to other methods in this place, as a case which has resisted
one form of treatment may react, for a time, satisfactorily to
another. It should, on the other hand, not be forgotten, what is
a well-recognised axiom in the management of epilepsy, that cases
of this disease may respond favourably for a time to each and every
change of treatment, medicinal or other, and even when active
treatment is stopped. As the disease is characterised by spon-
taneous remissions in the frequency and severity of the seizures,
a favourable result may occur, not on account of, but in spite of,
therapeutic or other measures.
Of all the recent systems, that which seemed likely to be of most
use was the introduction of the organic extracts in the treatment of
this disease ; but further experience with these preparations has
been, on the whole, disappointing.
Organotherapy. The administration of extract of the thyroid
gland, or of iodothyrin, was at one time strongly advocated, more
with a view to counteract the co-existent mental deterioration than
as a subduer of convulsions. In a number of cases of confirmed
epilepsy, in which preparations of the thyroid gland were given
over considerable periods, no appreciable diminution was detected
in the frequency of the seizures, and in only a limited number of
cases and for brief periods was there any lessening of the co-existent
dementia. My experience is that thyroid medication tends rather
to increase the number of fits and to produce at times irritability
and want of control.
Preparations of the thymus gland act injuriously in epileptics by
increasing the number of the seizures. Cerebrin has not been
found to be of any value.
Xfrotiu'm})!/. The treatment of epilepsy by the injections of
blood serum, either from another epileptic or by re-injection of the
blood serum into the same epileptic, as introduced some years ago by
Ceni, has not been sufficiently satisfactory to make its application
general. Later investigators have failed to confirm the earlier
results or to establish any benefit at all from such injections into
those subject to fits.
Diet in Epilepsy. In all cases of recent epilepsy some modi-
fication of the diet from that suitable to health is desirable. The
iooo Epilepsy.
primary object of the treatment of this disease is to subdue the fits
and keep them in abeyance by as small a dose of the bromide salts
as possible, as a prolonged course of treatment is usually necessary,
owing to the persistent character of the malady. Two hypotheses
may be mentioned as underlying the dietetic treatment of epilepsy.
The first is that nervous energy has its source chiefly in the
albuminous and nitrogenised principles of foodstuffs. The second
is that, owing to the striking homology in the properties, both
chemical and physical, of the bromide and chloride salts, deletion
of the chlorides from the food may assist the action of the bromides
in the treatment of this disease.
All forms of dietetic variations have been tried in the treatment
of epilepsy, and the general conclusions which have been formed
from these observations are that a diet without meat is the most
satisfactory, and that neither a milk diet alone nor a vegetable diet
is as beneficial as their combination. The deletion of table salt
from the diet of epileptics was recommended by Toulouse and
Bichet. They prescribed a diet in which the total quantity of
sodium chloride per diem was limited to 1 or 2 grammes. It
was thought that by diminishing the quantity of the ingested
chlorides, mainly in the form of sodium chloride or common salt,
the bromides might be administered in smaller doses and the risks
of bromism thereby lessened.
Hoppe has shown that one-third of the chlorine of the blood
serum has to be replaced by an equivalent amount of bromine
before any therapeutic result is obtained. When more than this is
replaced bromide intoxication may occur. When less chloride is
ingested saturation takes place sooner. It has been shown that
with a diet free from salt saturation takes place in from three to
four days. This method of " salt starvation " in the treatment of
epilepsy has been extensively tested, with varying results.
In some cases "salt starvation" has proved a useful adjuvant
to bromide medication, while in others little benefit has resulted.
Other observers have shown the dietary to be of especial value in
cases requiring large doses of the bromides and in those which
show a ready tendency to bromiie intoxication. My own experi-
ence of the method has been such that, when used in combination
with a purin-free dietary in cases of recent epilepsy, very substantial
benefit is derived, and relatively small doses of the bromide may be
prescribed.
Purin-free Dietary. A " purin-free " diet is made up of those
foodstuffs in which the " purin " or alloxur bodies are absent, or
present only in such quantities as to be negligible.
Epilepsy. 1001
Purin bodies exist in all forms of meat extract, in both the white
and red meats, commonly used as food. They are present in large
quantities in such substances as sweetbread, liver and beefsteak.
They are not present in milk, eggs, bread, butter, cheese, the
farinacea, most fruits, some vegetables, and honey. They exist to
only a moderate degree in most forms of fish, peas, beans, lentils,
tea, coffee and oatmeal. The following list of purin-poor or purin-
free foodstuffs will be found of use to those desirous of giving the
treatment a trial : Milk (fresh, soured, buttermilk, or whey) ; eggs
(boiled, poached, scrambled or raw) ; white bread and butter,
cheese, macaroni, rice, tapioca, semolina, vermicelli ; suet puddings
with currants, jam and treacle, apple dumplings ; pastries, pan-
cakes, jellies, tea-cakes ; all vegetables (except peas, beans, lentils) ;
of beverages, weak infusion of China tea is the best.
I have used this diet, or a modification of it, containing, according
to the need of individual cases, a small portion of fish, either once
daily or three times a week, for several years in conjunction with
the bromides or Gelineau's dragces. The results have been such
that I am led to advise it in all cases of recent epilepsy. In cases
in which the bromides alone have been of little or no use, the
adoption of the purin-free saltless diet has at once led to material
improvement. By its aid the dose of the bromides has been
largely reduced ; as it is in cases refractory to relief by bromides that
some physicians increase the salts to such an extent that bromism is
brought about and maintained. If properly supervised, symptoms
of bromism need never appear. If the patient shows any signs of
loss of weight the addition of cream or cod-liver oil is usually
sufficient. If not sufficient it is advisable to permit fish or even
a little lamb or mutton.
Hygienic Treatment. In conjunction with medicinal remedies
and dietetic modifications, general measures of a hygienic kind are
of value in the treatment of epilepsy, and require to be mentioned.
In a disease so difficult to handle and so prone to mental deteriora-
tion assistance from all sides should be given, for no greater mistake
can be made than to rely solely on medicinal remedies, which so
often fail in the treatment of epilepsy.
There are many cases of epilepsy in which treatment in an
institution may be undertaken with great satisfaction. On the
other hand, should this be impossible or inadvisable, the patient
ought to be placed under the care of a well-trained nurse attendant.
This instruction is usually necessary for the efficient treatment of
this disease in young people.
As epileptics suffer from lowered vitality and sluggish circulation,
ioo2 Epilepsy.
warm baths, spinal douches and massage are desirable. A certain
amount of exercise in the open-air is also necessary, but such
exercises as bicycling, rowing and swimming should be avoided,
owing to their danger.
The out-of-door life is usually regarded as the most suitable for
epileptics, hence farming or market gardening are frequently
recommended for epileptics of a robust constitution. Many epi-
leptics, however, are quite able to carry on their professional work
or business without difficulty.
It is preferable that those who are subject to even infrequent
epileptic seizures should be educated apart from healthy boys and
girls. In all cases private tuition is to be recommended. In cases
with marked mental impairment appropriate methods of teaching
should be adopted. No greater mistake can be made than with-
holding from young epileptics the advantages of education under
special supervision and direction. It is of primary importance
that the teacher and the physician should work together in this
connection.
If epilepsy develops during a period of mental stress or strain,
when working for an examination or under like circumstances,
complete abstinence from work for the time ought to be enforced,
but when the type of the disease has revealed itself education
should be resumed on the ordinary lines.
The marriage of epileptics ought to be discouraged. The popular
belief that if an epileptic girl is married the disease will be cured,
does not often come true. Isolated instances of this may be
observed, but in the majority of cases the risks attendant on child-
bearing are considerable, and the probability of giving birth to
epileptic children is great.
TREATMENT OF THE FITS AND COMPLICATIONS.
Prodromata. The recognition of the prodromal symptoms
which sometimes usher in a seizure is of value, as active and
energetic treatment at this stage may prevent the occurrence of an
attack. These symptoms are of many kinds, motor in the forms of
jumps or jerks, sensory in the form of segmental anaesthesias
(Muskens), vasomotor, and psychical or temperamental.
When such symptoms arise an extra dose of the bromide salt
should be given at once and continued daily until the period for
the seizure is safely passed ; secondly, the patient should be placed
in bed and kept at rest, and thirdly, a calomel purge ought in all
cases to be administered, whether constipation is present or not.
On the other hand, in many cases of epilepsy no prodromal
Epilepsy. 1003
symptoms are present, the seizure developing suddenly when the
patient is feeling particularly well.
To Arrest the Fit. The next consideration may be given to
the question whether it is possible to arrest an attack once the
warning has commenced. Many methods have been suggested for
this purpose, some of which are of old standing and date from the
time of Galen.
The attacks in which abortive measures are likely to be successful
are those commencing with a peripheral aura. The common method
of encircling the wrist, for example, with a ligature or tape, and
making traction upon it as soon as the aura is felt in the hand, is
well known. As great force is sometimes required to arrest the
attack, a strap is preferable to a tape or ligature. Sometimes the
patient alone is unable to produce sufficient compression and
requires the assistance of a second person. A circular blister was
suggested by Buzzard, in order to induce a more permanent effect,
sometimes with advantage.
Forced extension or movement in the direction opposite to the
warning sensation may be efficacious, when compression alone
is unsatisfactory. According to Herpin, the most effectual means
of arresting such attacks is a combination of circular compression
and forced movement in the opposite direction. Friction, or
rubbing the extremity of the limb where the sensation starts, has
also been of use, and I have known a patient to bite the finger
in which the aura commenced sometimes with a successful
issue.
Abortive means are less satisfactory in cases with a visceral
aura. Strong pressure by the hands over the epigastrium is
resorted to by some epileptics, while others prefer to drink cold
water ; swallowing a few drops of ether has also occasionally
resulted in arresting an attack. Inhalations of ammonia have been
used successfully. The insertion of a seton over the epigastrium
has been employed with advantage in diminishing the frequency
of the attacks. Other patients refer to a method of auto-suggestion,
bringing to bear a strong determination to overcome the attack,
a method which undoubtedly has been followed by success in
some cases.
The inhalation of nitrite of arnyl is a method of arrest, more
especially valuable in fits with cephalic warning. It may be
administered by the patient, who carries about with him capsules
containing the drug, one of which he breaks into his handkerchief
the moment the warning is detected.
During the Seizure. All that is necessary is to lay the patient
1004 Epilepsy,
on the floor so as to obviate danger of falling. The collar or any
constriction round the neck should be undone. Tongue biting may
be prevented by placing a cork or indiarubber ring between the
teeth. In fits occurring during sleep the chief danger to the patient
lies in rolling on to his face and inducing suffocation. This can
only be prevented by attending carefully to the patient until the fit
is over. The post-convulsive sleep should be encouraged and the
patient not awakened until he does so spontaneously. Placing the
patient upon the left side at the onset of a seizure has been
recommended as a satisfactory measure to minimise the intensity
of the fit.
Status Epilepticus. The chief complication of epilepsy is the
acute stage known as status epilcpticus. This may be the first
symptom of the disease, particularly in those forms which arise in
puerperal and ursemic conditions. It may also occur as an inter-
current symptom in any case of epilepsy ; but more especially it
may be artificially induced by the sudden stoppage of the bromides
in cases in which they have been given for a long time.
Status commences by a gradually increasing number of fits.
With this warning the dose of bromide ought to be increased to
double what is usually given, and chloral hydrate (10 to 15 gr.)
added, this mixture being repeated every four hours.
Should the fits be recurring with great frequency and severity,
no remedy is of greater benefit than the inhalation of chloroform,
given up to the stage of complete anassthesia. On the other
hand, in less severe types of status, or in serial epilepsy, a com-
bination of the bromide salts (20 gr.) and chloral hydrate (10 gr.)
may be repeated frequently (about every two or three hours) for
a time especially in the latter condition. The liquor morph. in 10
to 30 min. [U.S.P., morphinae hydrochlor., T \y to ^ gr.] doses may
be added to the mixture, or morphia may be administered hypo-
dermically in doses of 2 to 5 mins. of the injectio morph. tartratis
(B.P.) [U.S.P., morph. tart, -fo to J gr.] or ^ to J gr. given in
tabloid form.
The bromides given alone are of little avail ; but within recent
years their hypodermic administration in sterile solutions of not
more than 10 per cent. (Clark) has been recommended ; these may
be repeated until 60 or 100 gr. have been injected.
Lumbar puncture with or without the injection of the bromides
has also been advised. The latter may be given in sterile solution
of 30 gr. to the ounce, 10 or 15 cubic centimetres of the cerebro-
spinal being withdrawn before 10 cubic centimetres of the bromide
solution are injected.
Epilepsy. 1005
The hydrobromide of Iryoscine has also been used occasionally
with success (~V to T ^ o gr. hypodermically).
Acute Exhaustion. During the after-stage of exhaustion
following upon ordinary seizures no special treatment is necessary,
as the stage passes into that of sleep, from which the patient
spontaneously recovers.
In the acute exhaustion following serial or status outbursts, on
the other hand, great care and attention are required, the patient
having to be nursed as one suffering from acute illness. It is
during this stage that death may occur, a circumstance which is
as frequentl} 7 attributable to want of attention as to the clinical con-
dition. During the few days of stupor, abundant and nourishing
liquid diet, in the form of milk, eggs and custards, should be
frequently given. If the patient is unable to swallow, nourishment
should be administered in the form of nutrient enemata. Hypo-
dermic injections of strychnine (liq. strych. 5 mins.. [U.S.P.,
strychnina- hydrochloridi, ^ gr. ; Aquae, 111 5] or strych. sulph.
;.',, gr.) may require to be frequently administered.
If necessary, alcohol may be given in considerable doses, and
the action of the heart steadied and maintained by digitalis and
strophanthus. Later on, during the delusional stage, general
attention and care is all that is usually needed, while later tonics
may.be prescribed with advantage.
Acute Mania. This form of excitement, whether occurring
as a post-paroxysmal phenomenon or as a psychical equivalent, is
characterised by the suddenness of its onset, the intensity and
violence of its manifestations and the shortness of its duration,
extending usually over a few hours. All that is, therefore, required
lies in protecting the patient, and those attending him, from the
effects of the violence and excitement. For this purpose resort
may be had to the services of attendants, or, if a drug is con-
sidered advisable, none is more safe to administer, or more
speedy, certain and satisfactory in its action, than the hydro-
bromide of hyoscine in doses of T ^ o to ^ gr., injected hypo-
dermically. One injection is usually sufficient to induce quiet and
repose for a period of several hours.
Automatism. This requires no special treatment. If genuinely
epileptic the attacks are usually short and resolve naturally, all that
is required being the protection of the patient and the prevention
of undressing and exposure, which are not uncommon in this state.
If automatism is of an hysterical character resort may be had to
the affusion of cold water to the face and back or the application
of a strong faradic current by a wire brush to the limbs.
ioo6 Epilepsy.
CONFIRMED EPILEPSY.
Confirmed epilepsy is of two kinds. One variety is accompanied
by little or no mental change, although fits may have persisted for
twenty or more years. The second variety shows a tendency
towards an increase in the number of the seizures with associated
mental deterioration.
In the first type of case the bromides, either alone or in combina-
tion, as already described, are often of great use in subduing the
seizures, especially when of the major type.
In the second type medicinal treatment is of little or no value.
In most cases of confirmed epilepsy with dementia the bromides
are only of use when the doses are so large as to produce toxic
effects.
It has long been known that any change of treatment may
temporarily be beneficial in epilepsy, as, for instance, placing
epileptics under favourable hygienic surroundings in a hospital,
home or institution. This will often bring about temporary
improvement without the aid of any medicinal remedies. In like
fashion, modifications in diet whereby salt is eliminated from the
dietary along with highly purin foodstuffs are of but little use.
Most confirmed epileptics feel better when on a purin-free diet,
but there is no marked improvement in the frequency or severity
of the seizures. It would seem, however, as if the attacks of serial
epilepsy or status epilepticus may be more readily controlled
under this regimen.
Cases of confirmed epilepsy, in which the disease has become
established upon an organic foundation, are preferably lodged in
an institution for epileptics, where they may be prescribed
(1) regular and congenial employment, (2) judicious alternations
of work and play, (3) suitable and simple mode of living, and
(4) avoidance of excitement and abstinence from alcoholic drinks.
FEATURES OF EPILEPSY FAVOURABLE AND UNFAVOURABLE
FOR TREATMENT.
(1) The following features constitute a favourable type of
epilepsy : (a) The onset of the disease between the ages of sixteen
and twenty years and after forty-five years of age ; (b) attacks of
infrequent occurrence, and of the major type ; (c) the absence of
any obvious or pronounced mental impairment; (d) neither the
presence of a hereditary predisposition nor the duration of the
disease over many years are unfavourable features, provided that
the other symptoms of the disease in any particular case are
favourable.
Epilepsy. 1007
(2) Among the chief unfavourable features may be mentioned :
(a) The early commencement of the disease, more especially when
under five years of age ; (b) the presence of marked mental impair-
ment, stigmata of degeneration and fades epileptica , (c) great
frequency of seizures, especially when there is a combination of
minor and major attacks ; (</) psychical types of seizure, psychical
epileptic equivalents and post-paroxysmal psychoses ; (e) the
occasional occurrence of serial outbursts, and of the status
epilepticus.
For the Mental Aspects of Epilepsy, see p. 1310.
WILLIAM ALDREN TURNER.
THE SURGICAL TREATMENT OF EPILEPSY.
ALTHOUGH many operations have been devised for the relief of
idiopathic epilepsy, it is practically certain that this condition is not
amenable to surgical treatment. When, however, epilepsy follows
some definite head injury and the convulsions remain localised,
relief may sometimes be obtained by surgical interference. The
skull should be trephined over the site of injury and any local
lesion, such as depressed fragment of bone, thickened or adherent
meninges, suitably dealt with.
C. H. S. FRANKAU.
ioo8
HYSTERIA.
HYSTERIA is essentially a psychical disorder which may or
may not be accompanied by somatic manifestations, and the
ultimate object of all methods of treatment should be to correct
the abnormalities of the mind on which the disordered functions of
the different organs of the body depend.
One attribute of hysterical patients is their great susceptibility
to suggestion. It is often enough to prophesy the probability of
the presence of a new symptom to ensure its appearance, and the
types of a large proportion of the somatic symptoms, such as con-
tractures and paralyses, are undoubtedly frequently determined
by memories of previous experiences of similar disabilities in
others, or even suggested during examination by the physician.
Another peculiarity of hysterical patients is their craving for
sympathy, and it is common knowledge that once the bodily and
mental symptoms have appeared, their hold on the patients is
immeasurably strengthened by injudicious attention and pity, such
as they frequently receive from relatives and friends.
By reason of their susceptibility to suggestion and their
inordinate desire for sympathy it seldom happens that patients
suffering from hysteria of a pronounced character can be success-
fully treated in their own surroundings, and it is generally desirable
to insist upon their removal to a home or hospital, as the case
may be.
There one has command to a large extent over the nature
of the impulses which are allowed to reach them, and by closing
the door to visitors, forbidding letters and "news," the nervous
system can be isolated and guarded against all sense impressions
which would be likely by suggestion to strengthen some symptoms
or to start others.
Thus shut off from the world, the patient is in the best position
to profit by any treatment of body and mind which the physician
in charge considers suitable. The patient should be kept at rest
in bed. So far as treatment of the body is concerned, in most
cases the aim is to increase nutrition and to induce the patient to
put on weight. This is to be done by judicious feeding, especially,
where possible, by milk, the amount of which can be gradually
increased in quantity, until often the patient can take as much as
Hysteria. 1009
4 or 6 pints in the twenty-four hours. The precise way in which the
milk is given is a detail that must necessarily be determined for
every patient individually. Some take it best in quantities of a
few ounces every hour or two, while others, again, will get through
it more easily in larger quantities at longer intervals. The amount
that can be usually taken varies between 2 and 6 pints in the day.
The quantity of other kinds of food must be regulated in pro-
portion to the amount of milk taken and according to the
susceptibilities of the individual.
As an adjunct to the rest and full feeding, massage is usually
necessary. It promotes the lymphatic and hsemic circulations, and
in a sense takes the place of exercise by enabling the patient to
digest his food, and by preventing excessive deposit of fat. Thus
far, then, the treatment is on the Weir-Mitchell lines, and in cases
of slight intensity this combination of increasing the nutrition of
the body and isolating the nervous system from outside influences
may of itself be sufficient to effect a cure.
It cannot, however, be too strongly insisted upon that the mere
fact of putting patients to bed and isolating them in a " rest
cure " is in the majority of cases insufficient. If success is to be
obtained there is needed the addition of some form of psychical
treatment practised in a systematic manner.
Of the various methods that are in vogue that of simple
" suggestion " is the most commonly practised, and mention has
already been made of the proneness of hysterical patients to react
to this stimulus. Suggestion is indeed practised consciously or
unconsciously in some degree or other by nearly all medical men,
and is contained in the manner and personality, which cause
patients to have faith in them. Like most personal attributes, it
can generally be cultivated to some extent with care and patience,
and can often be used to great advantage. It is a difficult attribute
to define, but it consists essentially of the power of putting patients
into an optimistic mood ; of causing them to feel that their
physician sympathises with and understands them, and of giving
them the feeling that he is a real help to them in combating their
symptoms.
The practice of " suggestion " is allied to and can generally be
usefully combined with that of " persuasion," which latter method
has been elaborated particularly by Dubois. It consists in the
main, as its name implies, of talking out the matter with the
patient, explaining minutely where his reasoning has erred, and so
making him, what in ordinary daily life is known as, " to see
things in a different light."
S.T. VOL. ii. 64
ioio Hysteria.
Another method, and one which is giving much food for thought
among psychologists and psychiatrists of to-day, is that known as
Psycho-analysis.
This method, of which only the briefest outline can be given
here, originated from a physician in Vienna, named Breuer, with
whom Freud was closely associated. It is owing to the extensive
researches of the latter that the method has gained the important
position it occupies in the psychological world of to-day.
The basis of this method, in so far as it applies to the treatment
of hysteria, rests on the hypothesis that the symptoms of this disease
are due to a " mental trauma," that is, to some mental experience
unpleasant to the patient, the unpleasant memory of which has
become dissociated from the conscious mind and repressed into
that of the subconscious. But though kept under and outside
the consciousness of the patient, the memory is still there
and in certain circumstances is capable of activity and of
influencing the feelings and actions of the patient without his
recognition. In other words, as Freud says, hysterical patient*
suffer from reminiscences. In ordinary life the tendency in the
average individual is for such emotional experiences to be neutralised
and so rendered harmless and incapable of forming a dissociated
reminiscence. An insulted person, for instance, may work off his
feelings by angry words, grief may be made harmless by crying,
while in other cases length of time dims the memories of hurtful
experiences so that they either fade away or come to occupy their
rightful perspective in association with other ideas. Now and then,
however, either through some abnormality of the individual or
through some peculiarity of the stimulus, it happens that the sensory
effect is not neutralised by any suitable reaction, and it is then that
there is the danger of the memory being buried and yet able to
harass the patient in the way that has been mentioned above.
Groups of ideas which have a common emotional basis are designated
as " complexes," and it is towards unmasking these buried complexes
which unknown to the patient are influencing him that Freud's
method of psycho-analysis is directed.
The technique consists in the main in encouraging the patient to
communicate his ideas with absolute freedom as they occur to him,
withholding any self-criticism, no matter how disconnected or un-
pleasant his thoughts may appear to him to be. By this free
association of ideas the physician picks out the salient points and,
weaving them together, gradually arrives at the " complexes," which
have hitherto been hidden away in the patient's mind. These
"complexes," thus brought out, then become part of the patient's
Hysteria. ion
conscious mind; they are associated normally with other thoughts,
and cease to exist and to trouble him as " foreign bodies." The
difficulty of attaining this object lies in the fact that the patient is
not himself necessarily conscious of the ideas which have to be
searched for, indeed they are generally definitely repressed or
" censored " from his ordinary thoughts, and it is foreign to his
nature, so to speak, to reproduce them. Consequently a resistance
has to be broken down before they can be reached and brought to
light. In the earlier part of his researches Freud made use of
hypnotic suggestion in order to get behind this resistance, but later
on he discarded this as unsound and now relies mainly on persua-
sion and observation as the technique by which to reach the desired
goal.
Valuable assistance in arriving at the buried complexes may
further be obtained by the Association Method which has been
especially elaborated by Jung, and by following Freud's instructions
on the analysis of dreams.
The association method consists in reading out a selected list of
words to the patient, requesting him to respond as quickly as
possible to each word he hears by saying the first word that comes
into his mind and noting the time (i.e., the reaction time) taken to
make the association with every word as it is called out. By
studying large numbers of cases in this way it has been found that
when the stimulus word hits off an association with one of the
patient's hidden complexes, the time taken in making the associa-
tion is lengthened together with other peculiarities which indicate
that there has been some unusual stir in the mental process
concerned in making the associations. By careful comparison it
becomes possible in this way to form an opinion as to along what
lines the patients' minds are working.
In the cases of dream analysis Freud holds that dreams represent
in their essentials the fulfilment of some ungratified desire, but this
essential is clothed so thickly and so grotesquely with superadded
material that it is often a matter of great difficulty to arrive at the
core of the matter.
By the combined methods, then, of psycho-analysis, the associa-
tion method, and dream analysis, it is possible in favourable cases
to penetrate the innermost workings of the patient's mind and to
bring to light those buried painful reminiscences upon which the
faulty mental superstructure has been built. By restoring these
reminiscences to their proportionate place in the mental surround-
ings they cease to act independently and to be a source of
trouble.
642
ioi2 Hysteria.
While there is much that is at present controversial in Freud's
hypotheses and deductions, every one must admit that his works
have opened up new paths in psychology and that his methods may
frequently be used with great benefit to the patients in carefully
selected cases.
Hypnotism is recommended by some, and is no doubt occasionally
suitable in selected cases, but it is not a form of treatment to be in
any way systematically advocated in this disease. Freud made use
of it in his earlier days to aid him in unravelling the buried
reminiscences, but found it undesirable and discarded it in favour
of the more simple method of " free association " detailed above.
As already mentioned, Dubois relies largely on the Method of
Persuasion, which consists broadly of frequent talks in which
attempts are made to encourage the patient to direct his mental
outlook along more logical lines and to develop a sounder philosophy
on which to base his mental outlook.
As an adjunct to psychical treatment Physical Methods are of
course still important, and the most consistent success will be
obtained by those who make a judicious selection of the different
forms of treatment according to the requirements of their particular
patients.
The application of a faradic current, for instance, may be instru-
mental in curing anaesthesias, paralyses and contractures, though
it is an open question as to what degree the stimulus in these cases
is mental rather than physical. Massage, baths, douches and
other means calculated to increase the nutrition and improve the
tone of the body, all find a place in certain cases.
Of the value of drugs there is not much to be said ; iron, arsenic,
and other tonics are often useful in a general way, as also occasion-
ally are valerian and asatotida, but none of these have any specific
action on the disease. In the more acute cases where restlessness
is a prominent feature the bromides may be useful for a time, and
for sleeplessness it may be necessary to prescribe hypnotics, such as
veronal or paraldehyde.
Prophylactic Treatment is of the greatest importance, and
much can be accomplished in preventing hysteria by careful educa-
tion in childhood and youth.
Apart from the general moral training which should lead
towards regarding events in a reasonable light to one another
and towards keeping the emotions within reasonable bounds, it
is most important to exercise the motor output in due propor-
tion to the sensory intake. Useful and steady occupation of
one kind or another is perhaps the greatest safeguard against
Hysteria. 1013
hysteria, for it works off the forces which might otherwise spend
themselves aimlessly through the channels of emotion.
Finally, it is to he remembered that no fixed rules can be laid
down for the treatment of hysteria. Success is only to be gained
by careful attention to each case and by the application of such
system or combination of systems of treatment as the individual
patient appears to require.
H. CAMPBELL THOMSON.
INSOMNIA.
THE etiology of insomnia includes the consideration of a large
number of factors, and no rational treatment can be instituted
before an extensive inquiry concerning them has been accomplished.
The amount of sleep required by individuals varies with their age,
occupation and personal idiosyncrasy. Broadly speaking, children,
juveniles and young adults require much more sleep than do the
middle-aged, while the middle-aged require more than do the old.
Occupation of an exhausting character, whether of work or of
pleasure, requires more subsequent sleep than does an occupation
which needs but little output of energy or sustained attention.
Some persons, often of great intellectual capacity, can live healthily
on so small an allowance of sleep as would be ruinous to most ;
while, on the other hand, there are many whose sleep is so light
and is so liable to be disturbed by trivial causes that they need
more hours of sleep than do those whose rest is profound. Sleep
is also largely a matter of habit, and those whose habits are, in this
respect, irregular and who have no set time for going to bed and for
getting up, are prone to insomnia, as also are those who, practising
a regular habit, have had, for one reason or another, to break it.
Apart from interference with these habits and these idiosyncrasies,
there are two kinds of causes of insomnia, the nervous and the toxic,
and it will become plain, as we proceed, that the two are frequently
conjoined.
Sleep may either be defective in its quantity or its quality, and
it is important for the physician to diagnose accurately the true
condition before beginning his treatment, as frequently some slight
alteration in the patient's mode of living is sufficient to re-establish
the normal conditions.
Among the causes which we may classify as nervous, pain and
other paraesthesiae hold a most prominent place, and successfully to
combat these symptoms is also to remove the sleeplessness which
results from their presence. Mental anguish, anxiety, grief and
disappointment must also be remembered in this connection. The
worry of long duration, rather than the passing tribulation, is the
most prone to induce insomnia, and it is among those who are
Insomnia. 1015
harassed for months or years by business or domestic cares that
we find the worst and most obstinate cases. Moderate and
congenial mental occupation predisposes to sleep, but excess is pre-
judicial to it, and this is as true of emotional disturbance as of over-
much intellectual exertion, while in all cases insomnia is aggravated
if the particular work is of an anxious character. Sleeplessness,
apart from the presence of pain, is often a symptom of such affec-
tions as neurasthenia and other functional neuroses, of the more
acute disorders of mind, of hysteria and of organic lesions of the
brain.
Among the toxic causes of insomnia perhaps the commonest are
deficient aeration of the blood from the faulty ventilation of the bed-
room, chronic constipation and the excessive use of alcohol, tea,
coffee and tobacco. Among less frequently occurring toxsemic
states may be mentioned those of microbic origin, as, for instance,
in the various febrile states ; those of autogenetic origin, as in
gout, renal insufficiency, arterio-sclerosis and dyspepsia ; and those
of deficient blood aeration, as in various cardiac and respiratory
disorders. It seems not improbable that fatigue consists essentially
in the circulation of certain poisons in the blood, and it may well be
mentioned at this point, for it is a fruitful cause of continued
insomnia, however it may have been originally induced.
It will be plain from the above that the physician will, as a
prelude to his treatment of a sleepless patient, have a large field to
explore in the domain of etiology. In some cases treatment
becomes simplicity itself when once the cause has been definitely
discovered. In other cases, notwithstanding a careful inquiry into
all the systems of the patient, into his habits and into his mental
condition, the cause remains obscure, while in others, again, though
the cause may be discovered and removed so far as is possible,
certain adjuvants in treatment must be employed before the proper
amount and proper quality of sleep can be restored. Of these
adjuvants we shall now give an account, premising the necessity of
using, in the first instance, the simplest and such as cannot be
followed by nocuous or toxic effects. To have immediate recourse
to hypnotics is always unscientific and frequently results in the
establishment of a habit which is as harmful to the patient as was
the original insomnia. It should also be borne in mind that drugs
tend to lose their efficacy, and that it therefore becomes necessary
to increase the amount given. In small doses there are several
satisfactory drugs whose harmful effects are only likely to display
themselves in certain individuals having a peculiar susceptibility,
but with the increase of dose it becomes more and more probable
ioi6 Insomnia.
that symptoms will arise detrimental to health and perhaps
endangering life. Sleep induced by drugs is never the same thing
as normal physiological sleep and is rather of the character of toxic
sleep.
General Measures- Premising that, so far as is possible, the
original cause of the insomnia has been removed, it now becomes
necessary to regulate the conditions of the patient's rest. It should
be laid down that the patient's work should, especially if it is of an
intellectual variety, cease at least an hour, and where possible two
hours, before he goes to bed, though it should not be forgotten that
a due amount of fatigue towards the close of the day and before
bedtime is physiological and is perhaps productive of just those
fatigue bodies which are nature's own true hypnotics. The last
meal should be neither too remote from nor too close upon bedtime.
It is probable that an interval of three or four hours between that
which is perhaps the heaviest meal of the day and bedtime is either
too great or too little. During the earliest stages of digestion there
is a tendency, widely spread in the animal world, to fall asleep, and
of this tendency we do not take advantage, but when the body is
reaping the advantages of the meal and when its fires are being fed
and its energies revived we make ready for sleep rather than for
further activity. It will be found in some persons that to transfer
the heaviest meal to the middle of the day and to cause the last
meal to be of quite a light character will diminish the tendency to
insomnia, but it is difficult to be precise in any given case as to the
amount of time that should intervene between the last meal and
bedtime. The temperature of the bedroom should be regulated,
and above all the stream of air passing through it should be
adequate. The window should be open and, as a general rule, the
wider the better. The room of the sleepless patient should be
situated in a quiet part of the house, and such noises as those of
loudly ticking clocks or rattling windows should be prevented. The
mattress and pillows should be neither too soft nor too hard, the
bedclothes should be sufficient but as light as possible. If the
patient's circulation is poor the bed should be warmed with hot
bottles or a warming-pan. Having inquired into and regulated
these details, it will be as well to order a glass of milk, which in
some cases may be warmed, to be taken the last thing before settling
for sleep. If the wakeful period occurs in the middle of the night
and after some amount of preliminary sleep light food, such as milk
or cocoa, with a biscuit or two, may be ordered to be placed at the
bedside to be taken when the patient wakes. Of itself this often
induces sleep, and even if it does not, tends to diminish the sense of
Insomnia. 1017
weariness which supervenes upon a night without sleep. The
question of the administration of alcohol may here be raised.
Given in sufficiently large quantities alcohol will, of course, produce
a somnolent condition in most persons. It is, however, highly
undesirable that the physician should order such doses of a drug
which besides having toxic effects is liable to give rise to a habit of
most serious import. In moderate doses alcohol in its various
forms has different effects upon different individuals. A couple of
ounces of whisky in hot water with a slice of lemon or a glass of
stout taken just before bedtime will, in some persons, act as an
admirable hypnotic, but, on the other hand, may in others result
in increased wakefulness. Alcohol is perhaps most useful in
febrile states accompanied by restlessness and agitation, as, for
example, in catarrh of the upper respiratory tract or influenza.
It may also be used with advantage when the patient is weakly and
anaemic and when the circulation is poor.
Hydrotherapeutic Measures are of considerable importance in
the treatment of insomnia, and are capable of producing marked
sedative effects. As a matter of general hygiene useful for
prophylactic purposes the cold morning bath is, among such as
enjoy good or very fair physical health, excellent. Cold baths and
other modes of application of cold water are contra-indicated during
pregnancy, lactation and menstruation, as also, as a general rule, in
those who suffer from rheumatism, cardiac disease, arterio-
sclerosis or albuminuria, and some forms of neurasthenia, but
amongst others it may be laid down that where the subsequent
reaction is pleasant to the patient the treatment is correct, but that
where, on the contrary, the patient is left in a cold and depressed
condition the treatment is undesirable. In such individuals the
warm bath followed by a cold douche of short duration is often
better borne. Such a douche may be satisfactorily given without
any special appliance by the contents of a large can being poured
over the back of the patient. Whether the cold bath or the warm
bath followed by a douche is given, the patient should subsequently
be well rubbed down with a rough towel. The cold bath of short
duration may also be found useful immediately before bedtime.
The succeeding reaction takes place in bed, and during it the
relatively anaemic condition of the brain, due to the increased
amount of blood contained in the peripheral vessels, tends to
produce a drowsiness which soon passes on to sleep. Among other
patients a bath, the temperature of which is between 95 and
100 F., has a better effect. The cold or hot foot bath very often
has similarly good results and involves somewhat less disturbance
ioi8 Insomnia.
to the patient. Warm and cold packs are of the greatest service.
The patient is swathed in a sheet which has been dipped in water,
partially wrung out, and laid upon the mattress defended by a
mackintosh spread. He is then covered with a sufficiency of
blankets, and in a few minutes will commence to perspire and to
feel drowsy. He may npw be taken out of the pack or left in it,
and in either case the treatment will probably be followed by some
hours' peaceful sleep. It is occasionally only necessary to apply
a local pack, which is then usually termed a compress. For instance,
a towel damped in water may be laid over the abdomen and
covered by a layer of some waterproof material, or the lower
extremities may be enveloped in an analogous way. Whatever
procedure, whether that of the bath or that of the pack, is adopted,
it will often be found that simultaneous cold compresses wrapped
round the head will be of material assistance. The effect of
any of these methods may be further enhanced by the administration
of some hot drink.
Special Causes of Insomnia. In insomnia associated with dis-
or.der of some system, the treatment is necessarily directed primarily
to the treatment of that system. Constipation, for instance, is a most
fruitful cause of insomnia, and the treatment of the latter becomes
the treatment of the former. Forthwith to lead off with hypnotics
might plainly in these circumstances aggravate the constipation, and
so ultimately the insomnia, and it must be further remembered that
constipation may lead to a dangerous accumulation of the drug in the
alimentary tract and the consequent development of most serious
toxic symptoms. It should be borne in mind that many persons are
constipated without knowing it, and that this is especially the case
among women. The answer to a perfunctory inquiry as to the
regularity of action of the bowels is often wholly misleading, and it
is not until a regular examination of the amount of faeces passed is
instituted that it is discovered that a grave state of constipation
exists. It is not necessary here to enter into the details of the treat-
ment of constipation ; it is only necessary to affirm the importance
of discovering the fact of its existence, and to point out that those
hygienic measures which should first of all be put into practice in
the treatment of constipation are just those which are in large
measure appropriate in the treatment of insomnia.
A great source of disturbance of sleep is to be found in perversion
of the functions of the viscera in general and of the aliincitttir//
tract in particular. In the stomach and intestines the food
undergoes manifold changes which, under normal circumstances,
are produced by the activities of various agencies which pass
Insomnia. 1019
unnoticed. In disorder of the alimentary tract, whether by
alteration of the character of the secretions, by a process
of improper fermentation, by an undue degree of peristalsis, by
a congested condition of the portal system, or by the absorption
of toxins, there are obtruded upon consciousness a variety of
abnormal sensations which are inimical to sleep. The regulation
of the period which should elapse between the last meal and bed-
time has been already mentioned, and here we would rather refer
to the occurrence of those special phenomena which denote
dyspepsia, such as feelings of fulness, flatulence, eructations,
nausea, and, perhaps, pain and vomiting. Such symptoms are
very likely to rouse the patient after some hours of troubled sleep,
and to prevent his going to sleep again for two or three hours,
or until appropriate remedies have been administered. These
symptoms are usually dependent upon hyperchlorhydria, and at
least may temporarily be allayed by the application of a cold
compress and the administration of bicarbonate of soda. For the
dietetic and other measures which should be taken we must refer
the reader to the articles proper to this subject. Insomnia without
abdominal pain or any very marked dyspeptic phenomena may
occur in the course of a case of neurasthenia of which a con-
tributing cause has been functional derangement of the stomach.
Hydrotherapy in the form of warm douches and cold packs, to-
gether with massage, is then of great service. In such cases it is
important to remember that hypnotics may, very readily, still
further pervert the gastric functions. The practice of giving
purgatives at night must also here be mentioned. Such drugs,
especially in the case of dyspeptics, are prone to irritate the
alimentary tract, and it may be desirable to administer them, where
they are really necessary, at some other time when they will not
disturb the rest of the patient.
Insomnia is a marked symptom in many cases of cartlio-vascular
disease. In those maladies in which the cardiac cycle is not fully
and completely performed there may occur, from loss of vascular
tonus in the vessels, a hyperaemia of the brain. In such cases the
feet are often cold, and the mere application of a hot bottle to the
extremities may suffice to produce sleep. The same effect may be
produced by the administration of hot milk or other drink, by
means of which the blood is diverted from the brain to the
abdominal vessels. A more active hyperaemia may be the result of
ventricular hypertrophy, and in such cases the bromides and
nitrites may be useful. In cases where the heart is failing
sleeplessness is at times so distressing as to threaten the patient's
IO2O Insomnia.
life from the resulting exhaustion. Here, in addition to those drugs
and other measures which are appropriate to the nature of the
lesion, the bromides, paraldehyde, and morphia are of much
service. The hypodermic injection of quite small doses of morphia
not only relieves the distress and sleeplessness, but also improves
the general condition by the induction of the rest which is the first
requirement of such a patient. In arterio-sclerosis and Bright's
disease sleeplessness may sometimes be at once relieved by putting
the patient upon a milk diet. If it becomes necessary to administer
hypnotics, the bromides, paraldehyde and amylene hydrate will be
found to be efficacious and safer than other hypnotics. The insomnia
of old age, in part probably dependent upon arterial degeneration,
may suitably be treated by dietetic means, and to place the patient
upon a purin-free dietary and to regulate his meal hours will often
suffice. If drugs become necessary the bromides, sulphonal,
trional or veronal will be found useful. In those suffering from
pulmonary affections and amongst whom cough is troublesome and
interferes with sleep, various derivatives of opium are the most
serviceable. Morphia, dionine, codeine and heroin may each be
tried, but it is important, where the prospect of length of days is
good, that the physician should exercise strict control over the
amount of the drug administered. Paraldehyde is contra-indicated
in hepatic disorder, in bronchitis and in emphysema, since it
increases the difficulty of expectoration. But here also it is
important that the cough rather than the insomnia should be
treated in the first instance, and hypnotics should be resorted to
when other means have failed. In sleeplessness of febrile origin,
as for instance during the first or second nights of a nasal
catarrh or of an influenza, opium is of great service, and no
more modern preparation has replaced pulvis ipecacuanhas
compositus [U.S.P. pulvis ipecacuanhas et opii] given the
last thing at night with a hot drink. Quinine is similarly of
immense service. In those conditions in which, as in typhoid fever,
the febrile period is likely to be a prolonged one, the bath and pack
become of prime importance in the treatment of insomnia. Where
pain is the immediate cause of insomnia, opium and its prepara-
tions, antipyrin and acetanilide are indicated. If the disease is
one likely to last for a long time, and especially where it is unlikely
to have a speedily fatal issue, extreme caution must be used in the
administration of morphia, and the physician should rigorously
keep the use of the syringe in his own hands. At the commence-
ment the dose given should be a minimum one, and if possible the
patient should not know the name of the drug given.
Insomnia. 1021
Before passing to the hypnotic drugs the practice of hypnotism
must be alluded to. Suggestion without the deeper degrees of
hypnosis may well he practised by the physician as an accompani-
ment to other methods of treatment, and it may occasionally prove
of value with no adjuvant. It is not to be regarded as replacing
such therapeutic measures as may be suggested by a discovery of
the cause of the malady. Its practical application requires time
and often more time than the patient and physician can well afford,
and it may be regarded as being specially indicated where the
hypnotic drugs are contra-indicated either by the patient's
personal idiosyncrasy or by some particular feature of some
organic disease. The same applies to hypnosis of deeper degree, a
degree often very difficult to produce in sleepless persons, while it
should not be forgotten that even as the most harmless of drugs
have been known on rare occasions to produce toxic symptoms, so
also may hypnotism in certain individuals produce nocuous results.
It is, perhaps, hardly here necessary to emphasise the point that
hypnotism should on no account be practised by any person save by
a qualified practitioner. In the hands of the charlatan this
therapeutic agency becomes fraught with intellectual and moral
danger.
We now turn to a review of the hypnotic drugs. Of these there
is a large number, indeed, almost a redundancy, while the list
enlarges as time widens the scope of organic chemistry. Year by
year new drugs characterised by long, polysyllabic, scientific titles,
and by short, attractive officinal appellations, are introduced and
vaunted. A few of these stand the test of time, but for the most
part they disappear. The physician, bearing in mind that the best
of hypnotics is the therapeutic agent which removes the cause of
the insomnia, has a wide choice of medicaments which were
unknown to his immediate forebears in medicine. He will find
that his sleepless patient has probably also a wide knowledge of
such drugs, and it may happen that his first duty will be to
restrain the patient from dosing himself with many preparations,
or with increasing doses of some one preparation. Generally
speaking, when prescribing a hypnotic, it is desirable to bear in
mind, firstly, the age of the patient and his physical condition ;
secondly, the fact that drugs differ as to the amount of time they
take to produce effects ; and, thirdly, that some are depressing and
some stimulating. It is inadvisable to keep a patient too long on
any one drug, as, in the first place, drugs are apt with continuance
to lose their effects, and in the second place seemingly to become so
essential to the patient that he becomes obsessed with the idea
IO22 Insomnia.
that he cannot do without them. Hypnotics are often continued
for a much longer time than is necessary, and the physician
should make frequent essays to diminish the quantity originally
administered, and so gradually to withdraw the drug altogether.
It were well if it were generally feasible to provide the patient with
his medicament and not with the prescription therefor, and an
attempt should be made in every case to do this. Patients
continue to make use of prescriptions long after their legitimate
use has ceased, and, which is even worse, hand their prescriptions
on to friends whom they may hope to benefit. Among the most
commonly used drugs is veronal, of which the chemical synonym is
diethyl-malonyl-urea. It may be given in doses up to 10 gr.,
but quite small doses of 2 or 4 gr. are often efficacious. It
is very slightly soluble in water, and is best given in a little warm
milk about half an hour before bed-time. In the case of this drug,
as in the case of others, the time which elapses between ingestion
and effect varies with different individuals, but of veronal it may,
on the whole, be said that it is a rapidly acting drug. The
monosodiuni salt of this substance is known as medinal or
sodium veronal. It has the advantage of being soluble, and should
be given in half a tumbler of warm milk or water. Being a urea
compound, veronal should be administered with care and only
under the direction of a medical man. The accidents which have
happened owing to its use have usually occurred when it has been
given in the form of a tabloid or cachet, and where no doubt the
dose has been repeated before the original one has become dissolved.
Among the earliest toxic symptoms of an overdose of veronal is
a tottering gait, which is suggestive of a slight degree of drunken-
ness. Other symptoms of not infrequent occurrence are headache
and cutaneous rashes. The rash has been described by some as
rubeoliform, but more commonly is like the rash of typhoid fever,
though the elements are far more thickly set than are usually the
elements of the typhoid rash. It is of great importance in the
continued administration of veronal and kindred drugs to secure a
free evacuation of the bowels. The toxic symptoms which
occasionally develop after comparatively small doses almost always
occur in those who are constipated, and this is no doubt to be
attributed to the collection of the drug in the intestinal tract. If
this collection is prevented there is little to fear from the adminis-
tration of medicinal doses. Somewhat similar drugs are bromural,
hedonal, trional and sulphonal. The first of these may be given
in doses of 5 to 10 gr. in cachets or made up as tablets ; it is a
mild and seemingly safe hypnotic and particularly useful in cases
Insomnia. 1023
where the sleeplessness is due to some undue amount of excitement
or work. Hedonal may be given in doses of 15 to 30 gr. in
cachet, in tablet, or suspended in milk, and the effect is rapidly
produced. Sulphonal is very widely used. Its synthetic name is
dimethyl-rnethane-diethylsulphon, and it may be given in doses
of 10 to 30 gr. in cachets, capsules, tablets or suspended in
mucilage or in hot milk. The drug in the vast majority of cases
produces its effect about four hours after it has been taken, and
even in some cases not until the following day or night. It is a
medicament which should not be continued for many days together,
and it is of the utmost importance that while it is being given the
bowels should be freely opened daily. Among the most usual toxic
symptoms are feelings of weakness, inco-ordination of gait and
speech, vomiting, diarrhoea, or constipation and hrematopor-
phyrinuria. This last condition is of the most serious import, and
many patients exhibiting it die after a week or ten days. Trional
and tetronal are similar to sulphonal, but are less reliable. Trional
may be given with paraldehyde, suspended in oleum amygdalae, either
by the mouth or by the rectum. It is most efficacious in simple
sleeplessness in old persons and in some types of neurasthenia.
Paraldehyde is a very valuable drug, but unfortunately is repulsive
to the smell and taste, and as it continues to be excreted by the
lungs and perhaps by the skin for many hours after its effect has
passed off, it is exceedingly unpleasant both to the patient and to
his companions. Its dose is from 30 min. to '2 or 3 drachms, or
even more, and it may be given in capsules or with lemon juice or
other flavouring agents or emulsified with the white of an egg.
It is not wise to continue the use of this drug in old persons, owing
to its action on the respiratory tract.
Amylene hydrate is a useful hypnotic which may be given in
doses from 30 min. to 2 drachms. It may be administered in
capsules, but as it is not very unpleasant in flavour it may be given
with water only or with some mild flavouring agent. Dormiol is
of a very similar composition and action, but is more uncertain in
producing sleep. Potassium bromide and other bromide salts are
admirable drugs and are particularly indicated where there is any
suspicion of epilepsy being present. Seven to 30 gr. given at
bedtime will often produce speedy effects and the sleep is of a
peaceful character. The smaller doses of bromide frequently act
better than the larger doses. It may be given with chloral hydrate,
and its effect seems to be even better in this combination, especially
in those cases in which the insomnia is severe and of long standing
and in which the bromide salt alone is of little avail. Chloral is a
IO24 Insomnia.
very sure hypnotic and quickly produces sleep, but is a cardiac
depressant, and, like the bromides, in large quantities may produce
gastro-intestinal irritation. It should therefore be given with
considerable caution in diseases of the heart, lungs and alimentary
tract. Chloralamide may be given in doses from 15 to 45 gr. It
is best given dissolved in a small quantity of brandy and taken
with water at bed-time. Butyl-chloral hydrate and chloretone
are similarly mild preparations, and are useful only in slight
degrees of insomnia.
MAURICE CRAIG and E. D. MACNAMARA.
1025
LUMBAR PUNCTURE.
THE spinal cord in the adult terminates at the level of the lower
part of the first lumbar vertebra. Below this level the arachnoidal
sac extends, as a hollow cavity, as far as the second sacral vertebra.
Thus, between the second lumbar and the second sacral vertebrae, we
have a space devoid of spinal cord, containing only the roots of the
cauda equina suspended in the cerebro-spinal fluid. From this
region, by entering the arachnoidal sac from behind, the fluid can
be withdrawn without risk of injury to the cord.
The two widest interlaminal spaces are the one between
the third and the fourth lumbar, and the other between the
fourth and fifth lumbar vertebrae. Of these two the lower is
slightly wider and more easily accessible. To identify these
spaces we take the following landmarks: A horizontal line drawn
across the back at the level of the highest part of the iliac crests
intersects the vertebral column at the tip of the fourth lumbar
spine. We make our puncture immediately below this spine. A
platino-iridium needle of fairly large calibre and measuring at
least 8 cm. in length is used for performing the puncture. The
patient should, if possible, be made to sit on a low seat, stoop-
ing well forwards with the knees separated, the arms hanging
loose and the hands touching the ground. In this posture the
laminae are separated to their widest extent. If, however, the
patient is bedridden, or comatose, he may lie in the left lateral
posture, with the hips close to the edge of the bed, the knees and
shoulders being closely approximated. We carefully sterilise the skin
at the site of the puncture, and unless the patient is already uncon-
scious, we render it locally anaesthetic by means of an ethyl-chloride
spray. Placing the left index finger on the fourth lumbar spine as
a guide, we push the needle in with the right hand, about ^ inch
below this spot and slightly to the right of the middle line, directing
the point of the needle horizontally forwards and slightly inwards.
Deep in, the ligamentum subflavum, between the laminae, is en-
countered as a somewhat resistant band, but pushing firmly on, if
no bone is struck, the ligament is somewhat suddenly pierced, and
the needle penetrates the spinal theca, which lies close against the
dorsal aspect of the spinal canal. If we happen to strike a lamina
instead of a ligament, we withdraw the needle somewhat, and try
again, above or below. In a normal case the cerebro-spinal fluid at
once begins to escape from the needle. No suction should be
S.T. VOL. ii. 65
IO26 Lumbar Puncture.
employed to start the flow. If the fluid does not run, a sterilised
stilette should be passed along the needle to make sure that its
lumen is clear. If the lumen is clear and still no fluid comes, it
may be that the spinal theca has been displaced forwards instead of
penetrated by the needle. In this case, it is best to start afresh,
making another puncture at the interlaminal space above or
below.
Examination of the cerebro-spinal fluid thus obtained is frequently
of the utmost diagnostic value. The physical, chemical, cytological
and bacteriological characters of the fluid may be of supreme value
in many diseases of the central nervous system. With these,
diagnostic points, however, we are not directly concerned. For
fuller details, the reader is referred to text-books on the subject. 1
As a therapeutic measure thecal puncture may be employed in
various ways.
(1) Withdrawal of a certain quantity of cerebro-spinal fluid is
often beneficial for the immediate mechanical relief of cases of
increased intracranial pressure, e.g., in meningitis of any variety,
in uraemic coma, in coma due to fracture of the base of the skull,
and in certain intracranial tumours. Great caution should be
observed in cases of tumour in the posterior cranial fossa, lest
sudden withdrawal of the cerebro-spinal fluid may introduce prolapse
of the pons and medulla towards the foramen magnum, with conse-
quent pressure upon the vital centres.
(2) Thecal puncture may also be employed therapeutically for the
purpose of injecting remedial substances into the cerebro-spinal
cavity. Thus, for example, we may inject antitoxic sera in such
diseases as epidemic cerebro-spinal meningitis, tetanus, etc.
(3) We may also employ thecal puncture for the purpose of
injecting anaesthetic drugs to produce spiryal anaesthesia prior to
operation on the lower limbs and trunk. Amongst the drugs most
commonly used for this purpose we may mention stovaine (with or
without strychnine), and novocaine. Spinal anaesthesia is specially
valuable in cases of profound shock, in acute abdominal conditions,
in patients with severe cardiac or pulmonary disease, in fact, in
many cases where a general anaesthetic is particularly hazardous.
Spinal anaesthesia, however, should be avoided in young children,
in most cases of hysteria and in severe scoliosis.
PURVES STEWART.
REFERENCE.
1 Purves Stewart, " Diagnosis of Nervous Diseases," 2nd ed., 1908, p. 385.
IO2J
MIGRAINE AND OTHER FORMS OF PERIODIC
HEADACHE.
MIGRAINE.
IT is convenient to consider the treatment of this disease as con-
sisting of three branches, each of which is directed towards the
attainment of a distinct object : (1) Treatment directed towards the
removal or mitigation of the numerous conditions which- act as the
immediate exciting causes of the attacks ; (2) the continuous
administration of remedies during the intervals between the attacks
with the object of rendering the attacks less frequent and less
severe ; and (3) the treatment of the patient during the attack with
the object of relieving his immediate suffering.
Treatment Directed to the Exciting Causes of each Attack.
By far the most frequent individual exciting cause of an attack of
migraine IB fatigue, both physical and mental, and careful attention
must be paid to any conditions which tend to lower the nutritional
condition of the patient or which make too great demands upon his
physical resources. The hours of work, recreation and rest should
be judiciously apportioned, and causes for mental worry and
depression as far as possible avoided. The hygienic surroundings
of the patient should be good, and regular exercise, fresh air and
sunlight are highly desirable. It is of the greatest importance that
the nutrition of the patient should be improved and then kept at
as high a standard as possible, for it is an unvarying rule in this
disease that the better the general state of health of the patient is
the fewer and the less severe his attacks become. The most severe
and frequently recurring attacks are often seen in patients who,
from the conviction that the malady is owing to dyspeptic troubles,
have come to restrict their diet more and more, with the result that
nutritional failure and loss of weight have supervened. In such
patients, therefore, who are thin and cachectic it is often of signal
advantage to commence treatment with a few weeks' complete rest
in bed, with liberal feeding and massage. In this connection, too,
it is all-essential to rectify any unhealthy condition of the
alimentary canal, such as dyspepsia, dilatation of the stomach and
constipation, to improve the appetite by the use of such tonics as
iron, strychnine, arsenic, the hypophosphites and the glycero-
phosphates, by regular and compatible exercise, and by change of
652
IO28 Migraine.
air and scene, and to allow a liberal diet. It is best to avoid the
use of alcohol entirely except in patients who have passed middle life.
Indiscretions in diet and dyspeptic states have held an important
position both with the medical profession and with the laity as
exciting causes of migraine, and it is easy to realise that from the
early nausea and subsequent vomiting the patient may be readily
convinced that his " bilious headaches " are of gastric origin. But
while it is quite true that in a few patients certain articles of
diet will invariably bring on an attack of migraine, yet it is
probable that dyspeptic conditions play little or no part in the
etiology of migraine except as agents in the production of a poor
nutritional state, and that any improvement which careful dieting
and treatment of dyspepsia bring to the migrainous patient is the
result of the improvement in bodily health thus brought about.
Provided that a full and nutritious diet is secured for the patient,
and that those things are avoided that are known to upset his
digestion or to bring on his headaches, there is no need to lay
down any rules. Since there seems to be no evidence that the
gouty diathesis or the presence of actual gout is a causative factor
of migraine, though the two conditions not unfrequently co-exist,
no advantage can be expected from the exemption of meat and
other purin-producing substances from the diet nor from the
employment of hydro therapic and such other measures as are
commonly employed for the treatment of goutiness, though all of
these have been largely advocated for the treatment of migraine.
Errors of refraction, diplopia and other ocular troubles are in
some patients important exciting causes of migrainous attacks.
Two very striking examples of this have been observed by the writer,
for in both of these cases the artificial diplopia produced by placing a
prism in front of one eye for a few minutes was always followed by
an attack. Quite recently the old conception of the ophthalmic
origin of migraine has been revived, and some ardent advocates of
this theory have gone so far as to maintain that all migraine is
the result of eye-strain. The facts that no ocular defect exists in
the majority of severe cases of migraine, and that looked at from
the side of errors of refraction migraine is a remarkably uncommon
accompaniment, at once remove ocular troubles from the position
of essential factors of migraine into a true perspective, as simply
exciting causes of the attacks. It is, therefore, absolutely essential
that the eyes shall be carefully examined by a competent observer
in every case of migraine, and that any defect found shall be care-
fully corrected and repeatedly re-corrected as time goes on. In a
few of the cases where some ocular defect exists, great improve-
Migraine. 1029
ment in the migraine occurs when the defect is corrected ; but in the
majority of cases there is little benefit .in such correction alone, in
the absence of other treatment.
In many cases such events as a long railway journey, the travelling
in a closed vehicle, the attentive watching of a brilliantly-lit stage
or of a moving crowd, the driving against a cold wind, or a stay in
an overheated room are potent exciting causes of attacks. The
treatment is, 011 the one hand, to avoid as far as possible the exciting
cause, and on the other to fortify the patient against the exciting
cause by the administration of certain remedies, which should be
taken an hour before exposure. The most useful combination is
sodium bromide (10 to 15 gr.) with liq. strychnin On.5) [U.S.P.,
strychninae hydrochloridi, ^ gr.] and phenazone (10 gr.). A
cachet composed of aspirin (10 gr.), phenacetin (10 gr.), and
caffeine citrate (2^ gr.) is sometimes advantageous in place of the
phenazone.
Treatment Between the Attacks. In the foregoing paragraphs
enough has been written to give all indications for the general
management of the patient. As regards regular medicinal treatment it
must be pointed out to the patient that the remedies will only avail
him if taken with regularity and over a very long period, and that
he is to expect a slow and steady improvement both in the severity
and in the frequency of the attacks rather than that his attacks will
cease altogether, although the complete cessation of the attacks
under treatment is by no means beyond the bounds of likelihood.
He must be told that the remedies which he takes between the
attacks must be omitted at once if an attack occur, for if not they
will tend to make the headache during the attack unusually severe,
;uul he must be instructed that at the slightest warning of an
oncoming attack he must have recourse to other remedies, which
will be described below under Treatment of the Attack.
There seems to be one combination of drugs the value of which far
exceeds that of all others in the inter-paroxysmal treatment of mi-
graine, and it is made up of nitro-glycerine, strychnine, gelsemium
and an alkaline bromide, the necessary adjuvant being some
stable acid, such as dilute phosphoric acid, since nitro-glycerine
is only stable in an acid medium. The nitro-glycerine should
be given in the form of liq. trinitrini [U.S.P., spiritus glycerylis
nitratis] in doses of from to 2 minims, the object being
to give as large a dose as possible short of producing the
least discomfort from head-throbbing. As a rule, 1 minim is well
borne. The strychnine should be given in full doses of -$ gr. to an
adult and in much smaller doses to children, while 5 minims of
1030 Migraine.
tr. gelsemii and 10 gr. of potassium bromide with 5 drops of
dilute phosphoric acid complete the mixture, which should be given
thrice daily after food. The writer has not had the experience of
any case of migraine which was not considerably improved by this
treatment, which may be continued with increasing advantage for
many months. The recent researches of Spitzer have led him to
the conclusion that in cases of migraine there is a narrowing of one
or both of the foramina of Munro, which allows of the temporary
blocking of the foramen by the choroid plexus, with the production'
of a temporary distension of one or both of the lateral ventricles
with cerebro-spinal fluid, and that the symptoms of migraine are
the phenomena resulting from this temporary distension. The
distension, and, therefore, the symptoms, are relieved by the fall of
blood-pressure and of inter-cranial tension which occurs when the
stage of vomiting and partial collapse is reached. These considera-
tions have suggested a line of treatment which may be used with
advantage in addition to the foregoing, and especially in cases
where the attacks show a regular periodicity in their' recurrence,
and where we may with some degree of certainty anticipate the
advent of an attack by the administration of remedies. This line
of treatment aims at keeping the blood-pressure and the intra-
cranial tension low, and so hindering the tendency to the blocking
of the foramina of Munro, if such indeed occurs. Now it is quite
certain that the regular exhibition of diuretics tends to keep the
intra-cranial tension low by diminishing the output of cerebro-
spinal fluid, and those remedies which tend to lower the blood-
pressure, and keep it low, tend to lower the intra-cranial pressure,
in that the former is the chief causative factor of the latter.
Therefore the administration of such diuretics as theocin sodium
acetate (in 5 gr. doses), combined with potassium or ammonium
acetate and digitalis, and a remedy which tends to lower the
blood-pressure, such as sodium benzoate (in 10 to 20 gr. doses) given
thrice daily, should be used regularly in refractory cases and
temporarily in cases where an attack can be anticipated with
any degree of certainty. If we hold to Spitzer's theory of the
production of migraine we explain the value of nitro-glycerine, in
that it is a remedy which is likely to reduce the intra-cranial
pressure and so to prevent blocking of the intra-cerebral foramina.
However this may be, it seems certain that nitro-glycerine has
more, effect in benefiting the subjects of migraine when given in
the liquid than in the tabloid form, and in the writer's experience
it is more useful and produces fewer disagreeable effects than either
sodium nitrite or erythrol tetra-nitrate.
Migraine. 1031
Many other remedies have been strongly advocated for the relief
of migraine, and among them are ergot, belladonna, hyoscyamus,
cannabis indica, iron, arsenic, iodide of potassium and ammonium
chloride. Of many of these the writer has had no experience.
The important value of iron and arsenic has already been referred
to and explained, while of the cases reported in which iodide of
potassium has been of signal service it is just to presume that
some condition, other than pure migraine, capable of being
influenced by this drug may have existed.
Ross has found that the administration of the salts of calcium
is of much benefit in certain cases of migraine where the attacks
were associated with the occurrence of much puffiness beneath the
eyes, and it seems likely that this treatment may be of service also
in those patients in whom migraine is associated with albuminuria,
and in those cases of nephritis in which paroxysmal headaches
approaching to the type of migraine occur.
Surgical Procedures for the relief of migraine have been
advocated and found successful by Whitehead and others. They
consist in the revival of an ancient method of treatment by counter-
irritation : the placing of a seton in the back of the neck. It is
a well-known fact that when a migrainous patient is suffering
from any infective malady, such, for example, as typhoid fever,
pneumonia or influenza, the attacks do not occur, and it is quite
likely that the value of the seton lies in the fact that it induces a
chronic septic process which checks the occurrence of the
migrainous attacks.
Treatment of the Attacks. When an attack of migraine is
well developed it is seldom possible to cut it short or even to modify
its usual course to any useful degree by any kind of treatment. All
that can be done is to lessen to some extent the sufferings of the
patient. But in the early stages of the attack, and especially when
the first warnings of its approach appear, it is, in some patients,
very amenable to treatment, though in other patients quite
rebellious. The best remedy is a single full dose of any of the
coal-tar group of analgesic drugs, combined with a stimulant
diuretic. Antifebrin (in a 10 gr. dose) is perhaps the most useful,
but phenazone (20 gr.), phenacetin (25 gr.), ammonol (10 gr.) and
aspirin (20 gr.) are all useful, and it must be borne in mind that these
drugs are by no means identical in their effect, for it often happens
that one of them is highly successful and another fails altogether in
the same patient. The best diuretic to use with one of the above
is theocin sodium acetate (in a dose of 5 gr.). If these remedies
fail to check the onset of the attack, the dose should not be
1032 Migraine.
repeated, but recourse should be had to palliative measures and an
attempt made to cut short the succeeding attack by a fresh com-
bination of the above-mentioned remedies.
During attacks of any severity the patient should rest quietly in
bed in a well-ventilated and preferably darkened room, and should
be kept warm by hot-water bottles. The application of warmth to
the head, and especially to the occiput and back of the neck, is often
very grateful to the patient, and for this purpose electrically heated
pads, which can be kept at a uniform temperature and which can
be run off an ordinary wall plug by means of a single Tamp
resistance, are very convenient. As alternative measures hot
fomentations, poultices or sinapisms may be used.
It is desirable to engender sleep as soon as possible, and for this
purpose chloral hydrate (10 gr.), butyl chloral (20 gr.), or veronal
(5 gr.) may be used, and of these remedies veronal is in my
experience the most efficacious. It is obvious that these remedies
must not be given when the patient is vomiting, but they may be
used with advantage early in the attack or after the vomiting has
ceased. The hypodermic injection of morphine affords striking
relief in some cases, but it is more often useless, and sometimes
increases the vomiting and lengthens the prostration after the
attack is over. For these reasons, and because the habitual use of
morphine may be set up in those patients who are at once relieved
by this drug, it is better avoided altogether in the treatment of
migraine. The application of the constant current to the head, the
anode being applied by a large pad electrode to the region of the
pain, has been vaunted as giving relief during the attack, but in
most cases it is quite useless.
Alcohol is certainly beneficial in many cases, and it may be
expected to lessen the headache, check the vomiting and induce
sleep. A dose of \ oz. of brandy may be given early in the
attack, and this may be repeated with advantage when the stage of
vomiting is reached.
The feeding of the patient during the attack is not of importance
in most cases, for the attacks do not last more than twenty-four
hours, and from the nausea and anorexia which the patient suffers
he has little inclination to do more than relieve thirst. But when
the attacks last from two to three days, or when shorter attacks
occur at frequent intervals, it becomes imperative to feed the
patient during the attacks. Small and easily assimilable meals are
indicated, and a dry diet consisting of toast and underdone meat or
chicken, such as is used in the treatment of sea sickness, is often of
great advantage.
Periodic Headache. IO 33
OPHTHALMOPLEGIC MIGRAINE.
No special treatment is indicated .in the rare cases in which
paralysis of some of the ocular muscles, usually transient but
sometimes permanent, follows an attack of migraine : they are
amenable to the same procedures as are cases of the ordinary type.
OTHER FORMS OF PERIODIC HEADACHE.
It is a frequent experience to meet with patients in whom
periodic headaches occur, which differ widely in type from those of
classical migraine. Thus the visual phenomena may be always
absent, the headache may be bi-lateral and general, vomiting may
never occur, and even nausea may be absent. The majority of
such cases are essentially cases of migraine, and are to be treated
as such with success. A consideration of certain facts in the
history of the patient will often solve any doubt as to the nature
of the headache. In the first place if the headaches have dated
from childhood, this fact is strong presumptive evidence of
migraine. Secondly, careful interrogation will often bring to light
the fact that in some attack or other definite signs of migraine have
occurred. A patient of mine, who suffered from simple recurring
headaches, when questioned upon the subject, recalled most vividly
that twenty years before he had an attack in which the most
characteristic visual phenomena of migraine occurred. This was
the only occasion in his experience on which definite symptoms of
migraine appeared, and curiously enough on this occasion he had
no headache. Lastly, a history of migraine occurring in other
members of the family is important in the diagnosis, since this
malady is so often hereditary and familial.
There remain to be mentioned certain other conditions in which
recurring headaches occur, the treatment of which must not be
confused with that of migraine.
Headache resulting from Ocular Conditions. (Errors of
Refraction, etc.). These are not truly periodic in their
occurrence, and are apt to be at once brought on by eye-strain.
Characteristic symptoms of migraine are absent, but it must be
borne in mind that eye-strain may precipitate the attack in a case
of migraine. A competent examination of the eyes in every case of
recurring headache, and the correction of any defect that may be
present, is essential.
Headaches resulting from Disease of the Nasal Accessory
Chambers, Skull Bones, etc. The nature of the pain will usually
serve to distinguish these conditions. It is a fixed pain with
irregular exacerbations.
1034 Periodic Headache.
Headaches resulting from Gross Intra-cranial Disease,
Intra-cranial Tumour, Cerebral Syphilis, and Chronic Hydro-
cephalus. In the early stages of intra-cranial tumour, and before
the more obvious signs of involvement of the nervous system
appear, periodic attacks of headache associated with vomiting often
occur, and may closely resemble the common variety of migraine
in which no visual phenomena occur. These attacks are often
referred to by the patient as " bilious attacks," a term which is
frequently used by the laity for attacks of migraine. In this
connection it is important to bear in mind that it is rare to meet
with vomiting in cases of brain tumour in the absence of optic
neuritis, and that ophthalmoscopic examination is an essential step
in arriving at a correct diagnosis in every case of recurring
headache. The same remedies as have been advocated for the
relief of the migrainous attack will be found to be those most
successful in relieving the headache and vomiting of gross
intra-cranial disease.
Headaches associated with High Arterial Tension, Renal
Disease and Uraemia. The mechanism of the production of
recurring headaches in the subjects of high arterial tension is
obscure. Since the intra-cranial pressure varies directly with the
blood-pressure, provided that the walls of the cerebral arteries are
elastic and that their channels are not obstructed by endarteritis,
it is presumable that the headache may be the direct result of the
high intra-cranial pressure, and that measures which tend to lower
the general blood-pressure will relieve such headache.
This seems to be the case in subjects who have not passed middle
age, in whom the arterial tension is very high, and who do not
present a severe degree of arterial degeneration as determined by
the examination of the palpable arteries and by the ophthalmoscopic
examination of the retinal vessels, and in these patients measures
which tend to reduce the arterial tension should be employed. A
carefully regulated diet, with a reduction in the quantity of meaty
foods taken, the securing of a regular free action of the bowels, and
the administration of 2 gr. of pil. hydrarg [U.S.P., massa hydrargyri]
on alternate nights are all-important, while the blood-pressure may
be further reduced by the regular administration of sodium benzoate
(10 to 20 gr.) or sodium nitrite (3 to 5 gr.) thrice daily, with a
diuretic such as sodium acetate. The value of aspirin in 10 to
20 gr. doses in securing immediate relief from these headaches is
considerable.
On the other hand, where arterial degeneration is severe, and
especially in patients who have passed middle life and in whom
Periodic Headache. 1035
narrowing of the channels of the cerebral arteries is likely to exist,
the intra-cranial pressure is not raised to a corresponding extent
when the arterial pressure is high, and it is highly probable that
headache occurring in such cases is due to a relative insufficiency
in the amount of blood passing through the brain, caused by the
narrowing of the arterial channels from endarteritis, and experience
tells us that a stimulant method of treatment as opposed to the
above-mentioned depletive method of treatment is often highly
successful. To this end strychnine combined with bromide of
potash should be given, and the addition of digitalis is often useful.
Alcohol and an increase in the more stimulating portions of the diet
such as underdone meat are often indicated. In this connection it
cannot be too strongly insisted that to the patient with advanced
arterio-sclerosis a high arterial pressure is essential to his life, for
otherwise a sufficient circulation of blood through his tissues cannot
be maintained. Further, since the sclerosis of the peripheral
vessels has destroyed their motility, the peripheral resistance
cannot be altered, and the only means at our disposal by which the
arterial pressure can be lowered is the lowering of the heart's force,
an event fraught with every danger to the patient in the way of
heart failure and thrombosis in the peripheral vessels.
In conditions of renal disease and in uraemia headache is
doubtless the result of toxaemia, and when small white kidney or
granular kidney is present cerebral vascular disease may be adju-
vant causes. The treatment is that of Uraemia (sec special article,
p. 837). When it is borne in mind that a relative failure of
the heart's force is the precipitating cause of the appearance of
urieinic symptoms, the importance of cardiac stimulants in the
treatment of this condition needs no comment. Aspirin is a
valuable remedy for the immediate relief of the headache.
JAMES COLLIER.
EEFERENCES.
Gowers, Sir W. E., "Diseases of the Nervous System," 2nd edit., London,
1893, II., p. 984. Liveing, E., " On Megrim and Sick Headache," London,
IST.'J. Spitzer, A., Neurol. Centrabl., Leipzig, 1901, XX., p. 755.
1036
NIGHT TERRORS.
THE differentiation between nightmare and night terror is well
marked in cases at either end of the scale, but there are many
intervening degrees and apparently they are closely allied in their
mode of causation. Nightmare is commonly due to digestive
disorder or mal-aeration of the blood. The asphyxial type of night
terror is similar in origin and the terror is subjective. It depends
on deficient oxidation, due to adenoids or enlarged tonsils, or on
gastric disturbance, perhaps through reflex stimulation of the vagus.
The primary cerebral or idiopathic type occurs in neurotic or
neurasthenic children in whom no asphyxial or alimentary cause is
discoverable. The terror is objective and due to over-excitement of
the cerebral cortex. Frequently there is a neurasthenic basis and
an alimentary or asphyxial exciting cause.
During the attack the child must be calmed, petted and consoled,
although unconscious of his surroundings and unable to recognise
his attendant. It lasts for a few minutes to an hour, and is
rarely repeated the same night. The child frequently falls asleep
without recovering consciousness. Hypnotics are unnecessary. A
warm foot bath, with cold affusion to the head, is of use in prolonged
attacks.
In all cases an aperient should be given, the diet and digestion
attended to, and the mode of life regulated. A grey powder and
a mixture of rhubarb and soda will cure many patients. Allow no
late supper. Insist on regular meals and that no food is given in
the intervals. Alcohol, meat extracts, tea, coffee and cocoa extracts
should be prohibited, and the amount of saccharine and starchy
foods limited, if there is intestinal distension.
The child must sleep on a hair mattress, with no heavy bedclothes,
and a low firm pillow. A bobbin should be fixed to the spine to
prevent the dorsal decubitus. The sleeping apartment must be
ventilated thoroughly. A nightlight may be allowed and an
attendant should sleep in an adjoining room with the intervening
door open. Firmness, tact and sympathy are essential in the
attendant, and a stupid or neurotic nurse must never be employed.
Carious teeth and disorders of dentition must be treated. If the
alimentary tract is in a healthy state, any cause of asphyxia, such
as adenoids and enlarged tonsils, should be sought for and removed.
Night Terrors. 1037
Phimosis, retained smegma, refractive errors, impacted wax in the
ears, and other sources of local irritation, are of doubtful import, but
should receive attention.
In the primary cerebral or idiopathic type the usual digestive and
asphyxial causes must be treated, since they are as likely to be
present in the neurotic as in other children. In addition it may be
necessary to limit the school work to the morning hours or even,
in the worst cases, to forbid it altogether for some months. Children
subject to night terrors are usually clever and precocious, and will
not suffer mentally from some delay in their education. Examina-
tions, exciting and competitive games, pantomimes, parties and late
hours must be forbidden. The child must be protected from excite-
ment, threats, ghost stories and gruesome tales, unpleasant sights
and shocks, ugly pictures and the appalling toys wrongly considered
suitable for children, especially during the hours before bedtime.
A dose of bromide, phenazone, bromural, or bromide and chloral,
can be given at bedtime for a few days until the habit is broken.
If pavor occurs in the daytime bromides or phenazone can be given
three times daily.
Change of residence, cold bathing and sea bathing are often of
remarkable benefit. The general health is best assisted by iron
and arsenic for anaemia and by cod-liver oil for malnutrition,
provided always that alimentary disorders have been efficiently
treated.
EDMUND CAUTLEY.
io 3 8
NEURASTHENIA.
IN neurasthenia the symptoms depend essentially upon a con-
dition of irritable weakness of the nervous system, and their
character is determined by the part of the nervous system which
has been specially exposed to strain or injury, or is the seat of
inherent over-sensitiveness. It is to be regarded as a true disease
determined by derangement of function unaccompanied with any
gross change in structure, and is of two varieties.
The treatment of the condition of neurasthenia is one of no
little difficulty, requiring insight on the part of the physician, com-
bined with unlimited tact and infinite patience. In the slighter
varieties the patient is able to go about his work to all outward
appearance quite well. It is only to his wife or to his physician
that he unburdens himself, and in this act he unconsciously
exaggerates his symptoms. Such a patient is to be encouraged to
continue his work, which he usually carries out efficiently and
successfully. It serves as a distraction, and it is only under con-
ditions which offer no restraint that he becomes conscious of and
communicative about his discomforts.
Sometimes there is a degree of excitability which calls for firm
remonstrance and the use of sedatives. In such conditions bromide
is of inestimable service, and where it has to be given it should be
given generously in doses of 1 drachm, or even more, in the day.
The cold or tepid spinal douche, as a daily application, is also
useful in such cases, frequent rest and change are urgently called
for, and generous feeding is a necessity. The cephalic sensations
in such cases are not, as a rule, amenable to the influence of drugs.
Phenazone or phenacetin with caffein or some similar drug
occasionally gives a little relief ; a mustard leaf at the back of the
neck is much more useful, and spinal pain or discomfort is best
treated by means of the cold or tepid douche. Cardiac discomfort
is often relieved by a plaster, belladonna or any other variety,
over the heart region, and a flannel belt is often most useful in
relieving abdominal discomfort, especially if the patients, as is not
infrequently the case, are the subjects of enteroptosis.
To the sleeplessness which is so common in neurasthenia much
attention must be given. Sometimes it is found to be associated
with flatulence and dyspepsia, and the diet must be modified and
Neurasthenia. 1039
intestinal disinfectants or sedatives, like salol and bismuth, given
with care and discrimination. When the sleeplessness is of the
intra-nocturnal variety, i.e., occurring' after a period of sound sleep
and followed by a period of broken and unrefreshing sleep, it can
often be overcome by getting the patient to have a small meal of
biscuit and milk when he wakes from his first sleep. The solid
part of this meal is essential, as milk alone is often ineffective. In
many cases a little gentle rubbing, especially to the head and the
back of neck, will suffice to procure sleep, and this is especially true
of the cases in which sleep is difficult to obtain in the first part of
the night. Often, however, it is necessary to resort to sedatives,
and in my experience the most effective by far is bromide. I have
never known bromide do harm in these cases given, if necessary, in
drachm or even a whole drachm dose at bedtime, sometimes
alone, sometimes with bicarbonate of soda, sometimes with bismuth,
and usually in hot milk as a vehicle. I believe that to many
neurasthenics a nightly dose of bromide is not only harmless
but distinctly helpful. Trional may occasionally be given, and in
cases in which the sleeplessness is very obstinate the combination
of trional with bromide is nearly always effective. Opium in any
form is to be avoided.
In cases in which the condition of neurasthenia is very pro-
nounced it is only to be relieved by much more radical measures.
The active professional or business man who finds that the strain
is becoming intolerable must be ordered away at once. A sea
voyage, if it is fancied, is often of inestimable use if it is undertaken
in suitable conditions and with congenial companionship ; a quiet
month or two in the country in bracing mountain air, involving a
complete change of interest and environment, are often sufficient
to effect a complete cure. Similarly, to the often thin, anaemic,
sleepless housewife, so long as the nervous signs are not very
active, a complete change to a bracing climate with fresh air and
simple abundant food will often work wonders and effect much
more than many drugs, and even more than can be got from more
elaborate treatment. Mountain or moorland country is better as a
rule for such cases than seaside.
It will be seen at once that the treatment of a case of
neurasthenia is by no means simple. Each case is a problem in
itself, although there are broad general principles underlying the
treatment of all. Any local condition must, of course, be attended
to. Dyspeptic symptoms, a dragging feeling resulting from a
floating kidney, and actual mucous colitis, are not infrequently
present in association with neurasthenia, especially in women, and
1040 Neurasthenia.
undue attention may be concentrated on these symptoms. Appro-
priate treatment, both medicinal and mechanical, must of course
be adopted in such cases. In the cases of sexual neurasthenia
there is often present an exaggerated idea of the bad effect of
youthful indiscretions, and the physician must set himself to dispel
the patient's morbid remorse over such matters. And so with
other symptoms ; a strenuous effort must be made by his adviser
to get the patient to see matters in their real relationship, and to
dispel the distorted view of them which he has pictured for
himself.
In severe cases of neurasthenia these general measures are not,
however, sufficient, and the condition of the patient, her aches and
pains, her disagreeable faint feelings, her general weakness and
want of energy, make any treatment in which she has to assume an
active part almost impossible. It is necessary to get such patients
into good condition. This can only be done by copious feeding,
yet copious feeding when exercise cannot be taken can only lead to
discomfort and actual dyspepsia. The substitute for active
exercise is to be found in passive exercise or massage, and in the
use of a mild faradic current, which will cause contraction in the
muscles without pain or fatigue to the patient. The massage,
rubbing, pinching and kneading of muscles, so as to cause the
fibres to contract and to force blood through them, acts by leading
to such changes in their metabolism and in that of the organs
generally, as are produced by active exercise. And the same is
true of the contractions produced by faradism. It is necessary
to describe in some detail the conduct of a case under this, the
Weir Mitchell method of treatment, a method which, although
most useful as a rule in the case of female patients, is often called
for and successfully used in the case of males.
It is, of course, essential that the patient should be separated
from her friends, and in the great majority of cases, it is desirable
to have her in a nursing home. In any case she must be in
the hands of a well-trained capable nurse, who is kind, firm,
sympathetic, but unemotional. All letters are stopped, absolute
rest in bed is essential, and the patient is not allowed to leave it
for any purpose. In bad cases the adoption of the recumbent
posture even during meals is necessary for the first few days at
least and even for longer.
For the first three days, no food except milk and rusks is given.
The milk should be given in quantities of 4 oz. every two hours
at first, but the total quantity in twenty-four hours should be
increased to 2 quarts by the end of three days. The patient
Neurasthenia. 1041
should not be waked at night, but her milk should be placed by
her bed so that she may drink it if she wakes. After three days
of this simple diet, a small morning meal should be given, a little
fish with bread and butter, and bread and butter with milk in the
evening. Then two days later, i.e., on the fifth day of treatment,
a cutlet may be given in the middle of the day, and in two or three
days more three light meals should be given in addition to the
2 quarts of milk. The actual composition of the meals can be left
to the nurse, but it may be of service to indicate the kind of meal
desirable, e.g., fat bacon and an egg in the morning, a chop or
cutlet with stewed fruit and cream in the middle of the day, and
fish with butter sauce in the evening.
Meantime massage is given twice daily. At first, twenty
minutes at a time is as much as is tolerable, and this is gradually
increased until an hour is given twice daily in the course of the
fifth day. The faradic current is now to be used for a quarter of
an hour twice a day, and this need not be increased. At the end
of ten days raw meat juice is to be given, an ounce daily. If it
is very unpalatable it may be given in milk, or the meat may be
quickly cooked on the outside and the juice squeezed out of it.
Such juice from half -cooked meat is more easily taken by the
majority of patients than the actually raw meat juice.
Trouble with the bowels frequently arises. At the end of the
third day, a dose of calomel is desirable, but after this it is usually
easy to regulate the bowels with fruit and butter and cream. If
this is insufficient a small nightly dose of cascara and nux vomica
should be given. It must be remembered that abdominal massage
is very efficacious in overcoming even chronic constipation.
Such are the details of the Weir-Mitchell treatment, and in
many neurasthenic cases its effects are both striking and gratifying.
Difficulties are encountered in most cases, the patient having to
be persuaded to continue the treatment, little but unessential
points in detail being conceded. But this can be done so long as
the mind is steadily fixed upon the end in view, and everything
arranged accordingly. It must be remembered that one is dealing
with a patient whose nutrition has suffered, who is depressed and
ill, and who possibly has distorted views and morbid imaginings,
and that the measures adopted are aimed at enabling her to
assimilate much food of the most simple and nourishing character,
and so to increase her bodily vigour and to improve the nutrition
of her nervous system that she may throw off all her symptoms
and return to a natural useful life.
An interesting and important variety of neurasthenia was
S.T. VOL. ii. 66
1042 Neurasthenia.
described some years ago by the late Sir William Gull, under the
name of Anorexia Nervosa. This may develop in consequence of
overstrain from nursing, etc., but in many instances no such cause
can be traced. The subjects of it are usually girls between the age
of seventeen and twenty-five (although it sometimes occurs later),
often with a keen interest in some particular kind of work, an
interest which absorbs them, even leading to carelessness about food.
As a consequence, meals become irregular, there is no compelling
appetite, and gradually and almost imperceptibly the patient
wastes. The loss of appetite grows, food becomes positively dis-
tasteful, and profound emaciation ensues. The patient becomes
nothing more than a living skeleton, and seems to be in the last
stage of pulmonary tuberculosis. But there is no cough and
careful examination reveals no disease of any of the organs. Such
a patient may actually die from weakness, or may become the prey
of some disease, yet if taken in hand and treated with rest,
abundant feeding and massage, a most gratifying and complete
recovery may confidently be expected.
In reference to the treatment of traumatic neurasthenia the
same general principles must be followed, but the special character
of the illness makes it desirable to add a few particulars. It must
in the first place be recognised that the condition is a real one,
that the headache and feeling of weight in the head, the severe
backache, with actual acute pain in the cervical and sacral region,
the sleeplessness, restlessness, loss of sexual power and other
symptoms so familiar in cases seen in the courts of law, are real
symptoms and occur not only in those who are suing for damages,
but also in others with whom such a question has never arisen at
all. In all such cases time, as a rule, effects a cure, but in any
particular case it is impossible to say what length of time will be
adequate. Complete rest of body and mind is necessary, and it is
well for the patient to get away from home. Treatment will be, as
a rule, symptomatic ; but the general condition of the patient must
be kept prominently before the doctor responsible for his treat-
ment. The nutrition must be attended to by the use of abundant
easily digested meals. Abundance of fresh air, the adoption of
almost a sanatorium regime, is also desirable. Tepid or cold
douching to the irritable spine, gentle massage to the head, are
measures which will suggest themselves in the presence of appro-
priate symptoms. If in spite of all such measures a cure is still
delayed and the patient remains thin and anxious and sleepless,
recourse must be had to a strict Weir-Mitchell course. And it
should also be remembered that in those cases in which at first
Neurasthenia. 1043
the diagnosis of traumatic neurasthenia may be the only one
possible, symptoms and signs may develop as shown by the reflexes
and the state of the sphincters, which prove that the condition
of functional derangement has become associated with actual
structural changes in the nervous system.
JAMES TAYLOR.
662
1044
PSYCHASTHENIA.
BY psychasthenia is to be understood a mental condition which
is characterised broadly by deficient control over thoughts and over
actions, to use the technical jargon, by loss of inhibition.
Several varieties of psychasthenia may be distinguished. Probably
the most important, because the commonest, is characterised by
morbid and unreasonable fears of certain conditions. The patient
who fears to cross a wide deserted space, or who runs at once if he
finds himself in a road with no other human being visible, are
victims of the variety of psychasthenia which we know as
agoraphobia. In this variety the fear is not invariably of vacant
spaces or roads. Sometimes it applies also to spacious places like
railway stations in which there may be many people present ; yet
some patients are unable to make their way across such places
unless they have someone with them, not necessarily in actual
contact.
Another class of psychasthenic patients suffer in a way ~ which
is almost the converse of this they cannot be in closed places, in
places in which there can arise any difficulty about their ability
to get out at once. Such a sufferer, e.g., is afraid to go in a rail-
way carriage. If he does go it may cause him the most acute
agony. One patient, known to the writer, cannot travel in an
express train which goes long distances without stopping. He must
travel in a stopping train, although even this is a trying experience.
Many dare not enter a train at all. Probably the disorder may be
regarded as of a slighter variety in those who can travel in an
ordinary train, but are positively afraid to do so in a " tube." A
considerable number of people are unable to go to a church, or
theatre, or any public meeting, because of this fear of closed places
(claustrophobia), and among church-goers there are some who only
dare go to church if they can sit in the seat nearest the door.
Another form which these morbid fears take is much more
vague, the fear being a vague horror of the patient knows not
what, arising suddenly and unexpectedly and almost overwhelming
him with dread. To such a patient the very vagueness of the
dread gives an added horror, and anyone who has heard such a
patient describe his feelings cannot but realise the extreme mental
pain which they connote.
Psychasthenia. 1045
The patient who comes complaining of his uncontrollable
thoughts is really of the same class of psychasthenia as those
already described. These thoughts of which he complains are
usually on subjects of which he is almost ashamed to speak,
thoughts of a horrible character concerning his nearest and
dearest, thoughts of himself in relation to others, of a kind which
causes him acute distress, sometimes but not always sexual.
In another class of patients, also mostly women, the appearance
of anything bright or sharp carries the suggestion that such
weapons are convenient for purposes of self -in jury. Even knives
on a table may suggest such an idea, the unexpected sight of a
razor nearly always produces it, and similarly looking from a
height, whether a high building or a precipice, suggests the
temptation to throw oneself over. Of course, in the psychasthenic
patient such ideas are merely uncontrolled 'thoughts and never
eventuate in action, and they are to be sharply distinguished from
homicidal or suicidal impulses.
Closely related to these is the variety of the disorder in which
the patient, often a pure-minded virtuous woman, repeats to her-
self the most horrible language, and is in dread lest she may
repeat it aloud. In a less distressing variety, the patient simply
tends to repeat things, things usually meaningless and perhaps
foolish, but the distress caused to the patient is by the fact that she
cannot help repeating these things. Nearly allied to this is the
condition of which probably Dr. Samuel Johnson is the most
notorious example, the condition in which in doing certain things
a definite way of doing it must be followed. Dr. Johnson, as is
well known, had to touch each rail as he passed along the Fleet
Street railings, and was compelled to go back if he missed one !
Some patients also are uncertain whether they have locked a door
which they intended to lock, and may have to return repeatedly to
see whether they have; they may suddenly have doubts as to
whether they have actually posted a letter which they have taken
to the pillar box, and they are frequently in doubt whether in a
letter which they have closed, they have not said exactly the
opposite of what they meant to say, and if the letter has not been
posted it has to be opened and is always found to be correctly
expressed.
Psychasthenia also includes many curious psychoses. The
condition of cdiolalia, as it is called, in which the patient repeats,
like an echo, everything that is said to him. The condition known
as myriachit in Siberia, as latah in Java, characterised by the
imitation or repetition by the patient of every action carried out
1046 Psychasthenia.
or word spoken before him, are all examples of a condition in
which control of psychical processes is lost. And practically all
the other so-called "psychical tics" are really examples of a
psychasthenic condition.
The treatment of such conditions is obviously one requiring
skill and care and time. Change of environment is of the
essence of successful treatment, and the persons surrounding a
psychasthenic patient must be recognised by him as understanding
his condition and not merely laughing at it. Patience with the
apparent unreasonableness of a psychasthenic patient is absolutely
necessary ; good hygienic surroundings are essential, as are
guidance and moral support and physical companionship under
the conditions which are specially trying to the patient. Some-
times the patient's physical condition has become much reduced
in consequence of the anxiety and worry, and often sleeplessness,
attending the disorder. Such a physical state must be treated by
measures appropriate to the relief of any neurasthenic condition,
for in such circumstances one is dealing with a condition of
neurasthenia engrafted on one of psychasthenia. Drugs, except
such as are good tonics, e.g., strychnine, phosphorus, arsenic and
iron, are not of much value, but these should be given freely, and
sedatives, such as bromide, are of much value, more especially in
the sleepless, excitable and unstable patient.
Change of environment, as has been said, is most important;
good and constant and intelligent companionship is just as
necessary, and complete removal from work is essential. A long
rest is often necessary, but even with the most industrious and
intelligent and sympathetic treatment the cure in many cases is
an imperfect one, although in not a few instances such general
treatment as has been suggested, with the firm reassurance
received from a trusted medical adviser, will result in complete
cure, or at least in very great amelioration of the condition (see
also p. 1314).
JAMES TAYLOR.
1047
TICS AND SPASMS.
Facial spasm, in its various forms, is one of the commonest
clonic muscular contractions requiring treatment. The well-known
twitching of the upper or lower eyelid, usually of one eye only,
commonly brought on by fatigue and nervous exhaustion, and
known as " live blood " or " bird-in-the-eye," may continue for
several days and be severe enough to 'Call for treatment. A long
spell of sleep, followed by a day of mild exercise in the open air,
will always relieve this, but often immediate cessation of the
irritating contractions may be brought about by applying two small
round electrodes over the closed eyelids and passing a mild rapidly
interrupted faradic current for a couple of minutes. Clonic
blepharospasm may be due to reflex irritation from errors of refrac-
tion, conjunctivitis, carious teeth, etc., and the appropriate treat-
ment of these may cure the spasm. Direct irritation of the facial
nerve by pressure of a tumour or scar tissue, or pachymeningitis,
may cause clonic facial spasm of the whole muscular distribution
of the facial nerve on one side. This may be severe and frequent,
and when chronic may be arrested either by stretching the facial
nerve or by deep alcohol injection of the facial nerve at its exit
from the stylo-mastoid foramen. This causes more or less pro-
nounced paresis of the nerve, and the cure of the spasm will last
from three to twelve months or longer. Clonic facial spasm
frequently follows incomplete recovery from an attack of facial
paralysis or Bell's palsy, the muscular twitchings being combined
with excessive contracture. Facial massage in the slighter cases
and alcohol injection of the stylo-mastoid foramen in the more
severe types will be the best treatment. Electricity only does harm
in these cases.
Many forms of partial facial spasm, either uni-lateral or bi-lateral,
are psychomotor in origin a convulsive tic. This is really a
gesticulatory movement, reflex or voluntary in its origin, but by
constant repetition becoming imperative. Often associated with
other signs of neuroses, especially hereditary, it must be treated by
inhibitory exercises before a mirror, keeping the face absolutely
still for a certain number of seconds or minutes, the periods being
gradually lengthened, and followed by rhythmic facial movements
according to a concerted plan, carried out slowly, with slow relaxation.
1048 Tics and Spasms.
These contortions of the face are often seen in children, and
this treatment can be considerably aided by instituting a system of
small rewards for lengthening periods of complete immunity from
the spasm, this inducement having the effect of producing a con-
stant unconscious inhibitory tendency in the patient's mind. Fear
and punishment only make the condition worse. What has been
said of the treatment of facial tic or " habit-spasm " applies equally
to other forms of convulsive tic, whose variety is legion.
Shoulder-shrugging, sniffing, scratching, barking cough, and many
others musb be treated on broad lines, having regard to the spas-
modic movement being only an outward expression of a congenital
neurosis, the particular movement often being curable by the
above method of inhibitory exercises before a mirror, followed by
slow gymnastic exercises. Echolalia or parrot-like mimicry of
words and phrases just heard, echokinesis or similar mimicry of
movements of others, and coprolalia or impulsive outpouring
of abusive and obscene language, are also forms of tic, and may be
combined with other motor tics, such as torticollis. Training of
the deficient will-power and encouragement of the power of moral
restraint is the line of treatment.
The tics show a marked tendency to recurrence under the
influence of nerve-strain, or to reappear in another form. The
weakness of will-power characteristic of sufferers from tic is a
strong factor in the persistence of the movements. Hypnotism is
useless in the treatment of these cases. Self-abuse in children and
adolescents, it must be remembered, is an exciting cause.
Trismus may be reflex from carious teeth, or it may be purely
hysterical, though care must be taken to exclude organic causes,
such as osteo-arthritis of the temporo-maxillary joint, growths
infiltrating the pterygoid muscles, tetanus, etc. Clonic trismus is
always functional, and often wakes the patient at night, the teeth
coming together with a snap, sometimes even catching the tongue
or cheek. Bromide is of some use here (in 20-gr. doses morning
and evening). I have seen this form combined with an occupation
neurosis of spasm of the lips in a cornet-player.
Hiccough, singultus, or spasm of the diaphragm may be due to
irritation of the phrenic nerve, from the act of swallowing, from gastric
disturbance, or reflexly through irritation of the lower bowel. In
obstinate cases it may continue at frequent intervals for days, and
there are often other evidences of neurosis. Two of the most
obstinate cases I have seen occurred in men suffering, one from
progressive muscular atrophy, the other from pseudo-hypertrophic
muscular paralysis, and in both cases strong general faradisrn
Tics and Spasms. 1049
arrested the hiccough. Other modes of treatment are making the
patient hold the breath for long intervals, mustard plasters to the
epigastrium, blisters, etc.
Myoclonus, originally described by Friedreich, is sometimes
more or less general, and is often functional in origin, and is capable
of cure by prolonged rest, strychnine injections and galvanic baths.
The dose of strychnine should be increased gradually by 1 minim
every other day until T \y gr. is given twice daily, the whole course
lasting six to eight weeks. Other cases, especially the form
associated with epilepsy, are inveterate.
Hysterical spasm is best treated by moderately strong faradism,
the strength of current being graduated according to the depth of
the anaesthesia which is nearly always associated with it, the
patients being made to feel the current. Suggestion plays an im-
portant part in this treatment, and the patient must be encouraged
and told she is certain to get well. If the spasm has existed already
for years it is much more resistant to treatment, and actual organic
contracture may be produced.
Spasm of muscles is also met with in the occupation neuroses,
in spastic paralysis, athetosis, and post-hemiplegic chorea, in tetany
and tetanus, from toxic causes, as strychnine poisoning, ergotism,
pellagra and lathyrism. It is met with in the leg muscles in
anaemic girls and in lead poisoning, and in intermittent claudica-
tion. Spasm is also a notable feature of a congenital muscular
condition, Thomsen's disease. In addition to the obvious treat-
ment appropriate to these several conditions, massage is the most
useful form of local treatment.
WILFRED HARRIS.
REFERENCES.
Meige, H., and Feindel, E., " Tics et leur Traitement," English translation,
1907, by Wilson. Oppenheim, H., " Text-book of Nervous Diseases," 5th edit.,
English, translation by Bruce, Vol. II., p. 1237.
1050
TORTICOLLIS.
TORTICOLLIS is one of a number of nervous diseases which the
investigations of the last decade have shown to possess no noso-
graphical specificity. Morbid processes differing widely enough
from each other will, if their incidence is on the neck musculature,
produce forms of torticollis apparently identical to an uneducated
eye.
The following description is based on the important studies of
Rene Cruchet, whose definition of torticollis is " spasmodic or
convulsive movements, tonic, clonic or tonico-clonic, intermittent
in character, and involving the muscles of the neck."
(1) Neuralgic Torticollis. Accompanying occipital neuralgia
are torticollic movements, strictly analogous to tic douloureux of
the face. Should the convulsive movements continue independently
of the attacks of pain, the condition becomes one of habit torticollis
(see below).
Treatment must be directed to the neuralgia primarily (see under
Neuralgia). It may be remarked here that subcutaneous injections
of alcohol are often valuable, or of antipyrin in a 50 per cent,
solution (Grandclement). Just as tic douloureux of the face entirely
disappears after excision of the Gasserian ganglion, it has occurred
to the writer that in suitable cases removal of the posterior root
ganglia of the upper three or four cervical nerves, or division of
the posterior roots, might be worth trying.
(2) Professional Torticollis. This type of torticollis occurs
only at the moment of execution of a given functional or profes-
sional act which concerns the muscles of the neck ; at all other
times the movements of these muscles are perfectly normal. The
condition is similar to writer's cramp, and not infrequently
complicates that neurosis. If the movements become independent
of the professional act they may pass into the true spasmodic
type.
The ideal treatment, of course, would be the prohibition of the
movements in question, but this obviously is not often acceptable
to the patient (see under Writer's Cramp). Massage, galvanism,
farado-galvanism, are worth trying. Dally has reported a cure by
resistance exercises to the sterno-mastoid, coupled with treatment
by interrupted galvanic currents. Duchenne has recorded another
Torticollis. 1051
cure by continued voluntary contraction of the antagonistic muscles,
aided by a mechanical device for continuing their contraction.
Surgical treatment may be advisable, but only if the condition has
become typically spasmodic (see below).
(3) Paralytic Torticollis. Facial spasm and contracture
secondary to facial palsy may be matched by a paralytic torticollis
secondary to a chill or traumatism, or infective disease, where one
or more muscles of the neck have suffered from loss of function,
often unrecognised. The torticollis is rather one of attitude than of
movement, and is usually more pronounced when the patient walks
about or is on his feet, owing to the bilateral action of the neck
muscles to support the cephalic extremity on the vertebral column.
By over-functioning and hypertrophy of the non-paralysed sterno-
mastoid, the paralytic torticollis may develop into the true
spasmodic variety.
Prolonged electrical and massage manipulation of the affected
muscles, should they react at all, is the best treatment. Sedative
galvanism to the over-functioning muscles should be added.
This variety of torticollis is somewhat uncommon, and owing to
the fact that some muscles are already very weak, if not paralysed,
operative interference is more likely to cause permanent deformity
than in the spasmodic variety.
(4) True Spasmodic Torticollis. A valuable diagnostic
criterion of this type is that the inhibitory influence of the will
on its phenomena is' practically nil; antagonistic gestures are
frequently if not constantly inefficacious. Hemispasm of the neck
of this type, analogous to facial spasm and possibly neuritic in
origin, sometimes, at least, presents the characters of a true
spasm ; the whole of a muscle involved does not necessarily con-
tract at once ; the contractions may be fascicular ; associated move-
ments are common ; the platysma, the face, the muscles of the
shoulder, are often implicated ; pain and aching and muscular
tenderness are not infrequent; muscular hypertrophy is almost
inevitable. The condition may spread to trunk and arms. It is
either idiopathic or symptomatic, arising in the course of or as the
sequel to various diseases, such as influenza, rheumatism, typhoid
fever, diphtheria, malaria, etc. ; or torticollis of the types already
mentioned may become truly spasmodic as the result of the motor
centres concerned being constantly stimulated by sensory impulses
from the contracting muscles, as by a sort of vicious circle.
(a) It is extremely important to search for any possible source
of reflex irritation, the existence of which is responsible for the
spasms being maintained. Rest and quiet must be enjoined.
1052 Torticollis.
Sometimes prolonged rest in bed, the head between sand-bags,
produces excellent results. As a rule, mechanical devices of any
sort are to be deprecated. Sedative galvanism to the affected
muscles is often very effective. As the muscles that are not
involved in the spasm are apt to weaken from relative disuse, it is
a good plan to treat them also electrically. Massage and move-
ments, passive or resistive, are of minor value. Sometimes suspen-
sion by suitable apparatus may assist in the general progress
of the case towards recovery ; by itself it is in the writer's opinion
comparatively valueless, and also, perhaps, not entirely innocuous.
(&) Medicinal treatment by every conceivable sedative has been
tried over and over again ; there is no single drug that can be
specifically recommended. At one time continuous chloral drugging
was vaunted, the patient remaining mildly delirious for days at a
time, but its advantages do not outweigh its obvious disadvantages.
A much better case can be made out for the use of alcohol injec-
tions, which have been beneficial in many cases of facial spasm.
The difficulty is to reach all the nerves concerned, for the deep
posterior rotators' of the neck are commonly in action with the
sterno-mastoid. Counter-irritation by blisters, cautery, embroca-
tions, liniments, etc., is not of much avail.
(c) In true spasmodic cases surgical treatment is more likely to
prove satisfactory. The writer has seen a fair number of cases
where the results have been good, and sometimes exceedingly good.
But only the complete Keene-Stirling operation, viz., spinal acces-
sory on one side and posterior primary divisions of first, second,
third, and perhaps fourth cervical roots on the opposite side, can
be considered " radical " ; anything less than this is almost certain
to be disappointing. Nor is the operation one to be lightly entered
on without a serious and detailed scrutiny of the exact site of the
spasm, for many cases of spasmodic torticollis show an inclination
of the head to one side, coupled with its rotation to the other, and
the result of surgical interference is sometimes aggravation of the
inclination.
(5) Rhythmic Torticollis. This is a large clinical group com-
prising spasmus nutans, eclampsia nutans, hysterical tremors, the
rhythmical movements of idiocy and epilepsy, toxaemias, such as
alcoholism, tetanus, erysipelas, meningitis, etc.
Treatment must be directed to the affection determining the
condition.
(6) Tics of the Neck and Mental Torticollis. Little need be
said of these here, as the subject is fully referred to elsewhere.
Their treatment is often eminently satisfactory; on the other
Torticollis. 1053
hand, the muscular expression of an innate neuropathic diathesis
may be " cured " in one region and reappear in another. Surgical
treatment of a true mental torticollis is as illogical as operation
in a case of stammering. Probably, however, the category of
" psychical " cases has been unjustifiably enlarged. As Fere said,
a psychical theory has the immense advantage of dispensing with
every effort in search of a physical cause, but it has the disadvantage
of destroying all chances of finding it.
S. A. KINNIER WILSON.
KEFEKENCES.
Eene Cruchet, "Traite des Torticolis Spasmodiques," Paris (Masson), 1907.
Meige and Feindel, "Tics and their Treatment," translated by S. A. K.
Wilson, London (Appleton), 1907.
1054
GENERAL DISEASES OF THE NERVOUS
SYSTEM,
AMYOTROPHIC LATERAL SCLEROSIS.
THE question whether amyotrophic lateral sclerosis and pro-
gressive muscular atrophy are pathologically identical is still vexed.
However this may be, from the therapeutic aspect there is little, if
any, distinction to be drawn. The reader is therefore referred to
the article on Progressive Muscular Atrophy.
It may be remarked here that cases of amyotrophic lateral
sclerosis may exhibit spasticity of the extremities in varying
degree, and where this condition is at all prominent electrical
treatment is not desirable. Massage, and in particular passive
movements, are preferable (see Paraplegia).
Many cases of amyotrophic lateral sclerosis are associated with
bulbar palsy, or, more correctly, the pathological changes charac-
teristic of the disease may be found in the pontine and bulbar nuclei
as well as in the spinal cord; sometimes bulbar symptoms occur at
the outset (see Bulbar Palsy).
S. A. KINNIER WILSON.
ACUTE ANTERIOR POLIO-MYELITIS.
THE possibility that a febrile attack in childhood may depend on
acute anterior polio-uiyelitis should always be borne in mind.
When this disease is present it will be noticed that the child is
content to lie in bed, and does not cry to be taken on its mother's
knee as young children do when suffering from ordinary ailments,
and that there is immobility of one or more limbs In such a case,
that is, when a febrile attack is associated with paralysis, rest in
bed should not terminate with the cessation of fever, but should be
continued for at least three weeks after the temperature has become
normal, in order that inflammatory changes in the cord may have
time to subside. It is better for the child to lie on its side or on its'
face than on its back, but it is not desirable to insist on any
position which causes distress. The bowels should be evacuated
by calomel, castor-oil or liquorice powder, or by a soap enema, or a
glycerine suppository.
During the pyrexial stage the patient should keep to liquid food,
and small doses of aconite or salicin may be given every four hours.
Sometimes severe pain is present ; usually this is much relieved by
placing the patient on a water-bed and wrapping the limbs in
cotton-wool. Small doses of phenacetin or antipyrine may be
required ; occasionally an opiate is necessary. Mild counter-
irritation to the spine, by the application of warm fomentations or of
poultices, made with one part of mustard and three parts of linseed
meal, has probably a beneficial influence over the disease ; it will at
least ease any pain in the back and lessen the rigidity of its muscles
which is occasionally present. If the patient suffers from severe
headache which is not relieved by ordinary remedies, the question
of the withdrawal of a small quantity of cerebro-spinal fluid by
lumbar puncture may be considered. Convulsions which occur in
some cases require the administration of sodium or potassium
bromide. Attention must be paid to the condition of the bladder,
for sometimes there are signs of retention ; the use of the catheter
then becomes necessary.
When the muscles of the thorax are involved, great care should
1056 Acute Anterior Polio-Myelitis.
be taken to prevent the risk of bronchitis or of pulmonary com-
plications. Embarrassed breathing may be relieved by inhalations
of oxygen. If life is threatened, artificial respiration should be
performed in the hope that the wave of respiratory paralysis may
subside. Starr points out that " since it has been shown by
Flexner and Lewis that the virus of epidemic polio-myelitis is
eliminated by the naso-pharyngeal mucosa, the secretions of the
nasal and buccal cavities should be disinfected and destroyed."
When the acute stage has subsided there is often much
prostration ; the greatest care is then needed to ensure complete
rest to the patient, and to protect him from excitement or other
form of disturbance.
Gentle massage of the paralysed parts may be commenced at the
end of the first week, but it is advisable to postpone electrical treat-
ment for four or five weeks in order that rest, so essential during
the early period of the disease, is not interfered with. At first
massage should be very gentle, and performed only once a day ; but as
soon as the patient's general condition is satisfactory the flaccid
wasted muscles should be rubbed and kneaded at least twice daily,
and with sufficient force to stimulate the circulation, in the hope
that an increased flow of blood and lymph will promote nutrition
in the affected part. The circulation of a paralysed limb is also
improved by daily sponging in warm salt water, followed by brisk
rubbing, and afterwards keeping the limb warm by cotton-wool or
extra flannel clothing. Starr recommends a warm bath of about
99 F., in which the child is allowed to play for half an hour twice
a day ; this is followed by sponging in cool, but not cold, water.
Passive movements are also of great benefit, and the patient
should be encouraged to put forth as much voluntary pow r er as
possible, making constant efforts to move the weakened limb.
He should also be told to move the healthy limb against
resistance offered by the attendant, for in this way movements are
sometimes excited in the paralysed limb. As soon as any voluntary
power is regained it is desirable to institute a course of muscular
exercises ; a well-selected series of movements should be prescribed,
and much attention given to their proper performance.
Electricity, although less valuable than massage, is an important
agent in the treatment of infantile paralysis. It is highly improb-
able that its application to the spine can have any effect on the
cord lesion, but there is satisfactory evidence that its application to
the paralysed muscles is of service. It must be remembered that in
a localised polio-myelitis all the cells are not completely destroyed,
some are only damaged, whilst others possibly have escaped
Acute Anterior Polio-Myelitis. 1057
altogether. Now, electricity is powerless to restore muscular tissue,
the nerve-supply of which is destroyed, but it can stimulate
muscular tissue which is supplied by cells and fibres only partially
damaged ; by causing the muscle to contract, electricity exercises it,
and thus helps to promote its nutrition and growth, and so prepares
it to react to voluntary stimuli should the cells in the anterior
horns ever regain their functions.
In infantile paralysis it will be found that a certain number of
muscles respond to faradism ; these muscles will ultimately
recover, and their recovery may be hastened by the application of
either the faradic or the galvanic current. Many of the muscles,
however, do not react to faradism, and then galvanism is alone of
service. Either form of current may be applied directly to the
paralysed muscles.
In the case of galvanism it is convenient to apply one large flat
electrode, well soaked in salt water, to the chest or back, whilst the
other, a small one, similarly moistened, is stroked over the affected
muscles. The stroking or treatment electrode should be the pole,
negative or positive, which causes the most active contraction. It
must be lifted from the skin after each stroke, for the muscle only
contracts when the current is broken. Another method of inter-
rupting the current is by means of a make-and-break key attached
to the treatment electrode. The weakest current that will cause a
contraction should be used, and in order to avoid frightening the
child it is desirable to make several applications of the electrodes
when no current is passing. By this means the child becomes
accustomed to the apparatus and its confidence is gained. After
such applications have been made for a few days a very weak
current may be used, and daily strengthened until a definite con-
traction is elicited. Each muscle should be thus treated for a few
minutes twice a day for at least a year. If satisfactory contractions
are not obtained, the method of alternately reversing the current
may be tried. Two flat electrodes are fastened to the affected limb
and the current is rapidly reversed by the pole-changer in the
battery. A convenient method of applying galvanism to the lower
limbs is to place each foot in a separate bath containing warm
water, with the positive electrode in one bath and the negative in
the other.
Too much stress cannot be laid on the importance of persevering
with massage, electricity and active and passive movements of the
affected parts. It is astonishing how much restoration of power
may often be effected in a limb which at first seemed hopelessly
paralysed.
S.T. VOL. u. 67
1058 Acute Anterior Polio-Myelitis.
During the treatment great attention should be paid to the position
of the limb, in order to check as far as possible the development of
deformities. For example, if the lower limb is paralysed the
patient should not lie in bed with the knee and hip flexed ; if the
dorsi-flexors of the ankle are paralysed, the dropped foot should be
protected by a cradle from the weight of the bedclothes, and it may
be advisable to support the foot at a right angle to the leg by means
of an artificial muscle. The counteraction of other abnormal devia-
tions may usually be accomplished by the exercise of care and
practical ingenuity.
It is doubtful whether any medicine has an influence over the
morbid process. In some cases strychnine has seemed to be
beneficial ; it should be given at first in doses of -^^ gr., the
amount being gradually increased until ^ gr. is taken twice or
thrice daily. It is advisable to intermit the drug from time to
time ; thus to have an interval of three or four days between each
week in which the drug is taken daily. General tonics, such as
iron, quinine, or arsenic and cod-liver oil, are also useful.
When after prolonged treatment there is no hope of further im-
provement the skill of the orthopaedic surgeon is required to correct
deformities, to support loose joints, and in other ways to minimise
the effects of paralysis. Various mechanical appliances, tenotomy,
re-section of joints, tendon transplanting, nerve grafting, and even
amputation are measures which have to be considered in different
cases.
JUDSON S. BURY.
1059
INFANTILE PARALYSIS, NERVE ANASTOMOSIS IN.
THE success which followed the employment of anastomosis in
nerve injuries turned the attention of surgeons to the possibility of
its employment in cases of paralysis due to lesions of the central
nervous system, particularly in that form due to acute anterior
poliomyelitis or infantile paralysis.
The scope of the operation is limited, but in suitable cases improve-
ment results and almost complete restoration of function has
occurred. In 1906 I published the results of sixteen cases, including
three of my own. Out of fourteen cases reported sufficiently long after
operation to admit of recovery, power was restored to some extent
in each and in two the recovery was good. Since then I have
operated on seven further cases, making ten in all. In two, in
which the external popliteal group were paralysed, almost perfect
recovery has ensued. Had treatment been faithfully carried out
after the operation I believe recovery would have been perfect. In
two cases of Erb's paralysis, in which the fifth cervical nerve
was anastomosed to the sixth, slight recovery ensued, but not
sufficient to be of value. In one case, in which the anterior
tibial nerve was anastomosed to the musculo-cutaneous, the muscles
regained faradic irritability, but return of voluntary power was
very slight. The results obtained have not been so encouraging
in all cases ; thus Warrington and Murray have written on " The
Failure of Nerve Anastomosis in Infantile Palsy," based on five
personal cases, in none of which did any improvement result. The
improvement, however, which has so far resulted in certain of my
own cases, and in those recorded by Mr. A. H. Tubby and others,
is such that the operation has a definite place in the treatment of
this condition.
Certain rules may be laid down in the choice of cases. The
operation must never be undertaken until six months have
elapsed since the date of onset of the disease and the patient
has had thorough treatment for at least three months by massage and
galvanism, the paralysed muscles being maintained relaxed by suit-
able apparatus. It is indicated when single muscles, such as
soleus or gastrocnemius, or a group supplied by a single nerve,
such as the external popliteal, are affected, or in cases of Erb's
paralysis.
672
1060 Infantile Paralysis, Nerve Anastomosis in.
The nerve of supply to the affected muscles must be completely
divided and anastomosed to a neighbouring sound nerve. In the
cases of small nerves, such as those supplying the soleus and
gastrocnemius, it is enough to insert them in transverse slits in the
external popliteal. When a larger nerve is divided it should be
united end to end with a flap raised from the sound nerve.
Suture material must be absorbable and the junction surrounded
with membrane. The time at which the first sign of recovery is seen
depends on the distance to be traversed by the new nerve fibres.
In the cases of the nerves supplying the soleus and gastrocnemius
the distance is short and signs of recovery should be present in
three to six months ; in the external popliteal and brachial plexus
in from eighteen months to two years. Treatment after operation
must be prolonged, and so soon as voluntary power returns to a
muscle exercises must be instituted and persevered in to obtain
co-ordinate movements. If treatment is carried out on these lines
considerable improvement may be anticipated.
JAMES SHERREN-
io6i
BULBAR PALSY.
BULBAR PALSY may be either acute or progressive.
(1) Acute bulbar palsy is the result of thrombosis of one or other
of the bulbar blood-vessels, viz., vertebral or basilar artery, or of
branches, e.g., usually the posterior inferior cerebellar. In such
cases suitable treatment on the lines suggested elsewhere (see
Thrombosis) must be adopted without delay.
It may also arise from intoxication by a virus no doubt analogous
to that of acute poliomyelitis, so-called polioencephalitis inferior.
In cases of this description treatment as for poliomyelitis must be
pursued.
In hemiplegia a second stroke on the side opposite to the one first
affected may occasion a " pseudo-bulbar palsy " of an acute type,
owing to supranuclear interference with the motor fibres supplying
bulbar nuclei. Clinically the condition intimately resembles bulbar
palsy, although the pathological lesion is different. Treatment of
pseudo-bulbar paralysis is that of the underlying pathological state,
which is usually vascular and thrombotic.
For the above-mentioned types of bulbar paralysis, in addition
to specific measures, treatment on general therapeutic principles,
to be described below, ought to be followed out.
(2) Progressive bulbar palsy is a disease that forms part of
the clinical picture of amyotrophic lateral sclerosis (q.v.), though
it may occur by itself. Bulbar palsy is unfortunately a therapeutic
bete noire. No drug is known to exercise an arresting, still less a
curative, action on the malady. Injections of strychnine, how-
ever, are supposed to be of value. Local electrical treatment (sterno-
hyoids, sterno-thyroids, tongue, orbicular facial muscles) may be
persevered with.
The following general principles may serve to guide those who
have cases under their care.
It is apt to go very hard with bulbar cases should any inter-
current condition arise, especially one which affects the air-passages
and respiratory system. Hence all exposure to chill or cold must
be avoided. Exertion or strain, similarly, must be prevented.
The patients should seek a quiet existence in an equable
temperature.
The process of feeding must be taken seriously. Inhalation
1062 Bulbar Palsy.
pneumonia is more than a merely hypothetical complication. The
risk of exhaustion from a bout of coughing produced by inspiration
of food particles, or of choking during a meal, is a very real one.
Some patients experience difficulty in swallowing fluids, others in
swallowing solids. Nasal feeding may have to be resorted to. An
excellent substance to lubricate the tube, which is of soft rubber, is-
fresh butter. Where milk forms the staple constituent of the nasal
feed, it is a good plan to add sodium phosphate (20 gr.) to it.
A rigorous oral toilette is called for, otherwise unswallowed
particles float about the buccal cavity and sepsis is inevitable.
The mouth should be frequently washed out with boiled water.
Abrahams gives a most valuable mouth wash as follows: Thymol,
3 gr. ; acidi benzoici, 6 drachms ; tineturae eucalypti, 2^ drachms ;
aquae destillatse, 1 pint. This may be used immediately after
meals and at other times.
Sialorrhcea (whether mechanical or vital) may be checked with
atropine or belladonna, or by opium, in pill or liquid form, or
hypodermically, according to circumstances. Sometimes, however,
all these remedies prove unsatisfactory. Potassium chlorate has
been recommended for the same purpose.
S. A. KINNIER WILSON.
KEFERENCE.
Beevor, C. E., and Batten, F. E., article in " Allbutt's System of Medicine,"
2nd edition, 1910, VII., p. 716 (bibliography).
1063
CEREBRO-SPINAL SYPHILIS.
ALTHOUGH cerebro-spinal syphilis cannot, strictly speaking, be
called a disease, with a definite symptomatology and a recognised
course, yet it is convenient to describe under this title the treatment
of a frequent and important condition manifested by a large variety
of symptoms. In one case a paraplegia, in another a hemiplegia,
and in a third some form of ophthalmoplegia may constitute the
obvious evidence of disease, but the treatment of all three cases
will in its most essential feature be the same owing to their
common etiological factor. It is equally true that the exact nature
of the pathological process may present considerable variations ;
for instance a gummatous neoplasm, a gummatous meningitis, or
thrombosis of an artery which is the seat of syphilitic changes may,
in different instances, be responsible for the clinical picture or may
be associated in the case of one person. Each morbid condition
may be found either in the brain or in the spinal cord, and their
concurrence anywhere in the central nervous system is notoriously
frequent. This is important to bear in mind, because once the
brain or spinal cord has been the seat of a syphilitic lesion recur-
rences are liable to occur and one of the main objects of treatment
will be their prevention. When a man has suffered from an
ophthalmoplegia due to gummatous meningitis involving a third
nerve, the next manifestation of the disease is as likely to be a
hemiplegia secondary to thrombosis of a middle cerebral artery or
paraplegia due to syphilitic myelitis as any local recrudescence of
the initial trouble. The aim of prophylaxis must therefore be to
strengthen the defences of the nervous system as a whole rather
than to patch up a spot in its armour which is known to be weak.
It will be convenient to discuss the subject of general treatment
under the headings "prophylaxis" and "anti-syphilitic therapy"
and then to take into consideration some special forms of the
disease which may require special measures in their management.
Prophylaxis. The prophylaxis of cerebro-spinal syphilis has
only to be considered in persons who have contracted syphilis. It
has, however, to be considered in regard to all such persons, because
we have no means of ascertaining when or whether a syphilised
individual has been cured of his disease. Variations in individual
susceptibility and in the virulence of infection as well as in the
1064 Cerebro-Spinal Syphilis.
ability to tolerate treatment are probably largely responsible for
this difficulty. A year's mercurial treatment may doubtless per-
manently eradicate the disease in some persons, but it is impossible
to distinguish such persons from others who appear to be equally
well after a similar course and who yet develop syphilitic lesions
two, five, ten or twenty years after their primary chancre. It
cannot be said that the Wassermann test affords much assistance in
solving this problem, because, although a positive reaction may be
replaced by a negative reaction as the result of a course of treat-
ment, the positive reaction may reappear six months later. More-
over, it is not proved that an attitude of inactivity is a perfectly safe
one for a medical man to adopt so long as he is faced by a negative
Wassermann reaction in his patients. Experience teaches us that
the ideal treatment of a syphilised person is periodical recourse to
mercury for an indefinite length of time, the frequency with which
courses of the drug are administered being regulated more or less,
but not too dogmatically, by the information gained by the
Wassermann test.
This is not the place to describe in detail the measures which
should be adopted to prevent a syphilised person from developing
tertiary lesions such as those of cerebro-spinal. syphilis. In the
first place, the prophylactic treatment of cerebro-spinal syphilis is
the remedial treatment of syphilis, and the latter is fully discussed
in the article devoted to it. In the second place, it is necessary to
refer to the administration of anti-syphilitic remedies when dealing
with the immediate treatment of cerebro-spinal syphilis. In the
third place, this article is being written at a time when reports from
all over the world are tending to show that a new preparation
discovered by Ehrlich is likely to revolutionise the treatment of
syphilis and to make it necessary to modify what has been written
above. Even if allowance is made for the natural enthusiasm with
which a new discovery is welcomed, much is to be hoped for from
Ehrlich's "606" remedy, and if time shows that its administration
is successful in eradicating syphilis from the system the indefinite
prolongation of mercurial treatment will be rendered quite unneces-
sary and an incalculable boon conferred on mankind in general.
Apart from the medicinal element in the prophylaxis of cerebro-
spinal syphilis there is not very much to be done, but it is impor-
tant to remember that a person who has contracted syphilis should
not be content with courses of anti-syphilitic treatment, but should
take every possible care to keep up his general health and to avoid
excesses, mental, physical, sexual and dietetic, which are calculated
to undermine his natural resistance.
Cerebro-Spinal Syphilis. 1065
Anti-syphilitic Therapy. The discovery of an organic disease
of a patient's central nervous system nearly always suggests the
question has it a syphilitic basis ? Any reference to the means
which must be adopted in order to answer this question does not
come within the scope of this article, but if the medical man arrives
at the conclusion that the disease is luetic in origin his first duty
will be to apply anti-syphilitic remedies. Putting aside for the
moment the new preparation of Ehrlich, he will have to rely chiefly
on mercury and the iodide salts. The methods of using them are
numerous enough to give him a wide choice. Before referring to
them in detail the writer desires to express his opinion, based on
his own experience, that the failure of anti-syphilitic remedies to
give results which might reasonably be expected from them is
frequently due to one of two causes. Either the treatment is not
ordered to be pushed to the extent which is often necessary, or the
actual method of administration is faulty and has not been properly
supervised. In all probability surgical interference has not infre-
quently been invoked in cases in which the failure of medical
measures could be properly ascribed to one or other of the above-
mentioned causes.
Mercury and Iodides. It is always advisable to give mercury
in tertiary syphilis of the nervous system, and iodide of potassium
may be given either at the same time or subsequently. Some
authorities believe that the latter method is the more advantageous.
Mercury may be given by mouth, through the skin, or by injection.
If oral treatment is decided upon, the liquor hydrargyri
perchloridi in drachm [U.S.P. hydrarg. chlorid. corrosiv., gr. ^]
doses may be given in a mixture thrice daily or the red iodide of
mercury (^ to gr.) in the form of a pill at the same intervals.
Slight salivation is an indication that enough has been given and
that the administration must be stopped or the dosage reduced.
There is no better way of carrying out mercurial treatment than
by inunction. The dose can be carefully regulated and dis-
turbances of digestion are usually avoided by this method.
Unfortunately, it is too often adopted in a perfunctory manner, and
the results are unsatisfactory in consequence. The patient should
have a warm bath before each inunction. He should stay in the
bath at a temperature of 87 to 90 F. for about fifteen or twenty
minutes, and the part which is to be used for inunction should be
washed with soap and water. A drachm of mercurial ointment
mixed with some lanoline, or a similar quantity of oleatum
hydrargyri (10 per cent.) should be carefully rubbed into the
selected part during a period of twenty to thirty minutes. The
io66 Cerebro-Spinal Syphilis.
part should be covered by linen or flannel, and this should not be
removed until the bath on the following day. A fresh site must be
chosen each day and the rubbings continued for forty to fifty days,
or until signs of salivation present themselves. The arms, back,
calves and thighs are suitable parts for the rubbing and may be
used in turn. Salivation or gingivitis will be delayed if proper
attention is paid to the cleansing of the mouth. A toothbrush
should be used after each meal and a lotion of chlorate of potash
employed for washing out the mouth and gargling the throat two
or three times a day. In some cases of cerebral syphilis it is
necessary to obtain results as rapidly as possible, and the com-
bination of inunctions with oral treatment may attain this object
without the risk which attends large intramuscular injections,
although in some ways the latter are more simple in their
administration.
When the attack of cerebro-spinal syphilis has been cured by a
course of mercury at home it will be well, if circumstances allow,
to send the patient away for further courses. The inunction
treatment is well carried out at Harrogate or Matlock in this
country, or at Aachen on the Continent. During or between the
courses, iodide of potassium (10 to 40 gr.) may be given three
times a day with some bitter infusion about one hour before meals.
It is well to increase the dose of iodide rapidly up to 30 or 40 gr.
as the disagreeable effects of the drug are often more noticeable
when taking the smaller quantities. It is unnecessary to continue
with the iodide as long as with the mercury.
Of late years the injection method of giving mercury has been
largely used, particularly in the treatment of syphilis in the army.
A number of different preparations have been tried, some of
which are insoluble, slowly absorbed and slowly eliminated, and
others just the opposite. The injection of some of the more
soluble salts is usually attended by less pain than that of
substances like calomel suspended in oil.
Salicylate of mercury in doses of to 1 gr. suspended in about
ten drops of liquid paraffin may be injected deeply into the buttock
at intervals of four to seven days. This is an efficient method of
quickly exerting mercurial influence and may sometimes be useful
in urgent cases of cerebral syphilis to begin with, even if inunc-
tion is resorted to for continuing treatment. Intramuscular
injections of metallic mercury (1 gr.) suspended in a fatty base
are practically painless, but absorption is slower and the results
more delayed. The objection to the intramuscular injection
method lies in the difficulty of avoiding excess while being sure
Cerebro-Spinal Syphilis. 1067
that enough of the drug is being administered. The advantages
of simplicity, cleanliness, and saving of time are obvious.
In acute attacks of cerebro-spinal syphilis an intramuscular
injection may well be used for the purpose of getting a maximal
early effect, but in the more subacute and chronic conditions
inunction is probably the most satisfactory method to employ.
Emphasis has already been laid on the importance of oral
cleanliness during courses of mercurial treatment, and a word must
be said as to the effect of mercury on other organs.
The fear of untoward effects, especially of producing cardiac or
nervous depression or anaemia, is apt to be exaggerated ; as a
general rule, the effect of giving mercury to a patient suffering
from syphilis of the nervous system is more striking than that of
any tonic. The body weight increases, blood counts improve and
the general health improves in every way. Even if albuminuria
is present to start with, it is quite likely to disappear under the
treatment. On the other hand, if albumin makes its appearance
during treatment, if the patient steadily loses weight or develops
palpitation, cramps, tremors, colic, or gingivitis, these are signs
that toxic effects are being produced and that the treatment must
be stopped for the time being.
Arsenic. The value of arsenic in syphilis has been known for
a long time, but it is only within recent years that this metal has
been extensively employed as a remedy. The future of the various
arsenical preparations, such as atoxyl and Ehrlich's " 606," cannot
at present be determined owing to the fact that the use of some
of them has been attended by severe toxic effects resulting in
amblyopia, etc., in certain cases. At first it was generally believed
that mercury and arsenic should not be given simultaneously, but
more recently favourable results have been reported from their
combined use. It is safe to say that arsenic is a useful drug to
give between courses of mercury, and it may be that in the near
future it will have established its position as the most potent
weapon at our disposal both in the prevention and in the cure of
cerebro-spinal syphilis.
Intracranial Gummata. In most cases the proper treatment
for intracranial gummata is the energetic use of anti-syphilitic
remedies. On the other hand, a medical man may every now and
then be faced by a case of intracranial neoplasm, which may or
may not be gummatous, and in which the condition of the patient
renders any delay in relieving symptoms a matter of great danger.
For instance, the patient may be comatose with slow pulse and
respiration and with intense optic neuritis, all the symptoms being
io68 Cerebro-Spinal Syphilis.
the result of greatly increased intracranial tension. The medical
man knows that his patient's life and sight will probably be saved
by immediate trephining of the skull, and that unless anti- syphilitic
remedies take immediate effect there is serious risk of the patient
losing one or the other. In cases where the syphilitic nature of
the lesion is doubtful, it is good practice to open the skull and
dura mater over a wide area and, if necessary, administer mercury
and iodides afterwards. If, on the other hand, the syphilitic
nature of the growth is tolerably certain, if mercury and iodides
have not already been employed without success, and if the
condition of the patient is not really desperate, energetic treat-
ment with mercury and iodide of potassium will generally be all
that is necessary. When trephining is decided upon, it is well to
choose some area such as the right frontal or right temporal region
for the opening unless the physical signs clearly point to some
other part as the site of the growth.
In the writer's experience the removal of gummata by the knife
has not been attended with good results. On the other hand, both
in spinal and in cerebral syphilis, the subsequent effects of anti-
syphilitic treatment are sometimes materially improved by merely
opening the cranial or vertebral cavities and exposing the lesion.
This may probably be explained on the ground that injury to the
tissue in the immediate neighbourhood of the disease attracts more
blood, together with the drugs in solution, to the part. The
operation is, in fact, a somewhat drastic counter-irritant.
Syphilitic Cerebral Thrombosis. Syphilitic arteritis followed
by thrombosis of one of the main branches of the middle cerebral
artery is a frequent cause of hemiplegia and must be met by anti-
syphilitic remedies as well as by other measures which the reader
will find described in the article on Hemiplegia.
Spinal Gummatous Meningitis. This is a condition in which
the response to mercury and iodide of potassium is sometimes
disappointing and may be stimulated by a laminectomy followed
by an attempt to clear the spinal roots from the surrounding
fibrous adhesions. Here again the local reaction probably exerts a
beneficial influence in bringing the disease into closer contact with
the circulating drugs. Cases of gumrnatous meningitis of the
cauda equina and cases of pachymeningitis of the cervical region
are particularly benefited by surgical interference when recovery
under medicinal treatment is delayed. Syphilis of the meninges is
also responsible at times for the formation of localised cysts
within the theca, the evacuation of which may relieve the cord of
pressure.
Cerebro-Spinal Syphilis. 1069
Syphilitic Paraplegia. In the general treatment of the
paralysis, atrophic or spastic, which results from syphilitic myelitis
and meningo-myelitis, the reader is referred to the article on
Myelitis. In addition to the use of anti-syphilitic remedies,
measures described in that article for the prevention of bedsores,
cystitis, etc., are of urgent importance.
E. FARQUHAR BUZZARD.
1070
DISSEMINATED SCLEROSIS.
FEW things are more unsatisfactory than the treatment of a
disease like disseminated sclerosis, for we are so ignorant as to its
etiology that all treatment must of necessity be largely empirical.
All that we have to guide us in the treatment of the affection is
what can be deduced from its morbid anatomy, together with our
clinical experience that certain conditions of life prove prejudicial
to persons affected by the disease and are responsible for aggravation
of the symptoms, while decided benefit results when certain other
conditions can be secured. Whether the disease is ever perma-
nently arrested after having revealed itself by some of its character-
istic earlier manifestations it is impossible to say, although there
are good reasons to suppose that this does happen. The malady is
usually regarded as one of those in which nothing short of a fatal
issue is to be expected, although a great many years may elapse
before the end is reached. What is known of the long intervals
that may elapse between the time when the first manifestations of
the affection appear and the complete picture of the disease is
established justifies the speculation as to whether there are cases in
which these earlier manifestations occur without being followed by
those which characterise the fully developed disease. Furthermore,
cases occur in which the patient, damaged with certain irreparable
defects, nevertheless remains at a standstill so long that it is not
unreasonable to speculate as to whether any of these cases ever
remain permanently arrested. There are many difficulties that
arise in connection with such considerations, however, notably the
fact that syphilis may account for cases that appear to be dissemi-
nated sclerosis and that seem arrested. The modern tests for
syphilis will, however, assist in elucidating this problem, though
leaving it still hedged round with other difficulties, including that of
keeping in touch with the patient over periods sufficiently long to
come to any positive conclusion on this point. Nevertheless, some
cases have been followed for a sufficiently long time to make it
probable that arrest of the disease does sometimes occur.
A study of the morbid anatomy of disseminated sclerosis reveals
certain indications which appear to justify the belief that some
toxic agent is responsible for the earlier morbid changes which
result in the sclerosis. We know so little about the etiology of the
affection, however, that there is not much that can be done in the
Disseminated Sclerosis. 1071
way of prophylaxis. Nevertheless, the number of cases that first
reveal themselves after one or other of the infective fevers makes it
important that we should enjoin a sufficient amount of rest in the
convalescence from such infective diseases, more especially when
there have been any manifestations pointing to disordered action of
the nervous system during the febrile illness. For similar reasons
those engaged in trades which expose them to the influence of
metallic and other poisons should be protected as far as possible
from their baneful influences.
General Treatment. There are certain general considerations
that are of paramount importance in the treatment of this affection.
The patient's nutrition must be maintained at as high a level as
possible, so that it may be necessary to supplement a liberal nutri-
tious diet by the administration of cod-liver oil or preparations of
malt. It is especially important that those who have had any of
the earlier manifestations that may mean the commencing of this
disease should keep their general nutrition at a high standard of
perfection, and should avoid all excesses, fatigue and other depress-
ing conditions that might aggravate their complaint. There can be
no doubt that the more restful the conditions that can be secured
for the patient, the better the effect on the course of the malady.
The patient should, accordingly, be placed under conditions that
secure the maximum of peace of mind, and that degree of physical
repose that is found necessary to the individual case. "While the
avoidance of mental worry and strain is essential as far as this
state of things can be secured, absolute physical rest is not called
for in all cases. The amount of rest must be estimated according
to the ease with which fatigue is induced, so that all physical
exercise should be taken short of undue fatigue. Whenever there
is an acute exacerbation of the disease, with sudden or rapid increase
in the loss of power in the lower limbs, or increasing difficulty in
locomotion in consequence of spasticity, the patient should be kept
at absolute rest for a time. Similarly, even when increasing diffi-
culty in locomotion is much slower in its progress, the patient
derives distinct benefit from periods of complete physical rest.
Whether or not there is a good deal of additional neurasthenia in
the clinical picture, some of the more acute cases of the malady
benefit by a complete " rest cure." But while the securing of
mental rest is such an important factor in their treatment, care
must be observed not to allow the patient to become depressed by
too much isolation, so that this part of the regime of an ordinary
" rest cure " may have to be modified to suit the needs of individual
cases.
1072 Disseminated Sclerosis.
Excesses of all kinds, including wine and venery, must be carefully
avoided, and the frequency with which the manifestations of the
malady first appear after parturition, or during pregnancy, makes
it imperative that female patients suffering from the disease should
be carefully warned to avoid the possibility of becoming pregnant.
While the avoidance of fatigue is so essential, a liberal amount of
fresh air should be secured for patients suffering from disseminated
sclerosis, by drives in an easy motor or carriage or in a wheeled
chair, when the powers of locomotion are so impaired that walking
cannot be undertaken without a degree of effort that quickly induces
fatigue, and when the climatic conditions will not permit of rest in
the open air. Undue vibration is, however, to be avoided as far as
possible during motor or carriage exercise. Cold and damp are to
be studiously avoided, as many of the symptoms of the malady are
undoubtedly aggravated by these conditions, so that when the
patients' circumstances permit of this it is best for them to secure
residence in a warm dry climate, notably during our winter months.
Care must, however, be taken to secure the change to these favour-
able conditions of climate with the minimum of fatigue on the
journey, which should be made as restful as possible.
Nothing is known as to the real nature of the toxic agent that is
supposed to occasion the disease, but the surmise that it may be
infective in origin has been responsible for the hope that mercury,
administered in the earlier stages of the affection, may prove of
some service in arresting or retarding the progress of the morbid
process. It is always exceedingly difficult to estimate, with any
degree of certainty, the therapeutic effects of a remedy in a disease
which is subject to such natural remissions as occur in disseminated
sclerosis. Nevertheless, it has appeared to me that courses of
mercurial inunction, combined with measures calculated to build
up the strength of the patient on " rest-cure " principles, have been
of distinct service in some cases. This is not the experience of all
neurologists, however, and there are those who consider that
mercury is not only not helpful but actually harmful to the subjects
of disseminated sclerosis. The plan that I have employed, in
suitable cases, is as follows : 1 drachm of blue ointment is
rubbed in along one side of the spinal column every night. The
part is well sponged with hot water, then dried, and the ointment
rubbed in for half an hour along the whole length of the spinal
column on one side. The next night the opposite side is selected
for exactly the same treatment, and in each case the ointment is
allowed to remain in contact with the part for forty-eight hours,
that is, until the time has arrived for a fresh application of it. The
Disseminated Sclerosis. 1073
treatment is continued in this way for two or three months at a
time, unless any symptoms arise which may be ascribed to the
mercury, in which case it must, of course, be discontinued until they
have passed off. The patient is ordered to clean the teeth after
each meal, and to follow this by the use of a mouth-wash of chlorate
of potash (10 gr. to 1 oz.).
In view of what has been said as to the possible infective origin
of the disease, it is significant that arsenic has long enjoyed a
reputation in the treatment of disseminated sclerosis. It is not
surprising, therefore, that attention has been called to the possible
advantage to be derived from salvarsan " 606," in spite of the fact
that syphilis cannot be blamed for disseminated sclerosis. The use
of " 606 " cannot, however, be recommended in this way as long as
there is any reasonable suspicion that this preparation may lead to
blindness or any other serious defect. Some observers have recom-
mended the subcutaneous injection of other preparations of arsenic,
such as cacodylate of soda (f gr. once a day) or atoxyl (arsamin)
(f to 3 gr. two or three times a week) ; but the plan that has found
most acceptance in this country has been that of administering the
arsenic by the mouth, in the form of Fowler's solution. Various
plans have been recommended as to the best way to give the arsenic,
but one that will probably be found to be as satisfactory as any
other is to begin with 3 minims of Fowler's solution three times
a day after food, and to increase the dose up to 8 or 10 minims
in the course of two or three weeks, and then to diminish it again
gradually until the original dose is reached at the end of a further
period of two to three weeks. Courses of arsenic are given in this
way at intervals, and certainly appear to do good.
Charcot, Erb and others have employed silver in the treatment
of the affection with apparent benefit ; and more recently collargol
has been so employed by the mouth (1 gr. in pill or tabloid form,
suppositories of 2 gr., and even intra-venous injection of J to 1
per cent, solution), with results sufficiently satisfactory to induce
those who have tried it to advocate a more extended trial of this
method of treating the disease, especially as no risk attaches to the
use of collargol.
In the intervals between the courses of arsenic or silver various
tonic medicines may be substituted, including strychnine, which
has, however, to be employed with care, so as not to allow it to
aggravate any spastic phenomena that may obtain in the clinical
picture of the malady. Phosphorus has, of course, been employed,
and during recent years phytin (in 4 gr. doses in capsule three
times a day) has been substituted for the ordinary preparations of
S.T. VOL. ii. 68
1074 Disseminated Sclerosis.
phosphorus. Lecithin in different forms has also been tried, and
appears to prove of distinct benefit in some cases. A good way
of exhibiting this drug is in the form of ovo-lecithin, 2 gr. of
which may be given in pill three times a day. Glycero-phosphates
supply another useful substitute when arsenic has to be interrupted,
and may sometimes be combined with the arsenic with advantage.
The preparation of glycero-phosphates with formates is similarly
useful. The attempts to influence the course of the disease by
tonics has led to the use of certain gland extracts, including that of
the testicle, thymus and thyroid, with apparent benefit in some
cases ; although it cannot be supposed that these have any influence
on the organic changes which obtain in the central nervous system.
In view of the marked effect which fibrolysin has on cicatricial
tissue, much was hoped from its use in affections like that now
under consideration, in which sclerosis forms a prominent part in
the morbid changes which obtain in the central nervous system.
According to some observers, good results have followed the use of
fibrolysin in such conditions, so that it is a form of treatment that
must be considered. It has not been my experience, however, that
any good has resulted from its use in affections of the central
nervous system ; and in view of the fact that it is not a form of
treatment that is entirely without risk of harm resulting to the
patient, it cannot be recommended.
The belief that disseminated sclerosis is infective in origin, and
the beneficial effects that have been observed by Eaymond and
others by the use of X-rays in the treatment of syringomyelia, has
led to the use of the rays in this affection. They are, of course,
applied to different parts of the spine, notably the cervical and
lumbar regions. The results have been discrepant ; but those who
have seen improvement under the rays advocate their use in the
earliest possible stages of the malady, before permanent sclerotic
changes have occurred in the spinal cord.
No form of electrical or hydropathic treatment can be said to be
of material advantage in combating the disease, although they have
their advocates, notably amongst Continental physicians, and may
possibly prove helpful in treating individual symptoms. Faradism
is sometimes helpful when the subjective sensation of numbness is
troublesome in some part ; but this and all other forms of electrical
treatment must be employed with caution when there is much
spasticity, as harm, rather than good, may result under such circum-
stances. If any form of hydropathic treatment is adopted, great
care is necessary not to allow the patient to be unduly fatigued by it.
Special symptoms, of course, call for special lines of treatment.
Disseminated Sclerosis. IO 75
One of the most notable of these is the tvcakness of the sphincter of
the bladder, which is such a common feature, and often an early
manifestation of the malady. This is often* very decidedly influ-
enced by the administration of belladonna, 5 or 10 minims of the
tincture being given in conjunction with arsenic, if the patient
happens to be taking this drug, or the belladonna may be combined
with strychnine with advantage in some cases. Ergot enjoys a
similar reputation. Urotropine (in 10 gr. doses once or twice a day)
may be employed as a prophylactic against cystitis when there is
incontinence, or in the treatment of a cystitis already developed
which may call for lavage of the bladder as an additional measure.
Pain is rarely the prominent symptom in disseminated sclerosis,
which it is in tabes dorsalis. Nevertheless, a fixed pain in
the back or in some other situation may call for the exhibition of
one or other of the analgesic medicines at our disposal. Aspirin
(in 5 or 10 gr. doses) alone, or with 10 gr. of pyramidon or
phenacetin, usually proves most helpful, and it must be rare to find
any real justification for the administration of morphia or any other
form of opium. When reflex spasms prove distressing, these same
drugs may prove helpful ; but when they fail, veronal (in small doses
of 3 or 4 gr., repeated every four or six hours) sometimes gives
relief. This is, however, one of the most intractable symptoms of
an affection of the spinal cord, and often baffles all attempts at
treatment. Small doses of veronal employed in this way are also
said to be helpful in lessening the tremor which is such a character-
istic feature of the disease. Vertigo may be quite severe in some
instances, and may make it impossible for the patient to do otherwise
than keep in the recumbent posture. One of the bromide salts (in
doses of 10 to 20 gr.) is best for this, and either the sodium or
ammonium salt is to be preferred, given alone or in combination
with arsenic, and further combined with strychnine or belladonna,
according as other concomitant symptoms may demand. The
patient's power of locomotion may sometimes be hampered by
spastic it y rather than by actual motor paralysis, so that various
attempts have been made to influence this symptom of the affection,
but with small success in a large proportion of the cases. There
can be no doubt, however, that rest proves an important element in
the treatment of this manifestation, and to this, more than to any
other concomitant element in treatment, is usually to be ascribed
any improvement which may fortunately result. It is certain that,
in addition to the general good which results to the individual from
rest, this special feature is favourably influenced. The idea which
commonly obtains that the patients can walk off their stiffness is
682
1076 Disseminated Sclerosis.
accordingly a mistake, for in reality what is wanted is rest and the
avoidance of fatigue. While general massage is usually to be
deprecated, as proving too exhausting, massage and passive move-
ments confined to the parts affected by spastic paralysis, which
usually happens to be the lower limbs, is often of distinct service,
although it is naturally always a difficult matter to estimate how
much of the relaxation of the limbs has been due to the rest to the
spinal cord and how much to the massage. There can be little doubt,
however, that the massage and passive movements lessen the
liability to permanent contractures and the disabilities inseparable
from them.
J. S. RISIEN RUSSELL.
1077
GENERAL PARALYSIS OF THE INSANE.
IT is a general and popular belief that every disease must have
an appropriate cure, and that the lack of a curative method for any
particular disease constitutes evidence of medical ignorance of the
nature of the disease. Even if medical men believe that it is possible
to be acquainted thoroughly with the etiology and pathogenesis of
a disease and yet to admit its incurability, many years must elapse
before the public mind can be expected to fall in with an idea so
contrary to preconceived notions.
General paralysis may be cited as an instance of a disease the
essential cause of which is as firmly established as any in the
sphere of medicine. The knowledge that without syphilis there can
be no general paralysis, although invaluable from a prophylactic
point of view, is nevertheless at the present moment of little help
in the curative treatment of the established disease.
In spite of the accepted view that general paralysis is an incurable
and fatal disease, a view based on only too substantial a basis, there
are equally good reasons for believing that appropriate treatment
of individual cases can do much towards diminishing the suffering
of the patient and, perhaps still more, that of the patient's imme-
diate relations and friends. The fact, therefore, that there can be
only one end in sight does not relieve the medical attendant of
many and serious responsibilities. On the contrary, the manage-
ment of these cases is full of difficulty and affords the physician
opportunities of displaying resource and of rendering invaluable
help, in other words, of performing duties which are professionally
as important if not so much appreciated or so superficially brilliant
as those involved in bringing about a radical cure.
As in so many diseases, the first essential for successful treatment,
and " successful treatment " does not necessarily mean cure to
a medical man, is early diagnosis. Late recognition is not always
the fault of the physician, because it is the rule rather than the
exception for the patient or his relations to seek help only when
serious mental symptoms begin to display themselves, and often
not before money has been squandered in grandiose schemes or
a business ruined by rapidly growing incapacity. Early diagnosis
will enable the physician to give the warning necessary for the
salvation of material effects, and at the same time to remove the
1078 General Paralysis of the Insane.
patient from an environment which is calculated to aggravate his
symptoms and hasten the progress of his disease. He should be
taken away from business and shielded from worries of all kinds.
Mental and physical rest is necessary all the more urgently when
the patient, as is often the case, is anxious to over-exert himself in
every direction and believes himself possessed of superhuman
strength and endurance. If certifiable, the earlier he is removed
to an asylum the better for the patient and his relations. When
certification is impossible, a quiet country house with grounds is
more beneficial than a voyage and much more convenient if serious
symptoms requiring restraint or constant medical attention suddenly
develop, as they are very likely to do. The majority of patients
can be induced to retire into the country and to submit themselves
to regular hours of rest and exercise if they are persuaded that they
are ill. Whoever is in charge should have adequate assistance
within reach in case a violent phase should present itself. The
diet should include a maximum of milk, milk puddings, eggs and
fresh vegetables, and a very moderate quantity of meat. Alcohol
must not be given and sexual intercourse must be forbidden.
Insomnia is sometimes a troublesome symptom and the use of
hypnotics is not only justifiable but very necessary. If bromides
or chloral or sulphonal are not effectual, paraldehyde or amylene
hydrate may be substituted (sec Insomnia).
Anti-syphilitic Treatment. While most authorities agree that
anti-syphilitic remedies are rarely followed by complete arrest
of the disease, much difference of opinion is expressed in regard to
the advantage of employing them. In a disease which is notable
for its natural remissions under favourable conditions, it is difficult
to gauge the effect of drugs. Bianchi and Craig, amongst others,
do not favour the use of mercury; on the other hand, Leduc,
Lemoine, Leredde and Sachs record more or less successful results.
In considering statistical records allowance must be made for the
possible and sometimes excusable error of mistaking cases of
cerebral syphilis for incipient general paralysis. At the same
time, it is scarcely fair to say that the successful mercurial treat-
ment of a case in which parasyphilis has been diagnosed affords
proof that the diagnosis is erroneous.
The fact that patients suffering from tabes, a disease which is
regarded by many eminent authorities as the spinal counterpart of
general paralysis, are undoubtedly benefited by mercury may be
taken as an additional argument for trying anti-syphilitic remedies
in the early stages of general paralysis. The writer is of the
opinion that a course of mercurial inunction should be given in all
General Paralysis of the Insane. 1079
early cases if a positive Wassermann reaction is obtained, and that
the course should be repeated at short intervals as long as it
appears to arrest any progress of- the malady. If this line is
adopted care should be taken that the inunction is properly carried
out by persons who understand the business and that at least fifty
or one hundred daily rubbings should be given when the treatment
is well tolerated.
It is too early as yet to gauge what effect Ehrlich's " 606 "
preparation may have on the established disease, although, if
present hopes are realised, the general use of the preparation in
early syphilis may reasonably be expected to have an important
preventive influence.
Surgery. Trephining the skull has been tried in several cases
without permanently influencing the course of the disease.
Serum Therapy. An anti-diphtheritic serum introduced by
Ford Robertson has not proved to be as successful as early experi-
ments suggested it might be, and no other remedy on similar lines
has yet established any reputation.
SYMPTOMATIC TREATMENT.
Congestive Attacks. Rest and attention to the bowels, etc.,
are all that is required in dealing with a congestive attack from
which the patient usually makes a spontaneous recovery with
impaired mental power. It is said that the continuous adminis-
tration of liquid extract of ergot [U.S.P. fluid extract of ergot] in
doses of forty drops three times daily over a long period decreases
the liability to these seizures.
Irritability and Excitement. Rest is the most valuable factor
in preventing these symptoms, and, although hydro-therapy
generally is of little use in the treatment of general paralysis,
daily baths of a temperature of about 30 to 32 C. (86 to 90 F.)
have been found useful in allaying excitement. Antifebrin (2 to
5 gr.) is a drug which has been recommended for irritable patients,
and its efficacy is insisted on by Bianchi.
Refusal of Food. This must be met by forcible feeding.
A nasal rubber tube should be passed into the lower part of the
O3sophagus through the nares three or four times in the twenty-
four hours, and each feed should contain nearly a pint of milk,
vegetable extracts, one or two eggs, salt, and any drugs which it is
desired that the patient should take.
Constipation. A careful watch should be kept on the excretions
and any tendency to constipation overcome by the administration
of aperients or enemata. If symptoms of auto-intoxication present
io8o Landry's Paralysis.
themselves intestinal disinfectants such as salol or beta-naphthol,
in 5-gr. doses, may be given an hour or two after food.
Late Stages. With advancing dementia and increasing motor
paralysis the treatment of the patient resolves itself into careful
nursing and attention to the functions of the alimentary canal
and excretory organs. Meals should be supervised by the atten-
dant and the food given in such a form that little mastication is
necessary. The tendency to bedsores and bruises as well as to
bony fractures must be remembered in managing and nursing the
patient. The use of a water bed, strict attention to the bowels
and bladder, and careful cleansing of the skin are the chief pre-
cautions to be taken. The advent of some serious complication,
such as pneumonia, can generally be recognised at an early stage
by keeping a record of the temperature.
E. FARQUHAR BUZZARD.
LANDRY'S PARALYSIS.
THE treatment of acute ascending motor paralysis must remain
essentially empirical and symptomatic until the problem of its
etiology is solved. In the majority of cases it appears to be an
acute infective condition, and treatment such as is suitable for any
acute infection must be adopted. The chief danger to life results
from respiratory embarrassment, to the relief of which, therefore,
special attention is to be directed. Buzzard thinks the adminis-
tration of atropine or belladonna, with strychnine, may relieve
respiratory distress by diminishing bronchial secretion w 7 hen the
intercostal muscles and diaphragm become involved. Treatment
on hygienic lines, such as for acute myelitis, is to be prosecuted in
this disease.
In some recent epidemics of acute poliomyelitis a number of
cases clinically indistinguishable from Landry's paralysis have
been recorded.
S. A. KINNIER WILSON.
REFERENCES.
Buzzard, E. F., Goulstonian Lectures, "Brain," 1907, XXX., p. 1.
" Epidemic Poliomyelitis," Eeport of the Collective Investigation Committee
of the New York Epidemic of 1907, New York (Journal of Nervous and Mental
Disease Publishing Co.), 1910.
io8i
PROGRESSIVE MUSCULAR ATROPHY.
PROGKBSSIVB MUSCULAR ATROPHY of spinal origin, with which, for
the purposes of this article, chronic anterior poliomyelitis may be
taken to be synonymous, is a disease which, unfortunately, does
not offer much scope for therapeutic consideration. It is a sound
rule in therapeutics that where numerous medicaments are in
vogue for a particular disease no one of them is of any striking
value. All ordinary nerve tonics have been utilised to combat the
progress of the spinal degeneration that characterises this
condition, but the consensus of neurological opinion to-day declares
one and all equally inefficacious. Sir William Gowers, it is true,
holds that the administration of strychnine by hypodermic
injection is a method of treatment capable of arresting the disease
in 50 per cent, of cases. " In seven almost consecutive cases, in
middle life, this treatment has been followed by arrest within a
month of its commencement, and the arrest has been permanent
in all the cases but one. In the senile cases the treatment
has failed. . . . One injection daily has been given. . . .
The nitrate is the most convenient salt, g 1 ^ gr. at first,
quickly increased to ^ or j 1 -. The injections need to be
continued for months. . . ." The authority which Sir William
Gowers' experience lends to any statement published by him
is sufficient excuse for the quotation of the above, yet
strychnine has often been tried in vain. While at present the
belief is general that no drug is proved to have a specific action
in the treatment of progressive muscular atrophy, we need not
consider ourselves therapeutically helpless in face of the disease.
Any treatment that maintains the patient's general nutrition is
indirectly serviceable, hence the administration of nerve and
general tonics ought to be systematically pursued. Possibly some
of the newer combinations of arsenic deserve a thorough trial.
Formic acid and the formates are apparently of little use.
Phosphorus in different forms has been employed. Organic
compounds such as lecithin or nuclein may be worth a trial. If
the reports of the remarkably beneficial use of the latter in general
paralysis are substantiated it should be tried in progressive
muscular atrophy. Where such a grave disease is concerned no
treatment should be ignored because of its novelty or apparent
bizarrerie.
1082 Progressive Muscular Atrophy.
Electrical treatment has been faithfully administered over
prolonged periods in many cases which the writer has had oppor-
tunities of following, but its ultimate value is questionable, and
even temporary improvement is the exception. The same may be
said of massage. In regard to the former Sir W. Gowers makes
the shrewd remark that the disease is one of those in which
patients find it hard to believe that electricity cannot help them,
and for this reason and others, and also because of the
tendency of the lay mind to exalt the importance of local as
opposed to general treatment, electrical and massage treatment
to the affected muscles ought to be adopted. The galvanic current
is preferable to the faradic, and only currents of very moderate
strength should be employed.
Progressive muscular atrophy of syphilitic origin undoubtedly
occurs, and other etiological factors such as lead can sometimes be
traced, but the treatment of these types with suitable drugs is none
the less disappointing. Occasionally, however, apparent improve-
ment has followed the exhibition of mercury and the iodides, and
this is recommended by Marie and Leri as a routine measure in
all cases of progressive muscular atrophy, unless it is contra-
indicated.
With progressive muscular atrophy involvement of motor cranial
nerve nuclei is not infrequently associated. Sometimes the disease
begins in this way (see Bulbar Palsy).
In various spinal cord diseases, referred to elsewhere, muscular
atrophy may occur as a clinical symptom (see Syringomyelia,
Haematomyelia, Tabes Dorsalis). It may be a symptom in spinal
tumour.
S. A. KINNIER WILSON.
KEFEBENCES.
Gowers, Sir W. E., " Diseases of the Nervous System," 3rd edition (Gowers
and Taylor), London (Churchill), 1899, p. 531.
Marie, P., and Leri, A., article " Atrophie Musculaire Progressive Spinale,"
in Charcot- Bouchard " Traite de Medecine," Paris, 1904, IX., 632.
Wilfred Harris, Lancet, 1910, II., 551.
io8 3
SUB-ACUTE COMBINED DEGENERATION OF THE
SPINAL CORD.
THIS disease, which is practically confined to the latter half of life,
is characterised by primary diffuse focal lesions of the spinal cord,
with system degenerations secondary thereto. It usually runs a
steadily progressive course to a fatal termination in from one to four
years, but under careful treatment many cases improve temporarily,
and remissions of considerable length may occur. It is doubtful if
any cases really recover, but occasionally patients who present many
of its symptoms remain in an unchanging state for long periods.
The nervous symptoms are very frequently associated with a severe
anaemia, occasionally a true pernicious anaemia, but more commonly
a secondary anaemia of varying intensity. This anaemia has been
regarded as the causal factor of the spinal degeneration, but it is
now generally believed that they are related not as cause and effect,
but as concomitant effects of a single pathological agent (Collier).
We are as yet unaware of the nature of this etiological factor, but
it has been assumed that it is a toxin due to disturbed meta-
bolism, or one absorbed from the intestinal tract.
Treatment has been generally directed by the association of the
spinal disease with the anaemia, and on the hypothesis that the
latter is due to chronic oral or intestinal affections attention has
been given to the treatment of septic and infective conditions of
the mouth and gastro-intestinal tract, but apparently with little
satisfactory result. Intestinal antiseptics, which are frequently
recommended, should, however, be tried.
The drug that gives the best result is arsenic in moderately large
doses extended over a long period ; it frequently produces a remark-
able temporary improvement in the spinal symptoms as well as in
the anaemia. It may advantageously be combined with iron. Its
organic combinations, as atoxyl and soamin, have been recom-
mended for hypodermic administration, but the dangerous toxic
effects they occasionally manifest makes it imperative to employ
them with care in a disease in which the resistance of the tissues is
unquestionably lowered.
We can unfortunately rarely hope to relieve the symptoms that
are fully developed, but in the middle and early stages of the disease
the gait and the use of the arms may be much improved by careful
massage of the limbs, and in cases in which remissions occur at the
1084 Combined Degeneration of the Spinal Cord.
stage in which ataxia of movement, and especially of the legs, is the
most troublesome symptom, I have seen remarkable benefit obtained
by the re-education of movement on Fraenkel's system.
The panesthesiae are often the symptoms of which the patient
complains the most ; it is difficult and often impossible to remove
these sensations of numbness, tingling or formication, but relief
may be often obtained by gentle faradism applied with a brush to
the skin. Bromides in moderate doses and coal-tar drugs, as
phenacetin and ammonol, often alleviate the discomfort.
The sphincter disturbances must be carefully considered. Con-
stipation is almost the rule, and must be treated by the ordinary
appropriate means. The tendency to retention of urine and over-
distension of the bladder is more serious. Catheterisation becomes
almost invariably necessary, but should be delayed as long as
possible, owing to the danger of urinary infection and the
difficulty in avoiding it. As any sudden distension of the bladder
and stretching of its walls may seriously impair its functions, over-
distension must be regarded as a serious danger. It is best obviated
by careful and constant observation, and especially by urging the
patients from the early stage of the disease to attempt to empty
the bladder at regular intervals, for instance, every two or three
hours, whether they feel the need of it or not. If cystitis occurs,
systematic antiseptic irrigation of the bladder is imperative,
combined with the administration of urinary antiseptics, of which
urotropine is the most effective.
The troublesome reflex spasms of the latter stages of the disease can
be best relieved by moderate but frequently repeated doses of veronal.
Sub-acute combined degeneration is, however, a disease in which
the regulation of the patient's mode of life and careful nursing are
more important than any medicinal treatment. A regular out-door
life and plenty of fresh air should be prescribed, and food should be
as simple but as nourishing as possible. Bedsores, which often
develop relatively early in the bed-ridden stage, owing to the
anaemia and the low vitality of the tissues, hasten the fatal ter-
mination of the illness. They can be avoided only by careful
nursing and the use of water- or air-beds or cushions. The ordinary
draw-sheets may be replaced or covered by sheets of chamois leather,
as these are less liable to become wrinkled or folded, and thus exert
unequal pressure on the skin.
GORDON HOLMES.
EEFERENCE.
Collier, J., "Allbutt's System of Medicine," 2nd edit., 1910, VII., p. 786.
io8 5
TABES DORSALIS.
A CONSIDERABLE change has been effected in the treatment of tabes
by the growing belief that the affection is syphilitic in origin.
There are, however, those who, while admitting that there are good
reasons to believe that without syphilis there would be no such
disease as tabes, nevertheless deny the possibility of good from
anti-syphilitic treatment of patients affected by the malady, and
who, accordingly, rely entirely on a tonic line of treatment in the
affection. It is assumed that the effects of syphilis which result in
the disease are too remote from the original infection to make it in
the least likely that remedies which are known to produce beneficial
results in the earlier manifestations of syphilis can possibly effect
good in the so-called para-syphilitic affections, tabes and general
paralysis. However true this may be of general paralysis, the
argument does not apply to tabes ; for no one who has had much
experience of the results of anti-syphilitic treatment of this affection
can fail to recognise the good that results in many cases. The fact
that the Wassermann test for syphilis proves positive in so many
of those suffering from tabes is good evidence that the syphilitic
virus is still active in these people, and that anti-syphilitic treat-
ment may accordingly be reasonably expected to do good if properly
employed. It is not suggested that any amount of mercury or
iodide of potassium can be expected to remove sclerosis of the dorsal
tracts after this condition has been definitely established, but it is
contended in all reasonableness that, whatever view we accept as to
the way in which syphilis brings about this sclerosis, there must be
an early stage in which, antecedent to the actual establishment
of sclerosis, the early lesions which ultimately result in this can
be influenced by anti-syphilitic treatment ; and, moreover, that the
toxins of syphilis can be so neutralised that fresh lesions and
further progress of the affection of the nervous system can be pre-
vented. All that is claimed for the anti-syphilitic treatment of
tabes, therefore, is the arrest of the morbid process at various stages
of its progress, and not cure in the sense of removal of damage,
such as sclerosis of the dorsal tracts of the cord, a condition
of things which, if once established, must apparently remain
permanent.
The attempt is, however, made to influence the process also by
io86 Tabes Dorsal is.
the administration of fibrolysin concurrently with the anti-syphilitic
treatment. The wonderful effects produced by this drug on scar
tissue of external parts which can be reached directly encourage
the hope that it may even exert a favourable influence on deep-
seated internal structures. Favourable as have been the results
recorded by some observers, however, it does not seem probable
that much good is to be expected from the use of fibrolysin, in so
far as we are concerned with the removal of sclerotic tissue from
the central nervous system. This treatment is worthy of trial, in
the hope that, although it does not appear to influence sclerosis of
long standing, it may nevertheless produce some effect on the
earlier manifestations of this process in the central nervous system.
The treatment is not without its risks, so that some caution is
needed in the way that it is employed.
The essential part of the treatment of tabes, however, consists in
attempting to counteract the syphilitic toxins, and to influence the
earlier lesions of the disease by means of mercury. Iodide of
potassium has its place in the treatment of the affection, but this
must be regarded as secondary to that which may be justly claimed
for mercury. Of the different methods of employing the mercury,
that which consists in giving one or other preparation by the
mouth should never be selected, as this method cannot compare in effi-
cacy with that of administering the drug by inunction or by intra-
muscular injection. There are advantages and disadvantages
attaching to both of the latter methods of treatment ; but when it
is possible to do so it is best to subject the patients to treatment by
inunction, on the plan adopted at Aachen (Aix la Chapelle). There
are, however, cases in which, for various private and other reasons,
it is not politic for the patient to undergo a cure of the kind, either in
this country, at Aachen, or some other place where such treatment
can be secured, so that preference has to be given to intra-muscular
injections, in which case grey oil proves one of the most satisfactory
preparations of mercury for use in this way, and may be given in
10-minim doses once a week. Then, again, in the treatment of tabes
among out-patients in hospital practice the injection treatment
proves of decided advantage, for the reason that administration of
mercury by the mouth is not to be recommended, and the practice
of giving patients mercurial ointment to be rubbed in by themselves
cannot be too strongly deprecated, as it is only calculated to bring
discredit on a plan of treatment which, if carried out properly in
suitable cases, results in so much benefit to many of those who
suffer from this disease. In the selection of cases for treatment by
mercury the interval which has elapsed between the primary lesion
Tabes Dorsal is. 1087
and the first manifestations of the affection of the spinal cord
should not be allowed to influence us; for although, as may
reasonably be expected, the shorter the interval the more benefit is
to be expected, the opposite does riot hold good, for benefit may be
expected from mercurial treatment even where the interval has
been long, provided that the treatment is instituted at an early
stage of the spinal affection.
It must not be concluded that the mercurial treatment is only to
be recommended when the Wassermann reaction proves positive ;
for although this test often proves a useful guide as to how soon a
course of mercurial treatment should be repeated, a negative result
of the test should not be allowed to influence us to the extent of
withholding either the first or some subsequent course of mercurial
treatment in the case of a person suffering from tabes. Where it is
at all possible, the patient should be advised to go to Aachen for the
treatment ; but when this is not possible there are, of course, other
health resorts abroad and in this country where the treatment can
be secured. With few exceptions, however, the treatment is carried
out in the most perfunctory fashion in this country, even at many
places where the cure is undertaken ; but there are some places
where the treatment is properly carried out, although these are few.
Nowhere is the treatment so thorough as at Aachen, so that there
can be no doubt that patients should be encouraged to go there for
their cure when this is possible.
Various modifications of the treatment as carried out at Aachen
have to be adopted according to circumstances. When it is
not possible for the cure to be undertaken there, a good plan is to
encourage the patient to have daily rubbings of 1 drachm of blue
ointment for a period of about three months, or about 100 in all, to
be followed by fifty more similar rubbings in three to six months.
Similar courses of fifty inunctions should be repeated every six
months during the next three years or more, the exact length of
time that the treatment is continued being determined by the course
of the disease. When sulphur baths cannot be conveniently obtained,
an ordinary hot bath may be substituted, or a hot compress may be
applied for about twenty minutes to the part immediately before
the ointment is applied to it. Careful attention must be given to
the gums, so that the patient should be encouraged to clean the
teeth after each meal, and to follow this by using a mouth-wash
consisting of 10 gr. to 1 oz. of chlorate of potash. The kidneys
and bowels must, of course, be carefully watched for any indications
of affection of them by the mercury.
Iodide of potassium has its place in the treatment of the disease,
io88 Tabes Dorsalis.
and is sometimes administered by the mouth concurrently with the
course of mercury. A plan to be preferred, however, is to give
the iodide in the intervals between the courses of mercury.
Whichever plan is adopted, a dose of 20 gr. three times a day,
in conjunction with \ drachm of aromatic spirits of ammonia
or 3 or 4 minims of Fowler's solution of arsenic, usually
proves sufficient. The drug is, however, sometimes effective in
cutting short a paroxysm of lightning pains, in which case even
larger doses, e.g., 40 gr. three times a day, may be required to
secure this result. Where ordinary iodide is borne badly, iodo-
glidin, tiodine or iodipin prove useful substitutes ; while tiodine
(3 gr.) and iodipin (30 minims) have the further advantage that they
can be administered by subcutaneous injection once daily without
the risk of disturbing the alimentary tract.
The fact that good is claimed for mercury and iodide naturally
raises the question as to whether salvarsan " 606 " may be expected
to assist us in the treatment of tabes. Brilliant as have been the
results of the treatment of many syphilitic affections by this prepara-
tion, it cannot be said that we are yet in a position to come to any
very definite conclusion in regard to its efficacy in the treatment of
this disease. Indeed, there is reason to fear that we are not to
derive much assistance from this course, except that we may hope
that, by its use in the treatment of the primary syphilitic lesion,
diseases like tabes and general paralysis may be rendered less
liable to follow in the wake of syphilis. The treatment cannot,
however, be said to have had a sufficiently extensive trial in the
treatment of tabes to justify our withholding it in what w r ould
otherwise appear to be suitable cases for its use. The unfortunate
circumstances that have attended the use of another arsenical
preparation, soamin, have naturally led to the suspicion that
"606" may not be entirely free from risk in so far as sight is
concerned, and thus many have had considerable hesitation in
using this preparation of arsenic in a disease like tabes, in which
optic atrophy is one of the conditions to be feared in the ordinary
course of the malady. The evidence as to whether or not " 606 "
does cause optic neuritis or atrophy is conflicting at present, so
that until we are in a position to be sure that this danger does not
exist, or that it is sufficiently remote to justify our accepting the
risk, there must be a certain amount of hesitation in recommending
a line of treatment in which as yet there have been no large amount
of successes to be recorded in so far as tabes is concerned.
Other Medicinal Remedies. Nitrate of silver was at one time
much used in the treatment of tabes, and there are those who still
Tabes Dorsal is. 1089
advocate the use of silver, either in this or in some other form.
Tonics of various kinds are called for as adjuncts in the treatment
of patients suffering from tabes, and strychnine claims a prominent
place among these. Strychnine is, of course, specially indicated in
those cases in which paralysis and muscular atrophy form part of
the clinical picture of the disease, and may be given by the mouth,
or by intra-muscular injection. The drug is, however, useful in
the treatment of any case of the affection, irrespective of whether
or not paralysis exists, and may be given in the intervals between
the courses of anti-syphilitic treatment ; or in the form of nux
vomica combined with iodide of potassium when this is being used
in the treatment of the patient. It is well not to give strychnine
too freely, however, when lightning pains are troublesome, for, like
alcohol, it may tend to increase these. Arsenic, in the form of
Fowler's solution, may be similarly employed, as may iron or any
other form of tonic for which there may be any preference on the
part of the patient or his doctor. Cod-liver oil and the various
preparations of malt similarly find a place in the treatment of
these patients, in view of the fact that progressive loss of flesh
proves such a striking feature in so many cases.
No special symptom calls for assistance so frequently as pain.
Indeed, not only is this such a constant and prominent symptom
of the disease, but it usually occasions distress so early in the
life-history of the malady that it is commonly mistaken for
" rheumatism," " neuritis," or some other condition, and its real
cause is not suspected for a long time. There was a time when
opium, in some form, could alone be relied on to quell the pains
of tabes ; but, thanks to the introduction of the various modern
analgesics, it is now rarely necessary to prescribe morphia
for the relief of lightning and other pains that occur in tabes.
Various analgesics, including aspirin, pyramidon, phenacetin,
phenazone, antifebrin, exalgin, phenalgin, etc., must be tried in
turn or in different combinations until it is determined which suits
the patient best ; for that which succeeds in one patient may fail in
another. A combination that often proves useful in cachet is :
1 gr. of citrate of caffeine, 7 gr. of aspirin and 10 gr. of
either pyramidon or phenacetin. It sometimes happens that
obstinate cases are met with in which none of -these preparations
give any relief, and in which we are reluctantly compelled to resort
to morphia. As has already been said, large doses of iodide of
potassium, given continuously for some weeks, have a very decided
influence in checking the tendency to paroxysms of pain in some
cases. Counter-irritation of the spine, by the cautery or otherwise,
S.T. VOL. ii. 69
1090 Tabes Dorsal is.
may similarly prove helpful. When pain is localised to a given
region and of a fixed character, considerable relief is often obtained
by the application of a stimulating liniment to the part, a plan of
treatment that is more especially likely to succeed when the pain
appears to be superficial in character.
Whatever other plans are adopted in the treatment of the pains
of tabes, it is certain that physical and mental rest are important
factors, and that warmth, with the avoidance of cold and damp, are
equally important conditions to be secured. Similar methods of
treatment must be employed for the various crises to which these
patients are liable, but for which it may become necessary to have
recourse to morphia. Nothing short of morphia is usually of much
avail in the treatment of severe gastric crises, but bismuth and
other gastric sedatives may be of some assistance, as may lavage of
the stomach and the avoidance of all food by the mouth for a time,
the patient being fed by the bowel. A mustard leaf to the
epigastrium, and counter-irritation to the spine in the region of the
seventh to the tenth thoracic nerves, are supplementary measures
that may be tried in the treatment of these crises. It is of great
importance that such patients should be fed liberally in the
intervals between their attacks of pain and vomiting, so as to
assist them to combat the exhaustion induced by the severity of the
crises, and their inability to retain food in the stomach during the
attacks. In severe and obstinate cases of the kind, complete relief
has been obtained by section of the dorsal roots of the seventh
to the tenth thoracic nerves, a procedure that should, however, be
reserved for cases that have resisted all other methods of treatment.
W 7 hen the sphincter of the bladder proves troublesome, belladonna
(5 to 10 minims of the tincture three times a day) often is most
helpful ; but the difficulties may be such that cystitis is to be feared,
in which case, even where catheterisation has not become necessary,
it is a wise precaution to give the patient 10 gr. of urotropine by
the mouth once or twice a day. If the use of the catheter becomes
necessary, the strictest aseptic precautions must be enjoined in its
use ; while cystitis must be treated by daily lavage of the bladder, in
addition to the use of urotropine by the mouth.
Rest and the avoidance of undue fatigue are important adjuncts
in the treatment of the disease in general ; but in recommending
patients suffering from tabes to take physical rest, they must always
be warned not to remain entirely in bed or on a couch, for the
reason that such absolute rest carries with it the risk that the
longer the patient is off his feet the greater the danger of his
increasing the inco-ordination which exists or is threatened in the
Tabes Dorsalis. 1091
lower limbs. When it is at all possible, therefore, the patient should
at least walk about his room for a short time every day, even if he
does nothing more ; and when there are reasons why he is unable
to leave his bed or couch, some of the exercises to be recommended
in the treatment of the inco-ordination which results in the disease
ought to be carried out if the conditions permit of these.
The inco-ordination, which is such a source of inconvenience,
and which causes so much disability in tabes, is capable of
being most favourably influenced in a large proportion of cases,
notably in the earlier stages of the disease, by means of a series
of exercises devised by Professor Fraenkel for the re-educa-
tion of the affected muscles. Some have been devised for the
arms, and others for the legs ; and in the case of the lower limbs
there are exercises which the patient can perform in a recumbent
posture, and others which necessitate his standing and walking.
The essential feature of the exercises is that the muscles are trained
to perform, slowly and with precision, a series of movements which
are at first simple, and which are made more and more complex as
the treatment is in progress. The patient must be made to under-
stand that he must concentrate his whole attention on the' exercises
when they are being performed, and that while sight permits him to
recognise his mistakes, and allows of his attempting to correct
them, he must learn to give the fullest possible attention to the
appreciation of the sensations engendered in the limbs by the
movements, so that he is enabled, in time, to rely on these sensations
for his guidance in the execution of the various movements of the
limbs without the assistance of vision. The mental concentration
that is necessary readily induces mental as well as physical fatigue
at first, so that it is important that the patient should only perform
the exercises for so short a time each day that fatigue is avoided
This is usually best secured by only allowing the exercises to be
practised for ten minutes three times a day. The time can be
gradually increased until half an hour, and it may be even an hour,
is devoted to their performance three times a day.
In addition to their value in cases in which paralytic manifesta-
tions complicate the more usual picture of tabes, massage and
electrical treatment are useful adjuncts to the exercises for the
improvement of inco-ordination, for they assist in keeping up the
tone of the muscles, and are helpful in making numbness and
cutaneous anaesthesia less obtrusive. Care must be taken to see
that the amount of massage given does not cause undue fatigue, and
that a proper rest is secured for the patient in the recumbent posture
after the treatment. Faradism is the form of electricity which
692
1092 Tabes Dorsalis.
usually proves most helpful, but galvanism may be called for in
cases with peripheral paralysis and muscular atrophy. It has also
been supposed to do good when applied to the spine, but it cannot
be said that this plan has much to recommend it.
Apart from the place which sulphur baths take in the Aachen
treatment, it cannot be said that hydropathic measures are of
much advantage in the treatment of tabes ; and neither very hot
nor very cold baths are usually at all well borne by the subjects of
this disease.
As these patients usually lose flesh to a marked degree, their diet
should be liberal and nutritious, and should include as much milk
food and cream as they can digest. Alcohol is best avoided, as a
rule, for the reason that although whisky or some other form of
alcoholic stimulant may relieve an attack of pain, there can be
little doubt that alcohol keeps up the tendency to recurrence of the
pains. Patients suffering from tabes should try to secure a climate
that is dry and warm, and those who usually reside in this country
should seek a climate of the kind abroad during our winter months.
Cold and damp are both best avoided, as far as possible, for the reason
that those affected by tabes are never so well under such conditions,
and the pains often are made considerably worse.
J. S. RISIEN RUSSELL.
1093
DISEASES AND AFFECTIONS OF THE NERVES.
FACIAL PARALYSIS.
PARALYSIS of the facial muscles may result from any interrup-
tion of the nerve path between the cerebral cortex and the muscles.
Thus the lesion may be in the upper neurons, which extend from
the ganglionic centre in the ascending frontal convolution to the
nucleus in the pons ; or in the lower neurons, which include the
facial nucleus and the motor fibres which extend from it to the
muscles.
For the purposes of this article the internal auditory meatus
may be taken as a point of separation between two portions of the
path, namely : (1) an intra-cranial part, or the path through the
brain and across the posterior cranial fossa ; and (2) a peripheral
part, constituted by the nerve as it passes along the Fallopian canal
and out through the stylo-mastoid foramen, to be distributed to the
facial muscles of expression, the platysma, the stylo-hyoid and the
posterior belly of the digastric.
When facial paralysis is caused by a lesion of the intra-cranial
path, as above defined, it is associated with symptoms indicating
disturbance of the functions of other portions of the brain, or of
other cranial nerves. Thus if the lesion involves the internal
capsule there is hemiplegia, if the nuclei of the lower cranial
nerves as well as the nucleus of the seventh, there is bulbar
paralysis, and so on. The treatment of these conditions is that of
the haemorrhage, tumour, meningitis or degeneration producing
them, and is considered elsewhere (see Meningitis, Hemiplegia,
Tumours of the Brain, etc.).
It is with the treatment of disease of the peripheral part of the
path that we are now concerned. Apart from wounds and other
injuries, the most frequent causes of peripheral facial palsy are
suppurative middle-ear disease and neuritis. In cases arising from
ear disease the treatment of this is essential before any measures
are taken to improve the condition of the muscles.
Most frequently the paralysis depends on a parenchymatous
neuritis, which is usually most marked in the nerve at the distal
end of the Fallopian canal. In about 80 per cent, of the cases the
neuritis appears to be set up by exposure to cold : in some of these
ic>94 Facial Paralysis.
cases syphilis or alcohol has been an essential or a contributory
factor. Very often, however, no cause can be discovered, and we
have to consider the possibility of microbic infection, such as that
which is assumed to initiate acute anterior polio-myelitis.
If suitably treated, most cases of peripheral facial palsy make a
complete recovery, the mildest forms in a week or two, the severest
forms in from six to nine months. Occasionally no recovery takes
place, and it is common for a trace of weakness to be permanent.
Obviously, if there is reason to believe that alcohol has been a
cause, this must be prohibited ; if syphilis is suspected, mercury and
the iodides should be administered. In all cases it is desirable for
the patient to stay indoors for a time, and even in bed, should there
be much pain or any febrile symptoms. The neuritis may be
beneficially influenced by counter-irritation to the affected side by
means of hot fomentations every three hours for the first two or
three days, and afterwards by the application of a blister or a mustard
leaf to the mastoid process. Such an application should not be made
in front of the ear, owing to the risk of cellulitis being set up. The
bowels should be kept freely open ; in some cases a mixture contain-
ing salicylate of sodium and iodide of potassium appears to do good.
At a later period tonics, especially strychnine, are often beneficial.
For the restoration of voluntary power the chief reliance is to be
placed on electricity and massage, and these methods of treat-
ment should be commenced as soon as possible. In applying the
constant current, which, even before the reaction of degeneration is
present, is more useful than the faradic, two small electrodes are
necessary. The negative pole should be held behind the ear near
the stylo-mastoid foramen, whilst the positive pole, which is less
painful than the negative, is stroked across the forehead, around
the eye, down the cheek and along the lips. The strength of the
current should be just enough to produce contraction of the muscles.
At first 3 to 5 milliamperes will be necessary, but after the first
fortnight, when the reaction of degeneration has developed, the
muscles, owing to their hyper-excitability to galvanism, may react
to a weaker current. This method of stimulating the muscles,
which can be carried out quite well by the patient with the aid of
a mirror, should be repeated two or three times a day for a period
of ten to fifteen minutes, and should be persisted in for many
months or until voluntary power begins to return. In the latter
case it is well to discontinue electrical treatment in order to avoid
the tendency to undue tonic contraction, which may draw the mouth
to the paralysed side.
After each application of the battery, and indeed at other times,
Facial Paralysis. IO 95
facial massage should be employed. This also may be done by the
patient himself; he should rub the individual muscles with the
tips of his fingers, and knead and compress those of the cheek and
lips between the thumb, placed in the mouth, and the fingers out-
side. It is useful to rub the eyelids over the eyeball, and at night
to put a compress over the eye in order to keep it closed.
Massage and electrical treatment should be persevered in for a
period of six months ; if at the end of that time there are no signs
of recovery, or if from the first it is evident that the nerve is
divided or so completely injured that recovery is impossible,
surgical intervention is called for. In some cases the surgeon may
be able to join together the two segments of the nerve ; but when
this is impossible, and also in the intractable cases of neuritis, the
question of nerve anastomosis has to be considered. It is believed
that better results are obtained by uniting the facial to the
hypoglossal nerve than to the spinal accessory, but for information
on this subject the reader is referred to p. 1109.
JUDSON S. BURY.
1096
HERPES ZOSTER.
HERPES ZOSTER is an acute febrile disease whose virus has a
specific incidence on the posterior root ganglia of the spinal cord,
and for purposes of therapeutic description it may be considered
as being divisible into three stages.
(1) Prodromal Stage, of general malaise, with rise of tempera-
ture and pains, more or less severe, radiating round one side of the
body. The treatment here is simply that of any acute fever, to be
followed on general lines. The pain may be relieved by the local
use of soothing applications, such as hot fomentations with liq.
morph. hydrochlor. (^ drachm) [U.S.P. morphin. hydrochlor.,
gr. T 3 (j] sprinkled on the side next the skin. In spite of many
statements to the contrary, no treatment is effectual in aborting
the eruption (Head).
(2) Acute Stage. The characteristic vesicular rash usually
makes its appearance on the third or fourth day, to the continued
accompaniment of pain, which, however, may vary much in intensity.
Treatment during this period (which lasts perhaps ten days or less)
is both local and general.
(a) LOCAL. The chief indication is to protect the vesicles as they
appear and to minimise the risk of their contamination through
friction or contact with the patient's garments. For this purpose
the area affected may be swathed in cotton- wool and bandaged
firmly but not tightly, and often this method is all that is required.
Ointments, dusting powders, lotions or paints may be utilised.
The following have proved of practical value :
Ointments : Ichthyol ; boracic ; zinc ; cocaine (4 per cent.) ; ung.
borac., softened with the admixture of soft paraffin (.5 oz.), cocaine
(22 gr.) (Head) ; 1 per cent, solution of cocaine in ung. petrolatum
(Sinkler).
Powders : Pulv. amyli co. (pulv. amyli 3 parts, zinci oxidi 1) ;
starch (2 oz.), oxide of zinc (1 oz.), camphor powder (15 to 45 gr.),
with the addition of 15 gr. of powdered opium if there is much pain
(Head).
Lotions : Lead and opium ; calamine and zinc oxide (of each
1 oz.), glycerine (2 oz.), lime-water to 10 oz.
Paints : Collodion ; cocaine, 2 per cent, in flexible collodion ;
Unna's zinc gelatin (zinc oxide 3 drachms, gelatin 2 drachms,
glycerine 6 fluid drachms, water 1 fluid ounce) (Walker).
Herpes Zoster. 1097
Should the vesicles suppurate they must be treated with some
antiseptic ointment or dressing.
(b) GENERAL. In addition to local measures, it is often necessary
to treat the pain by suitable drugs administered by the mouth,
such as any of the accepted antalgesics. Caffein citrate, aspirin,
and phenacetin (of each 5 gr.) form a good combination; also
phenacetin (10 gr.), exalgin (2 gr.). Sometimes morphia in one or
other of its forms is the only drug which gives relief.
(3) Sequelae. As a rule, scabs form on the vesicles after the acute
stage is over and these gradually drop off, leaving not infrequently
a certain amount of scarring. Where the eruption has been over an
area of the skin that is exposed (face or neck), Walker recommends
picking the scabs off and keeping the part soft with a simple
antiseptic ointment, to allow granulations to reach the level of the
surrounding skin.
Much the most serious sequelae are post-herpetic parsesthesise and
neuralgia, which are sometimes peculiarly intractable. Local
counter-irritation should be tried (pigmentum iodi, actual cautery,
blister,, etc.), or cataphoresis of cocaine or sodium salicylate. With
the latter drug excellent results have been obtained by Mackenna.
It is applied on the kathode; cocaine on the anode. The active
electrode should be placed over the vertebral column at the level
affected, the indifferent electrode may be placed over the peripheral
ends of the primary divisions concerned. A current of 5 to
15 milliamperes is sufficient ; duration five to twenty minutes,
according to the patient's reaction. If ionisation fails to give relief
the posterior roots involved may be divided by operation.
Other complications, such as facial and other palsies, and more
rarely still medullary invasion, must be treated according to the
circumstances.
S. A. KINNIER WILSON.
REFERENCES.
Head, H., and Campbell, A. W., " Brain," 1900, XXHL, p. 353.
Leduc, " Electric Ions and their Use in Medicine," translated by Mackenna,
London (Rebrnan), 1908.
Walker, Norman, "Introduction to Dermatology," 5th edit, 8vo., Bristol,
1911.
1098
INJURIES OF NERVES.
A NERVE may be injured as the result of a penetrating wound ; by
pressure, sudden or long continued, or by overstretching (traction).
As the consequence of any of these, degeneration may occur in
the whole peripheral end of the nerve ; this is termed " complete
division." If the naked- eye continuity of the nerve is completely
interrupted, it is called complete " anatomical " division ; if the
division is complete and the nerve is in continuity, complete
"physiological" division. When the injury is incomplete, the
term "incomplete division" is used, "anatomical " if the nerve is
partially severed, " physiological" if there is no naked-eye solution
of continuity.
General Lines of Treatment. The treatment of a case of
nerve injury consists in keeping up the nutrition of the affected
parts, preventing overstretching of paralysed muscles and con-
tracture of their opponents and of the joints moved by them, until
restoration of function takes place through the re-establishment
of conduction, by nature alone, or aided by the surgeon.
Patience is needful on the part of both patient and surgeon if the
case is to be brought to a perfect recovery. This is possible even
after complete anatomical division and suture, if treatment is
faithfully carried out.
Paretic or paralysed muscles must be kept relaxed by suitable
splints. Recovery is much delayed if the muscles are allowed
to become overstretched, and may be rendered incomplete if con-
tractures are permitted to take place in the opposing muscles and
changes in the ligaments surrounding the joints upon which they
act. Neglect of this is a fertile cause of delayed and incomplete
recovery. While of importance in dealing with nerve injuries in
any situation, its influence is seen most often after injuries of the
ulnar and musculo-spiral nerves and the upper trunk of the brachial
plexus.
The nutrition of the muscles should be maintained by daily
massage and movements, aided, if possible, by electrical stimulation
with that form of current, interrupted or constant, to which the
muscles react. The splint should only be removed for massage
and electrical treatment and should be worn until voluntary
power is restored to the affected muscles. On the restoration of
Injuries of Nerves. 1099
voluntary power to any muscle daily and systematic active
movements should be carried out.
Parts deprived of their sensory supply must be carefully pro-
tected from injury until the restoration of protopathic sensibility.
Heat and cold of a degree insufficient to give rise to discomfort
to sound parts will cause the formation of blisters on the affected
part.
In many cases operation is required to restore continuity or
release the nerve from pressure. The treatment outlined above is
necessary in every case whether operation is carried out or not.
General Considerations regarding Operations upon Nerves.
In every nerve operation gentle handling is essential. The nerve
itself should never be caught up in forceps or lifted on a hook. It
should be lifted with fine-toothed forceps by its connective tissue
sheath ; a flat retractor should be used if the nerve has to be
pulled on one side, as a hook is liable to cause local injury.
The suture material must be absorbable and as fine as possible.
Silk, linen or Pagenstecher thread should never be employed.
These remain in the nerve as a foreign body, and several cases
have come under my notice in which complete recovery was
prevented by the onset of inflammation around the unabsorbed
stitch several months after suture. I have found No. 00 Van Horn
twenty-day chromic catgut the most satisfactory suture material.
The suture should be passed with a round, straight needle. After
suture or exposure of a nerve it should always be -wrapped with
Cargile membrane to prevent the formation of adhesions to
surrounding structures and the ingrowth of fibrous tissue and
" wound nerve fibres. "
Nerve Injuries in Wounds. Accidental wounds in the region
of the wrist are common causes of nerve injury. In every patient
with an accidental wound the question of nerve injury should
be settled before treatment is adopted. Unless it is known that
certain nerves have been damaged, it is easy to overlook them in
lengthy operations. That this is not infrequent is evident by the
number of cases of secondary suture that have to be performed.
The affected nerve must be fully exposed, in most cases a fresh
incision is necessary at right angles to the accidental wound, and
over the course of the nerve. If it is found completely divided,
the ends should be trimmed with a sharp scalpel if they are
irregular ; scissors should never be used for this purpose, as during
their application they crush the nerve and prevent complete
recovery. The ends should then be approximated by suture. One
stitch is sufficient in most cases ; it should be passed through
iioo Injuries of Nerves.
the whole thickness of the nerve at right angles to its long axis
and drawn sufficiently tight just to bring the ends into contact.
An attempt must always be made to unite the nerve without
any longitudinal rotation, bearing in mind that recovery will be
more rapid and perfect if the corresponding ends of the divided
axis cylinders in the central and peripheral ends are opposite to
one another. The union, for example, of axis cylinders in the
radial border of the central end of a divided median nerve with
those in the ulnar border of its peripheral end must result in delay
in complete restoration of function.
It occasionally happens that the nerve is divided at two levels,
a piece being loose ; this should be sutured in. In rare cases
so much nerve is destroyed that the ends cannot be brought into
contact. If the nerve is found cut into but not completely divided,
the gap should be closed by one stitch.
After wrapping the nerve in Cargile membrane the wound
should be closed, drainage being provided if there is much oozing
or if there are doubts with regard to its cleanliness, care being
taken especially in wounds in the region of the wrist to suture
up the deep fascia separately to avoid subsequent hernia of
tendons. The part should be put up so that there is no tension
on the nerve junction and the paralysed muscles are relaxed.
Subcutaneous Injuries. A nerve may be injured sub-
cutaneously as the result of pressure, or traction, or it may be
wounded by the end of a fractured bone. The pressure may be
external, the result of the use of crutches, or the effect of surgical
treatment, the pressure of tight bandages, strapping, splint,
Clover's crutch, or due to a direct blow. Internal pressure is
usually the result of fractures or dislocations. These will be con-
sidered separately. Overstretching is responsible for the majority
of the supra-clavicular injuries of the brachial plexus, and for
occasional injury to the great sciatic nerve and its branches and
the anterior crural in dislocations of the hip and reduction of con-
genital dislocations. The median nerve suffers overstretching in
rare instances from falls on the palm of the hand.
As the result of subcutaneous injury any form of division may
occur ; it may be impossible at first to estimate its degree.
The treatment of subcutaneous injuries (apart from those
complicating fractures and dislocations) is, with one exception, a
traction injury of the brachial plexus in an adult that given
below. When symptoms indicating a lesion of the brachial
plexus follow an injury, such as a fall on the head or shoulder
causing overstretching, exploration should be undertaken without
Injuries of Nerves. 1101
delay and the appropriate treatment adopted to restore anatomical
continuity, if this is seen to be needed. In other situations operation
is only undertaken under certain well-defined circumstances.
It may be impossible to diagnose between complete and in-
complete division until such time has elapsed as would permit the
development of changes in the electrical reactions of the paralysed
muscles. If at the end of a fortnight the reaction of degeneration
has developed or is present in a case coming under observation
later, exploration should be undertaken. The nerve may be
found anatomically divided, in which case secondary suture should
be carried out. If it is in continuity, experience only will enable
a decision to be arrived at as to the best form of treatment.
General rules can, however, be laid down. If there is little
alteration in the appearance and feel of the nerve, it should be
wrapped and the wound closed. If it is thin, fibrous, and adherent
to the neighbouring tissue, the ends being united apparently by
fibrous tissue only, the damaged portion should be resected and
anatomical continuity re-established.
Nerve Injuries in Fractures. The injury may be primary,
being produced at the time of the accident, or secondary, the
symptoms appearing later, as the result of involvement of the
nerve in callus or fibrous tissue, or from the pressure of displaced
bone. The musculo-spiral is the nerve most often affected and
suffers usually in fractures of the lower and middle thirds of the
humerus.
If the injury is primary operation should be carried out at once,
if examination proves it to be a grave one and the diagnosis of
incomplete division is doubtful. Anatomical injury to the nerve
should be repaired in the usual way. If there is no breach of
surface, the nerve should be simply wrapped. This will be most
often required in fractures of the humerus ; at the same time the
fracture should be plated if necessary.
If the injury, as is so often the case, is discovered on removal of
the splints, operation is indicated without delay if the symptoms
are those of complete division. If they are not, it is only neces-
sary if no improvement ensues after a course of treatment faithfully
carried out. If, as sometimes occurs, symptoms of nerve injury
first develop when the patient starts to use the limb, operation
should be immediately performed.
In all operations upon nerves involved in fractures the incision
must be of sufficient length to expose the nerve well above and
below the seat of fracture, and the nerve must be traced from both
directions to the seat of the injury.
iiO2 Injuries of Nerves.
If the nerve injury from the symptoms or operative findings is
obviously incomplete, the nerve, after being well freed, should be
wrapped in Cargile membrane and the wound closed.
When the signs are those of complete division and the nerve is
found in anatomical continuity, if the appearance and consistence
of the nerve approach the normal, it will be enough to free and
wrap it. If, however, it is thin, fibrous and adherent, its damaged
portion should be excised and continuity restored.
Nerve Injuries Complicating Dislocations. Symptoms of
nerve involvement are most often associated with dislocations of the
humerus. The injury may be due to the pressure of the dislocated
head, but more often to efforts at reduction, especially by the " heel
in axilla " method. The inner cord of the plexus suffers most often
and the injury is usually incomplete. Treatment follows the usual
lines and recovery is the rule.
Injury to the great sciatic or its branches is occasionally seen
after attempts at reduction of acquired or congenital dislocations of
the hip ; the anterior crural may suffer in the same way. There
are no special points in the treatment. Recovery generally follows.
The musculo-spiral nerve or its posterior interosseous branch
may be injured in forward dislocations of the head of the radius.
This is especially likely to occur, as pointed out by Stettin, when it is
complicated by a fracture of the ulna. Treatment must be by open
operation. The nerve is rarely completely divided, but it is impos-
sible to ensure the safety of the nerve in any other way even in
recent cases. If the patient is seen soon after the accident, it may
be possible to replace the head and suture up the orbicular
ligament. In old cases excision of the head of the bone is necessary.
The nerve itself should be dealt with as occasion requires.
Secondary Suture. This term is applied to operative re-estab-
lishment of anatomical continuity after degeneration has taken place
in the peripheral end of a divided nerve. This operation is
becoming rarer as nerve injuries are recognised at the time of the
accident. It is a reproach to the surgeon who first saw the case,
except in subcutaneous injuries, when it may be unavoidable.
Before proceeding to operation careful examination is essential
in order to ascertain how much recovery is likely to ensue. The
time which has elapsed since the injury has little bearing upon the
regeneration of the nerve after reunion ; it is probable that nerve
regeneration takes place up to many years after injury. The con-
dition of the muscles and of the fibrous structures surrounding the
joints is of the utmost importance. If careful and repeated elec-
trical examinations reveal no reaction to the constant current
Injuries of Nerves. 1103
in the affected muscles, operation is of no use from the motor
standpoint. Again, if deformity has resulted from overstretching
of paralysed muscles and contractures of their opponents, e.g., ulnar
claw hand, motor recovery will he incomplete. When the nerve
division is the result of a penetrating wound, its original manner of
healing will influence the prognosis. If prolonged suppuration
occurred, complete recovery is unlikely, owing to fibrotic changes
in the nerve which often supervene as the result of infection. From
the sensory standpoint it is worth while undertaking secondary
suture at any time after division, from the motor, if the paralysed
muscles retain their irritability to the constant current, which they
may do for long periods ; I have seen this twenty years after
separation from the central nervous system by nerve section.
In carrying out the operation an incision should be made over
the course of the nerve of sufficient length to expose it well above
and below the seat of injury. It should be traced from above and
below towards this point and freed. The ends are usually found
bound together by fibrous tissue. It is well before separating these
ends to stretch the nerve ; in this way apposition can be obtained
in most cases after removal of sufficient nerve. The bulb on the
central end should then be excised with a sharp scalpel ; the distal
end is usually pointed, and this fibrous extremity is all that need be
sacrificed. Chromic catgut (Van Horn, No. 00, twenty-day) should be
used to unite the ends ; two sutures are usually necessary, passed
at right angles to one another through the whole thickness of the
nerve. If the ends do not come readily into apposition, flexion of
the joints over which the nerve passes will often enable suture to
be carried out without undue tension. If in spite of this a gap is
left, resort must be had to some form of bridging.
Nerve Bridging. Many methods have been advised, but there
are only four of proved value : (1) Insertion of a portion of nerve
between the two ends (nerve transplantation) ; (2) union of the
ends by catgut threads ; (8) union of the peripheral end of the
divided nerve to a neighbouring sound nerve (nerve anastomosis
and nerve crossing) ; (4) shortening the limb by removal of bone.
Much confusion has resulted from the careless use of names in
nerve surgery, the term "nerve grafting" having been applied to
entirely different operations. The use of this term should be dis-
continued.
If the gap between the ends is short, less than 1 inch, several
sutures of plain catgut should be passed between the ends and the
whole surrounded by Cargile membrane. If the gap is longer, up
to about 4 inches, nerve transplantation is the operation of
uo4 Injuries of Nerves.
choice. In this operation the employment of a portion of nerve from
one of the lower animals (hetero-transplantation) is useless. The
results are worse than if catgut sutures only are used, and these are
not good in long gaps. The best result is obtained when a portion
of a nerve from the patient (auto-transplantation) is loosely sutured
into the gap and surrounded by Cargile membrane. The nerve most
often requiring operation of this nature is the musculo-spiral. In
this instance the incision should be prolonged downwards and the
radial nerve exposed and sufficient removed to lie between the ends
without tension. Resection of the upper two-thirds of this nerve pro-
duces, as a rule, no effect on sensibility. The internal saphenous nerve
also may be used. Its division causes very little inconvenience ; the
area of altered sensibility is on the inner side of the leg and does
not extend to the sole of the foot. In cases where a portion of nerve
from the same patient is unavailable the transplant should be
obtained from a nerve of the same size from a recently ampu-
tated limb (homo-transplantation). After removal it should be
placed in warm normal saline solution and used immediately. In
all transplantation operations the transplant should be handled as
little as possible. If gently handled the transplanted tissue does
not die, but degenerates and so takes an active part in regeneration.
If a portion of nerve from an animal is used (hetero-transplantation)
it dies, hence its comparative uselessness as a bridging medium.
Bone should be removed only in cases in which an ununited
fracture complicates the nerve injury.
In cases in which the gap between the ends of the nerve is more
than about 4 inches transplantation is unsuitable and a neigh-
bouring nerve should be utilised. In this group are included two
distinct operations : (1) Nerve crossing, in which a neighbouring
sound nerve is completely divided and its central end united to the
peripheral end of the affected ; this is never justifiable in cases of
injury ; (2) nerve anastomosis, in which the peripheral end of the
divided nerve is united to some of the fibres or one of the branches
of a sound nerve.
Nerve Anastomosis. The aim in operations of this nature is to
bring the axis cylinders in the peripheral end of the divided nerve
or the nerve supplying the paralysed muscles into end-to-end union
with some of those in the sound nerve. It is only justifiable if
carried out so that no permanent injury is done to the structures
supplied by the sound nerve, or if the muscles whose motor supply
is sacrificed are relatively unimportant compared with those it is
hoped to re-innervate.
It has been proved both clinically and experimentally that an
Injuries of Nerves. 1105
incision may be made into the trunk of a nerve for one-third of its
diameter without producing more than a temporary paresis, even
this being often absent. There is one exception, however ; if the
incision is made into the nerve close to the point at which a branch
is given off it may result in complete division of the fibres going to
that branch.
Nerve anastomosis may be divided into peripheral and central.
In peripheral anastomosis the peripheral end of the affected nerve
is brought to the sound, in central the sound nerve is divided and
brought to the affected; this latter is rarely, if ever, justifiable.
When the whole peripheral end of the affected nerve is used, and
this is the usual method, the operation is termed complete peri-
pheral anastomosis. Three methods have been employed to unite
the two nerves : (1) Insertion into a vertical slit in the sound
nerve; (2) insertion into a gap in the sound nerve produced by an
oblique incision ; (8) end-to-end union with a flap raised from the
sound nerve. In nerve anastomosis in cases of injury the last
is the method of choice. In the first two there is a serious
chance of the union of axis cylinders in the divided portion of the
sound nerve with those in the peripheral end of both sound and
affected nerves.
In carrying out the operation the greatest care must be taken and,
if possible, a separate funiculus of the nerve should be raised as a flap.
The incision into the sound nerve must be cleanly made with a sharp
scalpel, and the flap dissected up carefully for about finch to 1 inch.
After end-to-end union with the peripheral end both the junction
and the bare surface left on the sound nerve must be covered with
Cargile membrane.
JAMES SHERREN.
3.T. VOL. II. 70
iio6
TRAUMATIC NEURITIS.
UNDER this heading two distinct types are included, the chronic,
localised neuritis due to long continued pressure, such as occurs
in the ulnar nerve at the elbow and the lower cord of the plexus
from the pressure of a cervical rib, and that due to infection of the
nerve through breaches of continuity in its trunk or involvement
of its terminal branches in scar tissue. The disease in this latter
type is liable to spread, "ascending neuritis;" in the former it
always remains localised.
In the first type of case, muscular symptoms are most marked ;
pain, if present, is slight. In the second group pain is the principal
feature.
Treatment of the chronic , localised form consists in removal
of the cause, followed by the usual attention to the muscles.
Neuritis is rare as the result of wounds or subcutaneous injuries
of nerves in their course. It has been observed most often as the
result of gunshot wounds. There is always a latent period between
the injury and the onset of symptoms, viz., a burning pain appearing
in the distribution of the nerve accompanied by tenderness and
sometimes by " glossy " skin. If the inflammation affects a mixed
nerve, motor symptoms are present corresponding to the degree of
the original injury.
At first the limb should be kept absolutely at rest, and if the
symptoms have appeared shortly after the injury with obvious
signs of infection the wound should be opened and drained. As a
rule, however, the wound has healed completely before the onset of
symptoms. If the pain does not speedily subside the nerve should
be exposed, the damaged portion removed and end-to-end union
carried out.
Long continued irritation of terminal branches of nerves, such as
is often seen after badly performed amputations of the finger,
may set up neuritis. At first the pain is limited to the stump, but
there may be tenderness referred to the whole area supplied by the
nerve from which the branch arises. Later the pain spreads and
involves the whole area supplied by the nerve, the stump becomes
reddish blue and shiny and a similar condition may make its
appearance elsewhere.
As these symptoms are common after amputations of the fingers,
Traumatic Neuritis. 1107
care should always be taken to see that the digital nerves are cut
short, and if bone forceps are used to divide the phalanx they
should never be employed till the nerves have been freed and
cut short.
In cases of this nature operation must not be delayed. The
nerves involved must be carefully dissected out and cut short. It
is often necessary to remove more bone in order to get a satisfactory
stump.
In early cases the result is immediate and satisfactory. Later,
when muscular wasting has set in, prolonged treatment is necessary
and pain may persist, unchecked by the operation. In these cases
division of posterior roots must be considered.
Chronic neuritis of a similar nature may result from adhesions
or pressure or from excessive fibrosis, due to suppuration, of the
end-bulbs of nerve divided in limb amputations.
In these cases operation must not be delayed. The affected
nerve must be exposed and the bulb, together with an inch or more
of nerve, removed. In early cases cure speedily results. If
symptoms have persisted for a considerable time, this may fail to
bring about a cure. The posterior roots from which the affected
nerve springs should be divided intradurally.
JAMES SHERREN.
702
iio8
INJURIES OF SPECIAL NERVES.
Facial Nerve. For the purposes of treatment the facial nerve
consists of two parts, that below and that above its point of exit
from the skull. Injury in the former situation is uncommon and
usually the result of surgical operations, the terminal branches
supplying the lower facial muscles usually suffer, and recovery is
the rule if the wound heals by first intention. If a larger branch
or the whole nerve trunk is divided, the treatment for nerves
divided in wounds should be carried out.
During its course through the petrous bone the nerve may be
injured in fractures of the base of the skull, or during mastoid
operations, or it may be affected as the result of middle-ear
disease. The commonest type of facial paralysis is the so-called
"rheumatic" Bell's palsy. Treatment in all cases is along the
usual lines.
In fractures of the base of the skull the nerve is rarely completely
divided, the reactions are those of incomplete division and recovery
is the rule. If the reaction of degeneration develops, nerve anasto-
mosis should be undertaken after three months (vide infra).
Nerve injury the result of operations upon the middle ear is
usually incomplete. If it is discovered during the course of the
operation, the Fallopian aqueduct should be opened up and the ends
adjusted in the canal ; in this way the advantage of tubular suture
is obtained. This was first suggested by Jordan Lloyd and carried
out by Marsh. If noticed immediately after the operation, as is
usually the case, nothing should be done for a fortnight ; at the end
of this time electrical examination will show whether the nerve be
completely divided. If division is complete and the mastoid wound
clean, an attempt should be made to bring the ends of the nerve
into apposition in its aqueduct, as carried out by Marsh and Syden-
harn. If this is impossible, anastomosis should be performed (vide
infra) .
The development of facial paralysis in middle-ear disease,, apart
from operative interference, is an indication for a radical mastoid
operation ; this should be carried out without delay, and is often
followed by restoration of function in the nerve.
In Bell's palsy the usual treatment should be carried out. If at
the end of six months no improvement has taken place, and the
reaction of degeneration is present, nerve anastomosis is indicated.
Injuries of Special Nerves. 1109
Nerve Anastomosis and Nerve Crossing in Facial Paralysis.
Operation is rarely necessary in cases of facial paralysis. Spon-
taneous recovery usually takes place. When paralysis follows
mastoid operations, operation should never be carried out until the
post-auricular wound is free from infection.
Nerve crossing for facial paralysis was first performed in 1879 by
Drobnik, who divided the spinal accessory nerve and united its
central end to the divided facial. The modern operation is chiefly
due to Ballance, who first carried it out in 1895. The spinal
accessory was first employed, but, following the example of Korte
(1901) and Ballance (1902), the hypoglossal is now the nerve of
choice.
Complete peripheral anastomosis should be carried out, a flap of
about one-third of the hypoglossal nerve being raised and united
end to end with the peripheral end of the facial. Ballance, how-
ever, has recently suggested nerve crossing with the hypoglossal,
the distal end of the divided hypoglossal being then united end to
end with a flap of half the spinal accessory.
After anastomosis, treatment must be patiently carried out. In
about six to eight weeks it is noticed that the lower part of the face is
more symmetrical when at rest, and in three to six months voluntary
power returns to the muscles around the mouth, the orbicularis
palpebrarum and frontalis muscles being the last to be restored.
At first movement is associated with that of the tongue, but soon
becomes dissociated, and in from nine months to a year, in a favour-
able case, the patient should be able to perform all movements.
Emotional movements are restored at a still later date, it may be
many months later, and in some cases they are never regained. In
all the recorded cases of facial nerve anastomosis reported at a
sufficient time after operation some recovery took place, in a few it
was perfect.
No more than a temporary paresis of the tongue on the affected
side should result, this disappearing in three or four weeks.
The operation is carried out through an incision extending from
the mastoid at the level of the external auditory meatus to the great
cornu of the hyoid bone. The anterior border of the sterno-mastoid
is pulled backwards and the posterior belly of the digastric pulled
downwards and backwards or divided. The facial nerve is most
easily found by taking the styloid process as a guide, the nerve
passing out immediately in front of this to enter the parotid gland.
An attempt should be made to pull the nerve out from the canal in
cases in which it has been injured during mastoid operations ; if
this cannot be done, and in other cases, it should be divided with a
1 1 10 Injuries of Special Nerves.
tenotomy knife as far up the canal as possible. The hypoglossal
nerve is easily distinguished by its relation to the occipital artery.
The peripheral end of the facial nerve is freshened with a sharp
scalpel and then a flap of the hypoglossal, consisting of at least a
third of the nerve, is raised and united end to end with the facial
by one stitch of No. 00 chromic gut. The junction and the bare
surface of the hypoglossal are surrounded with Cargile membrane.
Brachial Plexus. There are several points in connection with
injuries of the plexus which require special comment.
Injuries of the plexus are usually supra-clavicular. Infra-
clavicular injuries are rare and are due in most cases to the direct
pressure of the dislocated head of the humerus. Recovery follows
the usual treatment, and operation is rarely called for.
Lesions of the plexus in adults due to overstretching, the most
common form of injury, should be explored as soon as possible. If
treated on the lines of subcutaneous nerve injuries elsewhere, the
prognosis is very unfavourable. Secondary suture of the plexus is
a difficult operation, and if the whole plexus has been affected the
attempt is never successful.
The presence of a cervical rib is an unusual cause of supra-
clavicular affection of the brachial plexus, the lower cord being
affected. Before coming to the conclusion that the symptoms are
due to the presence of a cervical rib all other causes must be
excluded, particularly syringomyelia. Several instances have come
under my notice in which the two co-existed, and in which the
cervical rib was removed without result. It must be remembered
that a cervical rib is a common deformity, but the rarest cause of
interference with structures innervated by the eighth cervical and
first dorsal roots. After removal of the ribs recovery follows if
correct treatment is carried out.
Brachial Birth Paralysis. The majority of these cases fall into
the group of traction injuries. Treatment consists in relaxation of
the affected muscles and massage. In the usual upper arm type,
Erb-Duchenne, the limb should be bandaged to the side with the
forearm flexed and supinated. It should be taken down every day
for massage, and special precautions used to prevent forward
displacement of the shoulder ; in cases where these are neglected
division of the pectorals may be necessary.
If the affected muscles are not kept relaxed, permanent deformity
will result, although the paralysed muscles may regain power of
voluntary movement and their electrical excitability. The electrical
reactions should be tested when the child is twelve weeks old ; in the
majority of cases they are then those of incomplete division, recovery
Injuries of Special Nerves. 1111
having obviously commenced. If the true reaction of degeneration
is present, operation should be carried out as soon as convenient.
If the health of the child is not good, a delay of a few months will
probably affect the final result very little.
In exposing the brachial plexus above the clavicle a free incision
should be made starting above at the junction of the upper and
middle thirds of the posterior border of the sterno-mastoid, extend-
ing downwards and outwards to the junction of the middle and
outer thirds of the clavicle. In the lower arm type of lesion it may
be necessary to divide this bone. If the injury is extensive, great
difficulty is experienced in identifying the nerves ; the deep fascia is
usually injured, thickened and intimately bound up with the fibrous
tissue around the nerves.
In the usual upper arm type of injury the anterior primary
divisions of fifth and sixth cervical are found and then traced to
their junction and its division into the supra-clavicular nerve and
branches to inner and outer cords of the plexus. The supra-
clavicular nerve should always be examined ; it is sometimes found
ruptured in addition to injury to fifth anterior primary division.
The phrenic nerve exposed on anterior surface of scalenus anticus
must be avoided. In cases in which the deltoid and spinati
muscles are alone paralysed and give the reaction of degeneration,
the damaged portion of the fifth cervical anterior primary division
should be separated and excised and a portion of radial nerve
inserted, or these fibres may be anastomosed to the sixth anterior
division.
In all other cases, after free exposure on the usual lines, the
damaged portion should be treated. If secondary suture has been
carried out, care must be taken to put the limb up in such a manner
that no weight falls on the sutured trunk and to keep it in this
position for at least three weeks.
In the lower arm type of paralysis due to traction injuries the
lesion is situated too high to admit of direct union. Anastomosis
to the eighth cervical anterior primary division should be carried
out.
Circumflex Nerve. It should be remembered that injuries of
this nerve are of great rarity. Before proceeding to operation in
cases in which, as the result of a subcutaneous injury, usually
violence applied to the shoulder, paralysis of the deltoid with
reaction of degeneration supervenes, careful examination must be
carried out. In many of these cases the lesion is in the fifth or
fifth and sixth anterior primary divisions or upper trunk of the
plexus above the clavicle.
1 1 12 Injuries of Special Nerves.
Even in cases in which the circumflex is injured and the signs
of complete division are present operation is by no means always
necessary. The sensory loss is over an unimportant region, and in
most cases sufficient abduction of the arm can be obtained by the
clavicular fibres of the pectoralis major and the supra-spinatus
muscles. If, however, perfect abduction is essential, operation
should be carried out in these cases.
Posterior Thoracic Nerve (Nerve of Bell). It is only in
isolated cases that- recovery does not follow treatment conducted on
the usual lines. In these cases operation must be considered.
Except in rare cases in which the nerve has been injured in a
wound, accidental or operative, direct treatment is out of the
question. If the functional disability is serious, the insertion of
the sterno-costal portion of the pectoralis major may be transferred
to the inferior angle of the scapula.
Musculo-spiral Nerve. It is of the utmost importance that
FIG. 1. Splint for the prevention of " claw hand " after
injuries of the ulnar nerve. It is applied to the
posterior surface of the forearm, hand and fingers.
relaxation of the paralysed muscles be insisted upon in all cases
until voluntary power is restored. The hand and fingers should be
maintained by splints in a hyper-extended position, and the splint
should only be removed for massage until voluntary power is
restored.
Ulnar Nerve. After complete division of the ulnar nerve
recovery of function is always imperfect unless the interossei
muscles are kept relaxed by means of a splint so arranged that the
fingers are maintained flexed at the metacarpo-phalangeal and
extended at the inter-phalangeal joints (vide Fig. 1).
Special reference must be made to the treatment of two affections
of the ulnar nerve : (1) Chronic neuritis in the region of the elbow,
and (2) dislocation of the nerve.
(1) Chronic Neuritis of Ulnar Nerve at the Elbow. Long continued
irritation of the nerve due to bony pressure in the region of the
elbow joint may lead to a gradual interference with its functions.
This is seen most often after fractures or separation of epiphyses
Injuries of Special Nerves. 1113
which have led to permanent deformity. Symptoms usually appear
at a considerable time after the injury, often many years after.
In all cases the cause should he removed and the usual treatment
adopted. The nerve should be exposed behind the internal condyle
and a groove chiselled in the bone to receive it and the nerve
wrapped in Cargile membrane. This is all that is necessary in the
majority of cases, but if the reaction of degeneration is present,
the spindle-shaped enlargement of the nerve should be excised and
continuity restored.
(2) Dislocation of the Ulnar Nerve. Operation must be undertaken
in all cases in which symptoms are present due to interference with
the functions of the nerve. After exposure of the nerve behind the
internal condyle, the groove in the bone should be deepened if
necessary and the nerve wrapped in Cargile membrane. The
groove should then be converted into a canal by stitching a portion
of the fascia of the triceps over it. The results of this operation
are very good.
JAMES SHERREN.
1 1 14
NEURALGIA.
NEURALGIA is essentially a neurosis of adult life, and is considerably
more cqmmon in women than in men, and is frequently hereditary.
Although there is, perhaps, no portion of the body which may not
be afflicted with neuralgia, by far the most important and numerous
types of the affection are found in the distribution of the fifth cranial
or trigeminal nerve.
DENTAL NEURALGIA.
When this is due to caries with an exposed pulp, not only may
the tooth itself be tender and react sharply to hot and cold or to
sweet food, but the pain may radiate from the affected tooth
along all the teeth in that side of the jaw, and may at times be
reflected on to the other jaw of the same side, so that the patient
may be completely mistaken as to the tooth and even as to the jaw
affected. The pain is never referred to the opposite side of the face,
but may spread beyond the area of the gums into the ear or forehead,
or even over the whole of that side of the head, back and front, and
even down into the neck. With this spreading neuralgia there are
likely to be very definite areas of tenderness of the skin, varying
with the tooth affected. The severity of the pain in such dental
neuralgia may be most intense, and it may be mistaken for tic
douloureux, or it may even set up hysterical delirium. When the
pain is due to exposed pulp in a carious tooth immediate relief may
invariably be obtained for at least several hours by gently swabbing
out the cavity with a piece of cotton-wool on the end of a probe
dipped in a solution of equal parts of oil of cloves, carbolic acid and
menthol. With a dead tooth which is no longer sensitive in itself,
severe neuralgic pain may be produced by inflammation of the
periodontal membrane, and the formation of abscess at the root.
The tooth then " stands up," and the jaws can scarcely be closed
owing to pain from pressure of the opponent tooth. Sometimes
the pain will quiet down under the use of lin. iodi to the gum, only
to recur probably at a later date. Sometimes the inferior dental
nerve trunk in its bony canal becomes irritated or inflamed by
direct pressure of the roots of the second or third lower molars, and
extraction of either of these teeth may partially damage the nerve,
giving rise to recurrent spasms of neuralgic pain and tenderness
Neuralgia. 1115
along the lower jaw and lip and side of neck. To arrest this pain
the nerve trunk must be totally destroyed by scraping out the
canal. in the bone.
A full dose (10 to 15 gr.) of quinine sometimes will arrest at
once the radiating neuralgia of dental origin, while in other cases
a better result may be obtained by repeated doses of 10 gr. of
butyl chloral hydrate in combination with 5 to 7 gr. of phenazone.
This may be given hourly for three doses, and then every four
hours if necessary. Very severe dental neuralgia, affecting the
whole of the area of the fifth nerve, ear and side of neck, may be
due to an impacted molar, a pulp stone, or to an erupting wisdom
tooth. Lancing the swollen gum in the latter case may relieve
the pain instantaneously, but removal of the offending cause is
necessary in the first two cases.
Severe paroxysmal neuralgia may be referred to the gum after
removal of the teeth, and it may often be arrested by painting
the gum with a solution of 4 per cent, each of cocaine and
menthol in equal parts of sp. vini rect. and water, together with
the administration of a few doses of butyl chloral hydrate and
phenazone.
SUPRA-ORBITAL NEURALGIA.
Pain starting over the eyebrow and shooting up over the forehead
is not infrequently the result of ocular troubles, as errors of
refraction, especially astigmatism, or it may be caused by glaucoma.
Neuralgic pain in this distribution is a not uncommon affection in
certain subjects, generally women, and it is especially common
during the monthly periods, during gestation, or when run down in
health from any cause. Small doses of quinine or of the coal-tar
analgesics here too may give relief ; massage to the head, especially
in the evening, may be useful, but attention must be paid to the
general health, and iron and other tonics administered when
necessary. Strychnine, however, must be used with caution, as
sometimes trifacial neuralgia is greatly aggravated thereby.
Periodic supra-orbital neuralgia, or brow-ague, often of the
greatest intensity, may be of malarial origin, or may follow an
attack of influenza; the attacks in the latter case are usually
of daily occurrence, starting about 10 to 11 a.m. and lasting
till late afternoon. There is usually marked tenderness over the
supra-orbital notch, and the agony of the pain during the attack
may be almost unendurable, though it usually disappears before
evening. Drugs in this condition are practically useless, except
morphia hypodermically, which may be given in j-gr. doses
iii6 Neuralgia.
daily for a few days half an hour before the expected onset
of the pain ; this treatment may stave off the attacks completely.
Failing relief by this means, certain cure may be brought about by
injection of 4 or 5 drops of 80 per cent, alcohol into the supra-
orbital notch, as in tic douloureux.
Neuralgic headache accompanied by soreness of the scalp
may sometimes be relieved by rubbing the forehead and scalp with
solid menthol ; in other cases a full dose (15 to 20 gr.) of
aspirin will relieve this type of headache, which is distressingly
frequent in some individuals, and is to be distinguished from
migraine.
TRIGEMINAL NEURALGIA : TIC DOULOUREUX.
This severe and intractable form of neuralgia affects both sexes
equally, usually after the age of thirty. I have, however, known it
start as early as seventeen and as late as eighty-one. The pain
rarely affects all three divisions of the nerve, usually either the
second or third division separately, or both together, on one side
of the face : very rarely indeed is the disease bi-lateral. The first
division is the least frequently affected, and then the pain is
limited to the supra-orbital distribution. In some patients the
spasms of pain are frequent and of daily occurrence, continu-
ing for years ; in others the attacks are more or less periodical,
continuing for some weeks, and then disappearing for
months. These intermissions of total freedom from pain
are frequently observed as a peculiarity of the disease,
and are not necessarily the result of the treatment employed.
In the majority of cases drugs are of little or no avail, even
morphia often failing to give relief, and there is a special danger of
morphinism being set up in these cases. Electricity, ionic medi-
cation and X-rays in my experience are all worse than useless,
and may considerably augment the severity of the attacks. Of the
drugs which may be tried, full doses of butyl chloral hydrate (15 gr.
to 20 gr.) and tinct. gelsemii (20 minims to 30 minims) are the most
successful in mitigating the pain. Aconitine (^^ gr.) appears some-
times to be of service, given in pill three times a day. Extrac-
tion of the teeth is useless, and should not be undertaken except
by the advice of a competent dentist. Practically the only sure
way of arresting the pain in tic douloureux is to destroy the branch
of the fifth nerve supplying the painful area. This may be done by
resection of the nerve, or by destroying the nerve trunk at its deep
foramen of exit from the skull by injecting it with strong alcohol.
These methods will give relief from pain for a period varying from
Neuralgia. 1117
six months to three years. Permanent cure can only be obtained
by excision of the Gasserian ganglion, or by a division of the
sensory root of the fifth between the ganglion and the pons. This
is an operation of considerable severity, with a total mortality of about
7 per cent., the fatal cases being practically limited to subjects over
the age of fifty. Ulcerative keratitis and loss of the eye through
destruction of the cornea has sometimes followed total excision of
the ganglion, but in the hands of a good surgeon this would
not occur. On account of this danger, partial excision of the
ganglion, leaving the ophthalmic portion, has been advocated ;
but, although this procedure may be successful in removing the
pain for some years, recurrence may and does occur. Division
of the trunk of the fifth nerve between the ganglion and the pons
has been said to give an ideal result, there being no danger of
any trophic ulceration, and yet complete anaesthesia, with no
liability to regeneration of the nerve fibres.
Alcohol injection is the most successful treatment for tic
douloureux at present available next to excision of the Gasserian
ganglion, and in view of the severity of the latter operation,
alcohol injection should always be tried first. This is done at the
supra-orbital notch for neuralgia affecting this branch of the first
division of the nerve, at the infra-orbital foramen and at the foramen
rotundumforpainin the second division affecting the upper jaw and
cheek, nose and upper lip, and at the foramen ovale for neuralgia of
the third division affecting the lower jaw, lower lip, tongue and side
of the temple. The supra-orbital appears to be the only branch of
the first division that is affected by this neuralgia. The supra-arbital
notch should be felt for with the finger-nail, and its position marked
by a vertical line drawn from it over the forehead. A hypodermic
syringe is fitted with a fine needle and filled with 80 per cent,
alcohol, and the skin is cleansed with ether soap. The needle
is then inserted through the skin over the notch, about
\ inch below the eyebrow, and the point is slowly and carefully
pushed in the direction of the notch, feeling for the nerve. The
moment this is reached by the point of the needle a sharp twinge
of pain is felt by the patient, running like an electric shock
straight up to the top of the head. Holding the needle perfectly
still, a few drops of the alcohol are slowly injected, and if the
point of the needle has been properly pushed into the nerve at
the notch, there will be instantly felt a strong burning feeling
spreading up over the forehead as far back as the crown, and after
the lapse of a minute the whole area of skin supplied by the supra-
orbital nerve will be found to be completely anaesthetic to all
in8 Neuralgia.
forms of sensation, including pressure. The neuralgic pain over
this area should cease from the moment of the injection. Con-
siderable swelling of the upper eyelid follows the injection, and
after two or three hours the eye may be nearly closed with the
swelling, and there may occasionally be some ecchymosis. The
swelling begins to diminish by the next day, and will be scarcely
visible after three or four days. The anaesthesia, at first com-
plete, begins to diminish after some weeks, tactile sensation slowly
returning, while yet a pin-prick is felt only as a touch for six
months or longer.
The infra-orbital foramen may be injected with advantage in those
cases of tic affecting the second division of the nerve, in which the
pain radiates especially in the skin of the cheek, side of nose and
upper lip, and in which even slight touches of the skin of this
area are liable to provoke the spasms. A stronger needle must
be used for this injection, 3 to 5 centimetres in length, and two
syringes to fit the needle, one containing sterilised 2 per cent, eucaine
solution, the other 90 per cent, alcohol. The skin is frozen by the ethyl
chloride spray, and when the needle-point has found the nerve
at the notch a few drops of the eucaine are first slowly injected
into it, and then, without moving the needle, the syringes are
changed, and from 10 to 15 minims of the 90 per cent, alcohol injected
into the nerve. After two or three minutes there will be deep
anaesthesia to touch and pin-prick over the cheek, lip, side of
nose and inside of nostril, and inside of the cheek. The preli-
minary eucaine injection almost abolishes the intense pain that
would otherwise be caused by the alcoholic injection.
Foramen Eotundum. In most cases of tic affecting the second
division of the fifth nerve the pain is not confined to the skin of
the cheek and nose, but is referred also to the upper gum and
palate. Injection of the infra-orbital nerve will not be sufficient in
these cases to arrest the pain, and the nerve must be attacked
further back at its exit from the skull at the foramen rotundum.
This is best reached through the cheek, just in front of the coro-
noid process of the lower jaw, using a needle 8 to 9 centimetres
long and 1*2 millimetres in diameter, with a short point. The
needle is pushed inwards and upwards at an angle of about 40
until the external pterygoid plate is reached, when the point is
then slowly worked forwards until it slips in front of the edge of
this bone, and is pushed inwards for another 5 or 6 millimetres,
when the superior maxillary nerve should be struck, at a total
depth from the surface of 5 to 5| centimetres. The nerve may not
be hit at first, and it must be carefully searched for until found.
Neuralgia. 1119
This is not an easy operation, and should not be undertaken by
anyone unless he has previously carefully studied the relationship
of the parts in the pterygoid region and in the spheno-maxillary
fossa, both on the skull and on the dead body.
With a successful injection of the superior maxillary nerve at the
foramen rotundum, in addition to anaesthesia of the skin of the
cheek, lip and nose, there will also be complete anaesthesia of
the upper gum and teeth and palate as far back as the middle of
the soft palate.
Neuralgia of the third division affecting the lower jaw and chin,
side of tongue and temple, must be dealt with by injecting the
nerve at its exit from the foramen ovalc. Using a needle 6'5 centi-
metres in length and from '8 to 1 millimetre in diameter, this is
pushed through the side of the cheek between the lower border of the
zygoma and the sigmoid notch of the lower jaw, at a point 3'2 centi-
metres in front of the external auditory meatus. Pushing the needle
through the pterygoid muscles very slightly backwards and upwards,
the inferior maxillary nerve will be hit at a depth of 4'5 centimetres.
Should the needle be sunk too deeply, to a depth of 2 inches or
more, the Eustachian tube may be punctured, causing a sharp
pain in the ear ; or the wall of the pharynx may be pierced.
Almost immediately after a successful injection of the nerve at
the foramen ovale the patient feels that the lower lip and chin and
tongue are feeling numb and swollen, and testing with a pin shows
this area to be anaesthetic ; in addition the lower gum and teeth,
and the side of the temple corresponding to the auriculo-temporal
nerve will be found to be anaesthetic. Usually also there will be
motor palsy of the masseter, temporal and pterygoids, but little or no
disability ensues from this. Some slight stiffness on opening the jaw
is sometimes complained of for a day or two, but soon passes off.
The cessation of the neuralgia is generally instant and complete,
though very occasionally several days elapse before the pain
disappears entirely, the duration of the cure perhaps lasting as
long as two to three years. In cases of severe tic douloureux, in
which the second and third divisions are involved, or even all three
divisions, it may be advisable to attempt injection of the Gasserian
ganglion itself with alcohol. This I have done successfully in four
cases, by pushing the needle on into the ganglion through the
foramen ovale to the depth of 5J centimetres. In these cases
anaesthesia of the whole distribution of the fifth nerve is produced,
and in all probability the cure of the pain will last much longer,
owing to the trophic centre of the nerve fibres being destroyed, and
it may even be permanent.
II2O Neuralgia.
Alcohol injection of a nerve trunk may be followed for a day or
two by considerable pruritus, which is quite unrelieved by
scratching the anaesthetic area. No trophic lesion ever results,
with the possible exception of slight falling out of hair on the
temple after successful injection of the supra-orbital nerve; this
does not always occur.
In its origin trifacial neuralgia may be due to central disease, or
involvement of the ganglion, nerve trunk, or peripheral filaments.
Of these the first is much the most rare. Persistent trigeminal
neuralgia I have once seen due to an area of sclerosis in the
medulla involving the spinal root of the fifth nerve, and in tabes
trigeminal shooting pains are sometimes met with. Tumours in
the pons or at the base of the brain involving the fifth nerve, or a
gummatous neuritis damaging the nerve, may each in turn be
mistaken for tic douloureux. Outside the skull malignant growths
may invade the nerve at the foramen ovale, and a slow-growing
endothelioma may thus for many months give rise to intense
pain along the third division of the fifth nerve, and later may
invade the floor of the skull and the Gasserian ganglion, when
the pain will spread into the upper jaw and cheek. Herpes
zoster usually affects the ophthalmic division of the ganglion only,
and in rare cases frontal parsesthesise or even actual pain may
persist over the frontal area of the herpetic scarring. In all
these cases careful examination will reveal definite evidence of
disturbance of the function of the fifth nerve, such as analgesia,
slight tactile loss to cotton-wool, etc. Alcohol injection should
never be used in such cases.
OCCIPITAL NEURALGIA.
This is often uni-lateral, involving the area of the great occipital
nerve and the back of the neck and scalp. When persistent and
intractable to ordinary remedies, such as mustard leaves or
blistering, full doses of aspirin or phenacetin, injection of the nerve
with strong alcohol may be successful. With a hypodermic needle
attached to a syringe containing 2 per cent, eucaine, the scalp
is punctured on a level with the auditory meatus at a point
| inch to one side of the middle line of the occiput ; the point of
the needle is slowly moved in different directions until a radiating
pain darting up to the crown indicates that the nerve has been
reached. Taking care to hold the needle perfectly steady, 2
drops of eucaine followed by 5 drops of 90 per cent, alcohol
should then be injected.
Neuralgia. 1121
BRACHIAL AND SCAPULAR NEURALGIA, RHEUMATIC
FIBROSITIS.
Brachial neuritis is a fairly common and often a very trouble-
some and painful complaint, like sciatica, often lasting many
weeks or even months ; indeed, the affection is almost precisely
comparable to sciatica. The evidences of actual inflammation
of the nerves are by no means always present, and as in the
case of sciatica, pain in many cases is the only symptom. The
pains radiate from the neck and shoulder down the arm to the
wrist and even to the fingers, but are not referable to the course of
any particular nerve trunk. Various tender points on pressure
may be met with, often varying from day to day, and the severity
of the pain may also vary considerably, sometimes disappearing
for a few hours or a day or two, and then returning with renewed
intensity. This point must be remembered in estimating the
effects of treatment. Though movements of the limb do not always
increase the pain, rest in bed with the arm and shoulder lightly
bandaged with cotton-wool, with the arm supported on a pillow, is
advisable. Packing the limb with antiphlogistine sometimes
relieves the pain greatly, and may be done every night. Cata-
phoresis with salicylate of soda on the negative pole, applied as a
sponge above the clavicle, the anode being moistened with lithium
carbonate and wrapped round the wrist and lower forearm, should
be tried twice daily for twenty minutes, using a steady current,
without any interruptions, of 8 to 15 milliamperes, according to
what can comfortably be borne. Some cases do better with radiant
heat applied locally by means of strong incandescent lamps backed
by a reflector ; this should be done preferably in the patient's own
house, or else in a nursing home, as the risk of chill from going to
an institution daily for the treatment is considerable. Various
liniments, such as lin. A.B.C., or methyl salicylate, menthol, and
lin. pot. iod. c. saponis in various combinations may be tried,
often with great benefit. In addition, sleep can only be obtained
in severe cases by the use of phenacetin, pyramid on or aspirin in
full doses. In certain cases, which must be carefully chosen, the
radiating neuralgic pains around the shoulder and down the arm,
even as far as the hand, can be quickly cured by the injection of a
few drops of strong alcohol at certain points. In these cases
careful examination of the scapular region with the pressure of
the finger or the blunt end of a pencil will reveal one or two or
more tender points, firm pressure on which produces not only con-
siderable pain at the point pressed on, but also radiating pain,
perhaps into the neck or even down the whole of the upper
S.T. VOL. n. 71
1 122 Neuralgia.
extremity as far as the hand. These spots must be carefully
localised, and after sterilisation of the skin and freezing with ethyl
chloride should be injected with 2 or 3 drops of 2 per cent,
eucaine, followed by from 5 to 10 min. of 90 per cent, alcohol.
Before commencing the injection care must be taken that the
limb has not been moved since the tender spot was localised, and
the needle must be pushed down to the bone of the scapula or rib,
as the case may be, and 2 or 3 drops of the alcohol should be
injected along the track of the needle as it is withdrawn. The
immediate result is usually considerable aggravation of the pain
around the shoulder, lasting for several hours ; but on the following
day local soreness is all that remains, the radiating neuralgia from
the injected spots having disappeared.
TOXIC AND DIATHETIC NEURALGIAS AFFECTING THE
HEAD OR LIMBS.
These forms may be met with in gout, diabetes, anaemia, malaria,
syphilis, Bright's disease and chronic poisoning by lead or alcohol.
The possibility of such various causes being responsible for a
case of obstinate neuralgia indicates the necessity for a careful
examination of the patient when the cause is not immediately
obvious, and its discovery when made will indicate the treatment.
VISCERAL NEURALGIAS.
These occasionally may simulate pleuritic pain, angina, or gastric
crises, and will have to be distinguished from chronic gastric or duo-
denal ulcer, gall-stones, renal calculus or appendicitis. Neuralgia
in the region of the solar plexus and ovary may be periodic in women
in whom there is no sign of visceroptosis ; this latter condition is a
common cause of vague abdominal pains and general neurasthenic
symptoms. Best, hot applications, radiant heat, an abdominal
belt and one of the coal-tar analgesics internally should be tried
for these visceral neuralgias.
POST-HERPETIC NEURALGIA.
This is sometimes excessively severe and prolonged in old people
over sixty, the pain bearing no proportion to the severity of the
scarring of the skin. This is a most difficult pain to relieve,
liniments, blisters, cataphoresis and injections usually failing alike.
I have known alcohol injection down to the inter-vertebral foramen
arrest the pain, but this is a difficult and uncertain operation.
With the exception of keeping the patient stupefied with morphia,
laminectomy and division of the posterior roots may be the only
remedy to give relief.
Neuralgia. 1123
PAINFUL HEEL.
This, causing limping from inability to bear the weight on the
heel, after excluding such causes as a bony spike growing from the
under surface of the calcaneum, foreign bodies, inflamed bursa
under the tendo Achillis, etc., may often be cured at once by an
injection of eucaine followed by 1 cubic centimetre of saline at the
tender spot.
PSYCHALGIA.
There is another group of cases in which the pains are really
mental in origin, a psychalgia, in which the pains may affect any
part of the body, scalp, face, trunk or limbs. In these the usual
analgesic remedies are of no use, and indeed each fresh treatment
seems to intensify the pain ; fortunately these cases are somewhat
rare, and when recognised the line of treatment appropriate for
obsessions must be employed. Persistent severe neuralgic pains,
lasting for many years, in which no cause could be found during life,
have been thought to be functional, but have been proved after death
to be due to sclerosis of a posterior root. The distribution of the
area of the pain should have prevented this error in diagnosis.
Neuralgia of a definite nerve or root area is never due to psychalgia
or neurosis. Nevertheless, undoubted functional pains may persist
for thirty years or more, as I have seen arise from lepraphobia in
one case, dread of hydrophobia in another, and other neuroses.
Such pains have been well named " douleurs d'habitude" by
Brissaud.
SCIATICA.
Acute Sciatica, or inflammation of the sheath of the nerve after
its exit from the pelvis at the great sciatic notch, is due in the
majority of cases to the spread of a fibrositis of the buttock or
lumbar region, either of rheumatic origin, or the result of a fall or
sudden muscular strain. Anti-rheumatic remedies, therefore, will
often be of service, such as aspirin, salicylates and colchicum. In
the acute stage when the pain in the limb is constant and severe,
extending down the back of the thigh into the leg and ankle and
preventing sleep, complete rest of the limb should be insisted on.
The patient should remain altogether in bed, preferably on a water
or air mattress, and cataphoresis with salicylate of soda and lithia
should be employed twice daily for twenty minutes. Using a
constant current battery of at least eighteen cells, the negative pole,
a flat pad of about 7 inches by 4, is soaked in hot water and
moistened with saturated solution of salicylate of soda, and then.
712
1 124 Neuralgia.
applied lengthwise along the back of the buttock ; the positive pad
should be larger, moistened with lithia carbonate solution, and
applied across the under surface of the thigh, just above the knee.
A current of from 20 to 30 milliamperes should be turned on
gradually, without any sudden breaks, and great care must be taken
not to burn the skin, the patient's sensations of stinging pain
being usually a sufficient index that the strength of the current
ought to be reduced. After ten days or a fortnight of this treat-
ment massage and passive movements may be commenced,
especially flexion of the hip, keeping the knee straight. This is
somewhat painful at first, but is necessary to prevent adhesions
being formed between the sheath and surrounding muscles. Other
forms of treatment that are frequently used, besides rest in bed for
several weeks, are blisters to the back of the thigh along the course
of the nerve, frequently repeated, radiant heat, arc-lamp rays, and
liniments such as A.B.C. and methyl salicylate,with iodide and soap
liniment. Tincture of iodine may be used daily to paint along the
course of the nerve, and the iodine may be advantageously
combined with the cataphoresis treatment by painting the skin of
the buttock under the kathode. If the pain at night is preventing
sleep, 10 gr. of aspirin with 5 gr. of pyramidon may be given, and,
if that fails, an injection of morphia.
In the worst and most obstinate cases of sciatica, in which almost
every movement is painful, extraordinary relief and rapid cure can
often be brought about by injection of the nerve near the great
sciatic notch with jiij to iv of normal saline solution, combined
with weak eucaine. This is known as Lange's method of infil-
tration of the nerve sheath, who recommended a solution of
eucaine (1 in 1,000 of normal saline). In my own practice I have
found it best to inject the nerve with 2 cubic centimetres of 2 per
cent, eucaine solution, following it up at the same point immediately
with 100 cubic centimetres of '9 per cent, saline. If eucaine is not
injected first into the nerve, the subsequent injection of saline is
very painful. This may be done either at the great sciatic notch,
which is vertically under a point 3^ to 4 inches horizontally out-
wards from the top of the inter-gluteal fold, or else where the nerve
passes between the tuber ischii and the lesser trochanter, according
as to which site is the more tender. The depth at which the nerve
is struck by the needle will vary from 2| to 4 inches or more,
according to the size of the patient. None but local anaesthetics
must be employed, as the only certain indication that the nerve has
been reached is the sensation felt by the patient of a sudden twinge
like electricity felt in the foot. The injection with eucaine is then
Neuralgia. 1125
made into the nerve, taking great care to hold the needle quite still,
and this is followed within half a minute by the warm sterilised
saline, using a large syringe for the latter. The effect is to inflate
the nerve locally at the point of injection, separating the nerve
bundles and breaking down adhesions. The immediate result is a
warm swollen sensation of the whole limb, and often the disappear-
ance of the sciatic pain is immediate. The patient should remain
in bed for twelve hours after the injection. Usually a certain
amount of pain reappears after three or four days, and a second
injection is often necessary at the end of a week. Ostwalt has
recommended injecting strong carbolic-acid solution into the nerve ;
Schlosser similarly advocates strong alcohol, and sulphuric ether
and chloroform have also been recommended, but immediate
paralysis of the leg will certainly follow if any one of these drugs
is actually injected into the nerve. However, if proper care is
taken, injections of strong alcohol may be used with much advan-
tage in those cases of sciatica in which there is great tenderness on
local pressure on certain spots in the buttock, often at some little
distance from the nerve, though pain may radiate from them over
the distribution of the nerve, as in the case of the shoulder
neuralgia already described. Just as in that case, these tender spots
should be injected with strong alcohol down to the bone of the
ilium, taking care, however, not to inject the alcohol if the needle
strikes the sciatic nerve, as indicated by a sudden pain in the foot.
Injection of the sciatic nerve is not an easy operation, and often
great patience is required before the needle is correctly placed. So-
called acupuncture of the nerve is of no value, and the operation of
nerve-stretching is worse than useless, considerable harm often
being done. In the convalescent stage, bath treatment at one of the
spas, such as Bath, Buxton, Harrogate or Aix-les-Bains, will assist
the improvement of the general health. It is important to warn a
patient, who has just recovered from sciatica, never to lift heavy
weights, move heavy furniture, or exert similar strain on the back
muscles, or a relapse may occur.
In old-standing chronic cases of sciatic neuritis, which have
existed from six months to a year or more, the progress of interstitial
neuritis may lead to actual damage of the nerve-fibres, producing
numbness and even anaesthesia of the foot, loss of the Achilles jerk
and muscular wasting. In these cases there is generally, though
not always, severe pain, and the patient hobbles painfully in a
crouched position, leaning upon a stick. Even in this late stage
two or three large saline injections may bring about a cure ; but if
they are unsuccessful, it may be necessary to cut down upon the
1 1 26 Neuralgia.
nerve under an anaesthetic, and scarify it longitudinally for several
inches, as the nerve may be found shrunken into a round firm cord
from scar tissue.
WILFRED HARRIS.
EEFEEENCES.
Schlosser, Verhand. des Congress fur Innere Medizin, 1907, XXIY., p. 49.
Lange, ibid. Levy and Baudouin, " Les N6vralgies et leur Traitement," Paris,
1909. Sicard, Presse M&licale, May 6th, 1908. Harris, W., Brit. Med. Journ.,
1910, I., p. 1404 ; also Brit. Med. Journ., 1910, II. , p. 1051.
1127
THE SURGICAL TREATMENT OF NEURALGIA.
THE term " neuralgia " is used to signify pain in the course of a
nerve. It is not a disease, but a symptom, and in every case the
diagnosis of its cause is of the utmost importance to successful
treatment. In every case of "neuralgia" the cause must be
carefully sought and the investigation carried out to discover if the
pain is " referred " from irritation of the nerve in its course by the
pressure of growth, simple or malignant, or inflammatory con-
ditions or by the pressure of a cervical rib in brachial neuralgia,
or as the effect of scoliosis in intercostal neuralgia, or one of its
branches, e.g., facial neuralgia due to irritation of a branch of fifth
nerve in connection with a tooth. Treatment consists in removing
the cause if this is possible. If the cause cannot be discovered
symptomatic treatment must be given a fair trial ; if this fails,
destruction of the nerve supplying the painful territory must be
discussed. This may be done by the injection of alcohol ; if this is
impossible or is not successful, intradural division of posterior
roots may be advisable.
Facial Neuralgia. Under this heading are included two groups :
(1) Minor neuralgia ; (2) epileptiform neuralgia, tic douloureux,
major neuralgia.
(1) The pain is usually referred and due to dental irritation;
other causes are disease of maxillary antrum and frontal sinus,
errors of refraction, glaucoma, etc. Treatment is directed to the
cause.
(2) Before concluding that the case belongs to this group the
most careful examination is necessary to exclude peripheral
irritation. In most patients, all the teeth on the affected side
have been removed before a surgeon is consulted. The gums,
however, must be carefully examined for areas of tenderness
marking the site of a stump giving rise to irritation or a small
infected cavity left after extraction. If a painful spot is found, a
tiny sinus will often be discovered into which a probe may be
passed. Under an anaesthetic this should be followed down and
the irritating focus dealt with. Even if no sinus is discovered, the
gum should be reflected from any painful spot, when an opening is
often seen leading into the bone ; this should be opened up.
Sensation should always be tested. In true epileptiform
neuralgia there is no alteration in sensibility between the attacks.
1 1 28 The Surgical Treatment of Neuralgia.
If this is present, the pain is due to pressure or involvement in
growth in the course of the division or intracranially.
Until recently intracranial operation upon the primary division
of the nerve or upon the ganglion was the treatment of choice in
all undoubted cases. Since the introduction, four years ago, by
Schlosser, of Munich, of the method of alcohol injections into the
branches as they leave their foramen in the skull, operation is
reserved for exceptional cases. The injection of alcohol into a
nerve trunk causes destruction of the nerve fibres at the seat of
injection and consequent degeneration. It therefore takes the
place of a peripheral neurectomy. Operative treatment must not
be considered until injections fail to relieve, or pain recurs at a
short interval (see p. 1117). The operative treatment of this
condition is not yet finally settled. Theoretically, in cases in which
two or more divisions are affected, the ideal procedure is division
of the sensory root of the ganglion, leaving the motor root intact,
as recommended by Spiller, in 1901, and first performed by Frazier.
If operation is decided upon, it should be intracranial. Time
should not be wasted in performing peripheral neurectomies. If
the pain is limited to one division, intracranial resection of that
division with the interposition of rubber tissue at its foramen of
exit should be performed. If two divisions are involved, the
operation consists of resection of these with the portion of the
ganglion from which they spring, leaving the upper part with the
ophthalmic nerve (Hutchinson's operation) intact. In this way
the risk of ocular complications is avoided, and there is less shock
as less retraction and consequent pressure on the temporo-
sphenoidal lobe is necessary, and there is less liability to damage
to the cavernous sinus and nerves in its wall. Only when the pain
involves the whole territory of the nerve should removal of the
whole ganglion be carried out.
The easiest access to the ganglion is obtained through the
temporal region. Cushing's direct temporal, infra-arterial method,
I consider superior to the high temporal route of Hartley-Krause ;
it gives the most convenient access with the least disturbance of
the part. A portion of the temporal bone immediately above the
zygoma is removed through a sickle-shaped incision extending
posteriorly over the zygoma; anteriorly it must not extend low
enough to injure the branches of the facial nerve supplying the
frontalis. The dura mater is stripped up from the middle fossa
and the foramen ovale found, and then the foramen rotendum. It
must be remembered that the ganglion lies in the cavum Meckelii
between two layers of dura mater.
The Surgical Treatment of Neuralgia. 1129
The results of the removal of part or the whole of the ganglion,
both immediate and remotely, are extremely good. Mr. Hutchinson
has performed his operation twenty-six times without a death and
has operated on the ganglion thirty-one times without a death.
Sir Victor Horsley has removed the ganglion in 149 patients with
a death rate of 7 per cent., but has had no deaths among the
patients below the age of fifty. In no case has the disease recurred
when the whole ganglion has been removed or in Mr. Hutchinson's
cases.
Sciatica. No case must be treated as sciatica until a thorough
examination has shown the absence of disease of the spinal cord,
cauda equina, bodies of vertebrae, sacro-iliac joint, hip joint, rectum,
etc. An X-ray examination should always be made. If no obvious
cause is found, or if the pain is in association with osteo-arthritis
of the hip, absolute rest should be the first treatment. The patient
must be confined to bed and a long Listen splint with weight
extension is applied. When all pain has ceased the splint may be
removed, and massage and passive movements employed before the
patient is allowed to get up. This treatment is usually successful.
In those cases in which it fails to relieve or relapse occurs, Lange's
infiltration should be tried. As a last resort, the nerve should
be exposed and carefully examined for adhesions, the finger being
passed up into the sciatic notch. If any are present, they should
be divided, and finally the nerve should be stretched, sufficient
force being used to lift the limb off the table (see also Sciatica,
p. 1123).
JAMES SHERREN.
1 130
NEURITIS.
NEURITIS may be limited to a single nerve or portion of a nerve
local neuritis, or may involve many or all the peripheral nerves-
multiple neuritis.
LOCAL NEURITIS.
Local neuritis may arise from: (1) Exposure to cold ; (2) injury
to the nerve ; (3) the involvement of the nerves in local affections
of the surrounding parts traumatic, inflammatory, arthritic ;
(4) pressure on the nerve from crutches, cervical rib, callus or new
growth ; (5) local affection of the nerve, as in syphilis, leprosy and
new growth ; (6) the local action of a general condition, as in
rheumatism, typhoid fever, gonorrhoea, gout, diabetes and malaria.
The treatment of local neuritis must be carried out on the fol-
lowing general principles : (1) The removal or treatment of the
exciting cause ; (2) the provision of absolute rest to the affected
portion of the nerve and the alleviation of the local condition ;
(3) the prevention of the development of deformity which may
result from the paralysis ; (4) the maintenance or improvement of
the trophic condition of the parts supplied by the affected nerve.
The Removal or Treatment of the Cause.
Rheumatic Neuritis. In addition to the local treatment which is
detailed below, the patient should be given 10 to 15 gr. of sodium
salicylate, combined with 20 to 30 gr. of sodium bicarbonate, every
six hours until the acute stage has passed off. In subacute cases
15-gr. doses of aspirin often prove successful. The bowels should
be kept freely opened and alcohol and sweet foods forbidden.
Gouty Neuritis. Treatment should be directed towards removing
the gout. The bowels should be kept free by means of a pill, and
Vichy water should be drunk in the morning. The internal
administration of colchicum or of potassium iodide and salicylate of
soda should be persevered with.
Syphilitic Neuritis. Active treatment with iodide and mercury is
essential. The iodide should be given in fairly large doses
(10 to 20 gr.) three times a day, and if necessary 3 min. of liquor
arsenicalis [U.S.P. liquor potassii arsenitis] may be added to it.
Mercurial treatment is best given by inunction, and should be
persevered with until the physiological effect of the drug is pro-
duced. Sulphur baths should be given daily before the inunction.
Neuritis. . 1131
It is yet too early to speak definitely of the result of treatment
with Ehrlich'snew preparation of arsenic, dioxydiamidoarsenobenzol,
commonly spoken of as " 606." It has certainly proved itself to he
the most effective drug in the treatment of syphilis, judging by the
rapidity of its action, but time alone can show whether the results
so obtained are permanent or not. So far the drug has only been
given by a limited number of skilled persons, and how far its
administration is possible in the hands of the general practitioner
remains to be seen. " 606 " may be given by intra-muscular or
intra-venous injection, the latter method being practically pain-
less in its application and more rapid in its effect. As in syphilitic
neuritis the lesion is primarily syphilitic, the nerve elements being
involved secondarily. The early administration of " 606 " should
prevent the occurrence of degeneration in the nervous tissues.
Diabetic Neuritis. Treatment of the causal condition is essen-
tial. Alkaline remedies have a specially good influence on the
neuritis. The prognosis as regards the neuritis is not unfavourable,
but many of these cases tend to develop chronic muscular atrophy,
which remains long after all traces of neuritis have disappeared.
Malarial Neuritis. Neuritis may sometimes develop in associa-
tion with, or as a sequel to malaria. In the former the treatment
of the malaria by quinine will usually remove the neuritis, in the
latter a combination of iron and quinine will be found more
useful.
Compression Neuritis. The removal of the compressing agent is
essential, callus, cervical rib, new growth, or inflammatory thicken-
ings being appropriately dealt with.
The Provision of Absolute Rest to the affected Portion of
the Nerve and the Alleviation of the Local Condition.- Rest is
secured by supporting the limb and preventing movement of the
affected portion of the nerve. Where there is an acute condition
local applications may be applied hot compresses, dry heat, anti-
phlogistine or blisters ; in more chronic cases the application of
the actual cautery is more effective. Iodide may be given in the
early stages of most cases, and may be combined with potassium
salicylate, potassium bromide and phenazonum, which serve to
relieve the pain as well as to help in removing the local inflamma-
tion. Should the pain persist, it may be necessary to administer
codeine or morphia hypodermically ; but these drugs must in all
cases be given only by the physician. The tenderness over the
nerve area associated with neuritis may sometimes be relieved by
the application of a liniment composed of equal parts of tincture of
aconite, belladonna and chloroform, or by painting the arm every
1132 Neuritis.
third day with a solution composed of 1 part of methyl salicylate
added to 3 parts of olive oil.
The Prevention of the Development of Deformity which
tends to follow upon the Paralysis. Deformity may arise from
(a) weakness of the paralysed muscles associated with the over-
action of the non-paralysed muscles ; (6) the continual adoption by
the patient of a posture in which the nerve is relaxed and freed
from the pressure exerted by muscular contraction. The paralysed
muscles should be supported so as to prevent over-stretching, and
where possible the limb should be placed in such a position as to
prevent over-action of the non-paralysed muscle : thus, in the case
of a dropped wrist, the hand and fingers should be bound up in the
hyper-extended position. In the case of dropped feet, the feet
should be kept dorsi-flexed at the ankle. This may not be
possible in the early stages owing to the pain produced by the
stretching of the muscles, but in every case the weight of the bed-
clothes should be removed from the feet, and passive movement
should be carried out two or three times a day as soon as the acute
stage passes off.
The Maintenance or Improvement of the Trophic Condi-
tion of the Parts supplied by the Affected Nerve. The trophic
condition of the paralysed parts may be maintained by keeping the
affected part wrapped in cotton-wool ; this will keep the parts warm
and prevent the occurrence of local injury. As the acute stage
passes off more active treatment is required ; passive movements,
galvanism and mild faradism should be given. Later, massage,
resistance exercises and graduated voluntary movements must
be carried out as soon as all tenderness has passed off. In
many cases there is a tendency for arthritic changes to develop in
the neighbouring joints ; this may be counteracted by the early
employment of passive movements and the application of dry
heat.
T. GRAINGER STEWART.
133
DIVISION OF POSTERIOR ROOTS.
THIS operation may be necessary for the relief of pain due to
ascending neuritis from the irritation of terminal branches of
nerves or the bulbs left on trunk nerves after limb amputations.
It is also occasionally performed for the relief of pain in involve-
ment of the brachial plexus in malignant disease of axillary glands
secondary to carcinoma of the breast. It has been carried out with
success, first on the suggestion of Forster, in June, 1907, for
the relief of spastic paraplegia and also to relieve pain in the
gastric crises of tabes.
The posterior roots supplying the affected area are divided
intradurally after removal of the laminae. When possible uni-
lateral laminectomy (Taylor) should be performed.
JAMES SHERREN.
134
MULTIPLE NEURITIS.
IN this condition there is a widespread involvement of the peri-
pheral nervous system. The following are the chief varieties :
(1) Cases due to the action of poisons derived from outside the body-
alcohol, the coal-tar products, lead, arsenic, mercury, copper and
phosphorus ; (2) cases due to the action of poisons developed in the
body as the result of infective disorders diphtheria, influenza,
malaria, typhoid fever, scarlatina, puerperal fever, gonorrhoea,
septicaemia and beri-beri ; (3) cases arising in association with general
disorders diabetes, gout, rheumatism, anaemia, mal-nutrition,
tuberculosis and carcinoma ; (4) cases due to the local action of
organisms leprosy and syphilis.
Alcoholic Neuritis. The first essential is to prevent the patient
from obtaining any more alcohol ; this is by no means easy in the
early stages of the disease, as the patient is in most cases a secret
drinker, and the cause of the illness quite unsuspected by the
relatives. The loss of moral sense in these cases is so great that
the patient, who often exercises a quite extraordinary degree of
cunning in obtaining supplies of alcohol, cannot be trusted in any
way. The patient should, therefore, be removed to a nursing home
or institution, or, failing that, be placed under the direct and
constant supervision of trusted attendants.
Having removed the cause of the illness and placed the patient
in favourable surroundings, the next care must be to improve his
general health and mental condition. The most urgent symptoms
calling for relief are pain, insomnia, disordered digestion, and
occasionally cardiac or renal complications. The patient must
have absolute rest and should be confined to bed, when possible
on a water-bed. Great care must be taken to prevent bed-sores
and to keep the patient clean and dry. Where vaso-motor
changes are pronounced the limbs should be kept warm by
wrapping them in cotton-wool.
Disorders of the digestive system are almost invariably present ;
the tongue is furred and foul, and the patient suffers from nausea
and a distaste for sweetened foods ; in some cases there is persistent
vomiting, and not infrequently the patient suffers from congestion of
the liver and painful and bleeding haemorrhoids. In the minor
cases cutting off the alcohol and proper dieting will cause a rapid
Multiple Neuritis. H35
improvement in the digestive functions. In more severe cases the
bowels must be regulated and the gastric irritation allayed by a
bismuth and soda mixture. The diet should be light and nutritious,
any excess of nitrogenous food being avoided. The appetite may be
stimulated by giving a bitter tonic containing cinchona and capsicum,
especially when there is much craving for drink. If cardiac weak-
ness is present, strychnine should be given by mouth, or 5 min.
[U.S.P. strychnine hydrochloride, gr. ^] of the solution may
be injected hypodermically two or three times each day. The
patient should be allowed plenty of fluid, and this may be given in
the shape of home made lemonade or imperial drink. The pain and
insomnia are best relieved by placing the patient in a comfortable
position, applying hot compresses or sponging alternately with hot
and cold water, and administering a mixture containing 15 gr. of
potassium bromide, 10 gr. of potassium salicylate, and 5 gr. of phena-
zonum. Where there is much depression, potassium iodide and
digitalis may be substituted for the salicylate. If these measures
fail to procure sleep, 10 gr. of trional or 7 gr. of veronal maybe given
at night for two or three nights in succession.
During the early stages of a severe case no active local treatment
can be employed, but much may be done to prevent the development
of contractures and deformity. These contractures develop mainly
in the stronger groups of muscles, and unless attention is devoted
to their prevention, deformities result which will retard recovery,
and even cripple the patient permanently, although all traces of the
neuritis have disappeared. The flexor and adductor groups of
muscles being the stronger, the deformities which result are : Drop-
foot, with drawing up of the heel ; flexion at the knees ; adduction
and flexion at the hips ; flexion of the wrists, fingers and elbows ; and
stiffness and adduction at the shoulder. A most important practical
point which must not be lost sight of, is that the mere overstretching
of the extensor muscles is of itself sufficient to retard recovery and
therefore measures must be adopted which will prevent this.
So long as there is acute tenderness the patient lies in the position
of greatest relaxation, the legs are drawn up at the hips, the knees
flexed and the feet pointed, while the arms are folded across the
chest, flexed at the elbow, wrist and finger joints. No attempt to
straighten the limbs can be made, owing to the pain which the least
stretching of the nerves and muscles entails. Care must be taken to
prevent the weight of the bedclothes from aggravating the drop-foot,
by placing a cradle under the upper sheet, and by not allowing the
hands to remain in a position which accentuates the drop-wrist.
When the tenderness lessens, gentle passive movements should be
1136 Multiple Neuritis.
given at all joints, and, as soon as possible, apparatus should be
employed to .counteract the contracture, which can be done only
when moderate pressure on the muscles no longer causes pain. In
testing for muscular tenderness it is necessary to divert the patient's
attention, as he will often scream at the mere idea of being touched,
when, as a matter of fact, all true hyperaesthesia has passed off. The
most suitable appliances for the lower extremities are made on the
principle of a " Gowers boot," which consists of a slightly flexible
leather splint extending from well up the thigh to the heel, and
being continued from the heel as a foot-piece. The splint, having
been well padded with cotton-wool, is applied to the posterior aspect
of the limb, and the foot-piece is made to exert pressure upon the
sole of the foot, so as to approximate the position of the foot to a
right angle by means of rubber bands or tubes, which are fitted to
either side and attached to the splint at the level of the knee, the
rubber bands being crossed so that the one which is fixed to the
inner side of the foot-piece is attached to the outer side of the knee,
and vice versa. The flexor contracture at the knee is overcome by
broad, crossed elastic bands, which stretch diagonally across the
front of the knee from one side of the splint to the other. Similar
apparatus can be applied to the arms and hands, the wrists and
fingers being straightened gradually by means of elastic tension.
The great advantage of such appliances over splints is that they can
be borne more continuously and be adjusted more easily, the
elastic bands being tightened as the patient gradually improves
and becomes able to bear greater pressure. The continuous pull of
the elastic is better than the pressure of a bandage, which does
not adapt itself to changing conditions. At first it may be
impossible to apply the apparatus continually, but perseverance is
necessary and. will be amply rewarded. Massage must be gentle at
first, and commenced only when the acute stage has passed off;
later, more active treatment becomes imperative, and galvanism and
faradism will be found useful, especially when combined with
massage and passive movements. The patient must be encouraged
in every way to make use of returning power, and every improve-
ment should be pointed out to him. Not infrequently progress is
arrested by the deformities and contractures ; when this occurs, hot-
air baths or, failing that, an ordinary hot-water bath may prove of
service in reducing the contracture and making passive movements
more easy. If this does not suffice, an anaesthetic should be given
and the joints moved, hot applications being applied afterwards to
reduce the reaction and pain. In other cases surgical interference
may be necessary.
Multiple Neuritis. 1137
In mild cases, and in a certain type of alcoholic neuritis, ataxia
is the most marked feature. This is best treated by putting the
patient through a modified course of Frenkel's exercises, the extent
to which this can be done being determined by the degree of neuritis
and tenderness which is present.
Treatment must extend over several months in severe cases, and
although at the outset attended by pain, this should not be allow r ed
to stand in the way of its continuance. Where necessary bromide,
analgesics or even veronal or trional may be given until the patient
becomes more accustomed to the movements and the apparatus.
One of the greatest difficulties which the physician has to encounter
is the obstinacy and mental apathy of the patient ; firmness and
encouragement are essential to the success of the treatment. As
soon as recovery renders it possible the patient should be encouraged
to use his arms and legs ; fresh air and outdoor life materially
hasten recovery.
Lead Neuritis. Painters, plumbers, typesetters, workers in
white lead, glaziers, etc., are liable to suffer from this condition. In
all such occupations prophylactic measures should be insisted upon.
Strict attention to personal hygiene must be enforced : the work-
ing clothes should be changed and the hands cleansed before
eating. The mouth and teeth must be attended to, and the bowels
should be kept well opened by means^ of a morning dose of Epsom
salts. Drinking sulphuric acid lemonade, made by adding 5 drops
of aromatic sulphuric acid to a wineglassful of water, is also recom-
mended, as it tends to prevent the absorption of lead into the
system.
If, despite these precautions, symptoms of lead poisoning develop,
the patient must relinquish his occupation, at any rate for a time.
Lead poisoning may result from the drinking of soft water,
alcohol or beer which has become impregnated with lead by being
stored in leaden receptacles or passed through leaden pipes. All
such sources of intoxication should be considered and, if possible,
removed. In any case of lead neuritis steps must be taken to
prevent further intoxication, and treatment directed towards the
elimination of the lead from the system. Whether this can be
effected by drugs or not is a moot question, but by keeping the
bowels well opened and encouraging diuresis and a free action of the
skin the natural process of elimination is doubtless increased.
Baths impregnated with sulphurated potash are also of assist-
ance, their action being increased if the patient is well soaped
and rubbed down with a rough towel after the bath. Iodide of
potassium has been recommended on the grounds that it hastens
S.T. VOL. n. 72
1138 Multiple Neuritis.
the elimination of the lead, but the experiments of Professor Dixon
Mann failed to prove that it has any appreciable influence in this
direction ; on the other hand, its efficacy in cases of acute lead
poisoning is undoubted, and its use should not be discarded.
Associated conditions such as anaemia, renal and vascular disease
must be appropriately treated. Pain and hypersesthesia are not
prominent features of lead neuritis, and, therefore, active local
treatment, massage, passive movements, resistance exercises and
electrical treatment should be commenced early, and the daily
injection of 5 min. of liquor strychninae hydrochloridi [U.S.P.
strychnin hydrochloridi gr. -$] is of special value. Most cases of
lead paralysis come under treatment early, and, therefore, it may
be necessary to confine the patient to bed. Apparatus for keeping
the hands and fingers hyper-extended, for assisting in the dorsi-
flexion of the feet, will enable the patient to use his hands and feet,
and by preventing over-extension of the paralysed muscles promote
a rapid recovery.
Arsenical Neuritis. Arsenical neuritis may arise from, the
prolonged taking of small quantities of arsenic, from intoxication
with arsenical pigments, or from a single large dose of the drug.
This condition differs from that of alcoholic neuritis in the extreme
degree of hyperaesthesia which is present, in the persistence of pain,
in the greater degree of ataxia, and in the more extensive and
severe muscular wasting which is liable to ensue.
Treatment for the relief of the pains and hyperaesthesia is essential,
and in some cases the administration of morphia or codeine may be
necessary. The inco-ordination may require special treatment by
means of Frenkel's exercises. In other respects the treatment is
similar to that of alcoholic neuritis, but complete recovery is often a
matter of many months.
Post-diphtheritic Neuritis. This form of paralysis has cer-
tainly become less frequent and less severe since the introduction of
the anti-toxin treatment. The early administration of anti-toxin
is, therefore, of importance as a prophylactic measure, as well as
being curative of the primary condition. The severity of the neuritis
bears no relation to that of the attack of diphtheria ; indeed, the
most severe - cases of post-diphtheric paralysis occur in patients in
whom the diphtheria has been so mild as to escape notice. Great
care is necessary in the treatment of cases of post-diphtheric neuritis,
as extension of the paralysis may take place very insidiously, and
cases in which mild palatal symptoms alone are present may rapidly
develop signs of cardiac and respiratory paralysis. Complete rest is
essential, and ample nourishment should be given. Care must be
Multiple Neuritis. 1139
taken to prevent food entering the larynx, and nasal feeding is
necessary in some cases. The condition of the heart and respira-
tory muscles must be carefully watched. Strychnine, should be
given by the mouth in mild cases, or by hypodermic injection in
severe cases. If respiratory paralysis threatens, repeated inhalations
of oxygen should be given. If cardiac failure is not averted by rest
and strychnine, venesection' should be performed and 8 to 10 oz. of
blood removed. The treatment of the paralysis of the limbs is that
of multiple neuritis in general, but active local treatment must not
be commenced too soon owing to the subacute onset of the condition
and the danger of cardiac failure. Very frequently the patient
passes through an ataxic stage before the paralytic stage becomes
manifest, and there is a natural temptation to start the patient upon
Frenkel's exercises at once. This should not be yielded to until all
chance of advancing paralysis is passed. The patient in most cases
recovers rapidly, and if the local treatment has been carried out
on the lines suggested for Local Neuritis (see p. 1130), there is little
chance of deformity or contractures delaying his progress.
Puerperal Neuritis. This may occur as a local condition during
pregnancy, or develop as a general condition during the puerperium.
The treatment is that of a multiple neuritis, but any complication
or possible causal condition should be dealt with at the same time.
The prognosis is good. -
Senile Neuritis. This results from general mal-nutrition and
changes in the vessels supplying the nerves. General tonic treat-
ment is indicated, the local treatment being determined by the
extent and severity of the disease.
Multiple Neuritis arising from some Unknown Cause.
The treatment of this condition as regards the paralysis is the same
as in alcoholic multiple neuritis. Nourishment and attention to
the cardiac condition are most important. The prognosis is good.
Beri-beri. This is an endemic form of neuritis, for the treat-
ment of which the reader is referred to the article on Beri-beri
(Vol. III.).
T. GRAINGER STEWART.
72-
1 140
NYSTAGMUS.
Horizontal Nystagmus may be physiological, and may be seen
in anyone sitting in a moving train and watching passing objects.
Its association with variations in pressure in the endolymph of the
internal ear may be shown by rotating the individual five or six
times rapidly, and then telling him to look towards the opposite direc-
tion to that in which he was turned. Syringing out the middle ear in
some cases of otitis media may produce the same effect. Many ocular
affections give rise to nystagmus, especially when acquired in infancy.
Thus perforation of the cornea from gonorrhceal ophthalmia may lead
to a central opacity on the lens, and as a result proper fixation is
never acquired, the fovea centralis is never educated, and nystagmus
is the result. When one eye is much more damaged than the other,
covering the worse eye with a ground glass may diminish the
nystagmus very much, or abolish it entirely for the time. Albinism
is almost constantly associated with nystagmus, or " dancing eyes."
Lamellar cataracts, acquired in infancy and due to rickets, if
unoperated on will lead to slow rolling movements of the eyes, and
if the cataracts are needled and thus cured by becoming absorbed,
nystagmus will develop in later childhood, unless the infant is made
to wear constantly the strong glasses necessitated by the loss of the
lens. This is owing to fixation never being acquired, the extreme
hypermetropia caused by the loss of the lens blurring the images to
such a degree that the fovea centralis is never developed. Nystagmus
may be congenital, and is then often hereditary, several members
of the same family suffering. There may be no trace of albinism in
these eases or anything demonstrably wrong with the eyes, except
slightly diminished acuity of vision. Although the nystagmus may
be very pronounced, the patients never admit that objects appear
to be moving. Miner's nystagmus is a well-known variety found
in the workers at the face of the coal, who hole the coal lying on
their sides, working in a bad light. It is generally associated with
other signs of neurosis, and is to be looked on as an occupation
neurosis or fatigue spasm. The same form of nystagmus may be
met with in mountaineers, and in violin players and others who
may beobliged to read music from an angle constantly. Nystagmus
in disease of the central nervous system is a valuable sign,
usually indicating that there is a lesion of the cerebellum or
Nystagmus. 1141
cerebellar tracts, as in Friedreich's disease and disseminated sclerosis.
The coarse slow movement is to the same side as the cerebellar
disease. Rotatory nystagmus is sometimes seen in disease of the
pons, especially if the anterior corpora quadrigemina are involved,
or in tumours of the third ventricle. In such diseases there is no
indication for the treatment of the nystagmus as a symptom, but
the sign may be a valuable one for the recognition and consequent
treatment of the disease itself. Head-nodding or spasmus nutans
in infants during the dentition period may be associated with
nystagmus, often of one eye only, and the nystagmus may be
rotatory. It is likely to be more marked when the head is held
fixed. Occasionally, instead of a nodding movement, there is a
lateral movement of the head. It is not a serious condition, though
it has been thought to be an evidence of rickets. Careful feeding,
cod-liver oil and iron are all that is necessary.
In some children with pronounced nervous heredity the nodding
movements of the head may occur only at night, " tic du sommeil,"
which has been known to persist for many years.
WILFRED HARRIS.
REFERENCES.
Oppenheim, H., " Text-book of Nervous Diseases," 5th ed., 8vo, Edinb., 1911.
Reid, A. C., " Brain," 1906, XXIX., 363. Gowers, Sir W. R., " Manual of
Diseases of the Nervous System," Vol. II., 2nd ed., 8vo, Lond., 1893.
1 142
TUMOURS OF NERVES.
TUMOURS growing in connection with peripheral nerves are called
"neuromata." They are divided into the "true," in which the
growth is composed of nerve fibres and nerve cells, and the "false,"
in which the connective tissue structures of the nerve are involved.
The true neuromata are of great rarity and are never diagnosed.
False neuromata may be circumscribed or diffuse, simple or
malignant.
Circumscribed " Neuromata." Simple. The affected nerve
should be exposed well above and below the tumour and an incision
carefully made in the nerve parallel to the course of its fibres down
to the tumour, which can usually be shelled out with ease. No
damage should result to the nerve from this procedure. If enuclea-
tion is impossible resection must be carried out and nerve continuity
restored.
Malignant. Sarcomata may arise in the nerve sheath and
spread rapidly up and down the nerve. If seen early, wide resection
should be carried out and portions of the ends removed for rapid
microscopical examination to be certain that the incisions are above
the infiltrated areas. This should be done before the wound is
closed. If the growth is adherent to surrounding parts, amputation
is advisable.
Diffuse Neuroma. Neuro-fibromatosis. Many conditions are
described under this head ; they have one feature in common, a
diffuse overgrowth of the connective tissue of a nerve or nerves.
Surgical interference should be limited to the removal of tumours
which are painful or interfering with the well-being of the patient.
Sarcomatous degeneration may occur in any of the tumours. This
is treated as are sarcomata elsewhere.
JAMES SHERREN.
H3
DISEASES AND AFFECTIONS OF THE BRAIN.
APHASIA AND OTHER SPEECH DEFECTS OF
CEREBRAL ORIGIN.
IN the management of patients in whom defects of speech have
resulted from lesions of the cerebral hemispheres there are two
entirely distinct aims to which treatment must be directed. The
first of these is the limitation, arrest and resolution of the cerebral
lesion that is responsible for the defect of speech, and the prophy-
laxis against the occurrence of further lesions of the same nature.
The second is the restitution by re-education and training of the
defective speech faculty, which may be brought about both by the
raising of the functional capacity of a partly damaged speech-centre
or by the compensatory acquirement of speech functions by cerebral
centres other than those chiefly and usually concerned with
speech.
During the early days of the illness measures directed towards
the limitation and resolution of the lesion are all-important, and
since vascular lesions are responsible for the cerebral defect in all
but a very few of the cases, the appropriate treatment will be found
under the heading Cerebral Vascular Lesions.
It is all-important to bear in mind that lasting defects of speech
result only from lesions of the convolutions as opposed to lesions of
the central white matter, and that the vascular lesions affecting the
convolutions are nearly always of the nature of thrombosis and
embolism as opposed to haemorrhage. The measures, therefore, for
the relief of thrombosis and embolism will be appropriate in almost
all the cases now under consideration. These measures may be sum-
marised as follows : (1) Those directed towards the lessening of the
coagulability of the blood, and which therefore lessen the tendency of
thrombosis to extend, and which lessen the liability to the occurrence
of secondary thrombosis after embolism. For this purpose it is
usual to administer the alkaline citrates or citric acid in full doses
and to relieve any marked degree of cyanosis by bleeding. (2) Those
directed towards the increase of the blood-flow in the smaller
vessels, and which tend not only to limit the thrombosis, but also to
lessen the amount of tissue-death within the thrombosed area by
favouring the occurrence of compensatory circulation and the
1 1 44 Aphasia and other Speech Defects.
re-channelling of thrombosed vessels. In this connection the
remedies which increase the heart's force and which relieve any
embarrassment to the circulation which may be present are
invariably indicated. Strychnine (in doses of gr. ^ thrice daily,
and for preference administered hypoderrnically), digitalis and
alcohol are the best drugs to employ ; but it must be borne in mind
that one of the most valuable means of cardiac stimulation at our
disposal is the administration of an easily assimilable diet con-
taining proteids and extractives, and to this end a simple diet,
reinforced by the addition of Valentine's meat juice, raw meat
juice, Fairchild's " Panopepton," pounded raw meat and beef-tea,
should be given, and, when the patient is able to take an ordinary
diet, the meaty part of the diet, and especially underdone meat,
must on no account be left out. It not unfrequently happens that
for some time after the occurrence of the lesion the patient may
be unable to swallow, and when this is the case nasal feeding should
be employed in good time, for the absence of assimilation by
lowering the heart's force and the blood-pressure tends to favour
the extension of the thrombotic process. If embarrassment of
the circulation is shown, by stertorous breathing and cyanosis
with distension of the superficial veins, venesection is a most useful
measure, and the letting of about 10 oz. of blood, so far from being
a depletive measure, will act as a cardiac stimulant, in that it will
relieve the congestion of the right heart. (3) All those events
which tend to produce temporary lowering of the blood-pressure or
lessening of the heart's force are to be studiously avoided, for if
such occur in the early days of the illness the extension of
thrombosis and the enlargement of the lesion is highly probable,
while at any subsequent time such lowering of the heart's force or
of the blood-pressure may be responsible for the occurrence of fresh
areas of thrombosis. It is for this reason that free purgation must
be especially avoided from the onset, mild aperients supplemented
by enemata alone being appropriate. The use of remedies which
have the effect of lowering the blood-pressure is contra-indicated, no
matter how high the blood-pressure may be. The administration
of iodide of potassium should be rigidly restricted to cases in which
the thrombosis is undoubtedly of a syphilitic nature, and in such
syphilitic patients it should only be used after a thorough exhibition
of mercury, and then only in combination with cardiac stimulants,
for it has, in the absence of mercury, an especial action in
rendering the blocking of a vessel permanent and irremediable.
Cardiac disease with embolism being excepted, the common
cause of rapidly oncoming aphasia in the first half of adult life is
Aphasia and other Speech Defects. 1145
syphilitic thrombosis of cerebral vessels. The diagnosis of this
condition may be aided and confirmed by Wassermann's reaction and
by the probable presence of lymphocytes in the cerebro-spinal fluid
obtained by lumbar puncture. In such cases it is imperative to
attack the syphilitic process as early as possible and with the most
rapidly acting and potent remedies, not only with for the purpose of
preventing the thrombosis of other diseased cerebral vessels but
also with the object of securing the re-channelling of the vessels
actually thrombosed. For this purpose Ehrlich's Salvarsan seems
to possess a decided advantage over other remedies. It should be
given by the intravenous method in two doses of 0*4 0'6 gr.
at an interval of a fortnight, and should be followed by a course
of mercury and iodide of potassium. In the writer's experience
the use of Salvarsan has not been followed by any ill effect and the
immediate and rapid improvement in recent cases has been remark-
able, while in cases of long standing the results of this treatment
have in many cases exceeded expectation.
Fatigue and exposure to cold are often the immediate exciting
causes of cerebral thrombosis, and the subjects of aphasia must be
\varned against such events.
Temporary Aphasia. In the subjects of cerebral vascular
disease, and more especially in the patients of advancing years with
cerebral arterial sclerosis, attacks of transient aphasia are not
uncommon. These attacks are the expression of a temporary
slowing of the blood-stream or of a temporary stasis of the blood in
diseased vessels of the speech-centres. They are warnings that the
patient is in immediate danger of the occurrence of thrombosis
within these centres, and they should be energetically treated in
accordance with the scheme above laid down.
Patients who have had a cerebral lesion upon the left side, and
who as a result of that lesion have developed a right-sided hemi-
epilepsy, may become speechless after each attack, the aphasia
passing off after a variable time. The aphasia is here the expres-
sion of exhaustion of the speech-centres during the cerebral com-
motion which is responsible for the convulsion. Such convulsions
with associated aphasia are very amenable to treatment with the
bromides. A single dose of 20 gr. of sodium bromide each night
continued indefinitely generally suffices to prevent the occurrence
of such attacks.
After complete or partial recovery from aphasia transient
relapses or transient exacerbations in the speech defect may occur
which are of the same nature, namely, epileptic seizures initiated
by the organic lesion. These may be accompanied by general or
1146 Aphasia and other Speech Defects.
local convulsion, but more often by slight impairment of conscious-
ness only. The regular administration of bromide brings about
the complete cessation of these attacks.
It is sometimes very difficult when dealing with an exacerbation
of aphasia in a patient who has partly or completely recovered to
determine whether one is dealing with an attack of organic
epilepsy, as described above, from the original lesion, or whether
the condition present is the occurrence of a fresh thrombosis near
the original lesion, for the symptoms produced by these two con-
ditions of widely different import and seriousness are identical.
Under these circumstances there is every advantage in combining
the treatment for the prevention and limitation of possible throm-
bosis, as given above, with the regular administration of bromides.
Temporary loss of speech sometimes occurs in young children,
soon after they have acquired facility with spoken language, as the
result of any severe illness, and may give rise to alarm. With the
restoration of general health, however, speech returns, but in some
cases so slowly as to make it obvious that the child is not utilising
any speech memories that he may have had prior to the illness, but
that he is learning to speak afresh.
It is necessary to bear in mind that asphasia may be an
important and early indication of certain conditions which call for
surgical procedures. Injuries to the head which have caused
fracture of the left temporal bone and rupture of a branch of
the middle meningeal artery, with a gradually increasing collection
of blood between the skull and the dura mater, give rise to aphasia
by the pressure of the tumour thus formed upon Broca's convolu-
tion. Aphasia following a cranial injury is almost invariably the
result of extra-meningeal haemorrhage and it is worthy of note
that many cases are upon record in which comparatively slight
injuries of the temporal region have sufficed to fracture the thin
temporal bone and to cause extra-dural haemorrhage.
In a few cases the direct pressure of a depressed area of bone upon
Broca's area or upon the left temporal lobe, has resulted in aphasia.
Under either circumstance the removal of the cause of compression
by surgical means results in a rapid disappearance of the aphasia.
Abscess of the left temporal lobe not uncommonly causes defects
of speech which may be " word-blindness," " word-deafness,"
aphasia, or a combination of these conditions. When in a case of
long standing disease of the left middle ear, cerebral symptoms
with defect of speech occur, the latter are of sure localising
importance and call for immediate exploration of the temporal
lobe. That many cases of abscess of the left temporal lobe are
Aphasia and other Speech Defects. 1147
met with in which speech defects do not occur, is explained by
the situation of the abscess, which in these cases is deeply placed
in the white matter and does not involve the convolutions.
When aphasia is due to the presence of a cerebral tumour in
the neighbourhood of the speech centres considerable temporary
improvement often follows the removal of a considerable area of
bone over the affected region with free openings of the dura
mater. The pressure is relieved and with it the evascularisa-
tion which pressure always produces ; with the restoration of a
sufficient blood supply the speech centres are likely to resume
their function. This operation has a further important recom-
mendation that it may reveal a tumour either of the bone or of
the meninges that can be extirpated without injury to the cerebral
hemisphere.
Whatever the pathological nature of a cerebral tumour may
be the effect of the administration of mercury and of iodide of
potassium in diminishing its size, slowing the rate of its growth
and alleviating the symptoms is remarkable, and in no case should
these remedies be omitted. The effect is enhanced by combination
with diuretics.
Hysterical Aphasia, or, as it is better called, " Functional
Aphonia " and " Functional Mutism," must be treated upon the
same lines as other functional paralyses. There is, however, one
very valuable method for the treatment of these conditions which
must be mentioned in this place. The patient suffering from
functional aphonia or mutism is placed lightly under the influence
of ether by inhalation. As soon as the excited stage of the
anaesthesia is reached the patient, having lost control, struggles,
regains the voice and shouts. The ether is at once discontinued
and the patient is encouraged to use the voice as the effects of the
partial anaesthesia pass off, and regains complete consciousness to
find that the voice has returned.
TREATMENT TO FACILITATE RESTORATION OF SPEECH
FACULTIES BY FUNCTIONAL COMPENSATION.
Any restoration of speech that occurs after a destructive lesion of
any of the speech-centres must be brought about by the develop-
ment of the lost speech function in some undamaged part of the
brain, presumably in those regions of the right hemisphere which
correspond with the damaged speech-centre in the left hemisphere,
and which are normally supposed to have a subsidiary function in
speech. It is at once obvious that the development of a compen-
satory speech function in such a centre must take place by training
1148 Aphasia and other Speech Defects.
and imitation, just as it does in the usual speech-centres when a
child learns to speak, and therefore the essential elements of any
treatment to facilitate the establishment of compensatory speech
function consist in the slow and laborious teaching to the patient
of the lost elements of his speech.
The degree to which this compensatory restoration of speech func-
tion may reach varies widely. It is greatest, in children, for up to the
sixth year of life uni-lateral lesions of the brain, however extensive,
do not result in permanent loss of speech, but complete compensa-
tory recovery takes place, provided that no great defect of intelligence
exists. It is least marked in old age, for at the degenerative time
of life not only is the capacity for fresh acquisitions much smaller
than at other periods, but also the general lowering of cerebral
functions, which invariably results from the cerebral arterial
sclerosis which is responsible for conditions'of aphasia in old people,
places a well-nigh insuperable obstacle in the way of any re-educa-
tion. During the periods from childhood to the end of middle-age
the capacity for re-education after destructive lesions in the region
of the speech-centre varies so much in different individuals as to
render prognosis in an individual case impossible.
The method of re-education is essentially the same in all cases,
and it is based upon the processes by which a child first learns the
elements of his speech, the details being varied according to the
nature of the speech-defect in each patient. For success much time
and patience are necessary, and since aphasic patients are easily
wearied and soon become inattentive, the frequent repetition of short
lessons must be employed. It is useless to attempt re-education
unless good general intelligence is preserved, and it must be
remembered that the outlook is much more hopeful when a defect
of the executive speech mechanism is present, such as aphasia or
agraphia, than when a defect of the recipient speech mechanism
exists, such as word-deafness or word-blindness.
Where aphasia alone exists the patient is able to understand
everything that is said to him, and the education is conducted by the
oral method ; the simple vowel and consonantal sounds are repeated
before the patient, and he is urged to watch intently the movements
of the teacher's lips and to make attempts to imitate these move-
ments. In this way the patient learns to repeat and afterwards to
utter voluntarily the simple sounds, and when this has been gained
the teaching is continued with simple words and syllables and after-
wards with increasingly more complicated parts of speech. During
this process of learning words it is often advantageous to present to
the patient's sight the object to which the word belongs, and if there
Aphasia and other Speech Defects. 1149
is no word-blindness to let the patient see at the same time the
written symbol of the word or sound that is being taught.
The patient suffering from agraphia is taught to write just as a
child is taught to write, but from the common association of right
hemiplegia with speech defects it is generally the left hand that has
to be educated. He must first learn to copy letters, syllables and
simple words, and he is taught to connect these symbols with their
corresponding sounds by the frequent repetition of the sound as
his attention is directed to the written symbol, and he becomes able
first to w r rite the letter or word at command and afterwards to do so
voluntarily for the expression of his thoughts. A patient with
word-blindness is first taught his letters by pointing out, each letter
and naming it aloud, and is afterwards taught simple combinations
of these letters and then the meaning of words, the corresponding
object being shown to him as the word he is being taught.
Word-deafness is much less amenable to re-education than are
the other speech defects, except in young children, in whom the
capacity for the development of a chief speech-centre upon the right
side of the brain is great. Moreover, word-deafness necessarily
entails defective intelligence, since it results from damage to the
chief centre in which the function of speech is located, and since
this centre plays an important part in the higher mental processes.
Attempts must be made first to teach the patient the meaning of
words by showing him an object and then repeating the name of the
object, and when the name has been learnt, to apply the oral method
as described for simple aphasia and urge the patient to pronounce
the name.
When both word-deafness and word-blindness are present in
severe degree the patient is ineducable, and any recovery that may
in rare cases take place is referable to the recovery of elements
which have been partially damaged, and not to functional compensa-
tion. It is obvious, however, that the restitution of function in
damaged elements may be greatly aided by the applications of the
above methods.
The conditions of defective articulation that not infrequently
result from cerebral lesions, anarthria and dysarthria, are to be
treated by the oral method : the former just as aphasia is treated,
the latter by the slow and careful articulation of words under the
supervision of the teacher.
JAMES COLLIER.
KEFERENCES.
Bastian, H. C., " Aphasia and other Defects of Speech," London, 1898.
WyJlie, J., " The Disorders of Speech," Edinburgh, 1895.
1 150
APRAXIA.
THE successful treatment of apraxia necessitates an exact com-
prehension of the nature and cause of this condition. Apraxia is
the inability to perform highly specialised subjectively purposive
movements, while the common movements can be performed. The
patient, though he is perfectly cognisant of the details of the act
which he wishes to perform, is entirely unable to execute it. The
following example exactly illustrates the condition : A highly skilled
professional violinist was seized with left hemiplegia. In the course
of a few weeks he completely recovered power in the left upper
extremity and could use it for all ordinary purposes, but on taking
up his fiddle he found that he could not play the simplest air,
for he could not execute the well-known movements of his left
fingers, though these were powerful and supple and could be moved
quickly. So complete was his knowledge of the technique of the
violin that he was able to continue his avocation in teaching the
higher branches of his art, but he was never able to play again.
Apraxia bears the same relation to the movements of the limbs
as does motor aphasia to the movements of the tongue and lips,
for in the latter condition, though there is no paralysis of the
tongue and lips, and though the patient knows exactly what he
wishes to say, yet the execution of the highly specialised move-
ments of speech is impossible ; so in apraxia, though there is no
paralysis, yet the patient is unable to execute the specialised acts
which formerly he performed with ease.
The cortical centres for the common movements of the tongue
and lips and also for the common movements of limbs are situated
in the ascending frontal convolutions of both hemispheres (motor
area or pyramidal centres), but the centre for the highly specialised
movements of the tongue and lips is placed immediately in front of
the corresponding motor area. It occupies the posterior half of the
third frontal gyrus, and it is developed in the left side of the brain
only. In the same way the centres for the highly specialised
movements of the limbs are situated immediately in front of the
corresponding motor area in the posterior parts of the second and
first frontal gyri. These centres are developed upon the left side
only, and are concerned with the highly specialised movements
upon both sides of the body. It is from lesions of the frontal
Apraxia. 1151
convolutions in the left hemisphere that apraxia more commonly
results, and from the proximity of the centres for specialised
movements (eupraxic centres) to the motor area the two are
usually involved together, and right-sided hemiplegia is for this
reason the usual clinical associate of apraxia. It is especially
when a right-sided hemiplegia is recovering or has recovered that
apraxia becomes manifest. The rapid recovery of power has
perhaps given rise to high hopes that complete usefulness will he
re-estahlished in the limb, but nevertheless the patient remains
unable to execute specialised acts in which he was formerly skilled.
His right hand has lost its cunning, since the centres from which
those skilful acts were started and guided have been damaged by
disease.
From the nature of the eupraxic centres it follows that apraxia
is usually bi-lateral, but, if the right upper limb is paralysed
by the lesion, the limb apraxia is manifest in the left upper limb
only. In rare cases small and isolated lesions have caused limb
apraxia, confined to the left side or to the right side as the sole
symptom of the lesion.
Since cerebral vascular lesions are responsible for the production
of apraxia, what has been said on that subject in the article upon
aphasia applies equally to apraxia. The special treatment of the
condition consists in the slow and laborious re-training of the
limb towards those acts which are lost or which are defectively
performed. The exercises performed must be simple or complicated
according to the severity of the apraxia. The regular taking out
and replacing of the pegs of a cribbage board or of the marbles of
a solitaire board are examples of useful exercises of the simple order.
The tracing over of figures and designs faintly marked on paper,
the use of the copy-book and of other measures by which a child
is taught to write are examples of exercises directed to the cure of
a particular variety of apraxia, namely, agraphia. The performance
of lost or defective acts in front of the patient by the teacher, the
patient meanwhile imitating the teacher so far as he is able, any
errors that he makes being pointed out and corrected, constitutes
the chief method by which apraxia may be benefited. It is at
once obvious that the exercises must be modified or invented
according to the nature of the defects of each individual patient.
As the result of such treatment excellent recovery may occur, but
some cases resist all treatment. Where rapid recovery occurs it is
probable that the eupraxic centres have been partly damaged only,
and that functional restitution has occurred in these centres. When
recovery occurs but tardily it is possible that this results from the
1152 Apraxia.
development of corresponding regions of the right hemisphere as
the result of education. Where no recovery occurs, complete
destruction of the eupraxic centres, the absence of any capacity for
the development of fresh centres or the severance of the paths
which connect the several nerve-centres concerned with the per-
formance of specialised acts are the probable explanations.
JAMES COLLIER.
KEFERENCES.
Collier, J., " Apraxia," Allbutt and Eolleston's " System of Medicine," 2nd ed.,
VIII., p. 447. Wilson, S. A. K, " Study of Apraxia," "Brain," London, 1910,
XXXI., p. 164.
THE CEREBRAL PALSIES OF INFANCY.
THE cerebral palsies of infancy fall into several groups, according
to their etiology, pathology and clinical symptoms ; but all varieties
are characterised by a spastic paresis, in which, as a rule, compared
with the cerebral palsies of later life, the degree of rigidity is
relatively greater than the loss of power. Many cases also present
spontaneous or involutary movements of the affected limbs, generally
of that type known as athetosis; and there is often considerable
mental impairment or lack of development. Epileptic seizures
frequently occur. From the clinical point of view they may be
divided into hemiplegia, in which only one side of the body is
affected, and di-plegia, in which the whole of the body is involved,
but the lower, as a rule, more so than the upper extremities.
Our knowledge of the pathological bases of these conditions is
very incomplete, and cannot be considered in detail here ; but a short
reference to it is necessary as a guide to appropriate treatment.
Infantile hemiplegia may develop in fetal life, during birth or in
early infancy. Congenital cases are not rare ; they may be due to
mal-development of certain regions of the brain, or to local lesions
that occur during fostal life. In the later cases there is usually a
porencephaly or microgyria, or on examination of the brain only a
focus or foci of sclerosis may be found.
The lesions that develop during birth are usually due to direct
injury to the head owing to difficult labour, or to the use of instru-
ments, or to a meningeal or even mtra-cerebral haemorrhage, which
is most often caused by rupture of the veins at their entry into the
sinuses. This is by no means infrequent. Spencer found it in
fifty-three out of the hundred and thirty newly born children whose
brains he examined. In other cases the cerebral lesions seem to
result from the vascular disturbances associated with asphyxia.
Infantile hemiplegia of post-natal onset may be due to the same
causes as this condition in the adult, but it results most frequently
from a non-purulent encephalitis.
Cerebral diplegia, which is usually congenital, though its symptoms
may be noticed only some months after birth, may be also due to
different pathological processes. Those already considered may, if
they affect both hemispheres of the brain, produce its symptoms,
but it is more commonly the result of a cortical agenesis. Other
S.T. VOL. n. 78
1 154 The Cerebral Palsies of Infancy.
cases are apparently born with an intact cortex, but its cells soon
degenerate owing to a hereditary diminished potentiality of life, or
from the action of toxins or infections to which they are unduly
susceptible.
The treatment of these different conditions may be considered
together, for as we can rarely remove or repair the cerebral lesion,
it must be mainly symptomatic, and the symptoms are essentially
the same whatever be the cause. They are due to the diminished
power of movement owing to the paresis and rigidity, to disturbance
of co-ordination, and the presence of involuntary movements.
Many cases improve considerably under treatment by massage,
and by passive movements directed to overcome or obviate the
development of contractures, but both must be persisted in for long
periods. If the rigidity is great, the massage may with advantage be
preceded by warm baths. Electrical treatment, on the other hand,
is, as a rule, inadvisable, as all peripheral stimulation tends to
increase the rigidity. In the slighter cases, whether one or both
sides of the body are affected, careful training by exercises and
gymnastic movements, and encouragement to the child to attempt
simpler movements and to use the limbs as much as possible, are
most important, and if persisted in may have unexpectedly favour-
able results.
Drugs are rarely indicated in the treatment of the main symptoms,
but as it is important, especially in cases with a progressive
tendency, to maintain the general health at as high a level as
possible, cod-liver oil and other tonics may be administered. Many
organic extracts have been tried but without benefit ; but improve-
ment has followed the use of thyroid extract in some cases, and con-
sequently this should always be given a trial in the comparatively
rare cases in which diplegia is associated with the signs of cretinism.
A large number of patients suffering from the cerebral palsies of
infancy are subject to epileptic seizures, for the relief of which drugs
must be employed, though it must be admitted that their treatment
is generally unsatisfactory. Bromides are the most efficient drugs,
but large doses and frequent administration are frequently necessary
to produce any effect. Biborate of soda (in doses of from 5 to 10 gr.
for a child) may with advantage be combined with the bromides.
Relatively large doses of belladonna are often useful, especially in
cases with minor epileptic attacks. The calcium salts seem to
diminish the excitability of the cortex, and consequently have been
given in these conditions, generally in the form of calcium lactate,
alone or combined with bromides, but I have failed to obtain any
promising results from their use.
The Cerebral Palsies of Infancy. 1155
In conditions so little amenable to medical treatment the aid of
surgery has been frequently invoked, but, on the whole, with equally
disappointing results. In certain cases of hemiplegia developing
afterbirth injuries, Gushing 1 has trephined and removed menin-
geal haemorrhages with favourable results. Surgical exploration of the
brain has been proposed in cases with frequent local or uni-lateral
epileptiforni seizures, for removal of the irritating lesion, if this is
possible ; the results of these operations have been, however, on the
whole, far from satisfactory.
Tenotomy becomes necessary when contractures have developed,
and frequently restores the mobility of the limbs considerably ; it is,
of course, useless unless there is a certain amount of power in the
muscles.
The muscles of the affected limbs are generally unequally
paralysed ; for instance, the extensors of the hand and fingers and
the dorsi-flexors of the foot are, as a rule, weaker than their
antagonists. Spiller 2 recognised this, and suggested the relief of the
weaker muscles by the transplantation or anastomosis of the nerves
that innervate them into nerves of less affected muscles. On the
same argument he suggests the same operation in cases of athetosis
in which there is disproportion between the innervation of the
flexors and extensors of the arm and fingers. In one such case
Frazier 3 transplanted the ulnar and median nerves into the
musculo-spiral with a good result.
It is not infrequent to find in infantile hemiplegia, and even
more so in diplegia, that the rigidity of the limbs is so great as to
prevent or seriously interfere with their use, though there may be
considerable power of movement. This rigidity is due to a reflex
over-activity of the subcortical and spinal centres which results from
the loss of cortical inhibition, but it is directly excited by peripheral
stimulation, and would disappear if this could be completely obviated,
as it would be by section of the posterior spinal roots. Forster 4
has consequently recommended this procedure, and has obtained
remarkably favourable results. It would be, of course, dangerous or
inadvisable to cut all roots that carry afferent impulses from a limb ;
but as all peripheral structures are innervated by the overlapping
of the fibres of two or three adjacent roots, section of alternate roots
may suffice to diminish the rigidity considerably, and thus permit
the exercise of the power that remains in the limb. Forster has
advised section of the second, third and fifth lumbar, and of the
second sacral roots, as a routine operation in cases where the lower
limbs as a whole are spastic, but the muscle groups which are
chiefly affected by the spasticity should be carefully determined in
782
1156 The Cerebral Palsies of Infancy.
each case and the operation modified accordingly. The operation
is less satisfactory in the relief of spastic paresis of the arms ; the
fourth, fifth, seventh and eighth posterior roots may, however,
safely be cut. Sufficient experience has not yet accumulated to
pass a definite opinion on Forster's operation, but the procedure
is rational, and his results on suitable cases have been promising.
The majority of children subject to cerebral palsies are either
backward or mentally deficient, and consequently require special
mental training and education adapted to their capabilities.
GORDON HOLMES.
REFERENCES.
1 Amer. Journ. of the Med. Sciences, Phila., 1905, CXXX., p. 563.
2 Journ. Ment. and Nerv. Diseases, 1905, XXXII., p. 310.
3 Amer. Journ. of the Med. Sciences, 1906, CXXXL, p. 430.
4 Forster, 0., Mitteil. aus d. Grenzgeb. d. Med. und Chir., 1909, XX., p. 493.
THE SURGICAL TREATMENT OF CEREBRAL
PALSIES OF INFANCY.
THE treatment of cerebral palsies of infants on surgical lines has
been greatly developed in recent years. The cause of the paralysis
is in every case an interference in the control normally exercised
by the cortical centres over the motor cells in the anterior horns of
the cord. The originating cause may be an error in development
of the upper neuron, a vertical haemorrhage occurring at birth
producing pressure on cortical motor areas, some form of polio-
encephalitis of toxic origin, or some interference with the pyramidal
tracts.
Apart from the characteristic spastic condition of the muscles of
the limbs there may be more or less pronounced mental defect.
In some cases there may be no obvious signs of mental impair-
ment, but when these are present two clinical types can be
recognised. In one the child seems placid and contented, in the
other the child is irritable, perhaps subject to fits, and often
is wantonly mischievous. The latter type is less amenable to
treatment than the former. Deficient control of the sphincters
of the bladder and rectum is a prominent symptom in some cases.
In deciding whether a case is suitable for treatment on the lines
about to be described, incontinence of urine and faeces and frequent
convulsions may be taken as a general centra-indication. A history
of convulsive fits decreasing in frequency is not necessarily a
centra-indication for treatment, for in some of these cases the fits
may cease or become much less frequent after operative treatment.
An absolute imbecile who cannot help the work of education by
making an effort to use his limbs is not suitable for treatment.
Great judgment is required, however, in estimating the mental
condition of a patient, for many cases are apparently imbecile who
have not a serious brain defect ; their trouble is that they have
never educated their brains by touching, feeling and tasting things
as a normal infant does. A child whose limbs are spastic and are
the seat of sudden uncontrolled spasmodic movements has never
come into proper relation with its environment. Treatment directed
to abolish the muscular spasm and rest the over-excited spinal
centres gives such a child peace and leisure to pay attention to its
1158 Surgical Treatment of Cerebral Palsies.
surroundings, and a rapid improvement in intelligence may some-
times be noted within a week of operation.
Clinically cases may be classed as: (1) Hemiplegia; (2) para-
plegia; (3) diplegia.
Most cases of hemiplegia are post-natal and are due to an ence-
phalitis, usually in the first two years of life, though some cases
occur later. The upper limb is usually more severely affected than
the lower.
Most cases of paraplegia and some cases of diplegia are due to
haemorrhage at birth, generally over the vertex and therefore com-
pressing the leg areas more than the arm areas. There is not space
in an article such as this to discuss the many other causes which
have been advanced as originating diplegia and paraplegia.
In the upper limb the following characteristic features may
be noted: the elbow is kept close to the side and flexed, the
wrist is pronated and flexed, the fingers are flexed, and the
thumb is flexed and adducted, being tucked into the palm of the
hand. If the child initiates a voluntary extensor movement of the
fingers, it is often interrupted by a sudden uncontrolled spasm of
the strong flexors. The great disability in such a case is (a) the
absence of balance between opposing muscles, (b) the lack of
co-ordination. Therefore treatment must aim (1) at restoring
muscular balance, (2) at educating the powers of co-ordination.
In cases of hemiplegia the patient has great difficulty in dissociating
the movements of the two hands. He always performs the same
movements with both hands at once ; to educate him out of this
habit is one of the most difficult parts of the treatment.
In the lower limbs the most constant features are spasm and
contracture of the adductors, so that the patient cannot abduct the
limbs. The hamstrings are frequently contracted, the calf muscles
are often short, so that the foot is in an equinus position, usually
with some varus deformity, and very rarely with a valgoid defor-
mity. In addition to these there may be spasm of the flexors of
the hip with shortening of the fasciae in the groin, producing
flexion deformity of the hip and lordosis of the lumbar spine.
Finally, there is often spasm and shortening of the tensor fasciae
femoris and gluteus medius, producing internal rotation of the whole
limb. Adduction may be so great that the knees are crossed. Even
in cases where the patient can walk his gait is shambling and
unsteady, he is insecurely balanced on his toes on account of his
spastic equinus deformity, he cannot separate his thighs on account
of the spasm of his adductors, and therefore cannot take a broad
base of support either when standing or when walking. If in doubt
Surgical Treatment of Cerebral Palsies. 1159
about spasm of the adductors in a mild case it at once becomes
more marked if the child is lifted by the shoulders.
Treatment of the upper and lower extremities respectively is in
the first place guided by these features.
In addition to the above there may be other phenomena, such as
irregular movements of the muscles of the head and face and
nystagmus. In cases of paraplegia the hands are often the seat of
irregular movements of an athetoid type, though not directly
affected by spastic paraly-
sis. Finally, there is a
strong tendency for simul-
taneous associated move-
ments to take place in
both limbs. Thus the
patient often cannot open
one hand without per-
forming a similar move-
ment with the other, and
a paraplegic generally
tries to advance both feet
at once and has to be
taught to walk advancing
one foot at a time.
The real difficulties in
treatment begin after the
operations to correct de-
formity, relieve spasm
and restore muscular
balance are completed.
The child must then be
educated to use his limbs
independently, a process
which is always slow and requires patience and perseverance.
Treatment of the lower limbs, as in a case of paraplegia,
the upper limbs not being affected.
Abolish the spasm of the adductors by fixing the patient
with the thighs fully abducted. We use a double Thomas' frame
with abduction (Fig. 1). In the mildest cases the adductors may
be stretched, in mild cases they may be divided subcutaneously ;
in the majority of cases of any severity the only satisfactory
procedure is to make an incision along the prominent tendon
of the adductor longus, and boldly excise about 1 inch of
the adductors longus and brevis at their origin and the upper
FIG. 1. Thomas' abduction frame. In the figure
the right limb only is abducted. In treating
spastic paraplegia both are abducted.
1160 Surgical Treatment of Cerebral Palsies.
transverse fibres of the adductor magnus. Unless this is done
freely the adduction deformity is very liable to recur. The skin
wounds must be carefully closed and sealed to protect them
from contamination by excreta. The patient is then at once put
into the abduction frame and kept in that position for six weeks.
If all these structures have been divided or ruptured or fully
over-stretched, the child does not complain of pain after the first
twelve hours, but any muscle which is tense and still capable
of resistance will be the seat of severe pain.
Flexion Deformity and Internal Rotation of the hip may require
correction by operation. A vertical incision (8 inches long) is
made a little below the anterior superior spine of the ilium. The
iliac fascia, tensor fasciae femoris and anterior fibres of the gluteus
medius are then divided. To prevent recurrence of internal rota-
tion we turn back and fix the cut ends of the tensor fasciae and
gluteus muscles to prevent them from reuniting, and have found
the results very satisfactory. Spasm and contracture of the ham-
strings is dealt with by stretching or lengthening the tendons of
these muscles. In some cases it is better to transplant one
or more of them into the quadriceps to reinforce the extensor
muscle.
Spasm of the Calf Muscles. We must enter a warning against
the performance of tenotomy of the tendo Achillis with a view to
correcting equinus deformity. The extensor group of muscles is
not paralysed, and contracts as soon as it is relieved of the resist-
ance of the tendo Achillis, the spastic muscles of the calf retract
and the tendon may not reunite. We made this mistake in several
of our early cases, and though the spasm was completely relieved
the patients afterwards developed a calcaneus deformity and walked
on their heels.
Now we always perform an open operation and lengthen the
tendon. It is sufficient to divide the tendon and moor the two ends
together with a few strands of strong catgut. We expose the
tendon, pass two strong strands through it and tie each firmly. The
tendon is then divided between the two sutures ; an assistant
places the foot exactly at a right angle, and the upper and lower
ligatures are tied together. The foot is then fixed at right angles.
Such of these operations as may be necessary are performed at
one time or at short intervals, while the child is lying in the
abduction frame.
It will be noted that the aim and object of these procedures
is not merely to correct deformity, but still more to abolish for
a time the action of the spastic muscles, so as to allow their
Surgical Treatment of Cerebral Palsies. 1161
opponents to recover power and so restore the muscular balance of
the limb.
It is always better to divide or rupture a spastic muscle rather
than simply to stretch it, for a muscle kept on the stretch is always
the seat of pain. Simple stretching is therefore only applicable to
those cases in which the muscle can be so completely over- stretched
that it is virtually paralysed for the time and ceases to resist.
If spasm has been entirely abolished by these means the child
no longer complains of pain, and after the second daj 7 a remarkable
and noteworthy change in its appearance may often be observed. The
child no longer starts awake at night but sleeps quietly. Irregular
grimaces and movements of the head and hands become less pro-
nounced and less frequent. The child's whole motor system seems
to come to rest. This we explain in the following way : athetoid
movements of the hands, irregular twitchings of the face, and
sudden starting at night are indications of an irritable spinal motor
system which is not properly under the inhibitory control of the
cortex. The spastic groups of muscles are the groups which are
actually or mechanically stronger than their opponents ; they have
overpowered their opponents and become short, and the over-
stretched antagonists cannot hold them properly in check. The
motor cells in the anterior cornua are not under the proper inhibi-
tory control of the cortex and are liable to send out irregular reflex
impulses. Spastic muscles are always in a state of partial con-
traction and are continually giving rise to reflexes which keep the
spinal motor cells in a state of constant irritability. "When the
spasm is abolished the spinal cord ceases to be irritated by a con-
stant stream of irregular reflex stimuli and comes to rest, and the
motor manifestations of its irritability disappear and the child
begins to take an interest in its surroundings. For example, a
child of five with spastic paraplegia could only speak two or three
words very indistinctly, and was constantly on the move when
admitted to hospital. A week after operation she slept quietly all
through the night, and six weeks after operation suddenly began to
talk and continued to learn rapidly. This case illustrates the fact
that apparent mental defect may be due not to brain defect,
but to the fact that muscular spasm occupies a child's attention and
prevents it from coming into proper relation with its surroundings.
The next stage in treatment is the education of muscles. At first
the legs are freed from the splint for a few minutes several times
a day while abduction, flexion and extension movements are prac-
tised. All movements must be made to word of command to train
brain and muscle to work together. Splints are next applied to
1162 Surgical Treatment of Cerebral Palsies.
keep the knees fully extended and prevent the hamstrings from
shortening before the quadriceps is strong enough to resist them.
In these splints the child is taught to walk, keeping the feet wide
apart. He must never be allowed to move both legs forward
together; hence crutches cannot be permitted. In teaching a child
to walk the following points must be observed : (1) He must learn
to balance himself ; (2) the legs must be kept wide apart : when
put back to bed his feet are tied to the sides of his cot to maintain
abduction ; (3) he must learn to put forward one foot at a time,
no matter how short the stride ; (4) he must not be allowed to look
at the ground, but must keep his eyes fixed on some distant object
as high as or slightly above the level of his eyes ; (5) he must never
be allowed to stoop forward or walk with his hips flexed, for flexion
at the hip and consequent lordosis of the lumbar spine is one of the
troubles to be 'guarded against. He should be helped by two people
walking one on either side during his lesson. A rope stretched
across the room is a help, for the child can hold on to this and
practise walking. The teacher should make the child practise all
movements of the legs to word of command.
In the case of a child which has never walked it will be six months or
a year before the child can stand alone. He should then be taught
to walk with two sticks, later these may be discarded one at a time.
Treatment of the Upper Limbs. In cases of spastic hemiplegia
the upper limb is generally more severely affected than the lower.
A description of the treatment appropriate to such a case will
therefore suffice.
As has been already stated, the fingers, thumb, elbow and wrist
are all flexed. The object of treatment is to restore the power of
co-ordinate movement to the wrist and fingers. All our attention
is therefore concentrated on the hand. The hand is put on to
a splint with the wrist dorsi-flexed and the fingers extended :
a thumb-piece keeps the thumb well abducted. As soon as possible
the wrist is dorsi-flexed to a right angle. The flexors are then
thoroughly stretched and we wait for the extensors to recover power.
The elbow is acutely flexed and the wrist fixed in a halter close
to the neck, with the hand in the supinated position. This position
is maintained night and day without a moment's relaxation. It is
desirable to have the extensor muscles in the forearm regularly
massaged, and this is done without changing the position of the
limb. When the patient can hyper-extend the fingers away
from the splint the latter may be shortened so as to allow move-
ment of the fingers, but a short splint extending to the tips of
the fingers is worn at night.
Surgical Treatment of Cerebral Palsies. 1163
At this stage education of the fingers is commenced, the patient
flexing and extending them one at a time to word of command.
He is encouraged to use his fingers in every possible way.
Adduction of the thumb is the most difficult part of the deformity
to correct. The adductor obliquus and transversus are shortened,
and act at much greater mechanical advantage than their oppo-
nents, the abductor pollicis and extensor ossis metacarpi pollicis.
When the thumb is abducted and fixed on the splint there is a
tendency to produce a luxation of the metacarpo-phalangeal joint.
To meet this difficulty we have a leather pad fixed in the palm
of the splint to push the metacarpal outwards, and find it very
effective in some cases.
Operative Treatment. (1) Obstinate pronation can be overcome
by converting the pronator radii teres into a supinator (Tubby).
The position of the muscle is first noted by making it tense. An
incision (3 inches long) is then made at the inner border of the
supinator longus over the pronator teres. The supinator longus is
drawn outwards and the radial nerve and artery inwards. The
upper and lower margins of the pronator radii teres are defined,
and the insertion of the muscle is dissected off the radius along
with the periosteum. A silk suture is now passed through the
tendon. The interosseous membrane is next separated from the
radius for 1 inches, an aneurysm needle is passed round the
bone and the silk suture threaded in the eye of the needle.
The tendon is then pulled through the gap in the membrane and
fixed to the back of the radius, or if possible to the point from
which it was removed.
We have so often found the muscle too short for this that we
prefer to stitch the separated pronator radii teres to the flexor carpi
radialis. The tendon of the flexor carpi radialis can then be
divided low down in the forearm, and will be found long enough to
be wrapped well round the radius.
(2) In some instances the extensors of the wrist may be rein-
forced with great advantage by transplanting the flexor carpi
radialis into the extensor carpi radialis longior and the flexor carpi
ulnaris into the corresponding extensor. Each tendon is exposed
by a separate longitudinal incision.
(8) The flexor tendons at the wrist are sometimes lengthened.
This operation is tedious and is seldom necessary.
(4) Spitzy, of Gratz, has recently published his .results of the
treatment of these cases by transplantation of part of the median
nerve into the musculo-spiral nerve just above the elbow. The
after-treatment is similar to that which we have described. It is
1164 Surgical Treatment of Cerebral Palsies.
still too early to estimate how much of his success is due to the
operation and how much to the after-treatment by splints and
massage. He encounters the same difficulties as we do in the
treatment of the thumb.
Summary. The treatment described above is an outline of the
routine we adopt. Its application is beset with difficulties which
must be met by the ingenuity of the surgeon as they arise. We
mention here some of the chief points to be considered before
undertaking the treatment of a case.
(1) Absolute imbeciles and cases with incontinence of faeces do
not, as a rule, live long, and are not suitable for surgical treatment.
(2) In severe cases of diplegia it is not much use trying to
improve the condition of the lower limbs unless the surgeon is sure
he can so far improve the condition of the upper limbs that the
child will be able to handle sticks.
(3) This difficulty often arises in cases of hemiplegia, for the
arm is often more severely affected than the leg. The difficulty of
teaching the child to walk is greatly increased if he cannot hold a
stick to steady himself.
Even excluding these more severe cases there are still a host of
children left untreated whose condition could be vastly improved,
if a systematic method of attack were more generally understood.
ROBERT JONES and D. McCRAE AITKEN.
CEREBELLAR CONDITIONS IN CHILDREN.
THE cerebellum has connections, both afferent and efferent, with
the cerebral hemispheres and the spinal cord. The symptoms,
produced by cerebellar disease, are due to interruptions in these
connections. Very frequently, especially in young subjects, com-
pensation may take place for the cerebellar defect, provided that the
cerebral hemispheres are intact, so that the symptoms of cerebellar
disease may materially diminish, and indeed almost disappear, with-
out any improvement in the local lesion. The interruption probably
in all cases affects both the afferent and efferent connections, the
typical symptoms being vertigo, inco.-ordination of muscular action,
and loss of muscle power, together with some loss of muscle tone.
Cutaneous sensibility is unaltered and the tendon jerks, instead of
being diminished, are usually increased ; nystagmus is generally
present, and in cases of tumour, optic neuritis and consecutive
atrophy are the rule ; the speech is often scanning. Since the con-
nections of the cerebellum are with the opposite side of the cerebrum
and the same side of the spinal cord, in uni-lateral lesions the ataxia,
muscular weakness and hypotonia are on the same side as the
cerebellar defect.
The abnormal conditions of the cerebellum may be congenital or
acquired. Of the congenital, one type shows itself at birth or
shortly after, and then gradually improves. Here the cerebellum is
congenitally deficient, and the improvement is due to the compen-
sation which results from the cerebrum taking on the functions of
the cerebellum. The improvement can probably be hastened by
educating the child in the co-ordination of movements by means of
carefully chosen exercises, such as picking up small objects, putting
pegs into holes, etc., care being taken to avoid causing fatigue to
the patient.
Another type of congenital abnormality is definitely inherited, but
the symptoms do not appear until the affected individual arrives at the
age of from ten to thirty years, after which the course is surely
but slowly progressive. The morbid changes are found either in the
cerebellum, when the affection has been called Marie's disease, or in
the spinal cord, when it is known as Friedreich's ataxia, but there
are a number of intermediate cases. Treatment seems to have
little or no influence in arresting or delaying the progress of the
disorder, and the most that can be done is that attention should be
given to the patient's general health.
After certain acute infectious disorders, such as measles or
ii66 Cerebellar Conditions in Children.
influenza, an encephalitis may develop, which specially attacks
the cerebellum. As a result of this the child becomes ataxic, and
has a scanning speech and nystagmus. Generally these cases
gradually recover, compensation taking place for the damage done
to the small brain. Here, as in cases of congenital ataxia, improve-
ment may be accelerated by exercises calculated to train the child
in the performance of skilled movements.
Tumour or abscess are the commonest causes of ataxia in child-
hood. Of these, abscess, which is generally secondary to disease of
the middle ear, is found in the temporo-sphenoidal lobe much more
frequently than in the cerebellum. The general symptoms of fever
and cerebral pressure may render it difficult to obtain definitely the
signs of local mischief, but with care these may often be found.
Exact diagnosis is of great importance, as the only treatment is
surgical : trephining over the abscess and letting out the pus.
Cerebral tumour is more frequent in children than in adults, and
especially tends to affect the cerebellum. In the early stages we
meet with the typical picture of cerebellar ataxia with optic
neuritis, but as the case drags on compensation takes place, so
that the localising symptoms improve while the general signs
of intra-cranial pressure may become more severe. Severity,
too, of the general symptoms may conceal the local signs. Severe
headache may be relieved by icebags, opium, phenazone (5 gr.),
or phenacetin (2 to 4 gr.), and vomiting may be allayed by ice
and rest. Beyond this there is little to be done for the patient
short of surgical removal of the tumour. Before deciding on opera-
tion one has to consider that the tumour is most frequently tuber-
culous, and as such is probably associated with tuberculosis elsewhere ;
that solitary tuberculous tumours sometimes, though very rarely,
become quiescent, allowing of the patient's recovery ; and that there
is always difficulty in the exact localisation of the lesion and danger
in the operation. On the other hand, several tumours have been
successfully removed, and if the tumour proves irremovable the
opening of the dura may relieve headache and to some extent blind-
ness by lessening the intra-cranial pressure. Trephining is often
advisable on this account alone when nothing further is possible.
It is true that pressure may be relieved temporarily by lumbar
puncture, but trephining and opening the dura are much more
satisfactory in cases of tumour of the brain.
ALFRED M. GOSSAGE.
REFERENCES.
Batten, F. E., "Brain," 1905, XXVIII., p. 484. Russell, Risien, Brit. Med.
Joui-n., 1910, L, pp. 425, 497, 626.
n6y
CEREBRAL EMBOLISM.
IN cerebral embolism the embolus originates in some part
of that portion of the circulatory system which conveys the blood
from the heart to the brain. Most commonly emboli originate
from the heart, either in consequence of an endo-cardial lesion or of
the detachment of a portion of an intra-cardiac clot ; they may,
however, be formed by the breaking off of a portion of a cerebral
thrombosis which becomes lodged in some more distal vessel, or may
result from a septic focus, in which case they are usually
multiple.
Cerebral embolism should be looked upon as a complication
arising in the course of the above-mentioned diseases, and as such
every precaution should be taken to prevent its recurrence.
Every patient suffering from cerebral embolism must be kept
absolutely quiet and still, and treated on the same general lines as
cases of cerebral thrombosis. Stimulants must not be given unless
the general condition of the patient renders their employment
imperative. In cases where the heart's action is too forcible,
sedative treatment should be employed, but in the large majority
of cases rest alone is necessary.
T. GRAINGER STEWART.
u68
CEREBRAL HEMORRHAGE.
THE terms apoplexy or " stroke " have been applied in their
widest sense to a clinical condition characterised by the sudden, or
relatively sudden, onset of paralysis on one side of the body, with
or without loss of consciousness, arising from some local interference
with the cerebral blood supply. The vascular lesion may arise in
two ways : (1) From rupture of a cerebral vessel (cerebral haemor-
rhage) ; (2) from occlusion of a cerebral vessel, either by the
formation of a clot within it (cerebral thrombosis) or by a clot
carried to it from some distant part (cerebral embolism).
It is often impossible to decide as to which of these causes the
stroke is due, and it is only by obtaining an accurate account of the
previous history of the patient and by a careful investigation of his
physical condition that a definite diagnosis can be arrived at.
There is a general tendency to regard cases of apoplexy as being
due to cerebral haemorrhage rather than to cerebral thrombosis, and
yet if the statistics of cases of apoplexy are carefully examined it
becomes quite clear that cases of cerebral thrombosis are more
numerous than cases of cerebral haemorrhage.
When it is possible, a careful history of the patient should be
obtained as regards his previous health, and the presence or
absence of premonitory symptoms as well as a full account of the
mode of onset of the stroke. Having learned as much as possible
of the history of the case, the physical condition of the patient must
be then examined. This examination, important as it is from the
point of view of localising the position of the lesion, is of still
greater importance from the point of view of determining its actual
cause. Thus we have to consider the age of the patient, his
general condition, the state of the blood-vessels, the condition of the
circulation, of the heart, and of the kidneys. By such examination
it may be possible to arrive at the immediate exciting cause of the
condition, either by obtaining positive evidence or by a process of
exclusion.
CEREBRAL H/EMORRHAGE.
Before discussing the treatment of cerebral haemorrhage it is
necessary to describe briefly the factors which underlie its production,
and to review shortly the effect of cerebral haemorrhage on the
functions of the brain. Unless these facts are appreciated, the
Cerebral Haemorrhage. 1169
treatment of any given case of cerebral haemorrhage must be purely
empirical.
(1) Factors Underlying the Production of Cerebral Haemor-
rhage. The two conditions accessory to the production of cerebral
haemorrhage are (a) a weakening of the blood-vessel, and (b) a
blood-pressure sufficiently high to cause rupture of the weakened
vessel. In the great majority of cases the latter is the determinant
factor, though a high blood-pressure is not of itself sufficient to
cause rupture of a healthy vessel. Capillary haemorrhage, it is
true, may result, as in whooping cough, from an acute rise in
blood-pressure, but such cases are rare.
In most conditions in which there is a constant high blood-
pressure, definite pathological changes occur in the vascular system.
It is obvious that the degree of blood-pressure necessary to cause
rupture of a blood-vessel will vary in inverse proportion to the
amount of weakening of the vessel. Thus in some cases of severe
vascular disease a slight rise in blood-pressure, if sudden, is
sufficient to cause rupture. It is important to realise, however, that
in a large number of cases of vascular degeneration a high blood-
pressure may exist for a long time without rupture taking place. It
may happen that, owing to some temporary or permanent failure
of cardiac power, thrombosis occurs, with resultant softening of the
surrounding supporting cerebral tissues. In consequence of this
there is a further local weakening of the vessel, which renders any
subsequent rise in blood-pressure dangerous to the patient, because
of the increased risk of rupture at that point.
Primary cerebral haemorrhage rarely occurs as the result of
vascular degeneration in the absence of high blood-pressure, except
in cases of aneurysm, traumatism, or septic softening. In cases of
aneurysm and septic softening the onset is, as a rule, sudden and
without warning. In traumatic cases, on the other hand, although
the onset of the haemorrhage may be immediate and sudden, it is
not infrequently gradual. The history of such cases records a blow,
recovery from the effects of the blow, and some short time after,
hours or days, a rather rapid but gradual onset of paralytic
symptoms, culminating in coma and death, due to the haemorrhage
bursting into the ventricle or spreading over the base of the brain.
In most of these cases, however, there is slight but definite clinical
evidence of damage to the cerebral structures, and if a daily
routine examination were made, the discovery of a gradual increase
in the paralytic signs would enable exploratory surgical methods to
be successfully undertaken.
(2) The Effects of Cerebral Haemorrhage. Cerebral
S.T. VOL. ii. 74
1 1 70 Cerebral Haemorrhage.
haemorrhage produces, in addition to the paralysis which may result
from the local destruction of the nervous elements, certain general
effects. These must be considered, as they have some bearing on
the treatment of the condition.
A severe cerebral haemorrhage increases the intra-cranial
pressure. This causes (a) a rise in the general arterial blood-
pressure ; (b) cerebral compression ; (c) coma, and ultimately death
from respiratory paralysis, owing to anaemia of the respiratory
centres in the bulb. Thus a cerebral haemorrhage does not of itself
cause death, unless the intra-cranial pressure becomes so high as
to cause anaemia of the respiratory centres in the medulla.
In cases of pontine or cerebellar haemorrhage the amount of
haemorrhage necessary to increase the intra-cranial pressure to
such a degree as to cause anaemia of the respiratory centres is much
less, because in the first place the subtentorial chamber is small, and
its walls firm and resistant, except for the relatively large opening
of the foramen magnum. Thus the intra-cranial pressure rises
rapidly, causing the formation of a pressure cone at the foramen
magnum, portions of the cerebellum being forced down through the
opening and compressing the medulla. In the second place, in all
cases of haemorrhage, even where the actual haemorrhage is small,
there is developed in the area of brain substance surrounding the
clot a condition of anaemia. Therefore, if a small haemorrhage
occurs in the neighbourhood of the respiratory centres, death from
respiratory paralysis may ensue on account of the centres being
implicated in the local anaemia.
Cerebral haemorrhage may be of sudden or gradual onset. When
the onset is gradual, no difficulty will be experienced in diagnosing
the situation of the lesion from the history of onset and the
presence of physical signs indicating preponderant paralysis of one
side of the body. In most cases it should be possible to diagnose
whether the haemorrhage is superficial, i.e., extra-dural or on the
surface of the brain, or deep, i.e., into the brain substance,
intra-cerebral.
If the haemorrhage is superficial and progressive, and especially
in traumatic cases, surgical interference should not be delayed, as
in many instances the actual seat of the haemorrhage can be
exposed, the clot removed and the bleeding arrested.
TREATMENT OF SUPERFICIAL, MENINGEAL AND TRAUMATIC
HAEMORRHAGE.
The bone above the seat of lesion should be trephined, or
preferably a large bone-flap should be made, the bleeding vessel
Cerebral Haemorrhage. 1171
ligatured, and the blood-clot removed. Whether the bone should
be at once replaced or a drain left in depends upon the circumstances
present in each case.
GENERAL TREATMENT OF INTRA-CEREBRAL
HAEMORRHAGE.
Treatment is directed to stopping the haemorrhage. Rest is
essential, and the patient must not be moved more than is
necessary. The neck must be freed from all tight clothing, the
patient placed in the horizontal position with the head and
shoulders slightly raised, and the face turned to one side to prevent
the tongue falling back in the mouth and obstructing the breathing.
Hot-water bottles covered with flannel should be applied to the
lower limbs.
When practicable, a bed or mattress should be made up for
the patient in the room where the stroke has occurred. If, however,
this is impossible, the patient should not be disturbed more than is
necessary ; his removal to another room should be delayed until
everything has been prepared for his reception. Great care must
be taken to prevent bed-sores, and for this purpose a water-bed is
best, and careful nursing is essential. The bladder must be attended
to and distension avoided, catheterisation being carried out as
required. Absolute cleanliness is only assured by assiduous care,
and the patient must be kept dry and clean, the limbs and body
being washed, dried, and the points of pressure afterwards rubbed
with spirit and then powdered.
At a later stage, when all risk of a fresh haemorrhage is over, the
patient may be moved from side to side to avoid undue pressure on
one spot, and to lessen the chances of hypostatic congestion of the
lungs. The mouth must be kept clean and sweet by sponging with
antiseptic washes, and much trouble will be avoided if the patient's
mouth and tongue are coated with vaseline or glycerine to prevent
them becoming dry and cracked. Light nourishment in the shape
of fluids may be administered by rectal feeding, or the patient may
be able to swallow small quantities of fluid placed on the back of
the tongue, care being taken to prevent the entrance of food into
the lungs.
Purgation. In all cases where there is a high pulse-tension
without signs of cerebral compression, active purgation is indicated.
This is obtained most easily by placing 1 to 2 minims of croton
oil mixed with olive oil on the back of the tongue. In every case
movement of the bowels should be obtained.
742
1172 Cerebral Haemorrhage.
Venesection. Opinions differ as to the wisdom of venesection
in cases of cerebral haemorrhage. It is well known that a rise of
intra-cranial pressure will cause a rise in the general arterial
pressure. This rise in arterial tension may be regarded as Nature's
attempt to maintain the supply of blood to the respiratory centres.
Death ensues in most cases of cerebral haemorrhage from anaemia of
respiratory centres due to the rise of intra-cranial pressure. Those
who hold that venesection should not be performed consider that
the lowering of the blood-pressure is dangerous, because it further
diminishes the blood supply to the already embarrassed respiratory
centres. On the other hand, we must not lose sight of the fact that
the rise in intra-cranial pressure is due to the intra-cranial
haemorrhage, and that the anaemia of the respiratory centres is
primarily due to the rise in the intra-cranial pressure and not to
any lowering of the arterial blood-pressure. It seems obvious,
therefore, that cases of cerebral haemorrhage can be divided into two
classes : (1) Cases in which there is evidence of a high intra-
cranial pressure coma and respiratory failure ; and (2) cases in
which there is little or no evidence of cerebral compression. In the
first class of case, those with cerebral compression, a lowering of the
blood-pressure by venesection may quite conceivably cause death by
upsetting the compensatory increase in arterial pressure which has
resulted from the high intra-cranial pressure, but it is obvious that
to save the patient's life in such cases the first step to be taken is
to reduce the intra-cranial pressure. This can only be done
effectively by removing the bone and evacuating the blood clot,
or by making the cranial opening of sufficient size to afford
complete relief of pressure. If either of these measures is employed,
the lowering of the intra-cranial pressure will be followed by the
lowering of the arterial pressure. In the second class of case, where
there is no obvious cerebral compression, the respiratory centres
are not in any immediate danger, and, therefore, venesection can be
quite safely performed, and the lowering of the blood-pressure so
brought about may suffice to stop the haemorrhage. Should it fail
to do so, the intra-cranial pressure will continue to rise, and with it
the arterial blood-pressure. There does not, therefore, appear to be
any reason against venesection being employed in those cases in
which symptoms of compression are absent. It must not be
forgotten that, although a rise in intra-cranial pressure would
cause a rise in arterial blood-pressure, there are many cases in
which the arterial pressure is above normal, because of other
conditions quite distinct from the intra-cranial pressure.
If the treatment by rest, purgation, or venesection has failed to
Cerebral Haemorrhage. 1173
arrest the haemorrhage, the employment of further measures must
be considered. So many people die from cerebral haemorrhage,
despite the efforts made to save them, that it appears to be
justifiable, at any rate, to consider the adoption of surgical
measures.
SURGICAL TREATMENT OF INTRA CEREBRAL HAEMORRHAGE.
The question of surgical interference where the haemorrhage is
presumably deep-seated is a point of much difficulty.
It may be urged that in cases of small haemorrhage surgical
interference, even if successful, would cause a greater amount of
permanent damage. In our present state of knowledge, therefore,
surgical measures should be confined to the more severe cases of
intra-cranial haemorrhage. It is obvious that when a patient is
dying from cerebral compression, decompression is indicated, this
alone offering any hope of recovery. Decompression may be
obtained by removing a large amount of bone and freely opening
the dura, or by making a small opening in the dura and by tapping
the clot, and thus relieving the pressure by removing its cause.
As regards the first procedure, where the dura is freely opened, the
blood clot will almost certainly burst through the brain ; this may
cause very extensive laceration of the brain substance, with sub-
sequent paralysis, or even the sudden death of the patient. To
make such an operation successful the bone should be removed for
a sub-temporal decompression, and at the same time as the dura
is opened lumbar puncture should be performed. This will, by
lowering the intra-ventricular pressure, lessen the tendency of the
clot to burst through the brain at the moment when the dura is
freely incised. If the clot does happen to burst through the brain
substance, the area destroyed is more or less silent, and its
destruction unattended by any serious paralysis.
Concerning the second surgical measure, namely, tapping of the
clot and draining it through the opening, Gushing advises that
the attempt should be made from a sub-temporal opening, a small
incision being made in the upper portion of the exposed area
corresponding to the lower portions of the central convolutions.
A blunt aspirator or curved director should be introduced directly
towards the internal capsule, care being taken to pass the instru-
ment through the summit of one of the exposed convolutions far
enough above the Sylvian fissure to avoid the insula. In the case
of severe hemorrhage, where the clot is large, it is quite probable
that the aspirator will reach the effused blood, and, if so, the
1 1 74 Cerebral Haemorrhage.
external opening can be enlarged, and through it the altered blood
and clot will escape. Drainage from the cavity will be maintained
naturally. If the clot is large enough and a direct opening
has been made into it, it is quite probable that the patient's life
will be preserved by the decompression, and that the ultimate
paralysis will be less because of the removal of the clot. It is not
to be expected that the paralysis due to the destruction of the
fibres will be affected in any way ; but, on the other hand, all
pressure paralysis will be recovered from.
Ligation of the carotid artery on the same side as the
haemorrhage has been advocated and carried out in some cases.
Theoretically it should stop the haemorrhage and prevent any
further increase in the intra-cranial pressure, and should not have
the effect of causing any diminution of the blood supply of the
respiratory centres, which would be carried on by the vertebral
arteries. The results of ligature of the carotid on one side are
extremely variable ; death or permanent softening of the brain has
ensued in about a third of such cases. It is, therefore, not justifi-
able to advise this operation in minor cases of cerebral haemorrhage.
In severe cases, on the other hand, although the haemorrhage would
be stopped, the cerebral compression would not be relieved, and
a decompressive operation or an operation for evacuation of the clot
would have to be performed subsequently. It would appear wiser,
therefore, to attempt to combine the checking of the haemorrhage
and the relieving of the cerebral compression by an operation at
the site of the haemorrhage, rather than run the risk of causing
widespread paralysis from cerebral softening, and yet not avoid
the necessity for decompressive operation in addition.
CEREBELLAR HAEMORRHAGE.
Haemorrhage into the cerebellum is uncommon, and, if extensive,
usually causes death very rapidly. In some cases, however, its
development may be more or less gradual. If, despite the usual
measures, respiratory paralysis sets in, no time should be lost in
opening the skull oh both sides below the tentorium in order to
attempt to stop the bleeding.
Where operation is impossible, lumbar puncture may be per-
formed in the hope of relieving the intra-cranial tension. This
procedure, however, is attended with a certain amount of risk. If
no fluid escapes from the sub-tentorial chamber, the withdrawal of
the spinal fluid alone may cause the immediate formation of a
" pressure cone " and the sudden death of the patient. The
pressure must be relieved as soon as possible, for any considerable
Cerebral Haemorrhage. 1 1 75
rise in intra-cranial pressure is attended with the greatest danger,
owing to the small size of the infra-tentorial chamber and the
proximity of the respiratory centres.
PONTINE H/EMORRHAGE.
The treatment of haemorrhage into the pons must be carried out
on the general lines of treatment for cerebral haemorrhage. If the
bleeding is severe, all treatment will be unavailing ; but if, as
sometimes happens, the haemorrhage is small, although giving rise
at the time to widespread paralysis, recovery is possible, provided
that the patient can be kept absolutely still. As in most cases the
patient is very restless, he should be kept under the influence of
morphia. Venesection, active purgation and surgical intervention
are strongly contra-indicated.
SUBSEQUENT TREATMENT OF CASES OF INTRA-CRANIAL
HAEMORRHAGE.
Patients who recover from the initial attack and regain con-
sciousness require constant attention. The sick room should be
well ventilated and the patient protected from the glare of light.
In many instances the patient is restless and uneasy, and to quiet
him 20 to 30 gr. of potassium bromide should be given once, twice
or thrice daily, as required ; in some cases it may be necessary to
give morphia. If cold applications to the head annoy the patient,
they should be discontinued. The bowels must be kept freely
opened. During the early stages rectal feeding may be necessary ;
but if the patient is able to swallow, he may be given a little milk
or water, 2 to 3 teaspoonfuls every two hours. In four or five
days the patient may be given 4 or 5 oz. of milk or chicken-broth
every two hours. The diet is then gradually increased by the
addition of eggs and farinaceous food, and still later of fish and
white meat. It is wise to be on the side of safety, and all stimulat-
ing foods must be avoided. The patient should not be excited, and
it is best at this stage to forbid the entrance of relatives to the sick
room ; on the other hand, it should not be forgotten that an aphasic or
partially aphasic patient may be worrying to see someone and unable
to signify his desire. Therefore, in some instances, it does the patient
good merely to be allowed to see his relatives. As recovery takes
place, treatment of the paralysis must be undertaken (see Hemiplegia,
p. 1181). The after-life of the patient must be regulated so as
to avoid any sudden or excessive mental or physical strain. He
should be guarded against emotional excitement of all kinds, and as
far as possible his life should be quiet and peaceful. When the
1176 Cerebral Haemorrhage.
paralysis permits, gentle exercise on the flat is not contra-indicated.
The diet must be light and spare, and fluids should be restricted
and alcohol prohibited. The patient should never be allowed to
become constipated. If the blood-pressure tends to rise, steps must
be taken to lower it. If syphilitic vascular disease is present, a
course of anti-syphilitic treatment should be carried out each year.
For the treatment of Aphasia, see p. 1045.
T. GRAINGER STEWART.
1 177
CEREBRAL THROMBOSIS.
THE patient should be kept absolutely still, the same precautions
being taken as in a case of cerebral haemorrhage. He should be
placed in the horizontal position, with his shoulders and head
slightly raised and all tight clothing removed from the neck. If the
tongue is obstructing his breathing his head should be turned gently
to one side. Having seen to his immediate needs the patient must
be examined with a view to finding out the factors underlying the
production of the thrombosis.
The factors which underlie the production of cerebral thrombosis
are : (1) Vascular degeneration syphilitic or atheromatous ;
(2) circulatory enfeeblement cardiac or general ; (3) combinations
of the above ; (4) abnormal blood states ; (5) intra-cranial neoplasms
or abscess formations, which by pressing on the vessels obstruct the
flow of the blood within them.
TREATMENT OF THROMBOSIS DUE TO VASCULAR
DISEASE OR DEGENERATION.
(1) Syphilitic Vascular Disease. Syphilis is the commonest
cause of vascular disease up to the age of forty, and it may be the sole
cause of cerebral thrombosis, some patients showing no evidence of
circulatory or renal disease. The actual extent of the syphilitic
vascular disease may vary widely ; in many cases the disease though
intense is extremely local in distribution. In other cases the
affection of the vascular system is more widespread, and in not a
few the vascular changes are associated with more obvious syphilitic
or parasyphilitic affections. In all such cases, whatever the degree
of severity of the paralysis present, the patient should be put to rest,
a mild aperient should be given, and a vigorous course of anti-
syphilitic treatment by inunction with mercury should be carried out
until the full physiological effect of the drug has been induced ; this
should be accompanied by the administration of large doses of
potassium iodide (gr. 15 to 40) three times a day. The question as to
whether any stimulant should be given may be answered on general
lines in the negative. It certainly must not be given in cases in
which there is a previous history of thrombosis, or in cases of
1178 Cerebral Thrombosis.
syphilis, where the vascular disease is complicated by the presence
of chronic renal disease. If, on the other hand, cardiac weakness is
present and is not recovered from as a result of rest, the judicious
administration of stimulants should not be prohibited.
(2) Senile Arterial Changes. In these cases rest is essential ;
purgation or anything which will tend to depress the circulation must
be avoided ; warmth should be applied to the feet and extremities.
The question of the administration of cardiac stimulants must be
decided by the state of the patient and by his previous health. If
there is a history of previous thrombotic attacks, or if there is
evidence of cardiac hypertrophy, although associated with temporary
dilatation, stimulants must not be given. On the other hand, if
there is acute cardiac failure, or if in a chronic case the heart fails
to respond to rest, stimulants should be given. There can be no
doubt that in these cases iron is one of the most satisfactory drugs ;
it may be given in combination with arsenic.
(3) Vascular Disease associated with Renal Disease. It
occasionally happens, more often than is fully recognised, that
patients suffering from chronic renal disease with hypertrophy of
the heart and general arterial sclerosis suffer from cerebral throm-
bosis, owing to some temporary or more permanent enfeeblement
of the circulation : thus, for example, a patient with chronic renal
disease and hypertrophy may have an attack of influenza, as a result
of which his heart's action becomes depressed and cerebral throm-
bosis ensues. All that is necessary in such cases, indeed all that is
justifiable, is to keep the patient at rest, and to employ only the mini-
mal amount of stimulant necessary to restore the heart to its normal
condition, for it must always be remembered that, whereas previous to
the thrombosis the condition of the vascular system and of the blood
pressure were more or less relative to each other, the fact of throm-
bosis having occurred weakens the vascular system locally, and may
render it incapable of withstanding a blood-pressure which has
become raised to compensate for the vascular changes. In such cases,
therefore, it n^ay be necessary, when the patient recovers from the
thrombosis, to take means to ensure that the blood-pressure is
prevented from returning to its former level.
TREATMENT OF THROMBOSIS DUE TO CIRCULATORY
ENFEEBLEMENT.
Pure cases of this condition are rare. As a general rule, the
cardiac cases are due either to acute cardiac disease or to some
acute affection which depresses the heart's action. In these cases
rest and treatment of the causal condition are indicated.
Cerebral Thrombosis. I! 79
TREATMENT OF THROMBOSIS DUE TO COMBINATIONS
OF THE ABOVE CAUSES.
In a large number of cases, although cardiac disability may un-
doubtedly be the preponderant factor in the production of the throm-
bosis, vascular changes in varying degree are associated with it. It
follows, therefore, that the line of treatment must be determined
by a consideration of the amount of cardiac weakness in relation to
the degree of vascular change which is present in each individual
case, stimulation being given in inverse proportion to the degree of
vascular change.
TREATMENT OF THROMBOSIS DUE TO ABNORMAL
BLOOD STATES.
Cerebral thrombosis may occur as a complication of chlorosis,
leukaemia, polycythsemia and pernicious anaemia. In certain other
conditions pregnancy, typhoid fever, pulmonary tuberculosis, dia-
betes, septicaemia and pyaemia the occurrence of apoplexy has been
attributed to cerebral thrombosis, due chiefly to changes in the blood
state. The treatment of all such cases is essentially that of the causal
factor.
TREATMENT OF THROMBOSIS DUE TO LOCAL
OBSTRUCTION BY PRESSURE FROM WITHOUT.
It occasionally happens that a cerebral vessel may become
obstructed as the result of pressure exerted upon it from without by
new growth, abscess or chronic inflammatory disease of the mem-
branes, such as gummatous meningitis. Signs of the obstructing
cause are usually present for some considerable period prior to
the onset of the thrombosis. The advent of thrombosis is shown by
the more or less sudden development of paralysis owing to the loss
of function in the parts supplied by the vessel. In these cases,
should the onset of thrombosis be suspected, the skull should be
opened, the pressure relieved, and, if practicable, the obstruction
removed.
SUBSEQUENT TREATMENT OF CASES OF CEREBRAL
THROMBOSIS.
In addition to the treatment of the paralysis which has resulted
from the stroke (see Hemiplegia, p. 1181), it is necessary to see that
the after-life of the patient is ordered so as to avoid excitement or
sudden physical or emotional strain.
In the syphilitic cases regular courses of iodide and mercury
should be prescribed each year, and if this is done the risk of
1180 Cerebral Thrombosis.
recurrence may be much diminished. As a number of these
cases recover completely from the stroke, the prognosis is good.
In atheromatous cases care must be taken to prevent the blood-
pressure either falling too low or rising too high, as there is the
double risk of thrombosis or haemorrhage should the limit of
safety be overs.tepped. In the cardiac cases the treatment is
practically that of the cardiac condition.
T. GRAINGER STEWART.
HEMIPLEGIA.
[EXCLUDING HEMIPLEGIA OF CHILDREN.]
HEMIPLEGIA is not a disease ; it is either a symptom indicating
the existence of an active morbid process affecting some part of the
upper motor neuronic system within the brain or the more or less
permanent result of some such process which has ceased to be active.
When it is a symptom, therapeutic measures must be primarily
directed to the arrest or eradication of the responsible disease,
whether it is vascular, neoplastic, inflammatory, toxic or hysterical
in origin. For guidance in these matters the reader is referred to
the articles on Cerebral Vascular Disease, Cerebral Tumour,
Cerebral Abscess, Encephalitis, Uraemia, Hysteria, etc.
This article is concerned with the hemiplegia remaining after the
storm of disease has passed, the object of treatment being to
promote, as far as is possible, the recovery of natural motor function,
and to minimise the effect of attendant disabilities and discomforts.
At the same time it must not be forgotten that all measures under-
taken for this purpose must be free from the danger of exciting a
recurrence of the primary disease and be subordinated to considera-
tions for the patient's general health. For example, the amount of
physical exercise prescribed for a man who is already hemiplegic,
as the result of a cerebral haemorrhage and who has a high blood
pressure, must be regulated by the fear of provoking a second
apoplexy. Owing to the frequency of vascular lesions of the brain
and to their fleeting character, it will be obvious that cases of hemi-
plegia suitable for treatment will be largely drawn from the
victims of cerebral haemorrhage, thrombosis or embolism. What is
applicable to them will be equally applicable to patients who are
left hemiplegic after the removal of a cerebral tumour, after the
evacuation of a cerebral abscess, or after an attack of encephalitis.
General Considerations. In order to appreciate both the possi-
bilities and the limitations in the treatment of hemiplegia the recog-
nition of certain well-established facts is essential. It is very rarely
possible to judge what proportion of paralysis, at an early stage,
is dependent on actual destruction of the fibres of the cortico- spinal
motor tract and what proportion is due to temporary disturbance
of their function. Ignorance on this point obtains equally in cases
of haemorrhage, when it is impossible to discriminate between the
1 1 82 Hemiplegia.
direct effects of blood extravasation and the indirect effects of pressure
exerted by a clot ; in cases of thrombosis, when the size of the
blocked vessel is unknown and the opportunities for the establish-
ment of compensatory circulation therefore undeterminable ; in
cases of tumour or abscess, when the relief of pressure is often
followed by intense but transient local oedema ; and finally in cases
of encephalitis, when the degree to which the nervous elements
have suffered from inanition or intoxication can only be gauged by
careful observation over a lengthy period of time. Our inability
to decide these questions on the spot requires the adoption of a
reasonably hopeful attitude in the majority of cases and makes it
imperative that every available method for facilitating recovery
should be utilised, lest subsequent improvement be hampered by
the neglect of this precaution. The correctness of this attitude is
constantly being illustrated by the gratifying and often unexpectedly
favourable results of early and persevering treatment on appropriate
lines.
The disablement of the limb in hemiplegia is dependent partly
upon a diminished power of initiating voluntary movements and
partly upon the resistance to their being carried out afforded by the
strong tendency of the different parts of the limb to assume fixed
positions. The relative preponderance of these two factors varies
considerably in each case, and our knowledge of the exact anatomical
changes upon which this variation depends is still incomplete.
There is good reason, however, to believe that the intelligent antici-
pation of the tendency to rigidity and the adoption of methods to
prevent its supervention or modify its strength may be attended
with a certain amount of success. In the upper limb the natural
inclination towards adduction at the shoulder, flexion and pronation
at the elbow, and flexion at the wrist and metacarpo-phalangeal
joints, may be fought with determination from the very beginning
by manipulations having an antagonistic influence. Similarly, in
the lower limb, flexion and adduction at the hip, extension at the
knee and extended inversion of the ankle may be more or less
effectually controlled. Even if the tendency to the hemiplegic
postures is not completely overcome, fixation by permanent con-
tractures can certainly be avoided. The responsibility for avoiding
contractures, for preserving the motility of joints and for keeping
up the nutrition of the paralysed muscles, lies with the medical
attendant, who will probably depute the actual manipulation and
massage to the nurse. The medical attendant must not, however,
be content with having ordered the adoption of these methods for
overcoming or preventing arthritic and muscular obstructions. He
Hemiplegia. 1183
must remember that a diminished power of initiating voluntary
movements, due to interference with the nervous tracts between the
cerebral cortex and the spinal cord, is much more serious than the
condition of the muscles or joints, and that his responsibility for
dealing with this part of the trouble is just as weighty and infinitely
more difficult to carry out than ordinary massage and passive
movements. In the fashionable desire to enlist the aid of massage
and electricity, the value of which is largely limited to their local
effects, the co-operation of the patient in his own treatment is apt
to be neglected. A medical attendant on a case of hemiplegia
should not rest until he has convinced his patient that no amount
of massage or electricity or passive movements will accomplish much
unless they are supplemented by constant personal attempts to carry
out voluntary movements. He should point out that there is
nothing wrong with the arm or leg, that their paralysis is due to
blockage in the nervous paths leading to them, and that the
patient's participation in treatment is needed for re-establishing
communication between the brain and the limb by forcing
impulses either through the obstruction or along alternative paths
which avoid it.
The neglect of taking the trouble to enlighten the patient on
this point may have serious consequences. In his ignorance the
patient waits, and waits in vain, for massage to restore movement
to his arm, and finally, in disgust, seeks help in other directions.
Sooner or later he will be induced to take up physical exercises on
the ridiculous plea that the muscles need development. To his
gratification the power of carrying out voluntary movements now
begins to return, not because the muscles become larger, but
because, unconsciously, he has been persuaded to make great efforts
at producing movements himself and has ceased to expect others
to produce them for him. The medical man is discredited ; the
advertiser of some curative system of exercise gains kudos and
other advantages which he has done little to deserve.
The rapidity with which anaesthesia may clear up under favour-
able circumstances, as compared with the rate of recovery of
movement is probably to be explained, in part at least, by the fact
that afferent impulses originate in the skin, joints and muscles,
irrespective of the patient's will, whereas efferent impulses for
the carrying out of movements must be started voluntarily, each one
involving a conscious effort on the part of the higher centres.
Finally, if cases of hemiplegia are studied with intelligence and
not all relegated without consideration into the same category, the
observer will soon realise that there are subtle differences, the
1184 Hemiplegia.
appreciation of which may be turned to useful account in treat-
ment. For instance, some patients suffer more from spasticity than
from actual loss of power ; others remain flaccid and yet make
little use of their apparently mobile limbs. Some of the latter
patients undoubtedly combine functional with organic disability,
the association being due to concomitant injury of higher psychic
centres and motor paths. In such a case methods of treatment
must not exclude persuasion, suggestion and other stimulating
measures which we are accustomed to employ in hysterical palsies.
At the same time it must be remembered that flaccid hemiplegia is
not necessarily functional in character; the flaccidity often depends
upon mid-brain lesions of particular localisation. Similarly the
power of moving a limb and the ability to apply the power to some
useful purpose are not always combined. In the condition known
as apraxia a patient may see and feel and handle an object and
yet may be unable to use it for the purpose for which it was given
him. This must not be mistaken for hysteria.
SYMPTOMATIC TREATMENT.
Paralysis. Keference has already been made to the fact that it
is always difficult and generally impossible to determine in the
early days of hemiplegia how far the damage to tissues is temporary
or permanent. In the majority of cases nature's process of repair
will permit of some return of voluntary power, and if nature is
assisted the amount of recovery may be very considerable. As
soon as the patient's general condition allows of attention to this
part of his malady the re-education of movement must be
started. It will generally be advisable to pay most attention at
first to those movements which are least affected, that is to say, to
movements which are more automatic and less specialised than
others. The attendant must engage the patient's collaboration by
explaining to him the principles which have already been detailed.
While passive movement is being performed at each joint the
patient should make every effort to assist in the performance, and
special attention should be given to those movements which the
medical man knows to be most important in counteracting the
tendency to rigidity. While in bed the inclination for the leg to
assume a position of internal rotation and adduction, with inversion
of the foot, must be pointed out, and movements of external
rotation, abduction, etc., be carried out daily in the manner
described. In the same way flexion and pronation of the forearm
at the elbow should be particularly counteracted by active and
Hemiplegia. 1185
passive movements of an antagonistic character. Thus the patient
will not only be re-educating his power of movement but will at
the same time be taking active measures against the supervention
of contractures. When the first attempts to walk are being made
intelligent instructions on the part of the attendant will prevent
the acquisition of bad habits. If left to himself the patient will
tend to walk with an extended leg, which he circurnducts or swings
in order to prevent the toes catching the ground. Under guidance
he will persevere in endeavouring to acquire the power of flexion at
the hip and ankle joints, and he will resist the tendency to sit with
his affected leg adducted and internally rotated, and with his toes
pointing inwards. Just as a schoolmaster successfully anticipates
wrong tendencies and harmful influences in the child committed to
his care, so must the doctor be forewarned and forearmed against
the disabling habits to which every hemiplegic patient is liable if
he is allowed to proceed along the path of least resistance. It is
unnecessary to multiply instructions under this heading; if the
principles are understood the details can easily be supplied, and
hemiplegia is too common a condition for any medical man to plead
ignorance of its special features. The chief difficulties present them-
selves when the attempt is made to re-educate the hand to perform
delicate actions. Unless the patient is thoroughly convinced of the
necessity for perseverance he will easily become resigned to the
habitual use of the sound hand for all finer manipulations. This
resignation should not be permitted unless the lapse of time and
the failure of prolonged and genuine efforts have demonstrated
the hopelessness of looking for further recovery. Ingenuity on
the part of the medical attendant in devising occupations and
games which necessitate or encourage the use of the clumsy fingers
will go far towards attaining success, if success is attainable. A
game of draughts or even of solitaire may have uses of which the
inventor never dreamed, and knitting may add to its many virtues
as a recreation.
Having once regained a movement efforts must be directed
towards increasing the power and precision with which it can be
made, both by daily repetition and by its performance against
graduated resistance offered by the attendant or nurse. Dumb
piano keys and miniature staircases are among the mechanical
contrivances which may help and amuse the patient without causing
annoyance to his neighbours. In learning to walk the support of
a companion is to be preferred to that of a stick or crutch, because
the former can inspire more confidence while rendering less
assistance.
S.T. VOL. ii. 75
1 1 86 Hemiplegia.
When loss of power is largely of a functional nature much can
be done by encouragement and suggestion, and the latter method of
treatment is often facilitated by the employment of some form
of electricity, especially faradism, through the medium of the
wire brush.
Spasticity. It is unfortunate that authoritative text-books are
to be found which suggest that faradism, massage and exercises,
should be begun several weeks after the onset of hemiplegia and
which omit to mention the most important prophylactic measures
belonging to the intervening period. Whatever the proper
scientific explanation of this spasticity may be there is ample proof,
both from clinical and experimental experience, that it is promoted
by prolonged immobility and retarded by passive movements of
limbs and frequent changes of position. If serious spasticity is to
be avoided, therefore, the early days of the disease must not be
wasted. Granted that there are cases in which the practice of
faradism and attempts at active movements are clearly contra-
indicated by other considerations for some weeks, it must be very
rare that careful attention to the position of limbs and the daily
performance of passive movements with perhaps a little gentle
massage can be anything but beneficial to the patient. Even the
period of unconsciousness which so often follows an apoplectic
attack is not one during which the limbs may be left to assume
any sort of attitude, especially as that attitude is almost certain to
include close adduction of the arm to the side of the trunk and
pronated flexion of the forearm across the chest.
Two principles are of paramount importance ; in the first place,
neither the arm nor the leg should be allowed to lie undisturbed for
long in any position. In the second place, during periods of sleep
and rest, care should be taken that the position of the limbs is the
opposite of that to which they are naturally inclined. A pillow
placed in the axilla will prevent extreme adduction ; a ball placed
in the hand will not allow the latter to close ; sand-bags can
correct the adduction and internal rotation of the leg ; a felt
slipper on the foot with stays drawing the toes towards the knee
may do much to obviate permanent and rigid plantar extension at
the ankle.
Such precautions combined with daily passive manipulation of
all joints will do much to counteract the spastic tendency, but
there are cases in which such simple measures have failed or in
which none have been carried out in the early months after the
onset of hemiplegia. Under these circumstances it may become
necessary to adopt other means than passive movements, massage,
Hemiplegia. 1187
etc. Galvanism is often recommended but is of little assistance
in the more severe cases. Drugs, such as belladonna, ergot and
veronal, are sometimes useful in modifying the involuntary and
painful spasms of the muscles, but cannot be said to effect any
marked alteration in the permanent degree of spasticity. Within
recent years other procedures have been suggested, some of which
deserve further trial. Based on the theory that spasticity is to some
extent maintained by peripheral stimuli originating in the skin,
joints and muscles, division of the posterior spinal roots in connec-
tion with the spastic limb has been carried out. If only alternate
roots are divided the actual sensory loss is not great and the
diminution of peripheral stimuli thus brought about is sufficient
to reduce the spasticity.
Another method which depends upon the production of temporary
paralysis of the more spastic muscles, being simpler, may prove
more acceptable. In the common spastic flexion of the fingers
which completely destroys the patient's manual dexterity the
flexors of the fingers may be temporarily put out of action by
exposing the median nerve and injecting alcohol into its sheath.
If 60 or 70 per cent, alcohol is used the paralysis will pass off in a
few weeks or months, and in the meantime every effort may be
made to re-establish the activity of the extensors so that they may
ultimately be able to hold their own in carrying out manual move-
ments. Sufficient experience of these more modern methods has
not yet been collected, but the alcoholic injection procedure is both
promising and suggestive. To know what not to do is also
important. When spasm reigns supreme, energetic massage and
strong electric currents only tend to make matters worse, and the
administration of strychnine is not likely to influence favourably a
condition which is partly reflex in origin.
Contractures. Permanent shortening of muscles and tendons
ought not to be allowed to occur. If it is present gradual passive
stretching may correct a moderate degree of contracture, but in
more severe cases division or lengthening of certain tendons is
clearly indicated. Subsequently gentle massage and faradism of the
muscles will be necessary to sustain their proper function.
Arthritic Adhesions. These are common enough, especially
in the shoulders. Early precautions on the lines indicated above
should prevent their occurrence. They must be broken down by
daily passive movements or at one sitting under an anaesthetic,
when they are found to be limiting the mobility of a joint.
Muscular Atrophy. A moderate amount of wasting is frequent
in the muscles of hemiplegic limbs when the condition is of long
752
1 1 88 Hemiplegia.
standing. In exceptional cases rapid muscular atrophy supervenes
in the early stages. This is difficult to explain, although it has
been shown that secondary degeneration of the peripheral neurones
may sometimes take place. Massage and faradism are necessary
for the restoration of the muscular nutrition and when the latter
is threatened should be at once employed. The reaction of
degeneration is rarely met with in these muscles ; should it be
present galvanism must replace the faradic current in treatment.
Ataxia. In some cases of herniplegia the recovery of voluntary
movement in the arm may be remarkably good and yet the useful-
ness of the limb be diminished by a considerable degree of loss of
sense of position and of the power of recognising objects placed in
the hand (astereognosis) . This condition may be present when
tactile sensibility is perfectly preserved. It is important not to
regard this as a sign of hysteria and it is equally important to try
and restore the lost sense by the practice of exercises on the
Fraenkel system. A definite period of time should be allotted
daily to carrying out manipulations with the affected hand (under
supervision to begin with), manipulations which are carefully
graduated in respect to their delicacy and difficulty. Thus, a
patient may commence by building houses with bricks and end by
building houses with cards, by which time he will be ready to pass
on to the finer arts of writing and sewing. By these means he will
be doing something to re-educate his sense of position, of shape
and of size.
Involuntary Movements. A few hemiplegic patients suffer
from involuntary movements of the affected limbs, movements
which are sometimes tremulous, sometimes choreiform and some-
times athetotic. In all probability their presence indicates a lesion
of some definite structure in the region of the basal ganglia and
has little or nothing to do with involvement of the pyramidal tract.
Such movements are difficult to deal with. The restoration of
complete control over movement by the motor cortical centres is
most likely to bring about their cessation, and the means of
promoting that control have already been amply described.
Pain. Hemiplegia may be a painless condition throughout its
course ; more commonly it is associated with aches and pains of
different degrees of severity and of varying origin. They may be
classified under three heads : (1) Pain due to arthritic adhesions
especially in the shoulder-joint. This pain is naturally evolved
by movement and must be treated by breaking or stretching the
adhesions and the application of local heat. (2) Rheumatic or
osteo-arthritic pain. The normal resistance to morbid processes
Hemiplegia. 1189
appears to be lowered on the hemiplegic side of the patient and he
is particularly liable to suffer from chronic muscular rheumatism
and chronic arthritis in the affected limbs. These must be treated
on ordinary lines, such as the administration of salicylates, iodides
or guaiacol, gentle massage and hot air baths. (3) Pain of central
origin : In some cases of hemiplegia in which there is an extension
of the lesion into the optic thalamus, the patient is liable to constant
aching pain over the whole of the paralysed limbs with paroxysmal
exacerbations of great severity. When this condition is present it
is usual to find that ordinary stimuli of heat, cold, scratching and
tickling may be extraordinarily disagreeable to the sufferer and that
the pain they elicit is not limited to the site of stimulation but
spreads widely in different directions. Therapeutic measures are
peculiarly ineffective in dealing with this variety of pain and even
morphia is often powerless to control the more severe paroxysms.
The patient must be guarded against exposure to the offending
stimuli, must avoid draughts and direct contact with cold or hot
water. He soon learns to abstain from touching metal or other
substances which give rise to chilly sensations. The continuous
administration of bromides may diminish, although it does not
abolish, this distressing symptom.
Vasomotor Disturbance. The paralysed limb is often the seat
of vasomotor disturbance in the form of cyanosis or oedema. This
liability must be fought by taking care that the limb is warmly
wrapped up in cotton-wool or flannel garments, by frequent change
of position, by gentle massage and, if necessary, by the local appli-
cation of heat. Such precautions are necessary not only for the
patient's comfort but because their neglect leads to malnutrition
of the arm or leg and to an increase in their spasticity. It is well
recognised by the patient that rigidity is worse in cold than in
warm weather, and that when a spastic hand or foot has been well
warmed in a hot bath more movements are possible than at other
times.
Length of Treatment. Speaking generally, the treatment of
hemiplegia should be persevered with during a period of at least
eighteen months, and in cases in which improvement is still taking
place for as long as this continues. When no movement is
possible in a hand after eighteen months of adequate treatment, it is
generally useless to expect recovery and the medical attendant must
be content if he has by this time succeeded in making his patient
resigned to his loss and in making the disabled limb as free from
discomfort and as little in the way as possible. Under these
circumstances, if the patient is in a position to afford it, a course of
1190 Hernia Cerebri.
baths combined with massage at places such as Gastein, Ragatz,
Harrogate or Teplitz, may be recommended. The change of sur-
roundings, the mental recreation it promotes, and the outdoor life
will do as much as anything can to mitigate the natural feeling of
misery induced by impaired activity.
E. FARQUHAR BUZZARD.
HERNIA CEREBRI.
WHEN this condition results from a septic wound such as a com-
pound depressed fracture, the application of firm pressure by means
of bandages over a dry dressing is sometimes of value. The local
application of astringents such as alcohol, alcoholic solution of
tannic acid or zinc perhydrol, by causing shrinkage of the swelling
may also be of assistance. When the condition is the result of
trephining for the relief of intracranial pressure due to a cerebral
tumour, no treatment is possible.
C. H. S. FRANKAU.
1 191
HYDROCEPHALUS.
HYDROCEPHALUS (that is, internal hydrocephalus, for true
external hydrocephalus is a rarity) is to be regarded as a clinical
symptom which may arise in the course of many differing
pathological processes. It is undesirable to speak of primary or
idiopathic hydrocephalus, although the term " congenital hydro-
cephalus " may be retained to denote that variety which dates from
birth and is associated with encephalic malformations. So-called
secondary hydrocephalus, produced mechanically or by irritation
of the pia or ependyma, may result from the presence of tumours
(abscesses, caseous nodules, parasites) in various situations (basal,
mesencephalic, pituitary, cerebellar, pineal, etc.), or may be
associated with meningeal or vascular conditions (acute serous,
tuberculous, or suppurative meningitis, epidemic cerebro-spinal
meningitis, venous sinus thrombosis, ependymitis (serous or non-
suppurative), etc., and if the underlying condition is recognised,
treatment must be directed to it as well as to the relief of the
symptom that is its expression (see under the respective articles).
Confining ourselves in this paragraph to the symptomatic
treatment of hydrocephalus, we may begin with the congenital
variety.
(1) Medicinal Treatment is, generally speaking, completely
inefficacious. Anti-syphilitic procedures have frequently been
adopted, empirically, but as a rule without avail.
(2) Lumbar or Cranial Puncture, the latter via the anterior
fontanelle or to one or other side of the sagittal suture, has found
many advocates, and while the general consensus of opinion in
this country seems to be that both methods are uncertain and
unsatisfactory, excellent results appear to have been obtained by
some (Grober, Quincke). It is clear that only certain types of
hydrocephalus can possibly benefit by repeated lumbar punctures.
(8) Various drainage devices have been tried and, as a rule, have
been found wanting. Drainage by means of portions of saphenous
veins into the superior longitudinal sinus (Payr), direct intra-
ventricular drainage, subcutaneous drainage from the ventricles to
beneath sutured pericranial integuments (Miculicz), peritoneal
drainage from the spinal theca (Gushing) may be mentioned. As
Gushing truly observes, " whatever method is used it is necessary
1 1 92 Hydrocephalus.
to determine first of all where the obstruction has taken place,"
otherwise failure is almost inevitable. Yet the determination of
the site of the obstruction may be peculiarly difficult. Occasionally
good results appear to have ensued. Bruce and Cotterill, of
Edinburgh, have reported a case where cure followed reopening of
the thickened roof of the fourth ventricle and drainage.
Even though only palliative results follow in carefully chosen
cases, punctures should be tried and repeated, and where an exact
local diagnosis has been made some form of surgical interference
may be adopted, although Auvray counsels abstention as perhaps
preferable.
S. A. KINNIER WILSON.
REFERENCES.
Gushing, H., article "Hydrocephalus" in "Osier and Macrae's System of
Medicine," Oxford, 1910, VII., p. 459.
Auvray, Maladies du crane et de I'encephale (Le Dentu et Delbet, Nouveau
Trait6 de Chirurgie, Tome XIII.), Paris, 1909, p. 482.
Bruce and Cotterill, Edinburgh Med.-Chir. Soc., 1911, N. S. XXX. 3.
193
SURGICAL TREATMENT OF HYDROCEPHALUS.
MANY surgical methods of treating hydrocephalus have been
devised ; but, as the pathology of this condition is somewhat obscure,
and the cause when known is irremovable, their success has not
been great. The following operation has in the writer's experience
prevented increase in the size of the head, and is attended with
very little, if any, risk to the patient from the operative procedure
itself.
Operation. A sharp pedicle needle, with a good curve, is
threaded with No. 12 plaited silk, both having been carefully
sterilised. The thread when doubled is at least thirty inches long.
The head is shaved and made thoroughly aseptic. A spot about
one inch to one side of the middle line is chosen as near the
posterior part of the anterior fontanelle as possible. With a
tenotome make a tiny incision through the skin in this position.
Push the threaded needle into the lateral ventricle, curve it through
the falx cerebri into the opposite ventricle, and bring it through
the skin in a corresponding position on the other side of the middle
line. Withdraw the pedicle needle, leaving the silk in situ.
Thread the double silk of one side on to a long probe and push
the probe beneath the skin backwards into the nape of the neck.
Do the same with the silk on the other side. Cut off the super-
fluous silk and put a stitch into the small wounds that have been
made in order to introduce the probe and the silk it carries beneath
the skin.
The procedure is the same as in the operation for lymphangio-
plastry as described by Sampson Handley. The doubled silk now
connects both ventricles with each other and with the connective
tissue of the neck. As regards limiting the distension of the
ventricles the results of this operation have been most encouraging.
H. S. PENDLEBURY.
1 194
CRANIAL MENINGOCELE.
IN the majority of cases of meningocele in which the child sur-
vives birth no operative interference is indicated in the first instance.
The swelling should be carefully protected from injury and pressure
which are likely to produce ulceration of the skin, and operation
should be postponed with the hope that with the growth of the
cranial bones the opening into the meningocele may be obliterated
or greatly contracted. When operation is decided upon the sac is
exposed by a suitable incision and its base is isolated as far as
possible ; if there is a definite pedicle, this is ligatured with stout
catgut ; if the attached base is broad, the meningocele should be
cut away near the base, but enough of the membrane on either
side should be left to allow the edges to be united by catgut sutures.
Care should be taken to avoid the sudden escape of a large amount
of cerebro-spinal fluid, as this may produce profound shock or even
death. If a considerable opening persists in the skull, it is advisable
to attempt to close it either by the means of pericranial flaps or by
some osteoplastic operation.
Operation is contra-indicated when the swelling is very large and
pulsates freely, and also when the skin is greatly thinned or
ulcerated.
C. H. S. FRANKAU.
PARAPLEGIA.
PARAPLEGIA, by which term is signified paresis or paralysis of the
lower extremities, is a symptom that may be occasioned by a
multitude of differing pathological conditions. A consideration of
its treatment must be prefaced with some remarks on its
pathogeny and clinical varieties, since on a knowledge of these
depends a rational therapeusis.
The customary division of paraplegia into " spastic " and
" flaccid," terms which explain themselves sufficiently, is useful
if not always practical ; spastic cases may become flaccid, a change
rightly regarded as serious from the point of view of prognosis ;
flaccid limbs may become spastic, or they may become con-
tractured, the latter a condition of rigidity not to be confused with
true spasticifcy. Many cases of paraplegia are not characterised
by any special degree of either condition. Nevertheless, the
distinction is one that is sanctioned by clinical usage and by the
fact that the general lines of treatment vary accordingly.
Paraplegia is said to be either organic or functional in origin,
but therapeutically the distinction is of comparatively little value,
unless " funcbional " be held synonymous with " hysterical," which
it is not ; moreover, organic disease always reveals itself by a
disturbance of function, and the earliest symptoms of an organic
paraplegia are not infrequently " functional." On every ground,
therefore, it is preferable to speak of " hysterical paraplegia " (see
Hysteria), and to discard the term "functional paraplegia"
altogether.
Organic paraplegia may be cerebral, spinal or cerebro-spinal in
origin.
Paraplegia of Cerebral Causation. This is usually, though
not necessarily, spastic in type. It may be the sequel to meningitis,
encephalitis, tumour growths (cerebellar, pontine, basal near the
mid line, etc.), vascular softening or haemorrhage, chronic hydro-
cephalus from any cause, bilateral cerebellar lesions (not a true
paraplegia) ; it is a symptom in Little's disease, cerebral diplegia,
double hemiplegia ; senile paraplegia, characterised by the demarche
a petits pas (short, shuffling steps, one foot scarcely passing the
other), is commonly due to bilateral vascular lesions in the basal
ganglia.
1196 Paraplegia.
Paraplegia of Spinal Origin. This may be the result of
pathological changes inside or outside the spinal cord. Involve-
ment of the pyramidal paths usually produces a spastic paraplegia ;
invasion of the anterior horns a flaccid paraplegia, coupled with
muscular wasting ; combinations of the two types are of frequent
occurrence. All spinal lesions below the lower part of the lumbar
enlargement tend to produce a flaccid paraplegia ; lesions higher
up may be characterised by flaccidity at the level of the lesion and
spasticity below ; any spinal paraplegia may be complicated by
sensory, sphincter, or trophic symptoms.
(1) Endogenous. We may expect paraplegia from any of the
numerous varieties of myelitis, meningo -myelitis or meningitis ;
in any form of spinal vascular disease, myelomalacia, hsemato-
myelia ; in meiopragia from disease of spinal blood-vessels
(insufficient vascularisation) ; in any toxic, toxi-infective or
infective condition syphilis, para-syphilis, lead, pellagra, lathy-
rism, poliomyelitis, Landry's paralysis, subacute combined
degeneration ; in intramedullary or intrathecal tumours (abscess,
cyst, parasites), syringomyelia, hydromyelia, Eriedreich's disease ;
from traumatisms of any sort, commotio spinalis, caisson disease ;
in certain familial diseases, family spastic paralysis, family periodic
paralysis ; in progressive muscular atrophy, peroneal muscular
atrophy.
(2) Exogenous. The commonest causes of paraplegia of
extrinsic origin are extrathecal tumours of any sort, malignant
disease of the vertebrae, Pott's disease of the vertebrae, caries sicca
senilis, fracture dislocation of the spinal column, laminal fractures,
sometimes associated with hasmatorrhachis.
Paraplegia of Cerebro-spinal Origin. This is seen in dis-
seminated sclerosis, cerebro-s'pinal syphilis, amyotrophic lateral
sclerosis, cerebro- spinal meningitis.
No reference in made here to the numerous varieties of
peripheral nerve lesion, which, if its incidence is on the lower
extremities, will cause paraplegia.
The multiplicity of etiological factors in the causation of para-
plegia renders the bare diagnosis of " paraplegia " as inadequate
as a diagnosis of " cough," although in the early stages the
determination of the nature of a particular case may be difficult,
if not impossible. For a consideration of treatment directed to
the cause, the reader is referred to the articles on the various
conditions enumerated above. In this article attention is directed
solely to the symptomatic treatment of paraplegia (see also Hemi-
plegia and Myelitis).
Paraplegia. 1197
Spastic Paralysis. Speaking generally, no known medica-
ment will per se reduce spasticity. A combination of ergot and
belladonna in pill may be tried. Involuntary flexor (more rarely
extensor) spasms of the legs, occurring chiefly at night and some-
times with great persistence, may be successfully combated by
the administration of veronal (5 to 10 gr.), as an an ti- spasmodic,
not as a hypnotic. The bromides, hyoscine hydrobromide, and
other accepted nerve sedatives, may on occasion prove useful.
Sometimes all that is necessary is to arrange a drawsheet firmly
and securely over the legs, drawing it tightly just above the knees.
Occasionally mechanical extension with weights is of service in
this connection ; it has also been used to obviate the development
of contractures. For this purpose, however, passive movements
are more efficacious ; they also prevent the formation of adhesions.
Electrical treatment, whatever be the form employed, is inadvis-
able, as it only serves to increase the tone of muscles already hyper-
tonic. Massage, likewise, is uncalled for, except where the trophic
and nutritional condition of the lower extremities is impaired.
Sometimes the reflex excitability of the legs is so great that merely
handling the limbs, or touching or otherwise stimulating the skin,
is sufficient to produce involuntary movements : hence it may be
useful to keep the bedclothes off the patient's limbs by a cradle.
In chronic cases, where there is reason to believe that the
central lesion is stationary, suitable tenotomy or myotomy
(division of plantar fascia, tendo Achillis, hamstrings) may over-
come the vicious positions that result from contractures, and often
is of the utmost value in restoring the power of walking in a
serviceable manner to the patient. Recently, Fb'rster has strongly
advocated division of certain posterior spinal roots for a like
purpose, only, however, to counteract true paralytic contractures,
and not where the vicious position is due to tendinous or
ligamentous retractions. For the plantar flexors he divides the
second sacral roots ; for the extensors of the leg the third and
fourth lumbar ; for the adductors of the thigh the second and third
lumbar. Good results have been reported in a number of instances.
Flaccid Paralysis. Strychnine is supposed to be our thera-
peutic mainstay in flaccid paraplegia, but it is not unreasonable
to ask whether it has not become a therapeutic fetish. Where
there are distinct central anatomical lesions its value is problema-
tical. As a " general nerve tonic " in asthenic cases, however
and many paraplegics are debilitated apart from the local lesion
it is, perhaps, worthy of a place in the physician's armamentarium.
Other general nerve tonics, arsenic, glycerophosphates, byno-
1198 Paraplegia.
glycerophosphates, lecithin, phosphoric acid, cannabis indica, zinc
valerianate, etc., may prove helpful for a similar reason.
Massage and electricity are, in many cases, invaluable. Massage
definitely aids paralysed muscles to regain their power as the cause
of the paralysis passes off. Either the interrupted or the constant
current may be utilised, and it is a good plan to place the
indifferent electrode over the spinal column above the level of the
lesion, so as to include the latter in the electrolytic circuit. The
constant current should be employed if no faradic response is
obtainable, except with a current so strong as to be painful.
Electrical treatment should be persevered with, although the
muscular contractions evoked are very small and feeble, but its use,
after all local muscular response fails, is questionable. Galvanic
or faradic baths are often the most suitable way to administer treat-
ment, the former especially with children.
The physician should always guard against unnecessary aggra-
vation of the condition of the legs through the weight of the
bedclothes, or otherwise, by giving every support he can to the
limbs. If the feet drop they should be kept at right angles to the
leg by sand-bags ; in recovering cases, Gower's boots may be very
serviceable. These are leather cases enclosing the limb to below or
above the knee, laced in front and fitted with elastic straps, tension
on which, continued for hours at a time, if need be, will bring the
foot or the leg to the desired position.
Graduated exercises should be complementary to massage. The
patient should always be encouraged to make innervating efforts,
though no visible result ensue. It is, perhaps, not sufficiently
realised that, as was pointed out by von Leyden, a patient may be
able to make movements of the limbs under water, which he is
unable to execute in bed. In recovering cases, therefore, where
disuse of the limbs is a barrier in the way of improvement, he
should have the opportunity of making the first attempts in this
way. The weight of the limb may be such as to prevent, say,
voluntary flexion at the hip, but with the support of the water,
the movement may become possible.
In chronic cases, all lesional activity having ceased, various
orthopaedic devices may sometimes become desirable musculo-
tendinous transplantations, nerve-grafting, subperiosteal grafts to
supplement paralysed muscles by sound ones, arthrodesis for
flail-like joints, etc. Each case, needless to say, must be con-
sidered on its own merits.
Eadiotherapy for certain paraplegias is still in the experimental
stage.
Paraplegia. 1 199
Genito-urinary and Rectal Symptoms. The comfort or
discomfort of a paraplegic patient depends greatly on the condition
of his organic reflexes.
Eetention cases must be catheterised two, three or four times,
or oftener, in the twenty-four hours, as the case may be, and
irrigation should follow as a routine practice. No drug is known
to exercise a specific action on the condition, but helmitol,
urotropin, ammonium benzoate, etc., are serviceable in preventing
improper fermentations.
Incontinence of urine may sometimes be ameliorated by the
administration of atropine or belladonna ; often, unfortunately,
these fail entirely. In male patients rubber urinals can be fixed
with comparative ease ; similar arrangements are less satisfactory
in the case of the other sex. A good and practical plan is the
employment of an ordinary sponge bag -with tapes and cotton-
wool.
Where rectal control is defective simple enemata are preferred to
aperients.
Rarely, priapism is a distressing symptom. Camphor mono-
bromate (5 gr.), extract of salix nigra (1 drachm), water to \ oz.,
three times a day, may be recommended.
Bedsores are always to be feared. Apart from unremitting
attention to the bladder and bowels, to the bedclothes, to involun-
tary spasmodic movements and to approximated skin surfaces, their
development may largely be prevented by a daily or more frequent
toilette of methylated spirit and dusting powder. Where the skin
is broken, however, peroxide of hydrogen and chlorinated soda
have, in the writer's experience, been exceedingly useful.
For the further management of paraplegic cases, see seriatim
under the various spinal and cerebral diseases concerned.
S. A. KINNIER WILSON.
REFERENCES.
Guinon, article in " Traite de Medecine," Charcot-Bouchard, Paris, 1904,
IX., p. 855.
Marie, article in "Traite de Medecine,"- Brouardel-Gilbert, Paris, 1903,
VIII., p. 531.
Dejerine, " S6miologie du systeme nerveux," Paris, 1904.
Forster, "Zeitschrift fur Orthopadische Chirurgie," 1908, XXII., p. 203.
Gottstein, " Berliner Klin. Wchnschr.," 1909, XLVL, p. 784.
Rose, F., " La Semaine M6dicale," 1909, XXIX., p. 313.
1200
THE MEDICAL TREATMENT OF TUMOURS OF
THE BRAIN.
THE great advances which have taken place not only in cerebral
localisation but in the knowledge of the pathological factors which
underlie the symptomatology of cerebral tumours, together with a
corresponding improvement in the technique of cerebral surgery,
have placed the treatment of intra-cranial tumours within the range
of practical surgery. The physician must make the diagnosis and,
if possible, locate the situation of the tumour ; but his chief responsi-
bility is to inform the patient or his relatives of the nature of the
malady, and to lay before them clearly (1) the ultimate result of the
disease if the pressure upon the brain is not relieved ; (2) the
possibilities of surgical treatment : (a) as a palliative measure for
the relief of the general symptoms, headache, vomiting, optic
neuritis and the prevention of death from respiratory failure, which
may occur quite suddenly in any case of cerebral tumour in which
the intra-cranial tension has not been relieved ; and (fe) as a curative
measure.
The number of cases in which cerebral operation offers a prospect
of permanent cure is small, as it depends upon the nature,
the position, and to a less extent the size of the tumour. In a
few cases it is possible to make a correct diagnosis on all these
points before an operation is undertaken, but in the great majority
of cases the nature and the extent of the growth can only be
ascertained by operation and examination. For this reason,
although the prognosis must always be grave, an operation as
an exploratory and palliative measure should always be insisted
upon. The employment of more radical measures, such as the
removal of the tumour, depends upon the conditions found at the
exploratory operation.
Although surgical treatment offers the only chance of cure or
of an indefinite prolongation of the patient's life, much may be
done to alleviate the general and local symptoms of the disease
both before and after the operation has been undertaken.
For convenience in description, the medical treatment and
indications for immediate surgical interference may be considered
in the following types of cases : (1) Cases presenting symptoms
of intra-cranial tumour, but in which no positive diagnosis can be
Medical Treatment of Tumours of Brain. 1201
made. (2) Cases of intra-cranial tumour in which the position of
the tumour has not been localised. (3) Cases of intra-cranial
tumour in which the situation of the tumour has been definitely
localised.
Cases presenting Symptoms of Intra-cranial Tumour, but
in which no positive Diagnosis can be made. In many cases
of cerebral tumour the earliest symptoms are general in character
headache, occasional attacks of vomiting and optic neuritis.
Headache may be present alone as the earliest symptom, or it may
be combined with vomiting. In all cases repeated careful routine
examinations should be made with a view to finding out the cause
of the headache. In favour of its being due to intra-cranial tumour
are (1) the absence of any previous history of headache ; (2) the
persistence and severity of the headache, especially at night-time
or in the morning ; (3) the deep-seated character of the pain ;
(4) the constant recurrence of the headache in the same situation,
its aggravation by sudden change of posture and its association,
when severe, with vomiting, unattended by any nausea or digestive
trouble.
Vomiting may be an early symptom. It bears no relation to the
taking of food, and is associated with severe attacks of headache,
and often induced by a sudden change of posture. It frequently
occurs when the patient first sits up in bed in the morning.
Optic neuritis may develop early or late, its onset is usually
unattended by any disturbance of vision, and its presence may be
unsuspected until detected by ophthalmoscopic examination. It is
true that a combination of the above symptoms may be present in
cases of renal disease ; but in such cases local brain symptoms will
be absent, or if present their onset will have been sudden, whereas
in intra-cranial tumours the onset of paralytic symptoms is usually
gradual and evidence of renal disease is wanting.
As these symptoms are for the most part due to a rise in
intra-cranial pressure, treatment should be directed to lowering it.
It is necessary to keep the patient's bowels freely opened and
promote diuresis. For the headache the best drugs are phenacetin,
antipyrin, phenalgin and aspirin. A useful combination for this
purpose is 5 gr. of aspirin, caffein and phenacetin, given either in
tabloid or powder form.
If a patient suffering from cerebral tumour should suddenly
become comatose, croton oil should be given at once, as it will
often revive him, and by preventing his sudden death enable an
operation to be undertaken.
Some cases of cerebral tumour, on the other hand, commence
S.T. VOL. ii. 76
I2O2 Medical Treatment of Tumours of Brain.
with local or focal symptoms, unattended by any of the general
symptoms. Thus a patient may suffer from fits, either localised or
general in character, or he may slowly develop paralysis. In such
cases it may not be possible to diagnose the cause of these
symptoms, as they may be due to epilepsy, vascular disease, or
syphilitic cerebral disease. The points in favour of their being due
to intra-cranial tumour are (1) the constant situation of the onset
of the fits ; (2) the development of permanent and paralytic
symptoms in the parts affected by the fit ; (3) the gradual onset
of paralytic symptoms ; and (4) the development of the general
symptoms of intra-cranial tumour in association with them.
Medical Treatment of the Local Symptoms in a Case
where the Patient is suffering from Fits. It is often advisable
to postpone giving sedative treatment such as bromide in order
that the character of the fit may be observed and the patient
examined immediately after, as in some cases the observation of a
fit may enable one to distinguish between idiopathic epilepsy and
fits due to some local irritative lesion. Once the fits have been
observed, or where the patient is having frequent fits, bromide
should be given, the dose being adjusted to the requirements of
each case. It must not be forgotten that bromide treatment may
stop the occurrence of fits and to a certain extent mask the
development of the symptoms, and therefore it is essential that
such cases should be examined carefully at frequent intervals. To
withhold bromide in a case of cerebral tumour in which the patient
is suffering from fits is bad practice, as haemorrhage may occur
into the tumour during a fit, or the patient may become comatose
or die from cardiac failure as a result of repeated fits, which if
treated in time would never have reached such severity as to
endanger life. Paralysis, when it occurs, should be treated on
general principles, but the importance of a slow increase in the
paralysis as an indication of a progressive lesion must ever be
borne in mind.
Cases of Intra-cranial Tumour in which the Position of the
Tumour has not been Localised. As a general rule, when a
tumour has developed all the cardinal symptoms and been diagnosed
though not localised, it is not wise to delay operation. It may in
some cases be possible to localise the tumour as being either above
or below the tentorium.
If the tumour is above the tentorium there is not so much risk
of -sudden death from respiratory paralysis, and therefore in some
instances it is justifiable to wait and see whether a correct
localisation can be made, but this period should not exceed six
Medical Treatment of Tumours of Brain. 1203
weeks. Operation must be undertaken immediately if the patient
tends to become comatose or to suffer from any respiratory
disability, or if the patient's vision begins to deteriorate : thus it is
absolutely essential that the vision should be repeatedly and
carefully tested as to its acuity and the condition of the visual
fields. Any deterioration in vision must be taken as a sign that
operation should not be delayed, as to do so is to risk permanent
blindness. In cases where the tumour is presumably subtentorial
in position, there is a constant danger of sudden death from
anaemia of the respiratory centres, and although careful attention
to the condition of the bowels and guarding against sudden changes
of posture may minimise this, it can only be removed by
deconipressive operation performed beneath the tentorial level.
Cases of Intra-cranial Tumour in which the Situation
of the Tumour has been definitely Localised. Operation
should not be delayed, and the skull should be opened over
the site of the tumour. If the tumour is not intra-cerebral,
that is, if it is an endothelioma, fibroma, fibro-sarcoma or gumma,
it should be removed. If, on the other hand, it is intra-cerebral,
its removal should not be attempted if the tumour is malignant and
of large size, or so situated that its removal would result in paralysis
or aphasia.
In many cases where the nature of the tumour is doubtful
the prescribing of a course of anti-syphilitic treatment has been
recommended. In all cases a Wassermann reaction should be
taken ; if negative, no time should be wasted in anti-syphilitic
treatment ; on the other hand, should it be positive, active anti-
syphilitic treatment should be carried out. If, despite this, the
symptoms increase or the patient's vision deteriorates, operation
must not be delayed. It must always be remembered that in the
case of cerebral gummata operation is often necessary for the relief
of pressure, and that timely intervention may save the patient's
life by removing the immediate cause of death, but the cure of the
condition and the prevention of its recurrence depends entirely on
medical treatment.
A medical man is often asked as to the risk of operation. In
every case there is less risk in performing palliative operation
than in leaving a patient suffering from intra-cranial tumour
unoperated upon, provided that the surgeon is especially skilled
in this branch of surgery.
T. GRAINGER STEWART.
762
1204
SURGICAL TREATMENT OF TUMOURS OF THE
BRAIN.
SURGICAL intervention in tumours of the brain may be described
as radical and palliative. The former consists of an operation which
aims at complete removal of the tumour. The latter is undertaken
solely for the relief of intra-cranial tension and the distressing
symptoms due to this tension, and makes no attempt at the removal
of the tumour itself. Obviously, in order that an operation may be
radical, not only must a diagnosis of intra-cranial tumour be made,
but its localisation be accurately determined. An operation begun
as a radical one may end as a palliative one, owing to the tumour
being irremovable or the localisation incorrect. Even in cases in
which the tumour has been definitely localised it is impossible to
say before operation whether the case will be suitable for palliative
rather than radical treatment.
The duration of the disease is no guide to the nature and size of
the tumour. Nevertheless, operation should always be undertaken
with the object of exposing the tumour. Should the growth not be
found or prove to be an inoperable one, the question of a palliative
treatment at once arises. The palliative operation, however, must
not be regarded as a substitute for a radical one. Whenever
possible, the tumour should be removed.
Palliative Operations. It is now well recognised that palliative
operations are not only free from danger to life, but are of the
greatest use in relieving distressing symptoms, pain, and especially
progressive optic neuritis. The relief of these symptoms is often
permanent through the remainder of the life of the patient. There
are two groups of cases in which a palliative or decompressive
operation should be undertaken : (1) Those in which the tumour
cannot be removed, though localised ; (2) those in which the tumour
cannot be localised, but where the operation is demanded for extreme
headache, and progressive loss of vision. Sanger suggests that the
best time for a palliative operation in these cases is when vision
commences to fail. If the operation is delayed till later, some optic
atrophy always remains. No other palliative operation, such as
puncture of the lateral ventricle or lumbar puncture, can be com-
pared in efficiency with trephining. Indeed, lumbar puncture in
cases of brain tumour is not to be recommended as a therapeutic
Surgical Treatment of Tumours of Brain. 1205
measure, owing to its unreliability and transitory effects. Moreover,
it is by no means a harmless procedure. Fatal results have been
recorded in intra-cranial tumours- with increased intra-cranial
tension. Grtmprecht reports 17, and Kous 14, such cases. In
many of the fatal cases death was due to cessation of respiration,
owing probably to disturbance of hydrostatic equilibrium, causing a
lesion in the respiratory centre of the medulla. In many cases
death occurred within a few minutes. In no case was artificial
respiration of any avail.
In performing the decompression operation there are two
important points to be kept in view : (1) The opening should be over
as silent and unimportant an area of the cortex as possible ;
(2) means should be taken to prevent an unnecessarily large hernia
cerebri. The occurrence of the latter can be obviated by the intra-
muscular method, by which means the muscles and fascia act as a
check to the brain.
An important point, and one which must be decided during an
operation for cranial tumour, is that of exploration of subcortical
growth. Should these cases be regarded as inoperable and an
attempt to find the growth be abandoned ? The answer to this
question depends upon how far by subcortical exploration we may be
interfering with the functions of the brain. Remembering always
that if the growth is not removed death will certainly follow, the
amount of permanent defect resulting from the operation is an
important consideration, and the responsibility of accepting it one
which must be left to the patients and their friends. The extent of
paralysis will depend on the situation of the tumour and the amount
of brain tissue it is necessary to remove in enucleating the tumour.
A. certain amount of recovery from post-operative paralysis may be
predicted with confidence, and it is astonishing in many cases how
complete this return of function may be. The want of success in
obtaining a radical cure is usually due to the infiltrating nature of
the tumour precluding the possibility of its entire removal.
Radical Operations. The surgery of the brain differs in no
wise from that in other parts of the body, in that the earlier the
disease is recognised and localised the more favourable is the chance
of performing a radical operation. Seeing that the disease is
always incurable and fatal without operation, any case of brain
tumour may be described as operable in which the tumour can be
wholly or partially removed. Those cases in which the tumour is
not localised, or being localised, is inaccessible, and show pro-
gressive optic neuritis, do not admit of any discussion ; they should
be decompressed at an early stage before vision begins to fail.
1206 Surgical Treatment of Tumours of Brain.
Grave responsibility rests upon the medical attendant who allows
a patient to become blind through optic atrophy due to tumour.
While the accessibility or inaccessibility of a brain tumour is the
main factor in the success of the operation, the nature of the
growth must also be considered, inasmuch as localised tumours
are easier of removal than vascular and infiltrating growths.
The fact should be strongly emphasised that syphilitic tumours
require to be dealt with surgically on precisely similar lines to
those which obtain in other forms of tumour. Valuable time is
lost in pushing anti-syphilitic remedies after the symptoms show no
sign of yielding at all. There are chronic syphilitic tumours that no
amount of mercury or iodide of potassium will cure. It is no un-
common event to see symptoms due to gumma continue to increase
while the patient is under syphilitic treatment. Surgical interfer-
ence is indicated where symptoms are increasing in spite of local
medicinal treatment, and where the localisation is exact. It is
impossible to lay down any hard and fast rule as to how long anti-
syphilitic treatment should be continued before having recourse to
surgical intervention ; but it may be said generally that when the
diagnosis and localisation have been arrived at, unless there is
very decided improvement in six weeks' time, operation should be
performed. Indeed, immediate operation is called for in those
cases where the symptoms are urgent, the risk to life being too
great to try medicinal measures. By the operative relief of urgent
symptoms time is gained for the subsequent use of anti-syphilitic
remedies.
The radical operation may be performed at one sitting or in two
steps, as a means of reducing the risk of death from shock to a
minimum. In the latter case the bone is removed or an osteo-
plastic flap turned down, and a week later the wound opened and
the dura attacked. This method, however, need not be followed
where the condition of the patient does not centra-indicate a one-
stage operation. The question of proceeding with the operation
may well be left to- the end of the first stage, the decision depending
upon the condition of the patient with reference to shock at the
time. The chief danger arises from interference with the respi-
ratory and cardiac centres, due .to pre-operative pressure on the
medulla or to post-operative oedema, resulting from the relief of that
pressure. Operation is useless when the heart has failed, but should
be attempted when respiration only is failing and the heart is
continuing to beat.
From the point of view of operation cases of brain tumour may
be divided into three classes : (1) Those in which the tumour is
Surgical Treatment of Tumours of Brain. 1207
completely removed and the patient cured ; (2) those in which it
is removed in part, with temporary benefit to the patient ; (3) those
in which the tumour cannot be removed at all, but symptoms are
relieved by a decompression operation.
The term " decompression " implies not simple trephining alone,
but the removal of a considerable portion of bone on one or both
sides of the cranium, together with the removal of the dura or the
free opening of it.
DONALD ARMOUR.
I2O8
DISEASES AND AFFECTIONS OF THE SPINAL
CORD.
CAISSON DISEASE,
THE treatment of caisson disease divides itself naturally into the
preventive and remedial measures.
Preventive Measures. The pathology of this disease is based
on the fact that, under increased atmospheric pressure, the fluid
tissues of the body absorb, through the lungs and the circulation,
increased quantities of air, the nitrogen of which is liberated in the
form of bubbles if the body is transferred too rapidly from the
increased pressure to normal conditions. If the transference, or
decompression, as it is technically described, is allowed to take
place slowly, the surplus gas is eliminated through the lungs with-
out the formation of bubbles. The formation of bubbles in the
tissues, particularly in those of the nervous system, is responsible
for the serious and not infrequently, fatal consequences of the
disease.
In order to prevent the evil effects of rapid decompression,
certain precautions must be taken. The higher the atmospheric
pressure under which a man works the shorter must be the length
of the shift. The process of decompression must be slow ; for
instance, twenty minutes must be allowed for every atmosphere of
pressure. According to Leonard Hill, the early stages of decom-
pression may be carried out rapidly, but an adequate time must be
spent in a " lock "at 18 to 20 Ib. pressure before returning to
normal atmospheric conditions. Finally, it has been shown that
men who are young, thin, wiry and in good health are less liable
to develop symptoms than those who are older, fatter or in any
way debilitated.
Remedial Measures. The only satisfactory method of dealing
with a case of the disease, when the symptoms are developing or
have only very recently developed, is rapid recompression. For
this purpose it is customary to provide " locks " on the surface,
where caisson work is being carried on, in order that the earliest
symptoms of the disease may be met by exposing the patient to
increased pressure. It is very necessary to remember that the
final decompression must be performed with great care so as to
avoid a recurrence of the symptoms. The fact that the onset of
Caisson Disease. 1209
the disease is sometimes delayed makes it desirable that men
who have worked under pressure should not be allowed to depart
out of reach of the recompression lock within an hour of their
ascent to the surface.
The treatment of cases in which recompression has not been
practised or only adopted too late, resolves itself into the relief of
pain and paralysis. The pain may be met by morphia if the state
of the patient's circulation and respiration permits, and the paralysis,
after a period of rest, may be influenced beneficially by a course
of regulated exercises and massage. In cases of severe paraplegia
the clinical aspect resembles that of myelitis, and general directions
with regard to the management of the bladder, bowels and skin
may be found in the article devoted to this condition.
E. FARQUHAR BUZZARD
I2IO
H^EMATOMYELIA.
THE treatment of haematomyelia naturally divides itself into that
of the acute stage and that of the stage of repair.
Acute Stage. Immediate and appropriate measures are of
supreme importance from the moment of the onset of symptoms,
which are usually rapid if not sudden in their development. For
this reason any case of sudden paraplegia following a slight or
severe strain or injury, or even occurring without apparent cause
in a healthy individual, should be regarded as possibly due to
spinal haemorrhage, especially if the signs point to the cervical
enlargement as the site of lesion. The patient must be removed to
bed with the greatest care, and, if possible, be given a hypodermic
injection of morphia before any necessary manipulations are carried
out. A water mattress, if possible, should be prepared at once.
The question of the patient's posture is probably of little import-
ance, although some authorities advocate a prone and some
a lateral position. Slight changes must be made with great care
from time to time in order to avoid pressure sores, and it is
probable that the patient will rest most comfortably aud effectually
if placed on his back to begin with, and afterwards tilted a little to
one side or the other. At this stage an injection of the liquor
ergotae hypodermica (10 min.) [U.S.P. ext. ergot., gr. J] may be
given, although its haemostatic" value in these cases can hardly be
taken as proved. Retention of urine must be anticipated and
catheterisation instituted before overflow incontinence leads to
soaking of the sheets and, what is more important, soaking of the
patient's skin.
The usual methods for preventing bedsores, rubbing the skin with
spirit and the free use of a non-irritating antiseptic powder (zinc
oxide 1, starch 2), with daily ablutions, should be employed from this
time onwards, instructions being given to the nurse that a minimum
of movement is essential. If acute pain is present the morphia may
be repeated and the patient should be warned that all voluntary
movements, sneezing, coughing, etc., are likely to be injurious.
Forty-eight hours may be allowed to elapse before the bowels are
opened by means of a gentle laxative followed by an enema. The
administration of sedatives and narcotics must be regulated by the
condition of the heart and respiration, especially in elderly persons,
Haematomyelia. 1211
in whom cardiac failure or hypostatic pulmonary congestion may
be feared.
The period of complete rest should not be less than six or eight
weeks, but after the first week the nurse may take each limb in
turn and perform gentle passive movements at the various joints
in order to prevent the formation of arthritic adhesions and to
guard against the rigidity which is likely to supervene. At the
same time she should take care that the position in which limbs
are placed is frequently varied, making use of sand-bags and pillows
for that purpose.
Stage of Repair. Two months having elapsed since the onset
of symptoms, it will probably be found that the extent of paralysis
has already diminished and measures directed to the promotion of
recovery may be undertaken with more freedom. The common
site of haemorrhage is in the cervical enlargement, and therefore
the majority of cases present atrophic palsy of the hands and arms,
together with spastic palsy of the trunk and legs. Massage and
galvanism should be used for the atrophied muscles and passive
movements of all four extremities continued daily. At the same
time the patient should be encouraged cautiously to attempt
voluntary movements on his own account and may undertake
regular exercises against graduated resistance offered by his
attendant. If the legs are spastic, only gentle rubbing should be
used for them, and electrical currents in these r/arts are better
avoided. Painful flexor spasms may be mitigated by the adminis-
tration of tincture of belladonna or tincture of cannabis indica in
10-min. doses, with an occasional dose of veronal at night. The
use of belladonna may also be beneficial if micturition is frequent
and precipitate.
E. FARQUHAR BUZZARD.
1212
MYELITIS.
IT is usual in writing an article on the pathology, sj'mptoma-
tology, etc., of myelitis to indicate different forms of the disease
according to their clinical or etiological features. In dealing with
the treatment of the disease, on the other hand, it is only necessary
to specify two varieties, the syphilitic and the non-syphilitic.
The treatment of the syphilitic cases includes the administration
of anti-syphilitic remedies as well as the general measures which
are applicable to all forms of myelitis and which form the subject
of this article. For the methods of administering anti-syphilitic
drugs, such as mercury, arsenic and the iodides of potassium or
sodium, the reader is referred to the article on Cerebro-spinal
Syphilis.
In considering the method of administering mercury it should be
remembered that parts which are quite anaesthetic are unsuitable
for inunctions or for deep injections, owing to the vulnerability of
the tissues.
Cases of myelitis which are non-syphilitic are uncommon and
are the result of infection of the spinal cord by various bacterial
organisms or their toxins. In some cases the particular organism
may be known or suspected because the disease in the spinal cord
has followed an infective process elsewhere. Thus, a typhoid
myelitis is recognised as a complication or sequela of typhoid fever.
In other instances the spinal lesion appears to be primary and
spontaneous, and, unless the causative organism is discovered in
the cerebro-spinal fluid by means of lumbar puncture, their
bacteriology remains obscure. Our knowledge of these cases is not
yet sufficiently far advanced for advantage to be taken of serum or
vaccine therapy in dealing with them. Generally the damage to
the spinal marrow is fully established and the acute stage almost
over before we are in possession of certain information as to its
bacterial origin.
On the other hand, it is important for the benefit of future
victims that in every case of myelitis lumbar puncture should be
performed and the cerebro-spinal fluid subjected to a most careful
examination.
Prophylaxis. So sporadic and uncommon is myelitis of the
non-syphilitic type that prophylactic measures can hardly be
Myelitis. 1213
specifically indicated in any particular individual. The mere fact
that so serious a disease may possibly follow or complicate any of
the acute infective fevers or any septic, focus in other parts of the
body should warn medical men against making light of these con-
ditions and should stimulate them to do all in their power, both to
increase the patient's resistance by careful attention to matters of
hygiene and diet and, secondly, to exercise a wise supervision
during the period of convalescence, guarding particularly against
injury or over-fatigue of the nervous system. A particular form of
myelitis has been described as occasionally associated with
pregnancy or the puerperium, but little is known about the
essential factors in its causation. It would be going too far to say
that the possibility of such a complication should present itself to
any one who has to deal with a pregnant woman or a confinement.
Prophylactic measures in syphilitic cases really resolve them-
selves into the efficient treatment of the primary chancre and is
discussed in the articles on Syphilis and Cerebro-spinal Syphilis.
TREATMENT OF THE ACUTE STAGE.
The premonitory symptoms of myelitis are usually too slight and
of too short duration to allow of any effective measures being taken
before the disease is fully developed, except in the case of the
syphilitic cases in which an alert physician may sometimes institute
mercurial treatment sufficiently early to render the attack abortive.
As soon as the diagnosis of acute myelitis is made, the patient
should be placed at rest on a water-bed and in charge of trained
nurses, either at home or in a nursing home or hospital. The
nursing of a case of myelitis cannot be entrusted to any but
experienced hands. Although rest is of great importance and
must be secured by forbid'ding any voluntary movements on the
part of the patient, a change of position should be made every
three or four hours by the nurses in charge. Although some
authorities, on theoretical grounds, advocate the placing of the
patient on his stomach, the writer does not believe that the supine
position has a harmful influence on the disease and is quite con-
vinced that prolonged lying in the prone position is unnecessary
and irksome. It is better to shift the patient at intervals, alter-
nating between the prone, supine and lateral positions. In this
way the nurse will find assistance in the prevention of bedsores,
and the patient will be less likely to suffer from the stiffness and
cramp produced by too long fixation in one attitude. Care must be
taken to see that the clothes and sheets in contact with the skin
are smoothed out, and it is generally advisable to provide a cradle
1 2 14 Myelitis.
at once in order to prevent the weight of bedclothes pressing upon
the paralysed legs, and so tending to excessive extension of the
ankles. The legs should be kept separate, but not allowed to lie
for long in a position of external rotation which they will tend to
assume if left uncared for. Well-padded sand-bags may be used
for maintaining desirable positions of the lower extremities.
Points of pressure, such as the sacrum, the trochanters, the ischial
tuberosities and the heels must be carefully watched and, if any
redness is detected, guarded by means of ring cushions, either
pneumatic or made of soft wool and smooth bandages.
The whole cutaneous surface must be washed two or three times in
the twenty-four hours and dried thoroughly with a soft towel. Parts
which are exposed to pressure should be rubbed for several minutes
with the palm of the hand moistened with spirit. The rubbing is
more important than the spirit and helps to prevent the formation
of bedsores by promoting the circulation in parts where there is
anaesthesia and vasomotor paralysis. After rubbing, the parts
should be dusted with a powder composed of equal parts of starch
and zinc oxide. In addition to the routine ablutions those
parts of the body which are exposed to soiling by evacuations from
the bladder or bowel must be carefully washed, dried and rubbed
whenever soiling occurs. In many cases evacuations are passed
without the knowledge of the patient and must be constantly looked
for by the nurse so that the skin does not become sodden.
The excretory functions of the patient claim immediate attention,
and if urine is not passed naturally the bladder must be emptied by
means of a catheter at regular intervals of six or eight hours. The
catheterisation must be done by someone who understands perfectly
antiseptic principles.
In the case of both male and female, patients a rubber catheter
should be used for choice and boiled before being passed. After
use it should be thoroughly washed in water and syringed through
with 1 in 40 carbolic lotion. It may then be dried or placed in a
bottle containing a solution of perchloride of mercury in glycerine
(1 in 1,000), or in 3 per cent, carbolic acid until it is required, when
it should again be boiled. The surface surrounding the urethral
opening should be swabbed with a mild disinfectant and the cathe-
ter smeared with carbolised vaseline before it is passed into the
bladder. The objection to the use of a glass catheter for female
patients suffering from myelitis only holds good when they are
subject to flexor spasms which may be excited by the passage of the
catheter and cause breakage of the latter in situ.
When a bed-pan or slipper is used it is always advisable for the
Myelitis. 1215
nurse to have one assistant, as it is difficult to place either article
in position without injuring the skin over the buttocks unless the
patient can be lifted.
When the vesical sphincter is paralysed and urine dribbles away,
a glass or porcelain urinal may be used by male patients, but the
anaesthetic glans penis must be carefully protected by soft pads of
wool from the liability to sores caused by pressure and friction
against the hard substance, and similar precautions must be taken
to prevent pressure upon the skin on the internal surface of the
thighs. With female patients it is best to place a large pad of some
absorbent wool, frequently renewed, in the perinaeum. A satis-
factory female urinal is not to be obtained, but a substitute can be
improvised by making a mackintosh envelope, which is filled with
wool and so placed that the triangular end is slipped under the
buttocks and the open mouth of the envelope kept in apposition to
the vulva. By renewing this whenever urine has been passed the
bed will not be soiled.
With regard to the bowels, an initial purge, such as calomel or
jalap, should be given early and subsequently an evacuation
secured every day, or every other day, by means of a dose of
cascara at night and an enema in the morning. If the anal
sphincter is relaxed a daily enema will probably prevent too
frequent soiling by thoroughly emptying the lower part of the
large intestine. In these patients there is often a tendency to con-
stipation and the formation of hard dry faecal masses in the colon
and rectum. Attention to the evacuations is indicated in order to
guard against this accident, and, if necessary, the rectum must be
cleared out by means of the inserted finger. In myelitis of the upper
dorsal region splanchnic palsy is sometimes a troublesome symptom
in the acute stages and may occasion discomfort and respiratory
embarrassment owing to the distension of the intestine by gas. This
may be relieved by means of turpentine stupes or may necessitate
the passage of a long rectal tube in order to allow gas to escape.
The question of drugs in cases of myelitis which are not
syphilitic in origin is of comparatively minor importance. Fever
is usually present at the outset, and the following mixture may be
given every six hours : Salicin., gr. 15 ; Spirit. ^Etheris Nitrosi, 5ss ;
Liq. Ammon. Acetat., 5J ; Aq. Camphorae, ad jj [U.S.P. *fy.
Salicin., gr. 15 ; Spirit. ^Etheris Nitrosi, 533 ; Liq. Ammon. Acetat.
oj ; Aq. Camphors, 51] ; Aquam, ad. jj] . It may be preferred to give
urotropin in 10-gr. doses at similar intervals on the ground that this
substance has a bactericidal influence on the cerebro-spinal fluid.
Pain in the acute stage is rarely severe enough to require more
I2i6 Myelitis
than a dose of phenacetin or phenazone, but morphia may be given
if the circulation and respiration are not interfered with by the
disease, as is sometimes the case in myelitis of the upper dorsal
and cervical regions.
Any tendency to bronchitis must be guarded against by avoid-
ance of exposure to chills, especially during the necessary ablutions,
and if catarrh develops, expectorants and stimulants may be ad-
ministered. A hypodermic injection of strychnine and atropine is
sometimes useful in these circumstances.
The writer does not advocate local treatment in the way of
cupping, the application of heat or cold to the spine, the use of the
actual cautery, etc., in the acute stage of myelitis. It is, to say the
least, problematical whether the disease is influenced in any way by
such measures, and it is certain that they entail considerable, and
probably unnecessary, disturbance of the patient. Unless great care
is exercised, moreover, there is always the risk of injuring the skin
and deeper tissues in regions which are trophically abnormal and
therefore prone to the formation of sores.
The diet should be that usually prescribed in acute fevers, milk
forming its chief constituent. Alcohol is better avoided, unless it
is indicated as a stimulant in the face of cardiac feebleness, when
strychnine or digitalin hypodermically are probably more suitable.
TREATMENT OF THE CHRONIC STAGE.
As soon as the patient's temperature has returned to normal and
there is no evidence of the disease making further progress, the first
duty of the medical attendant is to promote the recovery of those
parts which are paralysed. The measures which are necessary for
this end are not uncommonly neglected, with the result that the
patient develops osteoarthritic changes, muscular contractures, etc.,
which prove very obstinate to later treatment and materially hamper
his regaining the use of his paralytic limbs. Within a week of the
onset of symptoms the nurse should be directed to take each limb in
turn and perform gentle passive movements at all joints, as well as
gentle massage to all muscles. This should be done every day and
at the same time care should be taken that the limbs are not allowed
to remain fixed in any position for more than a few hours at a time.
As power begins to return more massage may be given and passive
movements carried out with greater frequency. At this period the
co-operation of the patient must be requisitioned and he must be
induced to force impulses, as it were, through the blocked lines. This
important part of the treatment may be encouraged by persuading
the patient to help in the performance of passive movements, and,
Myelitis. 1217
as the ability to do so increases, by offering regulated resistance to
his voluntary efforts. These measures are apt to be forgotten, the
patient relying too much on what may result from massage and elec-
trical treatment and too little on what he can bring about himself.
Spasticity of the lower limbs is one of the formidable troubles
resulting from myelitis above the lumbar region and for this reason it
is well to avoid applying energetic massage, electrical or stimulating
treatment of any kind to spastic parts. When spasticity is present
strychnine should not be administered, ergot and belladonna being
more suitable drugs in these circumstances. Painful flexor spasms,
which are common when spasticity is marked, are very difficult to
influence and particularly liable to interfere with the patient's sleep.
The spasms may be excited by contact with the overlying bedclothes,
so that the latter should be separated from the lower limbs by
means of a cradle. Light weights applied so as to keep the legs
extended are sometimes useful and it may also become necessary to
give such drugs as veronal, sulphonal or hydrobromide of hyoscine
to combat the reflex excitability of the spinal centres. In protracted
cases of the kind, in which no relief is obtained by these measures,
it is justifiable to consider the advisability of dividing a few of the
lumbo-sacral posterior nerve roots, but this procedure must not be
contemplated so long as there is reasonable hope of natural improve-
ment taking place.
Those parts which are the seat of atrophic flaccid palsy require
massage and electricity. That form of current should be chosen
which excites contraction of the paralysed muscles, and the treat-
ment should be carried out daily by someone who has the necessary
training, and continued so long as the response to electricity shows
that the damage to spinal centres is not irreparable.
During this stage cystitis may prove a troublesome and dangerous
complication even when every care has been taken in the way of
aseptic catheterisation. The inflammation of the bladder<must
be treated by means of irrigation once or twice daily, and the oral
administration of urotropin, boric acid, salol, etc. Good results will
usually follow washing out the bladder with a 4 per cent, solution of
boric acid, or sulphate of quinine in the proportion of 3 gr. to the
pint, and giving 5 gr. of urotropin with 10 gr. of boric acid three
times a day by the mouth. If symptoms of indigestion or diarrhoea
supervene, the boric acid should be discontinued, and it is often
advisable to change from one mild antiseptic lotion to another for
the purpose of irrigation, when the case proves intractable. In
performing irrigation the bladder should first of all be emptied and
then washed out until the returned fluid is free from turbidity.
S.T. VOL. ii. 77
I2i8 Myelitis.
Precipitate Micturition is a common residual symptom in
cases which have so far recovered as to be able to get about with
or without assistance, and it may be necessary to provide such
patients with some form of portable urinal. These are made of
indiarubber and can be obtained for either sex ; but in the case of
female patients who are unable to afford the expensive article, a
more or less satisfactory substitute may be found in a mackintosh
sponge bag, which can be filled with wool and slung in position.
Reference has already been made to the prevention of bedsores.
Unfortunately the latter may develop in spite of all precautions,
and every effort must be invoked not only to promote their
healing, but to discourage their tendency to spread and involve
the deeper tissues. As long as the skin is unbroken and only
reddening is present, further developments may often be prevented
by frequent rubbing, to which reference has already been made,
and by protecting the part from further pressure. A slight
abrasion may be treated either with boracic powder or boracic
ointment, but deeper sores require more serious attention. All
unhealthy matter and exudation should be swabbed or syringed
away with a peroxide of hydrogen lotion consisting of the official
solution mixed with equal parts of water. Having done this, the
sore should be plugged with lint soaked in a zinc sulphate lotion
(2 gr. to the ounce) and the edges of the wound rubbed dry with
spirit. A large sheet of dry lint may be placed over the whole
of the part, but it should be so adjusted that movements of the
patient will not lead to wrinkling or folds. Instead of plugging
with soaked lint, the sore may be tilled, after syringing, with
sorbefacin (a handy surgical dressing containing menthol, thymol
and boracic acid in a fatty basis) which gives very good results.
Such dressings must be renewed at frequent intervals.
When progress towards recovery appears to have reached a
standstill it is time to remove the patient to other surroundings
and the choice of the latter will naturally depend upon the
amount of locomotive power which he has regained. In the case
of well-to-do patients resort may be had to English or continental
spas, where a course of thermal baths and the change of air and
scene may have further beneficial results. Unfortunately, the
recovery from myelitis is often incomplete, and both patient and
doctor may have to be content with a condition in which the
ability to resume ordinary occupations is more or less impaired.
E. FARQUHAR BUZZARD.
1219
SYRINGOMYELIA.
THOUGH the cases included under syringomyelia form a definite
entity, their symptoms may be due to different pathological pro-
cesses. In one class the central cavity in the cord results from the
breaking down of a gliomatous tumour ; in another it is due to a
primary gliosis with secondary rarefaction.
As might be expected, therapeutic measures can have little
influence on the course of these lesions, so treatment must be
mainly symptomatic. There is considerable evidence that the
disease may set in after, or become aggravated by, traumatic
injuries to any part of the body, but especially to the vertebral
column, and the patient should consequently be warned of their
possible ill-effects. As the local trophic disturbances, such as
arthropathies, perforating ulcers and whitlows, may be excited by
local injuries, care should be taken to avoid them. The insensitive-
ness to painful and thermal stimuli increases the danger, since
trivial injuries that may lead to serious septic processes may be
unobserved and left untreated. When developed, these trophic
disturbances should be dealt with on ordinary surgical and
antiseptic principles. Even amputation may be advisable when
there is extensive destruction or suppuration of bone or other
tissues. Surgical intervention ia joint lesions is useless and
inadvisable.
The disturbances due to the atrophic palsies may often be
relieved by massage and faradisni of the muscles, while the
spastic symptoms should be treated by the ordinary means.
Belladonna and ergot are useful in relieving the flexor spasms
that occur in the more spastic cases ; veronal in moderate
doses is more efficient but less suitable for continuous adminis-
tration.
Gramenga, Raymond and others have recorded favourable
influence on the symptoms, as well as on the course of the
disease, from the application of Rontgen rays to the spinal
column. Beaujard and Lhermitte, who obtained excellent results
from this treatment, recommend the application of rays of
772
I22O Syringomyelia.
moderate strength once or twice a week to the spine. Touchard
and Fabre observed definite improvement following repeated
application of radium to the spine at the level of the chief medul-
lary disease.
GORDON HOLMES.
EEFEEENCES.
Eiv. Critica di Clin. Med., 1906.
Semaine Med., Paris, 1907, XXVII., p. 193.
Eev. Neurologique, Paris, 1909, XVII., p. 647.
1221
TUMOURS OF THE SPINAL CORD.
SPINAL TUMOUKS may originate in four situations :
(1) In the vertebrae, the cord symptoms being due to indirect
pressure.
(2) Outside the dura, between the outer surface of the dura and
the bone of the vertebral canal (extra-dural meningeal tumour).
(3) Within the dura mater, between the cord and the inner sur-
face of the dura (intra-dural meningeal tumours).
(4) Within the cord substance (intra-medullary tumours).
What is, however, understood by the term tumour of the spinal
cord is an extra-medullary but intra-spinal growth giving no evidence
of its existence, except by the symptoms of medullary pressure
which it produces.
Tumours of the fourth group, and most of those of the first group,
are unsuitable for surgical treatment, save for such treatment as is
directed towards relief of pain. In cases of tumour of the vertebrae
compressing the cord, operative treatment will not give permanent
relief, except in very rare non-malignant forms of growth.
The most practical classification of cases of spinal cord tumours
for clinical purposes is : (1) Medullary, or tumours of the cord ;
(2) extra-medullary, or tumours of any of the envelopes. This
classification is based on the seat of the tumour, irrespective of the
nature of the tissue from which it grows.
As regards treatment, too great stress cannot be laid on the im-
portance of early operation. It should be performed without delay,
as soon as the diagnosis is made.
Owing to the infrequency of gumma, it is even unwise to postpone
operation for the sake of trying anti-syphilitic treatment, if there
is no evidence whatever of the syphilitic nature of the tumour.
Delay in operating, in order to give a trial to an ti- syphilitic treat-
ment, may be the cause of an unsuccessful result when the
operation is finally performed.
For the successful operative treatment of spinal tumour, not only
is a correct differential diagnosis necessary, but the growth must
be exactly localised by a consideration of the upper limit of the
motor and sensory symptoms.
It is necessary to seek for the highest seat of the sensory and
paralytic symptoms and to refer them to the highest segment of the
1222 Tumours of the Spinal Cord.
cord which could be in question, and finally to ascertain the dorsal
spine which corresponds to the upper segment. Owing to the fact
that the tumour is found higher than is anticipated from the
symptoms, Bruns states that " if symptoms of a sensory nature
point to any one dorsal segment of the cord being pressed upon by
the tumour, the operation should expose the dorsal segment one or
even two levels higher."
With very few exceptions, it is impossible to determine the
nature of the tumour before operation. Gummata are very rare in
the spinal canal, and as before stated, it is never worth while to
delay operation for the sake of trying anti-syphilitic treatment. It
is only in syphilitic growths that medicinal treatment can be of
use, and here it is only in the early stages that such treatment can
be of value if employed at all. If used at all, syphilitic remedies
should be commenced at the earliest possible moment and pushed
with vigour. Operative treatment affords the only chance of relief
in other kinds of growth.
Tumours within the substance of the cord, excepting in rare
instances, cannot be removed without producing additional injury
to the cord. Fortunately, however, the greater number of spinal
tumours are extra-medullary.
All the evidence which we now have points to extreme repara-
tive power on the part of the cord, which has been simply suffering
from pressure, and to an almost equally remarkable tolerance of
operative interference.
It would seem proper, therefore, to conclude that every case of
focal spinal lesion, thought to depend upon a tumour, and not a
distinctly malignant and generalised disease, should be regarded
as amenable to operative interference, no matter how marked and
long continued the symptoms of pressure may be.
In cases which are hopeless as regards the restoration of func-
tion, it should be considered whether it may not be advisable to
operate merely for the relief of pain, even when there is no hope of
restoring the function of the damaged cord. The pain in some
cases is excruciating, and the sufferings of the patient are intense.
In such cases an operation with a view to the removal of the
source of irritation, or to the section of the posterior spinal roots
affected, should be considered.
Medicinal treatment can only be directed towards making the
patient comfortable and preventing many secondary consequences,
such as cystitis and bed-sores. To relieve the pain, resort must be
had to anodynes. The greatest attention should be paid to the
bladder in order to prevent the development of cystitis and its
Tumours of the Spinal Cord. 1223
consequences, and an equal amount of attention should be given to
the prevention of the formation of bed-sores. Should the forma-
tion of bed-sores take place, ordinary surgical measures should be
employed to keep them clean and prevent septic absorption.
Operation. The operation for the removal of spinal tumours is
that known as laminectomy or rhachiotorny.
The description given here is based upon the operation as
performed by the writer, though doubtless it differs in no essential
detail from other surgeons' methods.
The patient is prepared in the usual way for major operations.
Should a bed-sore be present, it is sealed up under antiseptic
gauze, and covered with a large piece of adhesive plaster. If the
incision is to be placed in the cervical region, the scalp is shaved
and carefully cleansed behind a line joining the two pinnae across
the vertex.
Chloroform anaesthesia is induced by means of a Vernon Harcourt
inhaler, and oxygen is administered during the operation as
indicated by the condition of the pulse, respiration, and the blood.
The patient lies upon his right side, with his back arched close
to the edge of the table and his knees flexed, the upper one lying
in front of the lower. This position is maintained by flexing the
upper arm at the elbow and placing the hand palm downwards
upon the table just in front of the body ; the arm is steadied in
this position by a nurse, who stands in front of the patient. A
specially devised arm-rest, fixed to the table, may be employed.
By either of these devices not only is the patient prevented from
rolling over on to his face, but interference with respiration is
reduced to a minimum.
The first assistant stands on the same side of the patient as the
operator, facing the patient's feet. A second assistant stands on
the opposite side of the patient. His duty is to hold the upper
retractor in the wound when required.
An incision 4 to 6 inches in length is then made in the
middle line of the back, with its centre over the segment of the
spinal cord it is desired to expose.
The incision is carried at once down to the tips of the spinous
processes. The knife is then carried along the lower sides of the
spinous processes, cutting through close to the bone all muscular
and tendinous attachments, until the laminae are reached.
A broad raspatory is then used to clear the muscular mass off
the posterior surface of the laminae. No attempt is made to catch
any vessels with artery forceps. The bleeding is almost entirely
venous. An} 7 endeavour to seize the vessels with artery forceps
1224 Tumours of the Spinal Cord.
only tears or bruises the muscular tissue amongst which they lie,
and gives rise to necrosis afterwards. Moreover, much valuable
time will be wasted.
The bleeding is readily and certainly stopped by packing the
wound with gauze taken from boiled water at 115 F. Exactly
the same procedure is carried out upon the upper side of the
spinous processes. By the time that the upper laminae are cleared
and this part of the wound packed, the bleeding will have been
entirely checked below. As soon as the wound is dry, the skin
and muscle mass are retracted, and three or four spinous processes
are cut through at their bases by means of bone forceps, and removed.
The processes selected are those of the vertebrae, the laminae of
which it is intended to remove. Then the laminae are cut through
as far out as possible on either side by bone forceps and removed.
The outer surface of the dura mater is then exposed by gently
scraping or pushing aside the loose fatty areolar tissue covering it.
The presence or absence of pulsation is ascertained. A careful
examination is then made to ascertain if the tumour is extra-dural.
The dura is gently displaced first to one side and then to the
other, and its lateral aspects, together with the issuing nerve roots,
examined.
By means of a long blunt probe or seeker, the anterior surface
is also explored upwards and downwards. Having convinced one-
self that the tumour is not extra-dural, the dura mater is opened
along its posterior middle line and the cut edges retracted to either
side.
For this purpose the cut edge may be seized on either side by
means of angular forceps. The cord is then carefully examined
much in the same way as the spinal canal was. When found, the
tumour is removed as its situation and connections demand. In
one case it will shell out, in another it will be firmly adherent
to the dura, or to one or more nerve roots which may have to be
sacrificed.
Should it be intra-medullary, the question will arise as to
whether an attempt should be made to remove it or not. Each
case must be judged on its merits. The general aspect of the
subject has been already discussed.
On removal of the tumour, the dura, if opened, is stitched up by
a few fine catgut or horsehair sutures. The muscles are then
brought together by catgut sutures, and finally the skin is closed by
interrupted silkworm-gut sutures. A drain is rarely necessary, but,
if required, a small gauze wick covered with protective tissue may
be left in for twenty-four hours.
Tumours of the Spinal Cord. 1225
Should the tumour not be discovered in the""area of the cord and
meninges exposed, it may be considered advisable to remove one
or more laminae, usually in an upward direction, to give further
exposure. This will depend upon the condition of the cord with
reference to pulsation at the seat of exposure, and also upon the
symptoms upon which the diagnosis has been based.
An abundance of gauze dressings are applied, covered with wool,
and the whole retained in place by a many-tailed bandage. No
splint of any kind is required.
The patient is placed flat on his back in bed, with his head
slightly raised, or if the operation has been in the cervical region,
supported between sandbags. It is advisable to have recourse to
a water-bed in most cases.
The dressings are changed at the end of twenty-four to forty-
eight hours, and as often afterwards as the comfort of the patient
demands. The stitches should not be removed for at least ten
days or a fortnight.
In cases in which there occurs a leakage of cerebrospinal fluid
through the wound, urotropine (in 10-gr. doses) should be adminis-
tered three times daily, and every precaution taken to prevent
infection of the wound, by frequent dressings under strict aseptic
precautions. The recumbent posture should be maintained for at
least six weeks, with such slight alterations in position as may add
to the comfort of the patient.
During this period massage, passive movements and electrical
treatment should be employed to maintain muscular nutrition and
prevent the formation of contractures.
DONALD ARMOUR.
1226
VASOMOTOR AND TROPHIC DISEASES.
ACROMEGALY.
IN this affection, as its name implies, there is considerable
enlargement of the extremities and also of many parts of the face,
such as the lower jaw, the brows, the malar eminences and the
nose. It is especially prone to develop in individuals who are above
the normal height, and quite a large proportion of giants are
acromegalic. The symptoms probably depend on some functional
alteration of the pituitary gland, where in many of the cases gross
anatomical changes have been found. The changes consist in the
gland being greatly increased in size, mostly due to sarcomatous new
growth, so that an intra-cranial tumour is formed, which raises the
intra-cranial pressure and leads to intense pain and vomiting. From
its situation the tumour presses on the optic chiasma and causes
blindness on the nasal side of each retina, bi-temporal hemianopsia.
The treatment depends on whether the proper symptoms of
acromegaly exist alone, or whether they are accompanied by signs
of a tumour in the sella turcica. In the absence of symptoms
suggesting the existence of a tumour, there is little to be done in
the way of treatment. Some patients are able to pursue their
ordinary avocations without any special discomfort beyond the
purchase of larger hats, gloves and boots. Others suffer from
muscular weakness, and, if poor, tend to drift into the workhouses.
Experiments have been made with the administration of pituitary
and thyroid extracts, but neither seem to have any real influence
over the complaint, though some cases have been said to improve
while taking extracts of the thyroid gland. The other class of
patients where there is evidence of a tumour calls for instant
treatment, since they suffer from visual defects and intense pain in
the head, and there is a probability of their early death. As pointed
out by Sir Victor Horsley, the only satisfactory treatment consists
in the removal of the tumour by the knife, and there should
be no delay in calling for the surgeon's aid. Unfortunately com-
plete ablation of the pituitary gland in arn'mals always leads to
death ; there is not sufficient evidence as to its effect in human
beings, but it is unlikely that they would differ from animals.
Achrondroplasia. 1227
Short of removal of the tumour the treatment can he merely pallia-
tive, the pain being deadened as far as possible by such drugs as
phenacetin, phenazone and morphia.
ALFRED M. GOSSAGE.
REFERENCE.
Hoisley, Sir Victor, Brit. Med. Journ., 1906, I., p. 323.
ACHRONDROPLASIA (CHRONDRODYSTROPHIA
FCETALIS).
OWING to a defective development of cartilage there is in this
disease a deficiency in the length of the long bones of the limbs
compared with the trunk. The humeri and femora are specially
affected. The hands take on a characteristic shape, which has been
called the " trident hand," and there is also a shortening of the
base of the skull, which causes a marked depression at the root of
the nose. The condition has been called foetal rickets, since it is
already manifest at birth ; but, although several of the affected
infants become rickety later on, there is no real connection with
rickets. In the majority of cases the children are born dead or die
shortly after birth. A certain proportion, however, survives, and
except for the deformities the survivors are not inferior, mentally
or physically, to normal children. The complaint cannot be
influenced by treatment.
ALFRED M. GOSSAGE.
1228
ANGIONEUROTIC CEDEMA.
IN this condition there is a tendency to the development of
cedematous patches on the skin and mucous membranes, the patches
varying in size from that of a hean up to an area as large as the
palm of the hand. The oedema appears in attacks lasting several
days or weeks, and the intervals between the attacks vary from
a few days to some months or even years. Each patch of oedema
lasts only a few hours, but the attack is continued by the successive
appearance of fresh patches in different parts of the bod} r . The
oedema shows itself especially on exposed surfaces, such as the face or
hands, but may also affect the covered parts of the trunk. Impli-
cation of the mucous membranes may lead to difficulty in speaking
or eating from the enormous swelling of the lips or tongue ; diffi-
culty of swallowing from swelling of the pharynx ; urgent and even
fatal dyspnoea, from involvement of the larynx. The mucous mem-
branes of the abdominal viscera are not always spared, colic and
vomiting resulting when the stomach is attacked, and intense
abdominal pain and diarrhoea when the small intestine is implicated,
so that in several cases abdominal section has been performed from
the mistaken diagnosis of intussusception. The disorder is often
hereditary, and has sometimes been traced back through many
generations ; but as far as can be judged from the recorded families,
it seems only to pass through individuals who themselves exhibit
the liability, so that normal members of an affected family may be
assured that they are not likely to transmit it to their descendants.
The fluctuating and temporary character of the oedema, as well
as the irregular and often protracted intervals between the attacks,
render the proper estimation of the effect of treatment very difficult.
Of first importance is attention to the general condition of the
patient. The sufferers are frequently highly neurotic individuals,
showing symptoms of hysteria, and to a still greater extent of
neurasthenia. With improvement of the general health the ten-
dency to oedema often disappears, hence freedom from worry, open-
air life, hydrotherapy, general massage and electricity may all be
of the greatest benefit. It seems possible that some of the cases
are due to intestinal intoxication ; at any rate, several cures have
been reported after the use of intestinal disinfectants, such as
aspirin, menthol and camphor. Unlike the closely allied condition
Angioneurotic (Edema. 1229
of urticaria, particular articles of diet do not seem to have any
influence in causing the development of the oedema, but fish and
strawberries have been reputed to have a causal relation in one or two
patients. If any aliment be discovered to have a malign influence,
it should, of course, be avoided. The number of drugs that have
been recommended for use is enormous, chiefly on account of ex-
perience in individual cases, but on wider trial most of them have
been found useless. Sir \V. Osier says that the only drugs which he
has found of benefit have been nitroglycerine (or the nitrites) and
calcium. The former he prescribes in ascending doses until the
effects are felt, viz., flushing of the face and throbbing of the vessels.
The treatment should be continued for ten days, and then an interval
of five days allowed, after which it should be re-commenced.
Calcium may be prescribed as 15 to 20 gr. of the lactate three
times a day. It has been reported to have benefited several cases ;
but the writer obtained no result from it in two patients, and others
have had a similar experience. Purin-free diet and a diet with a
very limited amount of carbohydrates have both been recommended,
and both seem to have been of value in some cases and quite useless
in others.
The severer conditions associated with oedema of the mucous
membranes often require active treatment. Fortunately, however,
the local oedema only lasts a few hours. Gastric or intestinal
oedema may simulate intestinal obstruction, but will never require
operation, and the pain may usually be relieved by hot stupes.
If this is not successful, a hypodermic injection of morphia will
become necessary. (Edema of the larynx may necessitate local
scarification or tracheotomy to save life. The tendency for the
development of this dangerous complication is much greater where
the condition is hereditary, and must always cause grave anxiety in
this class of patients.
ALFRED M. GOSSAGE.
EEFERENCES.
Osier, Sir W., Osier and McCrae, "System of Medicine," 1909, VI., p. 648.
Cassirer, "Die Yasomotorish-Trophischen Neurosen," Berlin, 1901.
1230
ERYTHROMELALGIA.
THIS is a rare but excessively painful affection, characterised
by hypersemia of one or more extremities, which is probably due
to some disorder of the vasomotor mechanism, resulting in a dila-
tation of the arteries of the affected area. During an attack the
extremity becomes bright pink in colour when dependent, and is
the seat of excruciating pain and tenderness ; but on raising it
above the level of the trunk the pink colour almost entirely dis-
appears, and the distressing symptoms are much relieved. The
course of the affection is very chronic, lasting many months or
years, and being but little influenced by treatment. At first only
a small portion of the extremity is attacked, but gradually the
redness invades a wider and wider area, until, for instance, the
whole lower limb may be involved as high as the knee. The condi-
tion may then remain stationary for a long period. Subsequently
it may gradually recede until complete recovery takes place ;
or some degree of the affection may remain permanently, or, at any
rate, until the cases are lost sight of. In many typical examples of
erythromelalgia no evident pathological changes have been found,
but in several recent cases thickening of the arteries has been
described, while similar symptoms are not so very uncommon in gross
disease of the nervous system, whether of the spinal cord (such as
syringomyelia), of the brain (as hemiplegia), or of the peripheral
nerves. Generally the distribution of the hyperaemia has no rela-
tion to the nerve-supply of the part, but in rare cases it has been
limited to the distribution of a single nerve.
In dealing with the complaint one has to remember its chronic
course, and the tendency sometimes exhibited for the patients to
get gradually well without any treatment. It is doubtful whether
the duration of the complaint has been actually shortened by any
method of treatment ; but since some sufferers seem to have been
relieved by certain measures, these should be given a trial, even
although they have proved ineffectual with others. Naturally in
such an obstinate disorder the number of remedies which have been
tried has been almost innumerable. The main consideration is to
relieve pain, the severity of which is often terrible. The dependent
position and exertion nearly always increase the hyperaeniia and
pain, so the patient should be kept lying in the horizontal position
Erythromelalgia. 1231
with the affected extremity, usually a foot, raised ahove the level of
the trunk on pillows ; but owing to the lengthy duration of the
complaint the patient frequently refuses to endure this for longer
than a few months. Cold applications, such as icebags or bathing
with cold water or salt and water, usually afford some relief to
the suffering, while warmth, as would be expected, increases the
hyperaemia. In exceptional cases, however, warm baths or even
radiant heat have proved beneficial, and sometimes cold has
aggravated the symptoms. In this connection it is of interest
to note that erythromelalgia tends to attack those persons whose
extremities are constantly exposed to wet, such as washerwomen
and men who with defective boots have to tramp the streets in all
weathers.
As in Raynaud's disease, the employment of electricity has been
advocated, both the constant current and faradisation. The most
efficacious method seems to be the immersion of the affected part in
fanidic baths for from fifteen to twenty minutes daily. Pain can
sometimes be assuaged by the application of the anode of the con-
stant current to the painful area, the kathode being on some
indifferent part. It must be realised that the measures indicated
not infrequently fail to give complete relief, and the administra-
tion of anodyne drugs becomes imperative. Phenazone, phenacetin
and aspirin should first be tried ; but if these fail to diminish the
pain, opium or morphia must be resorted to. Where the pain and
redness are confined to the distribution of a single nerve a portion
of its trunk may be excised if other means are of no avail.
ALFRED M. GOSSAGE.
REFERENCES.
Mitchell, 8. Weir, and Spiller, W. G., Amer. Journ. of Med. Sci., Phila., 1899,
CXVIL, p. 1. Cassirer, " Die Vasomotorisch-Trophischen Neurosen," Berlin,
1901. Osier, Osier and McCrae, " System of Medicine," 1909, VI., p. 675. Barlow,
Allbutt and Rolleston, "System of Medicine," 2nd edit., 1910, VII., p. 149.
1232
FACIAL HEMIATROPHY.
FACIAL HEMIATROPHY is a rare disease, and its pathology, not-
withstanding the fact that several autopsies have been recorded,
is still uncertain. Hence its treatment remains symptomatic and
empirical. As a rule, the atrophy is chiefly limited to the skin and
subcutaneous tissues ; the muscles themselves are not paralysed
and are sometimes only slightly atrophic. The appearance pro-
duced often closely resembles scleroderma, with which condition,
indeed, it may be associated.
Electrical treatment with the interrupted current may be tried,
but the muscles will be found to react well to it, while its effect on
the atrophic cutis is problematical. Local massage systematically
carried out is probably advantageous. Rubbing the affected parts
with oils or liniments may be useful. Injections of tibrolysin in
the neighbourhood of the atrophic area might possibly be attended
with good results. The appearance of the patient's face may be
improved by paraffin injections (Osier and Macrae).
General nerve tonics may be administered empirically. Walker
thinks he has seen improvement in cases of scleroderma from the
exhibition of thyroid substance, and it might be given a trial in
facial hemiatrophy.
S. A. KINNIER WILSON.
KEFERENCE.
Aldren Turner, article in "Allbutt's System of Medicine," 2nd edit., 1910,
VII., p. 167 (bibliography).
1233
HYPERTROPHIC PULMONARY OSTEO-
ARTHROPATHY.
THIS- is. ai. condition which occasionally arises in the course of
chronic ehest diseases, especially of a septic nature, such as
bronchiectasia or empyenia. It is characterised by an enlargement
of the bories of the limbs due to deposit from the periosteum. The
bones chiefly implicated are those of the forearms, hands, and
fingers, and of the legs and feet, in the case of the longer ones
mainly at their distal extremities. In addition there is always a
good deal of thickening of the connective tissue, which is the cause
of the associated clubbing of the fingers and toes. The joints, too,
;uv sometimes attacked, the synovial membrane being thickened,
occasionally with effusion of fluid. There is usually some pain in
the affected parts, which becomes more severe in paroxysms. The
condition is probably due to septic absorption, and can only be
ameliorated by measures which render the pulmonary discharges
aseptic, or which bring the suppurative process to an end, as by
free drainage of an empyema. Any pain that arises may be
relieved by warm local applications, or sometimes by such drugs as
salicylate of soda.
ALFRED M. GOSSAGE.
REFERENCES.
Marie, P., Rev. de Med., Paris, 1890, X., p. 1. Alexander, J. F .,St. Bartholo-
mew's Hospital Reports, Lond., 1906, Vol. XLIL, p. 41.
S.T. VOL. II.
78
1234
INTERMITTENT CLAUDIC ATION ; INTERMITTENT
LIMP.
INTERMITTENT CLAUDICATION (Charcot), or intermittent limp (Erb 1 ),
is regarded, in the great majority of recorded cases, as being due
to obliterative arteritis, or arteriosclerosis, of the smaller vessels
of the limb or limbs affected. The condition may be produced,
however, by mechanical or other pressure on one of the main
arterial trunks of the limb at a higher level, while Harris
has seen a typical case follow popliteal thrombosis. It is not
necessarily confined to the lower extremities, hence "dyskinesia
angiosclerotica " has been proposed as a more comprehensive
term. Recently, too, intermittent claudication of the spinal cord
has been described by Dejerine 2 ; according to him the process
is one of " meiopragia " of part of the cord, that is to say,
insufficient irrigation by the blood stream. The symptoms are
similar to those which characterise the peripheral condition, but
peripheral vessel changes are conspicuous by their absence.
Treatment, to be successful, must be directed to two objects,
viz., the underlying pathological condition, and its varying expres-
sion ; it must, in a word, be both causative and symptomatic.
(1) The treatment of obliterative arteritis or local arterio-
sclerosis is a large subject, and the following remarks are intended
merely to indicate the best methods (see also Arteriosclerosis).
(a) Many cases are syphilitic, but whether this is so or not
energetic antisyphilitic treatment should be adopted without fail.
The results are often remarkable. Mercury should be given by
inunction (the oleate is useful) and the iodides by the mouth.
Sodium iodide is preferable to the potassium salt, as more likely
to reduce tension and less likely to cause atheroma. It may be
given in small doses, not more than 10 gr. three times a day,
for three weeks at a time, and then with a break of one week. The
writer can testify to the value of iodipin (hypodermically or in
capsule). Teissier 3 recommends iodalose (a combination with
peptone). Sodium bicarbonate is an excellent drug for reducing
hypertension ; the dose need not exceed 60 gr. in the twenty-
four hours. For more rapid action it is advisable to resort to
the nitrites : Liq. trinitrini [U.S.P. spiritus glycerylis nitratis] in
minim or | -minim doses, three times a day, or sodium nitrite (2 gr.),
Intermittent Claudication ; Intermittent Limp. 1235
or erythrol tetranitrate, in |-gr. tabloids. Other antispasmodics,
such as belladonna or the bromides, may be helpful. Mistletoe
has been much vaunted recently. Potain thinks that manganese
carbonate (3 to 5 gr. a day, in pill, for a long time) tends to soften
rigid vessels.
The artificial inorganic serum of Trunecek has had a mixed
reception, but there seems to be little doubt that in certain cases its
hypotensive action is astonishing. Its composition is : Sodium
sulphate, '44 parts ; sodium chloride, 4'92 ; sodium phosphate, '15 ;
sodium carbonate, "20 ; potassium sulphate, *40 ; distilled water to
make up 100. Trunecek gives 1 cc. hypodermically, then four
days later 1J cc., then 2^ cc., and so on. Levi injects 1 cc.
additional every second day. Teissier 3 recommends an analogous
powder in cachet every morning for thirteen consecutive days.
(/>) Suitable dietetic treatment is of preponderating importance
in the cases under consideration. Put very briefly, the introduction
of noxious substances must be reduced to a minimum, and their
regular elimination must be encouraged. Alcohol is harmful.
Tobacco should be forbidden, unless denicotinised (sec generally
under Arteriosclerosis).
(c) Gaseous or effervescent baths are of proven value. On the
amount of carbonic acid in the water, the temperature and duration
of the bath, and the degree of activity of its constituents, depends
its hypertensive or hypotensive effect. The merit of the method
is the achievement of peripheral depression without acceleration of
cardiac action (see generally under Hydrology).
(d) The high frequency current may appear to have fallen from
its high estate into unmerited disrepute, for many convincing
clinical records have been published of its efficiency in reducing
hypertension. Only such cases should be submitted to the treat-
ment as are likely to benefit by it ; aortic and cardiac and coronary
cases are unsuitable. The large solenoid of d'Arsonval, inside which
the patient is placed, is the best apparatus, but few installations are
supplied with it. A seance should not last longer than five or six
minutes as a rule.
(c) Much will depend, in cases of intermittent claudication, on
the patient leading a quiet life, with regular but gentle brain and
muscle exercise, moderation in all things, that is to say, on the
intelligent maintenance of a hygienic regime that does not degenerate
into valetudinarianism.
(2) The more definitely symptomatic treatment of the disease
may briefly be noticed. Hot foot baths or body baths, followed
by massage, often relieve temporarily. Galvanism to the lower
782
1236 Leontiasis Ossea.
extremities is very useful. Galvanic baths are of considerable
value, especially where definite vasomotor symptoms bulk largely
in the clinical picture. Hot air baths, too, may reduce circulatory
embarrassment. By these means attacks of angina cruris can often
be moderated. The physiological value of rest in this connection
cannot be over-estimated.
Whether surgical procedures, such as arterio-venous anastomosis
or nerve-stretching, are of any value it is at present impossible
to say.
S. A. KINNIER WILSON.
REFERENCES.
1 Erb, W., " Deutsche Ztschr. fur. Nerveiiheilk." Leipz., 1905, XXIX., p. 465,
ibid., 1906, XXX., p. 201.
- Dejerine, J. , " Eevue Neurologique," Paris, 1906, XIV., p. 341.
8 Teissier, J., " Artrio-sclerose et atheromasie," Paris (Masson), 1908.
LEONTIASIS OSSEA.
VIECHOW first called attention to this condition, which is caused
by a hyperostosis of the bones of the face and skull. It is some-
times associated with Paget's disease (osteitis deformans), but more
commonly the bony increase is confined to the head. It usually
starts in late childhood and progresses slowly : during its course
the various grooves and hollows of the skull are filled up with bone,
so that the eyes are forced from their sockets, nerves are compressed
in their grooves and foramina, and ultimately paralysed, and the
vessels are constricted by surrounding rings of bone. Eventually
the patient becomes blind, deaf, mentally deficient, and generally
paralysed. Convulsions sometimes occur. No treatment seems to
have any power to arrest the progress of the disease or to avert the
unhappy conclusion. In the early stages anti-syphilitic remedies
should be tried on the chance of the symptoms being of syphilitic
origin, and attempts should later be made to alleviate the pain
(caused by pressure on the nerves) by phenazone, phenacetin, or
morphia.
ALFRED M. GOSSAGE.
1237
OSTEITIS DEFORMANS (FACET'S DISEASE).
THIS is a disease of obscure causation, in which the bones are
enlarged and softened so that the limbs become curved, the spine
bent forward, and the skull thickened. It starts in middle life, and
is usually associated with arterio-sclerosis, but in itself does not
seem to influence the patient's general health, the most marked
characteristics being shortening of the stature and deformity of the
limbs. The course of the complaint is slow r ly progressive, and
cannot be altered by any treatment. There is usually some pain in
the limbs, which can be best relieved by counter-irritation of the
skin and the internal administration of such drugs as quinine or
phena/one. Some French writers regard the disease as a late effect
of congenital syphilis ; but the evidence in favour of this view
is not strong, and the condition is not in the least benefited by
anti-syphilitic drugs.
ALFRED M. GOSSAGE.
REFERENCE.
Paget, Sir J., Med. Chirurg. Trans., Lond., 1882, LXV., p. 225.
OSTEOGENESIS IMPERFECTA.
A LARGE number of the infants afflicted with this disorder are
born dead, with their limbs considerably deformed by intra-uterine
fractures. The condition is a congenital one, in which the bones are
brittle and easily broken. Of the patients born alive most die in
infancy, but some survive up to adult life. The liability of the
bones to fracture gradually diminishes with advancing years, but
does not seem to be influenced by any method of ifreatment. In the
management of these cases it is important to protect them as far as
possible from injuries. Numerous fractures are certain to have
occurred before the child is seen, and even with the greatest care
others will take place. These must all be carefully set to avoid
severe deformities.
ALFRED M. GOSSAGE.
REFERENCE.
Nathan, P. W., Amer. Joura. of Med. Sciences, Phila., 1905, CXXIX., p. 1.
I2 3 8
RAYNAUD'S DISEASE,
IN 1862 Eaynaud called attention to a condition which was
characterised by attacks of (1) anaemia of the extremities : fingers,
toes, ears, etc., evidently caused by spasm of the arteries supplying
the parts ; (2) cyanosis and swelling, which usually followed the
attacks of local anaemia, but might occur independently of them ;
(3) gangrene of portions of the extremities. Both local syncope
and local asphyxia, as Eaynaud called them, as a rule, precede the
gangrene, and the latter only supervenes when one or both of these
have been severe and long continued. While the anaemia seems
clearly due to arterial spasm, the causation of the local cyanosis is
more obscure ; but there is probably a regurgitation of blood from
the veins, while the arteries still remain constricted and the
circulation in the affected region is at a standstill. Both anaemia
and cyanosis are associated with a decrease of local temperature,
and may be accompanied by some alterations of sensation, such as
slight anaesthesia, tingling and burning feelings, and very frequently
severe pain. The degree of pain is independent of the amount of
vascular change, and hence has been regarded by many authors as due
to some special involvement of the nervous system. The paroxysms
last from a few hours to several days, and in the intervals the
patient is well except for the results of the last attack (e.g., loss of
tissue from gangrene). In some cases the attacks are associated
with epileptic seizures, probably caused by spasm of the cerebral
arteries. In others, especially those with a history of malaria,
haemoglobinuria develops, following haernoglobinaemia.
The common c^yanotic swelling of the hands, which occurs in
many people during cold weather and is associated with chilblains
is not a paroxysmal affection and has no connection with llaynaud's
disease ; neither is the "dead finger,'' induced by cold and
disappearing with friction and warmth, necessarily a sign of this
complaint, although excessive cold may produce in the form of
frostbite all its phenomena. It is true that the paroxysms of local
syncope and asphyxia are more likely to develop in cold weather,
but they may occur in any season, and indeed may be induced by
the application of heat, such as washing the hands in hot water.
In the treatment of Eaynaud's disease we are confronted with
several problems. We wish to relieve and cut short the attack from
Raynaud's Disease. 1239
which the patient is at the moment suffering, and next we desire
to prevent, if possible, further attacks. The methods of treatment
may be divided into the general and the local. Sufferers are often
of the neurotic temperament, victims of hysteria and neurasthenia,
added to which there seems a greater liability to the paroxysms
when the general health is poor.
Hence attempts should always be made to improve the general
condition, both physical and mental, by such measures as open-air
exercise, hydrotherapy, electricity and massage. In many of the
neurotic class mental worry is a direct excitant of an attack, so
that they should be protected as far as possible from anything that
is likely to cause emotional disturbance. The greater frequency
of the paroxysms in winter and on exposure to cold, particularly
damp cold, suggest that the winter should be spent in a dry warm
climate, such as Egypt or Algiers. The garments should be warm
and of wool, and care should be taken on cool days to clothe the
extremities with loose warm coverings, such as woollen socks and
gloves. It is advisable also to cover the skin with some fatty
preparation. Since the condition is due to a paroxysmal narrowing
of certain blood vessels, one would expect that the vasodilator drugs,
like the nitrites, nitroglycerine, etc., would cut short an attack.
Occasionally their exhibition seems to have been successful, but in
the majority of cases where they have been tried they have had no
effect on the local vascular contraction.
Although there can be no doubt that some central defect is the
cause of the peripheral manifestations of the disease, yet empirically
we find that much more can be done for the patient by purely
local treatment than by general measures. Means which bring
about a local dilatation of the arteries not only tend to relieve an
actual attack, but if persisted in during the intervals seein to have
a considerable influence in preventing recurrences. Of such means
massage comes first. Massage of the extremities, including friction
of the fingers and toes from below upwards, induces an active
hypeni'inia with rapid blood flow. Such massage should be per-
formed daily for from ten to twenty minutes, care bei ng taken that
it is thorough, and persisted in for many months after the last
paroxysm. The employment of electricity has always been advo-
cated, and Raynaud himself advised the passage of a galvanic
current down the back over the spinal column, and also that the
affected extremities should be treated with the constant current.
Further experience has led to the abandonment of the application
of the current to the spine and to its limitation to the affected
parts. The best method is that advocated by Barlow in the form
1240 Raynaud's Disease.
of the electric bath. Here one electrode is placed on the back and
the other in a bath of salt water, in which the affected extremities
are immersed for about fifteen minutes daily ; meanwhile a slowly
interrupted constant current is passed, as strong as the patient can
bear, and at the same time he is encouraged to move the fingers or
toes. After the bath the limbs should be massaged. This treat-
ment will often relieve a slight attack, and, if continued over a long
period, may prevent recurrence.
Probably the most efficacious method of putting an end to an
actual paroxysm is that suggested by Gushing. A Martin's rubber
bandage is applied to the limb as if to prepare it for a surgical
operation, and then a tourniquet kept on for several minutes if the
patient can bear the pain. Following the release of the tourniquet
there is a vasomotor paralysis and the diseased part is flushed with
arterial blood. There seems no reason why in case of necessity
this treatment should not be carried out when the patient is under
an anaesthetic.
In many cases pain is excruciating and prevents the proper
application of the above methods of relief. The administration of
morphia or opium may then become an absolute necessity, but it
must not be forgotten that in several examples of this disease the
morphia habit has been developed. It is advisable, therefore, to
try at first the effect of phenazone or phenacetin. Eadiant heat
has sometimes helped in the relief of pain, and also been efficacious
in hastening the termination of an attack; it may thus be
employed when the patient cannot stand more painful methods
of treatment. Warm baths and hot opium stupes should also be
tried. During all but the mildest paroxysms the sufferer should
be kept in bed at an equable temperature while more energetic
attempts are being made to bring the vascular spasm to an end.
When the supervention of gangrene is certain it is still advisable
to pursue a waiting policy and not to remove the parts that are
apparently dying. The gangrene is dry and a distinct line of
demarcation appears before long ; besides, it is always much less in
extent than at first appeared probable. The separation of the
dead tissue is tedious, and should be hastened by antiseptic fomen-
tations. Where bone is involved the knife may have to be used
to trim the stump, and in rare cases amputation may become
necessary. The wounds heal, as a rule, without complication, and
so far no case of septic infection has been reported.
There is little special to be said concerning the treatment of the
more uncommon manifestations of the disease, such as epileptic
seizures and hasmoglobinuria. In the reported cases the epileptiq
Raynaud's Disease. 1241
attacks have never been fatal, and it is doubtful whether they could
be diminished by any means except an improvement in the general
health. Of course epilepsy and Raynaud's disease may be found
in the same patient without there being any causal relationship,
and the epilepsy will then require to be treated in the ordinary
way. Haemoglobinuria seems always to follow exposure to cold,
and it rapidly disappears if the patient is kept at an equable
temperature. It is best treated, therefore, by rest in bed.
Hsemoglobinuria is much commoner in those cases of Raynaud's
disease in which there is a previous history of malaria. Although
quinine does not influence the condition of the urine, it has been
said to have prevented attacks of local syncope and cyanosis in
malarial patients.
ALFRED M. GOSSAGE.
KEFERENCES.
I '.itrlow, SirT., Allbutt and Bolleston " System of Medicine," 2nd edit., 1910,
VII., p. 120. Monro, T. K., " Eaynaud's Disease," Glasgow, 1899. Cassirer,
"Die Vasomotorischen-Trophischen Neurosen," Berlin, 1901. Osier, Sir W.,
Osier and McCrae, "System of Medicine," 1909, VI., p. 625.
1242
VASOMOTOR NEUROSES.
THE subject of this article is not the consideration of the
familiar conditions associated with vasomotor spasm, such as
Raynaud's disease, erythrornelalgia, etc., reference to which will
be found under their individual headings, but rather of a very
definite group of cases allied to epilepsy on the one hand and to
neurasthenia on the other. They have been described by the
French as affolcment bulbaire (literally, " bulbar infatuation "),
and are known semi-popularly as " nerve storms," more particu-
larly in America. Sir William Gowers has drawn special
attention to their frequency and importance under the term
" vaso-vagal attacks." Briefly, whether they occur idiopathically
or as part and parcel of a more general functional disturbance of
nerve centres, they consist of attacks of breathlessness, suffoca-
tion, palpitation, cardiac arrhythmia ("thudding," "racing,"
"fluttering"), hot flushes, cold waves, trembling and shivering,
perspiration, a sense of fear, of impending death sometimes, with
epigastric sensations often superadded. Some of these symptoms
occur in so-called " cardiac neurasthenia." In the writer's expe-
rience the condition (in a more or less incomplete form) is far
from uncommon, and fully deserves to be carefully separated from
the neurasthenic tumulus. The response of many cases to
appropriate treatment is sometimes remarkable. The adjacent
vasomotor and vagal centres in the medulla are the seat of the
disturbance, whatever be its nature.
One of the most effective remedies is nitro-glycerine in one or other
form. A favourite prescription is liquor trinitrini [U.S.P. spiritus
glycerylis nitratis], (^, or 1 min.), liquor strychninae (4 min.)
[U.S.P. strychnin, hydrochlorid., gr. ^g], made up with any simple
agents, three times a day. It should be continued for months if
necessary, and if it does good. Its immediate effect on the attack is
less potent than that of amyl nitrite, but its regular administration
is sometimes invaluable. Sodium nitrite is also of service. As
a rule, the bromides do not realise expectations in these cases,
although a combination of bromide and nux vomica sometimes
succeeds. Bonnier recommends vinum ipecacuanhas in small
doses. The prolonged administration of a good general nerve
tonic, coupled with a milk regime, will be found a useful adjunct to
Vasomotor Neuroses. 1243
specific treatment. For the actual attack inhalations of amyl
nitrite may be tried. Gowers advises the application of chloroform
externally, sprinkled on lint, with oil silk over it to prevent
evaporation, to the pre-cordial, sternal or epigastric region. Thus
the cardiac distress, respiratory difficulty or gastric discomfort,
respectively, may be relieved. Painstaking attention to the
patient's general health, bodily functions and environment, will
be rewarded by the attainment of much-needed rest for the
nervous system, the basis on which successful treatment by drugs
must depend. A quiet, tranquil life is essential.
S. A. KINNIER WILSON.
REFERENCES.
Bonnier, P., "Le Vertige," 2nd edit., Paris (Masson et Cie.), 1904.
Gowers, Sir W. R. " The Borderland of Epilepsy," London (Churchill), 1907.
Levi, L., "La Presse Meiicale," Paris, 1905, XIII., p. 433.
1244
FAMILIAL DISEASES.
AMAUROTIC FAMILY IDIOCY.
THIS condition, also known as the Waren Tay-Sachs' disease, is
due to a progressive degeneration of the cells of every portion of the
nervous system ; it is limited to the Jewish race.
It commences within the first year of life, and usually proves
fatal within the second or third year. It is evidently due to an
inherited defect in the constitution of the ganglion cells, and no
treatment that has yet been discovered has had any effect in
arresting or influencing its course. It has been suggested, owing
to its familial nature, that the degeneration might result from some
substance ingested in the mother's milk, but no favourable effect
has been obtained by stopping breast feeding.
Spielmeyer, Higier and others have described as a juvenile
form of the same disease a condition with many similar symptoms,
but it is probably quite unrelated to it ; it sets in at a later age, has
a more chronic course, and is not limited to Jews. As in some
cases it seems to develop on a congenital syphilitic basis, vigorous
anti-syphilitic treatment should be tried. This has no influence on
the infantile, or Waren Tay-Sachs, type.
GORDON HOLMES.
EEFERENCE.
1 Higier, H., Deutsche Ztschr. f. Nervenheilk., Leipz., 1910, XXXV1IL,
p. 388.
1245
AMYOTONIA CONGENITA.
THIS form of muscular disease of childhood, known also as
Oppenheim's disease from the German neurologist who first
described it, is by its morbid anatomy, at least, closely related to,
or possibly identical with, the primary muscular dystrophies. In
many cases the disease is probably congenital, in others it is
acquired in early life. It is said, however, to be distinguished from
the simple myopathies by a tendency to improve, and certain
children affected by it have apparently recovered completely.
The line of treatment should be that described for the muscular
dystrophies ; the greatest benefit can be expected from regular and
persistent massage of the muscles, and from encouraging the child
to use the affected muscles as much as possible. A child who is
unable to walk should be allowed to crawl about the floor, and if
even this is not possible it should be trained to use the limbs in
simple games.
General tonics should not be omitted if there is any indication
for their use, and strychnine has been recommended in all cases.
GORDON HOLMES.
REFERENCES.
Oppenheim, II., " Monatschr. f. Psychiatr. u. Neurolog.," fieri-, 1900, VIII.,
p. 232. Collier, J., and Wilson, S. A. K, " Brain," Lond., 1908, XXXI., p. 1.
1246
CHRONIC DISORDERS WITH CEREBELLAR
SYMPTOMS.
THERE are several distinct pathological conditions that produce
cerebellar symptoms, such as the various forms of primary degenera-
tion of the cerebellum, cerebellar disease associated with cerebral
lesions or disease of other portions of the nervous system, local
cerebellar lesions, and spinal degenerations involving the spino-
cerebellar tracts, of which Friedreich's disease is the best recognised
type. The grouping and relationship to one another of these
different pathological processes cannot be considered here; but
as the majority are primary degenerations due to intrinsic or
inherited constitutional defects which therapeutics are unable to
arrest, the treatment of the patient must become largely the
treatment of his symptoms.
The chief symptoms of cerebellar disease are inco-ordination of
volitional movement, a disturbance of equilibration in standing and
walking, static ataxia, tremor and irregular movements of unsup-
ported parts of the body, vertigo, a change in articulation and
affection of the ocular movements, generally in the form of
nystagmus.
It is usually the inco-ordination of movement and the affection of
gait that most urgently require relief; but, unhappily, though
treatment may diminish these symptoms, it can rarely remove
them. As gait frequently improves with improvement of general
health and strength, attention should be directed to this. The
inco-ordination is frequently associated with feebleness of the
muscles, and in these cases massage of the limbs may improve their
functions. The effect of strychnine, iron, arsenic and phosphorus
should be tried. An attempt should be made to re-educate the
movements that are most ataxic ; but, unhappily, Fraenkel's exercises
are less efficient in cases where the inco-ordination is due to lesions
of the cerebellar apparatus than in those in which it results from
loss of the afferent impulses to consciousness that control volitional
movement, as is the case in tabes dorsalis.
GORDON HOLMES.
1247
THE FAMILY FORM OF MUSCULAR ATROPHY
IN CHILDREN.
THIS form of progressive muscular atrophy in children, known
also as the Werdnig-Hoffmann type, which sets in in early childhood,
is closely allied to progressive muscular atrophy or amyotrophic
lateral sclerosis of the adult. It appears always to be steadily
progressive, though the subjects may live till the fifth or sixth year.
No form of treatment has been found of any service in arresting its
course, but massage and passive movements may prevent the
formation of contractures and strengthen the muscles that remain
capable of useful function.
GORDON HOLMES.
FAMILY PERIODIC PARALYSIS.
NOTHING is known of the pathology of this curious condition to
guide or suggest rational treatment.
As severe exertion, excitement and emotional disturbances, as well
as excessive indulgence in rich foods, may induce an attack, the
patient should be warned of the danger, and attempt to regulate
his life so as to avoid them as far as possible. As it has been assumed
that the attacks are due to the accumulation of some poison or toxin
in the body, the administration of diuretics has been advised, and
their use has apparently diminished the frequency of the attacks
(Singer). Large doses of bromide, given on the first signs of attacks,
are said to check them or diminish their severity. It has been found
that the application of strong faradism tends to shorten the attacks
when applied during their course (Otto and Darcourt).
GORDON HOLMES.
1248
FRIEDREICH'S DISEASE.
THE symptoms of Friedreich's disease, or hereditary ataxia,
depend on a combined system degeneration of the spinal cord, due
to inherited defects in certain nerve tracts and cells, which is
steadily progressive and beyond our power to arrest. The course of
the disease is, as a rule, slower the later it appears in life.
But though we are unable to arrest its progress, we can often do
much to relieve its symptoms, when these are not too far advanced.
It is important to improve the general health of the patient, and
maintain it at as high a level as possible. An out-door life should
be recommended, with simple nourishing food. Strychnine, iron,
arsenic and other tonic drugs may prove beneficial. As the disturb-
ance of gait is usually the most serious symptom, attention must be
directed especially to the lower limbs. Massage often increases the
power of the muscles, and may check any tendency to the formation
of contractures. If these develop to a serious degree, tenotomy may
be necessary. The most efficient means for the treatment of ataxia
are exercises for the re-education of movement, such as have been
devised by Fraenkel for the treatment of tabes dorsalis ; but their
effect is rarely so favourable as in this disease.
It must be remembered that the power of walking may deteriorate
rapidly if patients with this disease are confined to bed or pre-
vented from getting about from any cause, and this should con-
sequently be avoided where possible. The disease in itself rarely
threatens life, though sudden death from cardiac failure, due
generally to myocarditis, is not uncommon; and the patients
enfeebled by inactivity may readily fall victims to intercurrent
illnesses.
GORDON HOLMES.
1249
HEREDITARY SPASTIC PARAPLEGIA.
HEREDITARY spastic paraplegia, or . primary lateral sclerosis, as
described by Striimpell and others, is a rare affection due to a
primary degeneration of the pyramidal tracts. Though it tends to
progress, some cases become arrested, and usually only the lower
limbs are severely involved. The rigidity of the limbs is generally
relatively greater and more troublesome than the paresis.
Over-exertion and fatigue must be avoided, as they increase the
rigidity and make walking more difficult and awkward ; many
cases improve with absolute rest for a time. Massage is the most
valuable therapeutic means we possess ; its use may be advantageously
preceded by hot baths or Turkish baths, which temporarily diminish
the spasms. Gowers recommends gentle upward rubbing rather
than kneading of the muscles. On the other hand, all forms of
electricity as well as any other form of peripheral irritation, are worse
than useless, as they reflexly increase the rigidity. Passive movements
must be employed if there is any danger of contractures. With the
exercise of reasonable care tenotomy is rarely necessary in adult cases.
Drugs are of little service in the treatment of this condition ;
strychnine should be avoided or given only in small doses, as it may
increase the rigidity and the tendency to spasms. When the legs are
very rigid some relief may be obtained from large doses of the
bromides, cannabis indica or belladonna, but it is advisable to
administer these for long periods. In the advanced stages of the
disease severe reflex spasms are often troublesome, especially at
night, when they may disturb sleep ; the same drugs often relieve this
symptom, but veronal in moderate doses is generally more effective.
GORDON HOLMES.
HUNTINGDON'S CHOREA.
HUNTINGDON'S CHOREA, which is characterised by its hereditary
tendency and by irregular purposeless movements resembling those
of Sydenham's chorea, associated with progressive mental deteriora-
tion, is due to a diffuse degenerative disease of the cerebral cortex.
Its treatment is unsatisfactory, as no drugs or other measures arrest
its course. Arsenic has been most frequently recommended by
those who have had most experience in its treatment, while
occasionally the bromides, cannabis indica and other sedatives have
given relief.
GORDON HOLMES.
S.T. VOL. ii. 79
1250
THE MUSCULAR DYSTROPHIES.
THE primary muscular dystrophies are progressive diseases which
almost invariably lead to the complete crippling of the subjects
affected by them, though a few instances of recovery have been
reported (Erb, Marina). The different varieties, as. a rule, progress
at different rates; usually the forms, such as the pseudo-hypertrophic,
which set in at an early age, progress the most rapidly ; while other
cases that appear at or after puberty may leave the patient capable
of locomotion or even of performing his occupation till after middle
life.
In such intrinsic and hereditary diseases little can be expected
from therapeutics, but treatment can frequently ameliorate the
condition or retard its progress. Our aim should be to arrest the
progress of the primary degeneration of the muscle fibres, and to
increase the functional activity of the fibres that remain intact or
are but little affected. As we are not acquainted with any measures
that can arrest the development of the morbid process, our thera-
peutic efforts must be directed to the latter aim. It is important
to maintain the general health and the nutrition of the patient at
as high a level as possible ; good food and out- door life should be
adopted, and for the same purpose cod-liver oil, iron, arsenic and
other drugs may be employed. Strychnine, especially by hypodermic
injection, is favoured by many, and often seems to have a bene-
ficial result. On the other hand, any tendency to adiposity should
be checked by regulation of the food-stuffs and by appropriate
exercises.
Long-continued electrical treatment by faradism or galvanism
seems to improve certain cases. Massage of the affected muscles is
undoubtedly more efficient, but it is often necessary to persist in it
for a long period before any effect can be observed. While over-
exertion has often a serious effect on the progress of the disease,
a certain amount of methodical exercise is essential, as voluntary
exercise is unquestionably the most efficient stimulus to the
muscles. The patient should be encouraged to walk as far as
he can without fatigue, while the muscles of the trunk and upper
limbs should be exercised by gymnastic exercises carefully regulated
to bring into action the weakest muscles and those most essential
in the performance of the ordinary functions of the limbs. The
The Muscular Dystrophies. 1251
defects in movement should be carefully analysed and the exercises
regulated to improve and strengthen those that are most seriously
affected. It is practically the rule in all cases, but especially in
those of the pseudo-hypertrophic form, that the power of walking
deteriorates rapidly when a patient is confined to bed for a time by
an inter-current illness or in the course of treatment, or if he ceases
to walk regularly, and it is frequently then impossible to regain
the power that was lost within a short time. It is consequently
extremely important to keep the patient on his feet as constantly
and as regularly as possible.
The Development of Contractures, owing to the excess of
fibrous tissue in the muscles and its shrinkage, is one of the most
serious features of the disease ; these can best be guarded against
by systematic active and passive movements of the limbs, and by
massage of these muscles that show any tendency to shorten. When
contractures have developed, tenotomy may become necessary, but
the operation should be followed as early as possible by massage of
the muscles, and regulated active and passive movements. Tendon
transplantation has been tried in a few cases with reported good
effects, but the time necessary to attain a useful result, and the
fact that the transplanted muscles, too, are usually affected, makes
it improbable that it can be generally applicable in such a pro-
gressive disease. Further, as degenerative changes may supervene
in a muscle on section of its tendon, the operation may not only fail
in its aim, but may lead to the serious weakening of muscles that
hitherto had been efficient. Favourable results on the power of
movement and utility of the arms have been recorded from surgical
fixation of the scapulae (Eiselberg, Raymond). Instruments to fix
and support the shoulder-girdle have been also recommended, and
may be of considerable use in cases in which the muscles of the
shoulder-girdle only of the upper limbs are seriously involved.
The injection of muscle extracts has been repeatedly tried without
definite benefit. Thyroid extract seemed to have a beneficial effect
in a case treated by Rossolimo, but others have failed to attain any
result. No benefit has been obtained from the use of other organic
extracts.
In the later stages of the disease, when only the prolongation of
life can be hoped for, it should be remembered that the greatest
danger lies in pulmonary complications. Even a slight attack of
bronchitis may prove fatal owing to the feebleness of the respira-
tory muscles.
GORDON HOLMES.
792
1252
MYOTONIA ATROPHICA.
THIS rare condition, which is characterised clinically by the
association of muscular atrophy with a slowness in the relaxation of
muscles after voluntary contraction, such as characterises myotonia
congenita or Thomsen's disease, is also hereditary, or, at least, may
occur in several members of the one generation. Treatment is
helpless to arrest its course, and can unfortunately do little to
relieve its symptoms. Massage to the wasted muscles should be tried,
and when there is much foot-drop from wasting of the anterior
tibial groups of muscles, a mechanical support may be employed to
obviate the difficulty in walking.
GORDON HOLMES.
EEFERENCE.
Batten, F. E., and Gibb, H. P., " Brain," Lond., 1909, XXXII., p. 187.
MYOTONIA CONGENITA.
THOMSEN'S DISEASE is characterised by an abnormal delay in the
relaxation of muscles contracted voluntarily, which diminishes on
rapidly repeated contraction ; it is due to an abnormal state of the
muscle fibres only. This peculiarity makes any movements in which
muscles that have been resting partake slow, difficult and awkward
when first started.
No treatment has had a favourable influence on the disease.
Thomsen, who was himself a subject of it, found he was better
the more active his life was, and some patients have improved after
systematic gymnastic exercises.
GORDON HOLMES.
1253
PERONEAL MUSCULAR ATROPHY.
THE Charcot-Marie-Tooth form of progressive muscular atrophy
is due to a degeneration of the ventral horn cells of the spinal cord
and of the peripheral nerves, associated with degeneration of the
dorsal columns, and often of other tracts of the spinal cord, though
at present we have no definite evidence of the primary site of the
disease.
It is often an hereditary disease, and no form of treatment has
yet been found to have any influence on its course, so the only
aim of therapeutics can be to diminish the symptoms by increasing
the power and functions of the affected muscles. For this purpose
massage is the most efficient means we possess, but it must be
persisted in for long periods. The power of locomotion may
be improved by mechanical supports for the feet when foot-drop ,
which is an almost constant symptom, is troublesome. When
contractures develop, tenotomy may become necessary.
GORDON HOLMES.
1254
DISEASES CHARACTERISED BY DISORDERS
OF MUSCULAR FUNCTION.
MYASTHENIA GRAVIS.
THE obscurity of the pathogenesis of this disease has, up to the
present, rendered impossible the adoption of any very satisfactory
line of treatment.
The relative frequency of morbid changes in the ductless glands,
especially the thymus and adrenals, tends somewhat to confirm the
view that, possibly, one factor in the production of myasthenia
gravis may be some defect in the balance of the internal secretions
of the body. It is, therefore, justifiable tentatively to administer
extract of the thymus, thyroid or pituitary glands or of the ovary.
Success has been claimed occasionally for one or other of these,
but, in the great majority of cases, no benefit results.
For the rest, the general health of the individual must be main-
tained at as high a pitch as is possible, and for this purpose cod
liver oil, iron, arsenic and nux vomica may be of service. Any
risk of fatigue must be rigorously guarded against. Massage is
beneficial if not overdone, and the same applies to galvanism.
The diet should be easily assimilable, semi-solid, and of a high
nutritive value. In more advanced cases the bulk of the nourish-
ment should be administered in the morning when the muscular
efficiency is at its maximum, and the food itself must be of such a
consistency as to obviate the necessity for mastication. Where the
power of swallowing is very limited, rectal feeding is probably to
be preferred to the use of a stomach-tube, in view of the emotional
disturbance and exhaustion produced by the latter (Buzzard).
Respiratory failure may be combated by artificial respiration and
the inhalation of oxygen, but is always of serious import.
JAMES TORRENS.
1255
PARAMYOCLONUS MULTIPLEX.
A CONSIDERATION of the treatment of this condition must be
prefaced by a few words on its nature and symptomatology.
When Friedreich described a condition to which he gave the
name " paramyoclonus multiplex " in 1881, it was supposed that a
new and complete morbid entity had been discovered. With
increasing knowledge, however, it has become abundantly evident
that we cannot regard paramyoclonus as other than a symptom
occurring under various conditions, and it is preferable to em-
ploy the term "myoclonus" symptomatically, as comprising "the
totality of more or less permanent morbid conditions characterised
by rapid, forced, abrupt, inco-ordinate muscular contractions,
rhythmical or arrhythmical, always affecting the same muscles and
resulting from the alternating contraction and relaxation of certain
muscular groups" (Vanlair). Even with this definition our
knowledge of the various forms of myoclonus is sadly in need of
revision and amplification. Myoclonus, paramyoclonus multiplex,
Bergeron's electric chorea, Morven's fibrillary chorea, Unverricht's
familial myoclonus, myokymia, and Dubini's disease, are conditions
whose varying names serve but to confuse. Further, myoclonus
is common in epilepsy, and movements analogous to myoclonus
are of frequent occurrence in hysteria and in the maladie des tics.
The pathology of myoclonus is unknown, and its treatment remains
symptomatic and empirical.
If we take paramyoclonus multiplex to be a condition characterised
by violent clonic spasmodic contractions of muscles usually sym r
metrically situated, without other disturbance of motor or sensory
function, and if we premise that we are dealing solely with a
symptom, search for the cause of which must be undertaken in
each case, we may proceed to discuss its treatment.
If the condition is patently hysterical, treatment along the lines
suggested for hysteria must be adopted. It is exceedingly important
to enquire for a history of epilepsy, as myoclonic twitchings,
"regional convulsions" (Muskens), are of frequent occurrence,
especially in the mornings, in patients who may not as yet have
suffered from actual fits. Suitable treatment as for epilepsy is
indicated. If there is reason to believe that the myoclonus is a
phenomenon of tic, regulated exercises to the offending muscular
1256 Paramyoclonus Multiplex.
groups is likely to prove satisfactory. Should the physician fail to
discover any etiological factor he must proceed empirically. Electric
treatment has proved the most satisfactory in many instances.
Strong galvanic currents should be applied to the neck and back
(central galvanisation) and the anode may be placed on any
sensitive points, if these exist. Prolonged static baths have proved
efficacious (Delherm). Spinal douches have also served to reduce
the symptoms. Every conceivable nerve sedative or hypnotic has
been tried by way of internal medication. Zinc valerianate and
cannabis indica, in pill form, ought to be given a trial. The bromides
do not appear to be of much value. Vanlair suggests repeated local
injections of cocaine in small doses. For that matter, the writer
has seen a case apparently cured by repeated injections of aqua
destillata. Starr reports a case cured by the combination of
galvanism to the spine, chloral and arsenic. Speaking generally,
local treatment seems to be more satisfactory than internal medica-
tion, but it cannot be said that the results obtained have been
brilliant.
S. A. KINNIER WILSON.
REFERENCES.
Blocq, P., and Grenet, H., article " Myoclonies," in Charcot- Bouchard
" Traite de M6decine," 2nd edit., Paris (Masson), 1905, X.,p. 416. Dana, C. L.,
" Journ. of Nerv. and Ment. Dis.," New York, 1903, XXX., p. 449. Meige,H.,
and Feindel, E., " Les Tics et leur Traitement," translated by S. A. K. Wilson,
London (Appleton), 1907. Vanlair, " Revue de Medecine," 1887.
1257
DISEASES OF OBSCURE ORIGIN CHARAC
TERISED CHIEFLY BY DISORDERS OF
MOTION.
CHOREA.
THE term " chorea " has been used for more conditions than one.
The present article does not refer to Huntingdon's chorea, senile
chorea, or post-hemiplegic chorea, but to ordinary St. Vitus' dance
as it occurs mainly in children and adolescents, particularly in
those who have a personal and family tendency to rheumatic fever
and its effects. Chorea in pregnant women is discussed elsewhere
in Vol. IV.
When St. Vitus' dance is met with in a boy or girl the first step
is to determine whether the chorea is the chief or only rheumatic
manifestation present or whether the patient also exhibits other
evidence of acute rheumatism, especially bruits indicative of
endocarditis, a pericarditic rub, pleurisy with or without effusion,
acute tonsillitis, joint pains and swellings, or skin lesions such as
erythema multiforme. If there is endocarditis the treatment of the
case will be carried out precisely on the same lines as if the acute
rheumatism and endocarditis had occurred without chorea, with the
addition, perhaps, of putting screens round the patient's bed and
giving more aspirin than might otherwise be ordered. The duration
of absolute rest in bed in such a case depends much more upon the
endocarditis than upon the chorea.
It is an important point about chorea that if it is uncomplicated
it is not associated with pyrexia, however violent the movements
may be. So long as there is no pyrexia and no evidence of
endocarditis or other complications of acute rheumatism, the treat-
ment may be regarded as that of the chorea itself. Cases may be
divided up according to the severity of the movements into those
that are mild, those that are moderate and those that are severe.
It would be unwise, however, to regard even a mild case as
unimportant, because without due treatment and care the move-
ments may very readily become more active and the disease
proportionately more severe.
Medicinal Measures. The best drug to employ in all cases is
certainly aceto-salicylic acid (aspirin), and it should be given in full
doses. Whether the movements are mild, moderate or severe, one
should give relatively enormous doses at first ; if the patient is about
1 258 Chorea.
eight years old, 10 gr. should be administered every two hours, except
during sleep, for the first three days; then 10 gr. every four hours till
the end of the week, after which 10 gr. may be given four times a day.
The administration of the drug needs to be continued for a con-
siderable number of weeks after the movements themselves have
ceased, for it would seem that aspirin merely minimises the move-
ments or causes them to cease without actually curing the malady
so completely that it does not at once recur when the drug is
stopped. It is like sodium salicylate in relation to acute rheumatic
joint pains in this respect. The aspirin has to be continued for
almost the same length of time as the movements ordinarily
continue when no drugs are employed at all, namely, upon the
average about three months. Under its influence, however, the
movements may cease entirely in a week or two, and they seldom
continue for more than eight weeks, which is something like three
or four weeks less than is their average duration when other
remedies are employed. Dr. Cecil Wall was amongst the first to
point this out, and the writer can endorse his views. It would seem
that aspirin behaves as regards choreic movements more or less as
potassium bromide does as regards epileptic fits. It gets them
under control but it does not cure their cause. The remedy is best
given as a powder in cachets ; children find it difficult to swallow
the ordinary tablets. The 10 gr. doses should be continued four times
a day for four, six, eight, ten or twelve weeks, as the case may be,
according to the length of time that elapses between beginning the
treatment and getting the movements under control, and according
to the effect that will be observed when attempts are made first to
diminish and finally to omit the remedy.
Sodium salicylate, though sometimes employed instead of aceto-
salicylic acid, is by no means so good ; if there are joint pains in
the case, or rheumatic pyrexia, these will be benefited by sodium
salicylate, but the chorea itself lasts just as long when this drug is
given as when no particular remedy is employed, and this no
matter whether the doses are small, medium or large.
Bicarbonate of soda is an old remedy for rheumatism which is
coming into favour again, and there is no reason why it should not
be prescribed in chorea cases in addition to aspirin, either in the
same cachet or as a separate mixture.
Arsenic was the drug most usually employed in the treatment of
chorea until recently, and by some it is still preferred to anything
else. Comparison between it and aspirin, however, is all in favour
of the latter, and moreover some of the worst cases of peripheral
neuritis have occurred whilst chorea was being treated with medicinal
Chorea. 1 259
doses of arsenic. The ordinary liquor arsenicalis [U.S.P., liquor
potass, arsenitis] is generally employed, the close being as a rule a
small one, such as 2 min. in a mixture thrice daily to begin with ;
the rule being to increase this by 1 min. every five or six days if it
is well borne, until the patient, even though a child, may be taking
as much as 10 or 12 min. three or four times a day.
When the movements have resisted arsenic by the mouth
cacodylate of sodium has been given either rectally or sub-
cutaneously, beginning with J gr. daily and increasing to twice
this amount. Hypodermic medication is to be avoided, however,
unless material advantage is to be gained by it, and this cannot be
said to be the case with sodium cacodylate.
Although the above are the commoner remedies that are used in
the treatment of chorea, there is a very long list of other prepara-
tions that have been employed in different cases. The difficulty
is to know whether they are really beneficial or not, and the
probability is that they have been used chiefly when the cases were
either very severe or very obstinate, and it is very difficult to say
whether the relief that may seem to have been due to the last
remedy resorted to in any prolonged case would not have come
about spontaneously. Zinc salts were much advocated at one time,
notably valerianate of zinc given in pill or powder form in doses
of from ^ to 4 gr. Hemlock has been tried on account of its
sedative effects upon the nervous system, though its action in
medicinal doses of the succus conii (1 to 2 drachms) or of the tinctura
conii ( to 1 drachm) [U.S.P., fluid extract conii, mins. 6 12] is
both uncertain and transient. Antimony, particularly small doses
of the vinum antimoniale [U.S.P., vinum antimonii], given in mixture
form, is beneficial in many maladies, and it may be prescribed along
with arsenic. Quinine in small doses either by itself, or in Easton's
syrup, which contains f gr. of quinine sulphate in each drachm,
or as iron and quinine citrate in 5 to 10 gr. doses may serve to
improve the patient's general tone and thereby assist in the treat-
ment of chorea in puny children ; whilst cod-liver oil, extract of
malt and iron, Pamsh's food and tonics generally may be used in
the treatment of chorea in the same way.
Belladonna, especially the tincture in 3 or 4 min. doses [U.S.P.,
tinct. bellad. fol. 4 or 5 min.], has been advocated as a means of
diminishing the excitability of the nervous system and thus
lessening the movements ; whilst in America particularly cimicifuga
has a reputation for benefiting chorea, though it is seldom
employed in this country.
When the movements become more than moderately violent the
1 260 Chorea.
question of the use of stronger sedatives or even of hypnotics may
arise. Choreic patients, however, usually sleep well even though
their movements are violent during the day ; hypnotic remedies
should not lightly be resorted to therefore. If they should be
necessary, however, those which do least harm are probably
chloralamide in doses of from 10 gr. upwards ; bromides, particularly
potassium bromide or a combination of 10 to 15 gr. of sodium or
ammonium bromide, with ^ to 1 drachm of syrup of chloral hydrate
as a draught at night, to be repeated if necessary, will often not
only produce sleep but also afford material relief to the violence of
the movements next day ; whilst trional has also been advocated in
doses of 3 to 10 gr. three times a day or in a larger single dose
at night-time. It can only be in rare cases, however, that such
potent remedies will be required. Still less will the physician
resort to opium or morphia, and it is only when the movements are
phenomenally violent that chloroform inhalations will be thought
of. Cannabis indica, lobelia, physostigmine, thyroid extract and
curare have all been employed, but seeing that they are such potent
remedies they are to be avoided whenever possible in children.
Rest- Best, especially to the mind, is most important in the
successful treatment of chorea ; the patients are nearly always active-
minded, the majority being almost too keen upon their school work
whether they are high in their classes or not; indeed over-pressure at
school is one of the chief factors in bringing out choreic movements
in children who are predisposed to acute rheumatic symptoms,
especially when there has been some final exciting cause, such as
competition for a prize, a fright, or other excessive stimulation of
the brain. Opinions differ as to whether the patients should be
kept strictly in bed or not, but there can be no doubt about the
necessity of their being kept away not only from school but also
from school friends, from books of study, from exciting narratives,
and from the various excitements that are almost necessarily
associated with visits from other children, relatives and strangers.
If, in a mild case, it is possible for the child to live quietly in a
sunny garden, there is no reason for confinement to bed in the
house, but in towns, especially amongst the poorer classes, it is
almost impossible to ensure absence of mental and physical excita-
tion unless the child is put to bed. The severe cases must be kept
there until the violence of the movements subsides, the danger of
self -injury by striking some part against a hard portion of the bed
being minimised by surrounding the patient with banked up pillows,
by bandaging cotton- wool over the hands and other parts that are
particularly liable to injury, and if need be by having soft cushions
Chorea. 1261
on the floor lest by the violence of the movements the child becomes
bodily ejected from the bed. So violent may the movements be
sometimes that it is a physical impossibility for the patient to feed
himself, and it may even be very difficult indeed for the nurse to
hold a feeding cup in contact with the lips without running con-
siderable danger of injuring the mouth or soft parts near it. Nasal
feeding becomes necessary in violent cases of this kind, and
material relief is sometimes obtainable from the use of large linseed or
other poultices applied to the trunk as hot as-ean be borne. Fortu-
nately, if a case is not already of this degree of violence when first
seen, the adoption of the aspirin treatment, together with ordinary
quietude, seldom fails to alleviate the severity of the movements
without the attack becoming worse. When it is impossible for the
child to have a room to itself it is wise to prevent it from seeing
what is going on in the rest of the apartment by screening off the
cot or bed.
Diet. A choreic patient should be fed well but at the same time
upon simple food. Milk and bread and butter should constitute the
chief part of the dietary, at any rate to begin with, and if there is any
rheumatic complication, especially joint pains, it is advisable to
continue with milk diet for two or three weeks at least before this is
increased. Uncomplicated chorea also improves better upon a milk
and bread and butter diet than when fish, meat, potatoes and vege-
tables are allowed early, provided always that the patient will take a
sufficiency of the simpler foods. Milk puddings of any kind, ripe
fruits, whether fresh or cooked, are also to be allowed in ordinary
cases, and after the first two or three weeks, if the violence of the
movements has abated, eggs, fish and meat may be allowed in
ordinary quantities, even though the chorea has not entirely ceased.
Alcohol is contra-indicated so far as the chorea itself is concerned,
though it may sometimes be ordered in spite of the chorea if there
is a severe heart lesion at the same time.
The bowels need no particular attention in chorea beyond what
they receive in the case of other sick children. There is no need
to be alarmed if a motion is delayed for two days. If there is no
action for longer than this a simple glycerine suppository may be
used or a small soap and water enema given, but it is unwise to
resort to purgatives if they can be avoided. Their use is apt to
necessitate their continuance. Constipation has an exaggerated
importance attached to it as a cause of increased violence of choreic
movements, though naturally it would be unwise to allow the
patient to go many days without taking minimum steps towards
ensuring an evacuation.
1 262 Chorea.
Nursing is one of the most important factors in the treatment
of a severe case. Skill is required in keeping the patient clean ; it
may be impossible for the child to sit upon a bed-pan, chamber or
commode, owing to the violence oi the movements, in which case
the motion has to be passed as best it may be into towels placed
under the child in bed ; similar difficulty may occur with the urine,
and it may not be at all easy to keep the skin quite clean. Feed-
ing may be easy in mild cases, but the inconsequent twists and
squirms and jerkingj^of a severe case may make it very difficult to
convey each spoonful safely to the patient's mouth, and each meal
may require a great deal of patience on the nurse's part and take a
long time in the giving.
Blistering of the precordia is often resorted to in cases of acute
rheumatic endocarditis ; but when the latter is associated with
chorea the irresponsible movements of the latter are so liable to
lead to damage even of the healthy skin that blistering is contra-
indicated.
Convalescence. When there is no cardiac or other rheumatic
complication most choreic patients have no period of convalescence
in the ordinary sense ; as soon as the movements cease the child is
generally to all intents and purposes well. If confinement to bed
has been long, however, a change of scene and air is to be recom-
mended before school work is begun again, and extract of malt and
iron or other tonic remedy may be employed. Small doses of arsenic
may be very beneficial at this stage. The change should be to a quiet
rather than to an exciting place, either to the country or to a sea-
side resort, where there are good sands to play upon. The question
of a place of residence may arise, and in this connection there can
be no doubt that some districts are much more saturated with
rheumatic cocci than others are. London as a whole is as full of
acute rheumatism and its effects as any other place, and children
who have a disposition to suffer from chorea or any other manifes-
tation of acute rheumatism should, whenever possible, be taken out
of London to live elsewhere ; even quite close to London there are
many places upon sandy or upon chalky soil where acute rheu-
matism is much rarer than it is in London itself, though at no
place will the child be absolutely immune. It is an old observation
that a susceptible child may become choreic as the result of visiting
a chorea patient. It used to be said that this was due to one child
imitating the other, but it is much more likely that it is due to the
chorea being actually caught as the result of a susceptible child
having stayed in surroundings full of the rheumatic cocci. Be
this as it may, it is unwise for children with acute rheumatic
Chorea. 1 263
tendencies to associate with others who have acute rheumatism or
chorea.
Electrical treatment has been advocated by some, and all varieties
of electricity have been employed, though none with any benefit that
can be laid stress upon.
Special baths and spa treatment have sometimes been advocated,
but they are not indicated unless, perhaps, in a very few cases,
during convalescence, and then they are treatment for the con-
valescence rather than for the chorea itself.
Massage will seldom if ever be recommended in the acute stages
of the malady, but in patients whose general nutrition suffers during
an attack or in those in whom the movements, obstinately resisting
treatment, persist in a mild degree for months, careful massage of
the ordinary rubbing type may be prescribed with much benefit ;
passive movements of the limbs and of each joint may be employed
at the same time with a view to improving the tone of the muscles
and preventing any risk there may be of contractures from long
rest in bed.
A fatal case of chorea occurs now and then, but it will nearly
always be found that the fatal ending is not due to the chorea
itself so much as to other rheumatic manifestations, particularly
myo-, peri- and endocarditis of malignant intensity. Most cases
get well within three months and many within much less time than
this when excitement is avoided ; partial or complete rest is insisted
on, fresh air and sunshine are allowed, and the feeding is simple
but generous. When aspirin is used in large doses for the first
three days and in smaller doses during the succeeding weeks the
duration of the attack is shortened upon the average by a month or
more, though it is most important to continue with the remedy for
some while after the movements have ceased.
HERBERT FRENCH.
1264
OCCUPATION NEUROSES AND CRAFT PALSIES.
THE occupation neuroses, or fatigue spasms, must be distinguished,
on the one hand, from the craft palsies, which are mostly local
muscular wastings produced by certain trades, and, on the other
hand, from the symptoms of pain and cramp that may be amongst
the early symptoms of the onset of a grave nervous disease, such as
hemiplegia, syringomyelia, etc.
OCCUPATION NEUROSES.
These are a group of functional disorders, whose most prominent
symptoms are spasm or cramp, pain, tremor and weakness. These
disorders are peculiar to adults, and are found associated with many
occupations, the chief of which is writing. Besides writer's cramp,
similar symptoms are met with in telegraphists, piano and violin
players, tailors, cobblers, milkers, compositors, cigarette makers,
smiths, barbers, and in several other occupations in which the same
movements are constantly repeated. Miners' and mountaineers'
nystagmus, clarionet players' and glass-blowers' spasm of the lips
also belong to the occupation neuroses. The cramp is never met
with during the learning stages of writing or of the trade concerned,
and occurs only when, after long and constant practice, the repeti-
tion of the movement has become automatic ; it is therefore not
muscular in origin, but central, due to breaking down of lines of
resistance between the co-ordinating and association centres con-
cerned in the movements, and it is therefore rest for the brain that
is called for, by total cessation of the special movements causing
the spasms. Other points *that go to prove the neurotic origin of
the complaint are the frequency of the occurrence of other neuroses
or psychoses in near relatives of the sufferer.
Writer's cramp, indeed, may be hereditary, or several members
of the same family may suffer. The earlier treatment is begun the
more chance there is of arresting or curing the disease ; but if this
is of long standing and the spasm is no longer strictly limited to
the particular movements, such as of the hand in writing, but is
beginning to be felt in other movements of the same muscles, the
disease is practically impossible to cure unless total rest from the
affected movements is observed. Writing, then, with the right
hand must be totally given up for at least six months, and mean-
Occupation Neuroses and Craft Palsies. 1265
while may be practised with the left hand. It is true that
occasionally the spasm may spread to the left hand ; should this he
the case, however, the patient is no worse off than if he had never
tried to use the left hand. If the right hand can thus be rested
completely from all writing for six months, or, better still, for longer,
it may be possible to effect a cure, and the writing may again be
taken up by the right hand ; moreover, the spasm may never return,
in spite of a considerable amount of writing work being done. This
good result will be the more likely if spasm and not neuralgic
pain and tenderness is the prominent symptom. Again, the
prognosis will be better if the trouble has appeared during a tem-
porary mental stress or anxiety, such as domestic sickness, financial
worries, etc. If these difficulties are satisfactorily surmounted,
there will be less tendency for the neurosis to recur. .
If the patient is unable to give up writing altogether, or if the
symptoms are slight and not fully developed, various treatments
may be adopted with a view to lessening the spasm. Firstly, as the
disorder affects especially those who use a steel pen and cultivate a
cramped and copper-plate style of writing, in which the hand rests
upon the little finger and the pen is gripped low down, alterations
must be adopted to produce a freer style of writing, in which the
pen is merely held between the fingers and thumb, and the letters
are formed by movements imparted to the pen by the larger
muscles of the forearm and arm, rather than by the intrinsic
muscles of the hand. A stylographic pen or pencil should, if
possible, be substituted for the steel nib, or if the latter is essential,
a stout cork penholder must be used. Various styles of holding the
pen may be adopted as a change, such as holding it between the
first and second fingers, and care must be taken that the arm rests
comfortably on a smooth and polished table.
Other mechanical devices which are sometimes of great service
are Nussbaum's bracelet, and a ring attachment to the pen through
which the index finger may be slipped. The ring should be f inch
in width, and of such a diameter as to fit the finger closely and
comfortably, and it should be firmly fixed to the side of the pen-
holder about 3 inches from the point of the pen. The object of
this device is to prevent the pen from slipping from the grasp
during writing, and also to avoid the necessity for continual tonic
contraction of the first dorsal interosseus and opponens muscles, and
thus lessening the tendency to fatigue spasm. The bracelet is of ser-
vice in holding the spread-out fingers together, and thus diminishing
the tendency towards irregular spasmodic movements of the fingers,
causing the pen to be either lifted off the paper or the point driven
S.T. VOL. n. 80
1266 Occupation Neuroses and Craft Palsies.
through the page. A quill pen has been recommended, but its
shaft is too small, though a quill nib may be used on a cork
penholder.
Local treatment to the hand and arm by massage and Swedish
gymnastic exercises, graduated against resistance, may be extremely
useful, and sometimes also galvanic arm-baths. The electrode
should not be stroked over the hand and forearm muscles, but both
electrodes should be dipped into the two ends of an arm-bath
sufficiently long to take the forearm and hand with the fingers
straight out. Warm water without any salt should be placed in the
bath to a depth just sufficient to cover the forearm, and a steady
constant current of about 30 milliamperes sent through the
bath. Of this current about one-third, as a rule, passes through
the tissues of the patient. If this method is tried it should be
persisted in daily ; it is likely to be of more use in the neuralgic
cases.
Possibly suggestion plays the chief part in the cure in some
cases. When these methods fail and rest from writing is impos-
sible, either the left hand must be trained to do the work or else a
typewriter must be substituted for the writing by hand. This,
however, is often impossible for lawyers' clerks and others who
have to do engrossing and copper-plate writing. Giving up the
employment is the only other alternative.
Next to writer's cramp, telegraphist's cramp is perhaps the
most important ; here, again, as with writing, the disease does not
show itself in the learning stages, but develops only after some
years of constant practice and familiarity with sending messages.
In the present form of machine used the operator learns to send
the dots and dashes of the Morse code by listening to the noise
that the key makes as it is depressed and released. This is a
greater strain upon the attention than watching the movements of
a needle, as in the older types of sending machines.
The cramp shows itself by inability to perform correctly the
proper spacing of the dots and dashes, and certain combinations
will be found more difficult at first than others, varying with
individuals, but eventually extending to all letters, so that the
rapidity of the operator is greatly diminished, and the work
ultimately becomes impossible.
A contributing factor in the development of telegraphist's cramp
is the operator's method of working with the instrument on the
edge of the table, so that the arms are not supported. If the right
arm can be rested upon a table, one element of strain is thus
removed, and the left hand should be used, if possible, in order to
Occupation Neuroses and Craft Palsies. 1267
rest the right. As in writer's cramp, so also in this form and in
other occupation neuroses, nervous heredity, nerve strain, and
worry play an important part. Nerve tonics, such as the glycero-
phosphates, iron, arsenic and strychnine, should be thoroughly tried,
and bromide may be added with advantage if neurasthenic sym-
ptoms, such as irritability, lack of power of concentration and
sleeplessness, are present. If the latter symptom is severe and
amounts to actual insomnia, veronal (in 7-gr. doses) should be
given in addition nightly, the dose being gradually diminished and
then the drug withdrawn.
The terms hammerman's cramp, smith's cramp, or hephsestic
hemiplegia as it has been called, have been applied to more than
one disorder, including apoplexy from cerebral haemorrhage. Actual
fatigue spasm may attack the right arm in men who have to deliver
repeated blows with a hammer in their work. The triceps becomes
weakened by this movement, and the sufferers instinctively hold
the arm adducted to the side to help them in the blow. Tremor of
the arm may be very marked, and the triceps which is weak in
delivering a blow may appear quite strong in holding the arm
firmly extended against resistance, this inconsistency proving the
disorder to be functional. Further symptoms of functional hemi-
plegia and hemi-anaesthesia may develop, and prolonged treatment
and massage and faradism, with plenty of encouragement, is
required. Rest from work in this stage is necessary for a time.
CRAFT PALSIES.
Various forms of neuritis and consequent muscular atrophy may
result from pressure on nerves and muscles in certain occupations
and trades ; hence the term occupation neuritis has been applied to
these cases, which must be distinguished from occupation neuroses.
Thus the pressure of a trowel in gardening or the constant use of- a
scrubbing-brush may cause atrophy of the thenar muscles, usually
without any anaesthesia. House painters, too, may get similar atrophy
from pressure of the brush-handle and partly from the toxic action
of the lead rubbed in. Atrophy of all the intrinsic muscles of the
hand may also be met with in ironers, scrubbers, plate polishers,
joiners, etc., or this form of atrophy may result from the pressure
of the handle of a walking-stick or similar support in persons
suffering from some permanent weakness of a leg, such as old
poliomyelitis. If the cause 9f such atrophy is recognised in time,
recovery may ensue on the cessation of the cause of the pressure,
aided by faradism applied in the form of a wave-current.
Ulnar paralysis may occur in oarsmen, glass workers, and in
802
1268 Occupation Neuroses and Craft Palsies.
wood engravers and telephone operators from the ulnar nerve
being pressed on through leaning the elbow on a high table or desk
while at work. In such cases it is usually mostly a motor paralysis,
with muscular wasting of the interossei and ulnar flexors of the
fingers and wrist, with little or no sensory symptoms beyond some
pain at the elbow and slight pins and needles on the inside of the
hand and little finger. In order to effect a cure the cause should
be recognised early, and the faulty position must be corrected, and
if possible the arm be given as complete a rest as possible.
Electricity in the form of the faradic wave-current is perhaps
here the best stimulus to the regeneration of the muscular tissue.
With one flexible electrode wrapped round the fingers and the other
fixed round the forearm immediately below the elbow, this form of
current is produced by slowly sliding the secondary coil to and fro
over the primary, so as to produce alternately tetanisation and
relaxation of the muscles.
Similarly, paralysis of the long thoracic nerve may occur through
violent muscular strain of the serratus magnus and scalenus medius
in the act of swimming, especially with the side-stroke, and the
musculo-spiral nerve may also be damaged in the upper arm by
violent contraction of the triceps muscle.
Actual atrophy of muscles continually engaged in prolonged
heavy work may occur without any pressure upon the nerve-trunk
supply of the muscle. Such wasting of the deltoid and triceps may
be seen occasionally in smiths, whose occupation necessitates the
frequent wielding of a heavy hammer. Cessation of the harmful
trade is the only possible remedy in these cases, followed by
massage and faradism as above described.
WILFRED HARRIS.
KEFEREXCES.
Oppenheim, H., "Text-book of Nervous Diseases," 5th edit., English transla-
tion by A. Bruce, 1910, II., p. 1268. Gowers, Sir. W. E., " Manual of Dis. of
Nerv. Syst.," 2nd edit., 1893, II., p. 710.
1269
PARALYSIS .AGITANS.
OUR present uncertainty as to the etiology of this disease
necessarily handicaps us severely in our attempts at the allevia-
tion of its symptoms. The brain, the spinal cord, and even the
muscles, all in turn, have been accused of being the seat of the
primary pathological process. The fact, however, that the dis-
tribution of the symptoms is usually unilateral at the onset,
points to the conclusion that we have to do with an essentially
cerebral affection, and that the inconstant changes described by
various observers in the vessels or nerve-cells of the spinal cord,
or in the muscle fibres, must be regarded as accidental concomi-
tants of the disease, not its primary cause.
Although causing the patient considerable discomfort, and in
its later stages producing muscular rigidity, paralysis agitans is
not a fatal disease. The motor disability which supervenes is not
due to paralysis, but results from two other factors, tremor and
rigidity. There are also certain vasomotor symptoms, such as
sudden subjective sensations of heat or cold passing through the
body, which may call for alleviation. In the later stages of the
disease the patient often complains of restlessness and of a curious
difficulty in finding a comfortable position in bed. In such cases
a specially hard mattress is preferable to a soft one, enabling the
patient to change his position with less difficulty.
Kecognising, then, that cure is out of the question and that our
treatment must be frankly symptomatic, let us consider what
remedial measures are at our disposal.
Worry, excitement, business anxiety and strenuous mental exer-
tion all tend to aggravate the symptoms ; therefore a quiet, restful
mode of life, if this can be arranged, is advisable. If the patient's
means admit of his going occasionally to some one or other of the
climatic or balneo-therapeutic resorts which he may fancy, care
should be taken to ensure that he is not overwhelmed by strenuous
physical, electrical or balneological treatment, all of which measures,
if too zealously pushed, may only aggravate his discomfort. Gentle
passive movements, however, sometimes alleviate the rigidity. So,
also, do warm baths and mild galvanic baths in certain cases.
Strong massage, faradic electricity, and gymnastic exercises, on the
other hand, in my experience, usually aggravate the disease.
1270 Paralysis Agitans.
Amongst the drugs which have been employed, that which has
hitherto produced the greatest beneficial results is hyoscine. By its
means, tremor and restlessness are often appreciably diminished,
and the patient tends to sleep better. We may commence with
^<kj gr. of the hydrobromide morning and evening, gradually
increasing to T Q g r - or even ^ gr. If the drug is left off for
a week or so once a month, the results, on the whole, are better
than if it is administered continuously for long periods ; more-
over, toxic symptoms are less likely to supervene. Other drugs
belonging to this same group (duboisine, scopolamine, hyoscya-
mine) act in a similar fashion. Drugs which induce sweating
commonly aggravate the disease. In severe cases, when sleep is
much interfered with, we may be justified in administering heroin
or morphine hypodermically.
I have seen many cases in which the blood pressure was abnormally
low, in marked contrast to the senile facies, and in such patients I
have found occasional benefit from the administration of pituitary
extract in full doses, in combination with hyoscine. It should be
noted that pituitary extract has comparatively little pharmacological
effect if given by the mouth. It should be administered hypo-
dermically.
PURVES STEWART.
1 27 1
TETANY.
THIS symptom of recurrent attacks of muscular spasm, affecting
especially the limbs, abdominal and respiratory muscles, is often
associated with considerable pain. Its causes are very various, and
consequently the treatment must be not only symptomatic, but also
directed towards the primary disease. Many varieties of tetany are
toxic-infective in their origin ; it may occur after or during the course
of diphtheria, typhoid and many other infections, and in certain
districts it has been described as both endemic and epidemic at certain
seasons of the year. Shoemakers and tailors suffer not unfrequently,
probably owing to absorption of some toxin from the leather or cloth
handled. Total removal of the thyroid gland may be followed by
tetany, which is then of very serious prognosis ; it is said to be due
to the removal of the parathyroids, which in man are buried in the
thyroid. Consequently treatment with parathyroid substance (2
or 8 gr. daily) will be necessary. Tetany may also be combined
with either myxcedema or exophthalmic goitre, scleroderrnia, etc.
I have seen chronic tubercular peritonitis associated with tetany.
In suckling women tetany is not rare if the lactation is prolonged
unduly or the woman is run down in health. Trousseau named
this form Nurse's contracture. The lactation must be given up
and tonics administered. One of the most dangerous forms of
tetany is that found with excessive dilatation of the stomach. Gastric
lavage is here a special danger, and fatal results have occasionally
occurred. The tetany in these cases is thought to be due to absorbed
toxins from the stomach. Lavage of the stomach must be avoided
in such cases, and if the weight is falling in spite of careful diet-
ing, rectal feeding must be employed for a few days, with daily
subcutaneous injections of pint of saline, followed by gastro-
enterostomy.
If the pain of the spasms is severe, bromides, morphia, or chloral
hydrate must be given (see also Tetany in Children, p. 1272).
WILFRED HARRIS.
1272
TETANY IN CHILDREN.
THE treatment of tetany is based on its probable origin in a
toxaemia of gastric or intestinal causation. Impaired nutrition,
notably that associated with rickets, is a predisposing factor. The
poison acts on and induces hyper-excitability of the nerve cells in
the bulb and the anterior cornua, the efferent nerves and the muscles.
The hypotheses that the affection depends on an excess of lime salts
in the diet or a deficiency thereof in the brain, blood and muscles
may be disregarded. Apparently the toxic body is a product of
microbial activity or of imperfect digestion. Tetany is most common
at six to eighteen months of age, a period of life when rickets is
developed and infants are often erroneously fed. It is generally
associated with chronic dilatation of the stomach or chronic diar-
rhoaa, occasionally with chronic dilatation of the colon. It is rare
in acute diarrhoeal affections, for the poison, if formed, is rapidly
eliminated.
Preventive treatment includes suitable diet, warm clothing and
the ordinary measures of general hygiene. Dilatation of the stomach,
so apt to occur in rachitic infants, must be guarded against by
limiting the size of the meals and giving food which is not liable
to undergo gaseous fermentation in the stomach.
Active measures include elimination of the poison, reduction of
the hyper-excitability, and treatment of the underlying cause. The
condition of the alimentary tract must receive attention. In the
ordinary case, dependent on chronic intestinal catarrh, an initial
dose of castor oil or calomel should be prescribed, and subsequently
drugs, such as bismuth or benzo-naphthol. For gastric disturbance
either alkalies or hydrochloric acid are required. Mild diuretics
assist elimination.
For the reduction of hyper-excitability rest in bed in a dark
room, complete quiet, hot baths and chloral are required. In
bad cases a bath at 95 to 105 F. should be given every six hours.
Sometimes the chloral must be given per rectum in doses of 5 to
10 gr., in an ounce of water, every six hours or even more fre-
quently, according to its retention, its effects and the severity of
the cramps. In milder cases in infants chloral (1 gr. for each
three months of life up to one year of age), is given alone or with
double the quantity of sodium bromide, in a drachm of syr. aurantii
Tetany in Children. I2 73
or syr. mori, every three to six hours. Bromides alone may be
sufficiently sedative for mild attacks. In very bad ones chloroform
up to complete anaesthesia should be utilised as a temporary measure
until the chloral has time to act.
As soon as the alimentary tract is in a healthy state and the
spasms have subsided, the rickets or other underlying factor present
must be treated. It should not be assumed that the child is cured
as soon as the cramps have ceased, for the tendency thereto, a con-
stitutional state known as spasmophilia, persists and recurrence is
not uncommon (see also article on Tetany, p. 1271).
EDMUND CAUTLEY.
1274
MENTAL DISEASES,
GENERAL CONSIDERATIONS.
THE treatment of mental disorder is unfortunately not solely a
medical matter. With it are involved social and legal considera-
tions which, looming large in the popular and forensic minds, have
most seriously interfered with the therapeutic art in this branch of
medicine. But a few generations ago and amongst the most civilised
nations the mentally afflicted patient was regarded as one possessed
and therefore as one to be dealt with on a penal system. That this
state of affairs has, at least in this and other civilised countries,
been swept away is due to the efforts of members of the medical
profession, and we believe that there is no brighter record on the
pages of our therapeutic annals than that which compares the vile
horrors of a not remote past with the humanitarian methods of
to-day. The progress made, though less rapid, is, in the saving of
life and the shortening of illness, .comparable to that of abdominal
surgery. But while these magnificent strides have been made pro-
gress has been retarded to an appreciable extent by certain legal
and social developments. About the middle of the last century
there arose a popular and sentimental agitation fomented by literary
scaremongers. It was alleged that the liberty of the subject was
endangered and that but too often inconvenient relatives were
immured or "put away" within asylums and there, though sane,
were compelled to pass the remainder of their days. Under the
influence of this agitation legislation was carried through which,
without doubt, though it might be expected successfully to protect
the liberty of the sane individual, rendered it necessary to bring
every insane individual within the purview of the law and to pre-
vent treatment outside that purview. The result has been that for
the most part the treatment of the insane or, as we should prefer
to put it, of the mentally disordered has been, as a matter of
obligation, carried on in asylums, and so has been fostered the
popular notion that the lunatic must be under lock and key, that
" treatment " consists in his being immured in an asylum from
which he is not to be allowed to " escape," that he may thus, with
the lapse of time, get well or not without any medical intervention,
and that mental disorder is a thing apart from other branches of
Mental Diseases. 1275
medicine and by no means to be treated on the same lines as are
disorders of that which is called the body as distinct from that
which is called the mind. The social and legal stigmata which
attach to that which too often is regarded as a conviction of lunacy
operate on therapeutics most seriously in that patients are only as
a last resort brought under treatment ; everything except sub-
mission to proper treatment is done to postpone the moment when
the patient is " put away," that moment being, as a rule, determined
at the stage when the patient has become a nuisance to society or
dangerous to himself. This attitude has led to the treatment of
patients being neglected during the recoverable stage of their
illness, and it is not to be wondered at that the prognosis of fully
developed mental disorders is regarded by many medical men with
pessimism when we appreciate the chronic nature of the malady
they are called upon to treat. We find enormous institutions in
which are herded large numbers of persons of unsound mind under
the care of medical staffs which are absurdly inadequate in number,
where that individual attention which is so important in this class
of case is perforce absent and where the advent of degradation in
mental level, be it slow or rapid, is regarded with fatalistic resigna-
tion. If this state of affairs may be considered as an important
factor in combating our therapeutic efforts it is also to be remarked
that by general consent and in all grades of society the presence of
a " lunatic " in a family is regarded with feelings other than those
aroused by other forms of illness. Sympathy and a desire to help
to the utmost are, to the credit of our race, in a large majority of
cases present, but there is intermixed with these praiseworthy
emotions a curious half -deprecating attitude of shamefacedness
and a dislike to admitting the fact that the patient is mentally
affected. No one objects to having had in person or to having a
relative who has had appendicitis, while a reputation for " nervous
breakdowns " seems even to enhance the interest of an otherwise
uneventful and colourless life, but a history of insanity, recognised
as such, is referred to with bated breath, or, indeed, as is too often
the case, suppressed altogether. The almost necessary consequence
of this is that the earlier symptoms are set down to anything rather
than to mental illness ; that the patient is subjected to the schemes
and devices of ignorant persons, charlatans and crochet-mongers
and that time of extreme value is wasted.
To neutralise these various circumstances which untowardly
militate against the treatment of mental disorder at that very
time when it is not firmly established, various schemes have been
suggested. In part it has been hoped to educate the public and in
1276 Mental Diseases.
part to mitigate the rigour of the law. There can be but little
doubt that the establishment of mental hospitals or, better still, of
special wards in general hospitals, would have a remarkable effect
in persuading patients and their friends that mental disorders are
to be treated on the same lines as are those diseases which are
termed physical or " bodily," that it is desirable that advice should
be sought at the earliest moment and that there is no reason to
despair, at least in many cases, of the ultimate issue. But to
inaugurate reform on these lines it is necessary that the law should
be modified, or, if not modified, that everything should be done in
a spirit which realises that some of its provisions have become
antiquated and that at its base is not the fundamental principle
that a patient is to be treated, but the principle that the liberty of
the subject is to be jealously guarded. To the medical profession
it is plain that the result is that the treatment of our patients is
rendered difficult or impossible, while there is probably not one of
us who has ever known of an authentic case where a sane person
has been wrongfully detained. Provision for the early treatment of
mental disorder among the poor is practically non-existent, and it
must fall to many of us to watch cases gradually drifting from bad
to worse until the day at length arrives when no course is open to
the relatives but to send the patient to an asylum ; the absence of
such provision is a crying scandal, and its establishment would, we
believe, save many useful citizens who now encumber the ground
at our asylums. Among the well-to-do the early treatment of
insanity can be carried on in the patient's home, a medical man's
house or nursing home, but section 316 of the Lunacy Act, 1890,
has always to be borne in mind. In framing this section our legis-
lators no doubt had what they considered to be the good of the
majority in mind, whereas the physician working in this branch of
medicine at once appreciates that to obey the letter of the law all
too often inflicts a cruel and unnecessary wrong upon a patient
without the smallest compensating advantage. Section 316 of the
Lunacy Act, 1890, runs as follows :
"Every person who, except under the provisions of this Act,
receives or detains a lunatic, or alleged lunatic, in an institution for
lunatics, or for payment takes charge of, receives to board or lodge,
or detains a lunatic or alleged lunatic in an unlicensed house, shall
be guilty of a misdemeanour, and in the latter case shall also be
liable to a penalty not exceeding fifty pounds."
The question must here arise as to what a "lunatic " is. The
Lunacy Act, 1890, defines as follows : " ' Lunatic ' means an idiot
or person of unsound mind." If every person who presents
Mental Diseases. I2 77
symptoms of mental disorder is to be regarded as a " lunatic," and
such is tlie law, and if no such person is to be received for treat-
ment by those skilled in the therapeutic art unless he or she is
legally certified as a " lunatic," the Act plainly becomes an engine
of ridiculous tyranny. In Scotland the Lunacy Commissioners
have, in a recent report, officially expressed an opinion that those
perform a useful function who receive such patients as it is not
desirable to certify, even though they present symptoms of mental
disorder. In the suggestions which we shall hereinafter make
with regard to the treatment of the mentally disordered we shall
not contrast that which is sometimes called "asylum treatment"
with treatment which may elsewhere be instituted, for we are of
opinion that there should in fact be no such contrast. It is too
often held that an asylum is less a place for the treatment of
acute insanity than one for harbouring the chronically insane and
demented, but we hold most strongly to the opinion that an asylum
should be primarily a mental hospital at which treatment should
be carried on with the care and attention to detail which mark the
administration of our general hospitals.
The practical problem which will confront the medical man and
the relations of the patient is as to how the patient is best to be
treated and where, and it is to the latter part of this problem we
propose now to address ourselves. The financial resources of the
patient to a large extent govern the situation. If the number of
nurses can be unlimited, if the largest part of the time of a medical
man can be secured, and if a certain part of the patient's house can
be set aside for his own exclusive use, it may be quite possible to
treat the patient who is acutely ill at home. The expense involved
is naturally very great, and the patient cannot in this way be so
completely withdrawn from home influences as if he was housed
elsewhere. If adequate medical attendance and nursing cannot be
obtained at home, or if the patient cannot there be properly
secluded, an alternative lies in his removal to the house of some
skilled person willing to receive him. Noisiness and violence on
the part of the patient is perhaps the chief bar to reception into a
private house, while the treatment of a marked case of paranoia
outside an asj'lum is difficult. If delusions of suspicion and perse-
cution are pronounced a homicidal tendency should be suspected,
and such a tendency is clearly best controlled in an institution. So,
too, in the case of a suicidal patient it is best that he should be in
an institution where the possibilities of an attempt at self-destruc-
tion are carefully guarded against. In addition to these indications
against treatment in a private house it must be borne in mind that
1278 Mental Diseases.
unremitting medical attention and nursing involve an expenditure
which cannot often be borne, and when this is the case a choice
must be made from among a large number of licensed institutions
where expenses are less owing to the large number of patients
received. In cases of chronic insanity the disposal of the patient
must depend on the severity of the symptoms. In some mild cases
there is no reason why the patient should not live at home, but in
severe cases institutional treatment is more desirable than treat-
ment in single care, for there is a wider range of society, of work and
of amusement to be found within the walls of a well-regulated
institution. When it has been decided that it is desirable that the
patient should be certified and the objection of the relatives to such
a course has been overcome, the process of certification or legal
recognition of the person as of unsound mind has to be effected.
Certification. The most usual method whereby certification is
executed is by a reception order made upon the presentation of
a petition supported by medical certificates. Forms may be
obtained from Shaw & Sons, Fetter Lane, E.G. The petition
consists of an application which is made by a near relative of the
patient and contains particulars concerning the history of the
patient. If a near relative is not available the petition may be
signed by someone else, but in this case it must be explained
why the petition is not presented by a near relative or connection.
This petition is presented with the medical certificates to a
magistrate, having special jurisdiction in such matters, who there-
upon makes an order for the reception of the patient into the asylum,
hospital or house which has been selected. It is to be remembered
that it is not necessary that the magistrate should see the patient,
nevertheless the decision rests with him. Two medical certificates,
signed by two registered practitioners, are required and contain the
facts observed by the practitioners at the time of their examination
of the patient and facts communicated to them by others. One of
the certificates should, whenever practicable, be under the hand of
the usual medical attendant of the patient. Each of the practi-
tioners must personally examine the patient separately from the
other and the examination must not have occurred more than seven
clear days before the presentation of the petition. Neither practi-
tioner may be the father or father-in-law, mother or mother-in-law,
son or son-in-law, daughter or daughter-in-law 7 , brother or brother-
in-law, sister or sister-in-law, partner or assistant of the other.
The following cannot sign the certificate : The petitioner, the
superintendent, proprietor, or medical attendant of the asylum,
hospital or house to which the patient is to go; any person
Mental Diseases. 1279
interested in the payments on account of the patient; or the
husband or wife, father or father-in-law, mother or mother-in-law,
son or son-in-law, daughter or daughter-in-law, brother or brother-
in-law, sister or sister-in-law, partner or assistant to any of the
foregoing persons.
In some cases it is desirable that the patient should forthwith be
placed under care and the above procedure may be made shorter by
the use of the urgency order. In this case the authority to receive
the patient is given by a near relation or connection of the patient,
and need only be accompanied by one medical certificate drawn up
by a practitioner who has seen the patient within two clear days
before his reception at the house or institution in which he is to be
detained. The ordinary papers must then be completed within a
week from date of order. Such are by far the most common
methods in vogue, and it is unnecessary here to detail those by
which lunatics wandering at large, or persons of property, or
persons not properly cared for, can, by the order of a justice, or
by order of two Commissioners in Lunacy, or by the process of
inquisition, be brought under care. It may however be remembered
that in the case of pauper patients only one medical certificate is
necessary and all arrangements have to be made through the
relieving officer. In Scotland and Ireland the procedure, though
substantially the same, differs in a few details.
AVe propose now to pass to those medical aspects of the treatment
of mental disorder which are our chief concern. The present
classification of mental disorder, although vastly improved in recent
years, is not perfect, and to deal with therapeutics on the basis of
that classification would, we believe, lead to much reiteration. It
has seemed to us better for our purpose to select, for the most part,
groups of symptoms and to endeavour to indicate the treatment
proper to them. In the first instance we shall discuss at length
prophylaxis and the treatment of the important groups which pass
under the terms " mania " and " melancholia." and thereafter pass
to those whose etiology or symptomatology suggest separate
consideration.
Prophylaxis. A due consideration of the problems involved in
the prophylaxis of mental disorder would in itself necessitate works
of enormous magnitude upon biological, pathological and sociological
subjects. Here we can alone deal with some of the proximate and
most obvious factors which appear to tend to the production of
morbid mental states.
Among the matters of special importance upon which the medical
man is occasionally, but far too infrequently, consulted, is that of
1280 Mental Diseases.
the marriage of persons whose family or personal histories contain
evidence of a neurotic inheritance. The problem as to whether the
advice of the physician should always be thrown into the scale
against such unions or whether the advice should be modified by
special circumstances is as yet not solved, and we propose here to
offer only a few general rules, wbich we trust may be of some assist-
ance in particular cases. It is plain that persons who are presently
insane, and to a less degree those who have been insane, are not
persons who are the most suitable for the procreation of children ;
but again it is equally plain that to deny marriage to one who
is perfectly healthy because his family history reveals a case or two
of insanity would be over-cautious and certainly quite idle. We
believe, however, that under the circumstances mentioned here
below it is wise and right to advise that marriage should not take
place. A family history which shows many members of the family
to have been insane or neurotic, and especially if such insanity has
broken out in successive generations, centra-indicates the procreation
of children, and a fortiori is this the case if such defect occurs in the
family histories of both parties. Epileptic, diabetic or pronounced
alcoholic family histories should in the same way act as an objection
to matrimony. The presence of gross stigmata of degeneration in
either male or female, and all the more if the stigmata are observed
in both parties, the fact that one of the parties, has had or has
epilepsy, or has shown symptoms of certain types of mental dis-
order, or has not completely recovered from an attack, so that he
or she is occupying a lower mental level than was occupied before
the attack, are all centra-indications. It is for the moment
undecided as to when, if ever, the risks of paternal or maternal
syphilis become extinguished, and we can only affirm that children
should certainly not be procreated until the long period of treatment
prescribed by our present day knowledge has been safely passed and
there are no evidences of the disease being present. On the other
hand, there are cases in which it does not appear to us that we
have sufficient justification in advising, without hesitation, against
marriage. Defective family history on one side only, if limited to
a single member or a distant relation, with a sound family history
on the other side, need not compel us to advise against marriage.
In the case of the individual who has had one attack of insanity
the future circumstances of the married state should be considered.
If they are such that a life of comparative peace is likely, that work
need not be pushed to the breaking point of the individual, and that
early and intelligent treatment can be instituted and carried out on
the slightest signs of any relapse, then, again, we cannot absolutely
Mental Diseases. 1281
recommend that marriage should not take place. Further, if the
attack of insanity appeared to be due not so much to the inherent
weakness of the individual as to the exceptional stresses to which
he was subject, and if such stresses can in the future be avoided, we
need oppose no bar. There is but little doubt that to a large extent
the salutary weeding out of weakly individuals which is effected in
accord with the so-called law of the survival of the fittest has -been
hindered by the advance of civilisation and knowledge. There are
said, in certain quarters, to be signs of racial degeneracy or, at any
rate, that a larger proportion of weaklings is nowadays kept alive
than was formerly the case. If this is so, there can be but little
question that it will become necessary for the community closely to
enquire into the hygienic conditions of the stock from which future
generations of citizens are to be reared. In the meanwhile, we are
of opinion that it is desirable in the relatively small field in which
our work lies to direct our advice against those unions from which
disaster to the contracting parties and to their offspring is almost
certain to ensue.
The education of the individual has a very distinct bearing upon
the prophylaxis of mental disorder. Here, again, civilisation and
science have evolved a scheme of education which, while in some
respects admirable, is less Spartan than of yore, and has led to the
production of a type of child who, precocious in knowledge, is
deficient in self-control. Intellectual abilities are rightly highly
esteemed, but their educational cultivation at the expense of that
which is known as " character " is to be deprecated. It is of the
greatest importance that the child, especially the one that comes
from a neurotic stock, should be tended from all sides and not only
from the intellectual or only from the physical. Steady growth in
all directions should be promoted and tendencies towards the pro-
digious curbed. A process of slow and equal growth is likely to
result in a stable period of maturity, whereas early brilliancy too
often leads later to enfeeblement and even to intellectual extinction.
The intellectual education of the neurotic child may, as a rule,
be postponed for a year or two beyond the time at which it is
customary for education in this country to commence, and the time
may very well be spent in the country, where he may learn the
rudiments of some manual craft. When at length intellectual
education is commenced it' is of great importance that the pro-
gress of the child should not be forced or his faculties spurred
in the pursuit of prizes and scholarships. During the period of
puberty the child should be especially keenly watched, and work and
play so regulated that no undue fatigue occurs. There is probably
S.T. VOL. ii. 81
1282 Mental Diseases.
no age too early ior the inculcation of self-restraint, of obedience
to proper authority and a due regard for the claims of others.
Observation of many patients cannot but make us feel that from
the want of such education ill-regulation of life ensues and, as a
further sequence, a mental instability which renders the patient
prone to fall a victim to the adventitious causes of mental disorder.
It is, unfortunately, not infrequently the case that the neurotic
child is educated by the neurotic parent in a neurotic family
atmosphere, and that as a consequence the child who, under
other circumstances, would have grown into a normal adult, has
just those characteristics markedly developed which should have
been pruned away, and, in the feebleness of its will power and the
unrestrained strength of its emotions, pursues modes of life which
tend to mental disorder. It is of course clear that under these
circumstances the physician, on those rare occasions upon which it
is thought desirable to seek his advice, should recommend removal
from home to the charge of those fitted by character and training
for the judicious handling of the young.
To any person, whether a child, a juvenile, or an adult, in whom
there is a neurotic diathesis certain simple rules of life should be
recommended. Food should be plain and plentiful, and it should
be sought to keep the patient's weight at a few pounds in excess of
the amount proper to the age and sex. A decrease of weight,
especially if it is rapid, is to be regarded with particular suspicion.
So far as is possible the digestion must be kept in order and
regularity of the bowels maintained. Milk is, as a rule, the best
drink for neurotic persons and they are, for the most part, better
without alcohol. Meals should not be hurried. A larger and larger
proportion of the population daily hurries from a hasty breakfast to
its work, bolts a scamped lunch, and, thoroughly tired at the end of
the day, hastens back to a meal for which the appetite has been
robbed by fatigue. It is not surprising that from among those who
live this life comes a large proportion of the dyspeptic and the
nervous. Work should be carried on between regulated hours, and
the day should be so mapped out that the meals can be taken quietly
and in peace. So, too, the practice of working late into the night
should be discountenanced, for it is a fruitful source of insomnia.
For the neurotic holidays are of great importance, and the attempt
to continue work when body and mind are jaded is only too likely
to end in breakdown. Such comparatively simple rules as these
should be the constant theme of the physician in the presence of
his neurotic patients. They can hardly be inculcated too often, for
it is in their breach that lie the most potent causes of mental dis-
Mental Diseases. 1283
order, yet it must not be forgotten that there may be a danger that
the patient may be trained into a hypochondriacal valetudinarian,
and the utmost tact must be used, while advising regularity of life,
to avoid this extreme.
At this point it is important to insist upon due regard being paid,
both by the patient and by the physician, to early symptoms.
These are but too frequently overlooked, though there can be no
doubt that it is in their early recognition that the best hope of the
patient lies. A falling body weight, an appetite which is becoming
poor, sleep, the amount of which is becoming shorter and its quality
lighter, are all notable phenomena in a neurotic individual. Inability
to attend properly to work or even to play, restlessness, irritability,
and slight changes of conduct, should be noted and call for immediate
treatment, but it is too often the case that not till alteration of con-
duct has eventuated in some gross breach of manners or morals
that the relations are sufficiently aroused to take action and to seek
advice. If, however, the relations are sufficiently wideawake or if
the patient has had a previous attack and knows the character of
the prodromata, then there is much hope that, on their appearance,
timely treatment may avert a further development. The patient
should, where it is possible, at once give up work and rest, while it
must be sought to improve the appetite and promote sleep. With
such simple measures health is often restored in the course of a
few weeks, whereas if the patient had drifted on a breakdown would
have resulted which would have laid the patient aside for many
months, passed perhaps in an asylum, and with serious risk of
permanent mental disablement.
MAURICE CRAIG and E. D. MACNAMARA.
812
1284
MANIA.
THERE are but few cases of mania in which prodromata
are wholly absent, and as treatment at this stage may do much
to lessen the severity of the coming attack it is of supreme
importance to recognise them. Unfortunately, in most cases, these
prodromal symptoms are not recognised by friends and relations
as evidences of illness, and the patient is not brought under the
notice of the physician until a further and much more marked
stage has been reached. The early stages of exhilaration and
excitement may very probably lead the patient into paths of
conduct in which the incitements to an agitated disquietude are
powerful, so that, entering upon a vicious circle, the condition
of the patient rapidly becomes worse. At this stage he has
probably become intolerable to society and the physician is called
in to lend his aid in effectuating legal restraint. But whether the
patient comes under care at the earliest or at later stages of the
disease, the therapeutic measure of first importance is, so far
as is possible, to put the patient in such circumstances that
incitation to excitement is reduced to a minimum. The presence
of relations and friends, transparently solicitous, almost always
ignorant and often tactless, should be forbidden, and excuses that
the patient will be more worried by their absence than by their
presence may safely be ignored, for experience teaches us that this
is simply not the case in conditions of acute mental disorder. In
the case of the master or the mistress of a house it is inevitable
that while at home he or she cannot be restrained from interest
and participation in the affairs of home life, and this is true,
though perhaps to a less extent, of other members of a family. It
follows that removal from home is imperative. The room in which
the patient is to be nursed should be large, airy and quiet. The
fewer objects in the room which may excite attention the better, so
that pictures, ornaments and unnecessary pieces of furniture should
be conspicuous by their absence. Wall-papers and hangings should
be of some neutral tint, and blinds should be so arranged that,
while air is not excluded, the bright light of the sun is tempered.
If the patient should become violent it obviously becomes yet more
imperative that there should be nothing in the room which he can
use as a missile or as a means of attack upon others, or with which,
Mania. 1285
in his impulsiveness, he might damage himself. Although patients
of this class are but little inclined to suicide or to premeditated
assaults on bystanders, yet, nevertheless, they should be watched
day and night, for impulsive acts of violence are not uncommon
whereby they may injure themselves or others. Tearing of clothes,
smashing of furniture, masturbation and the handling of faeces, are
all acts which may be expected and should be guarded against.
At this stage it may be convenient to point out that, though the
patient should be guarded against the assault of others and pre-
served from accidental injury to himself, yet that this is but badly
effected by mechanical means of restraint. Such means may
readily convert moderate excitement into extreme fury, which not
only renders supervision and nursing doubly difficult, but increases
those very symptoms it is sought to abate and induces an exhaustion
from which the patient but slowly recovers. Mechanical means
of restraint further tend to produce a false sense of security
and a relaxation of that close attention on the part of the nurse
which is all-important. To reduce the sensory incitements to
motor activity to a minimum, rest in bed is of supreme importance.
In the great majority of cases submitted to this procedure agitation
is notably reduced, the patient is taught to recognise the fact that
he is seriously ill, his vital forces are spared to do their utmost
in combating further deterioration of nervous tissues, circulation
and nutrition are in general facilitated, and nursing, in place
of being a perpetual struggle, approximates to that necessitated
by an acute infective process, in which the patient's temperature
chart, his pulse rate, his respiration rate, the occasions upon which
his bowels are opened and the amount of water passed, are all duly
noted and recorded, his skin is kept clean and active by frequent
ablutions, food is given regularly and frequently, while all the time
he is being subjected to a kindly and tactful discipline which
is directed to the removal of all sources of disquietude. From the
onset it may happen that the patient will take kindly to this form
of treatment, but, on the other hand, he may prefer to get up and
restlessly to wander about his room. In a large number of such
cases the patient can be induced by kindly persuasion to return
to his bed after a short interval, but in others the patient persists
in aimlessly walking about, and when this is the case he should
on no account be forcibly kept in bed, for fruitlessly to struggle
against superior force is even more wearing and exciting than
to walk about. Persistence in this line of treatment is likely
in a few days to eventuate in the patient's submission, and it will
then be found that as time goes on he will become more and more
1286 Mania.
peaceful, motor restlessness will diminish, and there will be less
and less need for perpetual management. We do not wish it to be
supposed that we are vaunting this mode of treatment as a panacea.
There are cases, though but few in number, in which it is impos-
sible, without the exercise of nocuous and unwarrantable restraint,
to keep a patient in bed, and in which excitement is rather increased
than diminished by persistence in this line, but we strenuously urge
not only that this line of treatment has been empirically found
to be the best, but that it is far more in accord with our present day
knowledge of the pathology of the nervous system that that system
should, when diseased, be treated as are the other systems of the
body, and not, as heretofore, on wholly opposite lines. To excite
an already pathologically excited patient by travel or change
of' scene or social gaiety, in the hope of " distracting his mind,"
is to place upon the neurons already labouring under the stress
of exhaustion, or of toxines, or of both, additional burdens which
they are in no position to bear. As an adjuvant to rest, fresh air
is of very great importance, and if suitable provision can be made
for the accommodation of the patient's bed in the open-air, the
good effects of the treatment will be notably increased. It is of
course not desirable that the bed should so be placed that the
multitude of impressions received from without becomes greater
than when the patient is confined to his room, but with a system
of screens this can be prevented, and it will be found that the
restlessness of mind and body characteristic of the syndrome
becomes diminished, sleep improves, the appetite becomes better,
anaemia becomes less marked, the functions of the alimentary tract
are better performed, and flesh is put on.
Combined with rest in bed, or in some cases substituted for
it, balneation holds a prominent place. The temperature of the
bath should be from 94 to 98 F. The length of time the patient
is kept in it may be on the first day from half an hour to an hour,
and this time may be increased as the days go on until he spends
the greater part of the day, or at least several hours, in the bath.
At times patients have been kept in their baths for days, weeks,
and even months, and the combination of the effects of the complete
rest and of the bath has appeared to be productive of greater good
than could be expected from either mode of treatment separately.
For the first few days, and even in some cases for longer, it is
desirable to apply to the head, while the patient is in the bath,
a compress wrung out in ice-cold water or an ice-bag. The
patient should be so supported that there is no danger of his
mouth and nose slipping below the surface of the water. Among
Mania. 1287
other hydrotherapeutic measures may be mentioned daily baths,
preceded by a thorough shampoo of the skin, and in some cases
the wet pack is of value. The patient is placed in a sheet which
has been damped with water at a temperature of about 50 F. and
which is loosely laid over and about him, while over this is placed
a blanket. The patient may be kept in such a pack for from
ten to twenty minutes, and a sedative effect is often obtained.
The cold plunge and the cold douche have been rightly abandoned
in the treatment of acute mania.
It is to be remembered that in a large number of cases in which
the syndrome of mania occurs the patient's " bodily " health has
for some time been deteriorating, and that with this deterioration
there has, in all probability, been much loss of weight. The
extreme restlessness of the early and acute stage, during which the
activities of mind and body know no pause, still further depletes
the tissues, and a still more marked decrease in weight occurs. It
is plain that to meet this condition the body must be sustained
by an ample supply of good food. In many cases there is little
or no difficulty in getting a patient suffering from acute mania
to take food, and, in almost all, such difficulty as exists can be
met successfully by the attentive persuasion of a skilled nurse,
while it is but rarely that forced feeding, such as is described
under the article on melancholia, has to be resorted to. Food may
be very varied, but whereas the patient is apt to bolt it and
in consequence its preparation for the stomach by efficient mas-
tication is defective, it should be given in a finely divided form.
At least 3 pints of milk should be given during the twenty-
four hours, and in each draught of milk one or two eggs may
be beaten up. The ordinary three meals a day should consist
of minced meats and milk puddings, with a liberal supply of fresh
or stewed fruits, care being exercised in the exhaustion cases, lest
diarrhoaa should be produced. These meals should be supple-
mented by smaller feeds, administered between the larger, or, on
the other hand, the patient may sometimes with advantage be put
upon regular two-hourly feeds ; but in any case a treatment of
super-alimentation should be pursued until the patient's normal
weight has been regained, and only then very slowly relaxed until
the patient shows definite mental improvement.
The medicinal treatment of the maniacal syndrome consists
in the administration of sedative and hypnotic drugs. It is,
however, eminently desirable to be restrained in the use of
medicines, seeing that these are one and all liable to produce
toxic effects. Rest in bed, fresh air, hydrotherapeutic measures
1288 Mania.
and feeding, are all more reliable and safer measures. Opium
is occasionally employed, but on the whole there seems to be
a widespread objection to its use in mania, for in the acute stage
it is apt to increase the incoherence and agitation ; nevertheless, in
extreme cases accompanied by much physical exhaustion, and also
later, when the excitement is abating, its good effects are obvious.
When opium is given it should be given in the form of the tincture,
commencing with from 5 to 10 min. [U.S.P. 3 to 6 min.] , and
gradually increasing the dose. It is, of course, to be remembered
that the dose must be diminished and the drug gradually withdrawn
so soon as its desired effect has been produced or when it has
become plain that no further good can be expected from its con-
tinued administration. The bromides may occasionally exercise a
sedative influence, but they are often most disappointing. With
the bromide salt chloral may be given, but during its administra-
tion the heart must be carefully watched. Paraldehyde, sulphonal
and veronal are among the most useful hypnotics. Hyoscine and
Hyoscyamine are at times useful and lessen both motor restlessness
and activity in the processes of cerebration. It must be remembered
that both drugs are powerful poisons and that they must be
administered in the smallest quantities, Hyoscine Hydrochloride
or Hydrobromide in T ^Q to 200 S r -> an d Hyoscyamine from J a to
xio 8 r - doses. Beyond the serious syncopal symptoms which may
supervene upon a large dose of either of these drugs, it is to be
remembered that they are apt to give rise to hallucinations
especially in just those cases of acute mania in which there is the
most need for the drug.
It will, unfortunately, only too often be found that, directly
the more acute symptoms have passed off, the relatives of the
patient become desirous of removing him from medical care, and
by this course not only is recovery retarded, but sometimes
a relapse is caused. On no account should convalescence be
hurried, and it .should only be by the easiest stages that the patient
is returned to a normal routine of life. When there has been no
sign of mental symptoms for a month and when the patient's
general health has become satisfactory and his weight has again
reached the normal, a change may be advised and the patient sent
to some quiet country resort, where he may enjoy some mild and
unexciting change in occupation. Life in the open-air combined
with such games as croquet or golf, or such an occupation as
gardening, contribute to restore appetite and sleep. After a mouth
of this sort of life a period of travel, bereft of the bustling aspects
which too often makes hard labour of a modern tour, may be
Mania. 1289
>
suitably recommended, and after this the patient may return
to his home and, later, to the business occupation of his life.
It must be borne in mind that the- period of excitement will be
followed by a phase of depression in the maniacal depressive cases.
It is plain that we are now prescribing a course of treatment which
can only be applicable to persons of means, but for others we would
lay it down that the longer the period of treatment in an asylum or
mental hospital the better ; the disasters following upon too early
removal are so many and so serious that a general rule such as this
is wise. Of course, wherever it is possible, we would counsel change
of scene before the patient returns to his ordinary avocations.
The treatment of so-called acute delirious mania does not
markedly differ from that of acute mania. Inasmuch as the
constitutional symptoms are even more marked and the patient
soon falls into a typhoidal state, skilful nursing and feeding
are of the utmost importance. Food should be given every
two or three hours during the night as well as during the
day, and should consist chiefly of milk and eggs, to which may
be added such carbohydrate and proteid foods as can be mixed with
the milk. Stimulants may be required, and there need be no
hesitation in giving brandy, port wine or stout. In some cases
the violent restlessness of the patient is such that it becomes
well-nigh impossible to do anything for him, and he can only
be fed forcibly with the assistance of several nurses. Under
these circumstances it may be desirable to administer chloroform,
and while the patient is under its influence the bowels may
be opened with an enema, the stomach washed out and then
replenished with food, to which may have been added some
hypnotic drug, and the patient may be washed and put to bed,
where he may obtain some hours' sleep. The prolonged hot
bath has been alleged by continental authorities to be of signal
service, but should be used with caution.
MAURICE CRAIG and E. D. MACNAMARA.
I2QO
MELANCHOLIA.
IN- the treatment of melancholia, as in the treatment of mania,
attention to the surroundings of the patient is of prime import-
ance. The patient should be placed in as peaceful an environment
as it is possible to find, and in all but the very mildest cases
it is necessary that he should be removed from his habitual
surroundings ; for the cares of home, and it is with the cares and
not with the comforts that the patient's mind is filled, the contrast
between his present misery and his past happiness, and contact
with relations and friends all militate against a reduction in the
number of those impinging irritants which are harmful to such a
patient. The " rousing treatment," whereby by voyages or an
unceasing round of distraction and physical activity the patient's
depleted energies were yet further exhausted, is fortunately passing
out of vogue and indeed possesses as little justification as did
the indiscriminate bleeding of earlier generations. The body,
invariably in an enfeebled and wasted state and still further worn
by the ceaseless and all engrossing misery of the mind, patently
pleads for rest, and the plea should be no more disregarded than
it is in the case of any other exhausting malady. Best, especially
in bed, is, in the early stages, undoubtedly the best treatment for
patients who exhibit the syndrome of acute melancholia. Where
possible it is highly desirable that treatment should be carried on in
the open-air, and that the patient should, in this respect, be treated
exactly as is the patient suffering from tuberculosis. Improve-
ment in physical health is in this way accelerated, the patient's
appetite becomes larger, sleep becomes longer and deeper, the
temperature rises to the normal and the circulation of blood
improves, while, on the mental side, it will be found in most cases
that restlessness, anxiety and anguish of mind are diminished.
Rest in bed has the further advantage of rendering attempts at
suicide less feasible, though it must not be forgotten that patients
have been known to conceal in the bedding weapons which they
have, when the watch has been relaxed, used upon themselves,
while under the cover of their bedclothes some have attempted to
strangle themselves. Where continuous rest in the open-air is
impracticable care should still be taken that as much fresh air is
admitted to the sick room us can possibly be obtained.
Melancholia. 1291
In the acute stage of the illness the visits of friends are always
harmful, and the various symptoms become worse after the inter-
view. Where relations, often out of distrust of those in whose
hands they have placed the patient, insist upon exercising their
right of seeing him, they should be counselled that conversation
should be short, upon general topics and not upon such as may in
any way further arouse the apprehensions of the patient. There
are many lay persons who regard themselves in this, as in other
branches of medicine, as endowed with some peculiar faculty in the
therapeutic art, and who especially seek opportunities of exercising
'their powers in those cases where the morbid changes are recondite.
Such will, when visiting a patient, take the opportunity of practis-
ing their peculiar method, and often to the very great harm of
the sufferers. In the later stages the visits of relations may be
allowed, but only tentatively, and must be at once stopped if there
is any evidence that the effect has not been good. In a similar way
correspondence is almost always bad for a patient. To write a
letter is often a wearisome labour, and especially when its com-
position becomes a matter of hours duration, as it does in the
exhausted condition in which the patient is ; while it is but rarely
that the reception of even the most judiciously worded letter does
not produce an exacerbation of the patient's symptoms lasting for
several days.
The next object of urgent importance to which treatment must
be directed is so carefully to watch the patient that any attempt at
suicide may be prevented, for the golden rule that every melan-
cholic patient is a potential suicide must never for an instant be
forgotten. The attention of the nurse must be continuously
directed to this point, and he or she must be so frequently relieved
that there may be no chance of this attention becoming tired and
therefore relaxed. Unless a sufficient number of nurses can be
provided it is undesirable that, the patient should be treated else-
where than at an institution. Care should be taken that the
patient is deprived of every possibly lethal weapon, and all cutting
instruments such as scissors or knives should be searched for and
removed. Drugs should not be kept in the patient's room. Hand-
kerchiefs, pieces of clothing, of string or of tape, may be used for
purposes of strangulation, the flames of candles, fires and gas-
burners may be used for the purpose of setting alight to clothing,
and various articles such as pieces of glass or china may be
swallowed with a view to causing serious intestinal lesions. Patients
not uncommonly seize opportunities of throwing themselves from
heights, and special care is required on those occasions when
1292 Melancholia.
it may be necessary for them to ascend or descend staircases, while
the windows of their rooms should be jealously guarded, and so
blocked that the lower sashes can only be opened to a slight extent.
On no account must a patient be allowed to go to the water-closet by
himself, and it is perhaps best that motions should be passed into
the pan of a commode in the bedroom, where their amount and
character can be better noted. Food should be so prepared that
the use of a knife is unnecessary.
Feeding is always a matter of great difficulty in the treatment of
melancholic patients, for to the patient himself the taking of food
is an insufferable nuisance. The sensibility of his organs of taste
is diminished, his alimentary tract is performing its work ill and
sluggishly, he is too preoccupied with sorrow to think of food, he
is afraid of being poisoned, or he. is desirous of mortifying himself,
while there may very probably be present a hope, the only one of
the melancholic, that death by starvation will be a welcome release.
Nevertheless, food, abundant in quantity and substantial in quality,
must be regularly administered. Happily, in most cases this is
effected by patient persuasion on the part of the nurse, and it is
but comparatively rarely that forcible feeding has to be resorted to.
At least 3 pints of milk should be given during the twenty-four
hours, and to some of this may be added eggs or some miscible
carbohydrate or nitrogenous foodstuff, while, if the milk has been
skimmed, cream may be added to it. No special dietary is
indicated, though in cases where the blood pressure is high the
meat foods should be reduced in quantity, and the only important
point to insist upon is that the patient should have a large quantity
of good food. Some patients will not trouble to raise the food from
the plate to the mouth, and in these cases the nurse must give the
food with a spoon, while in others the opposition on the part of the
patient is such that recourse has to be had to forced feeding, and
the food is placed in the oesophagus or stomach by means of the
nasal or oesophageal tubes. The patient should be laid upon a
mattress on the floor and be securely, though with the utmost
gentleness, held by nurses so that he cannot interfere with the
operations of the physician, and the nasal tube (sizes 9 or 10),
previously lubricated, is then passed through one or other nostril
into the cesophagus. If, as occasionally happens, the tube is passed
into the larynx, cough or dyspnoea are at once set up, and the tube
must be partially withdrawn and again passed. In the case of the
oesophageal tube it is necessary that a gag should be used, and
this constitutes the great objection to its use, as there is risk of
damage to the teeth. To the other end of the tube, whether
Melancholia. 1293
cesophageal or nasal, a large glass funnel is attached, and into this
the foodstuffs are poured. These should consist of milk, eggs,
soups, powdered meats, vegetable extracts, cream, and such carbo-
hydrate foods as can be readily passed through the variety of
tube selected in the particular case. Patients should be fed three
or four times a day, and if there is a tendency to vomiting, an act
sometimes artificially excited by the patient, the amount passed in
should be about \ or f pint ; in other cases the quantity may be rather
more than a pint. The tube should be treated as carefully as
the teat of a baby's feeding bottle and should be thoroughly washed
and disinfected after each time of use. Tentative efforts should
constantly be made to feed the patient by more natural methods,
and it not unfrequently happens that after one forced meal the
patient is willing to feed himself adequately.
It is surprising that considering the dirty state of the tongue
and the pronounced constipation with which melancholic patients
are invariably affected there is in general so little complaint of
gastro-intestinal disorder. Such an aspect of the tongue and
condition of the bowels as would usually be an indication for some
strict dietetic regime, in the melancholic syndrome only indicates
the giving of large quantities of substantial food. Nevertheless,
the condition of the tongue should not be neglected, for it is at least
possible that the syndome is in some cases the result of a chronic
intoxication, the place of generation of the poison being the
alimentary tract. The first indication, then, is to secure a regular
action of the bowels. In some cases this may be done by getting
the patient to take an adequate amount of water, a fluid he has
probably recently neglected, while in others the drugs most usually
found useful are calomel, cascara sagrada, the saline purgatives
and castor oil. Enemata are not unfrequently necessary, especially
in those cases in which there is some degree of obstruction owing
to impaction of hardened fseculent matter. While there can be no
doubt as to the desirability of relieving the bowels, the neutralisa-
tion or counteraction of the supposed poisons and the destruction
of the micro-organisms which possibly make them is rather more
debateable. Given the poison or the micro-organism or both, such
drugs as salicylate of bismuth, salol, sodium sulpho-carbolate or
beta-naphthol may be ordered or the stomach or large intestine
may be washed out, or the lactic acid bacillus may be given.
Hydro therapeutic measures may in some cases be found to improve
the enfeebled nutrition of the patient, but it should not be
forgotten that the reaction of such is often slow, and that
the indiscriminate use of the cold douche may provoke internal
1294 Melancholia.
congestions. Nevertheless, the cold douche, especially following
upon the hot one, has its place in mild cases and, during the stage
of convalescence, in bad cases. Douches at moderate temperatures,
packs and warm baths have a soothing and hypnotic effect, and
may therefore be given at night. In any case, however, washing
for cleansing purposes should be strictly enforced and the emunctory
functions of the skin fully utilised. About many melancholic
patients there is an odour which is peculiar to insane persons, and
which is strongly suggestive that some extraordinary process of
elimination through the skin is being carried on.
Electricity has not proved of much use in the treatment of
mental disorder in general nor of melancholia in particular. Some
have recommended that a mild faradic current should be applied to
the limbs once a day. Our experience favours the use of the static
varieties of electricity. There is no objection to a few such appli-
cations being made and, if any good seems to ensue, to their being
continued. Similarly massage may occasionally be found to be of
some value, but in the majority of cases in the acute stages it is
disagreeable to the patient and unproductive of any other result.
In later stages, when convalescence has set in, both electricity and
massage have their place in improving the general nutrition of the
patient.
The fact that occasionally patients presenting the syndrome of
melancholia are seemingly benefited by being attacked by some
non-mental illness has suggested a line of treatment whereby some
comparatively harmless malady is induced in the hope that its
occurrence may abate the mental symptoms. For instance, a con-
dition of hyperthyroidism has been induced by the administration
of large doses of thyroid extract. The initial dose may consist of
10 gr. taken three times a day, and this may be increased up to 15
or 20 gr. by the fourth or fifth .days of treatment. During the
next few days the dosage is gradually reduced so that 10 gr. three
times a day is given on the eighth day. The patient is kept in bed,
for his body weight is rapidly reduced and his mental symptoms
initially exaggerated, while the pulse rate may be quickened and
the temperature unduly lowered. At the end of the week the
patient is ill with hyperthyroidism, and the ordinary routine treat-
ment for melancholia being instituted it is hoped that a more rapid
improvement in mental symptoms will follow than would have been
the case if thyroid had not been given. We ourselves regard this
mode of treatment with suspicion.
While we urge that rest in bed is of the first importance in the
treatment of melancholia, especially in cases of maniacal depressive
Melancholia. I2 95
insanity and the exhaustion psychoses, yet we are quite willing to
admit that there are eases in which it appears to do harm rather
than good. In such cases we would urge that the amount of
exercise taken should be moderate in amount and should stop
short of exhausting the patient. So long as mental disorder was
regarded as a thing apart from neuronic disorder so long was it
approximately reasonable to endeavour to reduce the mind to order
by violent action of the body ; the practice was in fact an extension
of the ascetic doctrine. At present there is a general consensus of
opinion that the proper expression of mentality depends upon the
healthy performance of the functions of the neuronic systems and
that, so far as our present knowledge goes, there is no reason for
treatment of the functional disorders of the nervous system upon
principles other than those which govern us throughout thera-
peutics. If, then, we find that the patient's restlessness or the
profundity of his depression is in fact increased by his being in
bed we may permit of short walks taken in the open-air, or even
perhaps of some such light work as can be found in gardening or
in regulated gymnastic exercises or drill. When the acute stages
have passed off exercise will in any case be indicated, but such
exercise as is appropriate to a patient recovering from a serious
illness. At first the amount should be limited to an hour or so a
day and should consist in walking, a period of repose immediately
succeeding, but as the days go on the time may be increased and
the character of the exercise may be varied, mild games such as
croquet, lawn tennis and golf being permitted.
There has of recent years been introduced a somewhat portentous
but useful term, " psychotherapy." It is employed to denote the
organised use of the therapeutic powers inherent in the action of a
healthy mind upon one diseased. These powers have, since the
dawn of history, been known and utilised, but generally by those
who have sought to endow them with mystic significance, and they
are even now very largely exploited by members of the numerous
bodies whose creeds consist of a curious jumble of bad metaphysics,
bad science and infinite credulity. In acute cases of mental dis-
order appeals addressed to the reason with a view to inducing the
patient to restrain himself or to take a more hopeful view of things
appear perfectly futile, or if they produce an effect it is but
momentary. Nevertheless, conversational intercourse with the
patient should be conducted as if it were with a sane individual.
It is often surprising how much patients remember, when they are
recovered, of what has been said to them and of what has been done
to them, and how often too they acknowledge an influence to have
1296 Melancholia.
been exerted, the effect of which certainly did not immediately or
obviously show itself. Bearing this in mind, the physician's
attitude should be one of assured hopefulness, and even in the
presence of the most convinced despair he should point to a happy
issue ; he should be ready with those approximate explanations of
symptoms, often to him absurdly platitudinous, which even
mentally sound patients delight in, and he must above all things
exercise an infinite patience. To listen to the eternally reiterated
moaning of the depressed individual and to meet every insane
assertion by a reasoned statement of the facts as they appear to
the healthy understanding, and to do this with a show of real
interest, is to practise an art of the greatest difficulty. We believe
that it can only be practised by those whose show of interest is
founded upon a real interest of the most intense character and
whose will is immovably and hopefully directed to the effectuation
of the recovery of the patient. Tactfulness by no means
necessarily presumes, as is too often thought, entire acquiescence
in another's views, but rather in the endeavour to present reason-
able views in a light attractive to the patient. To " humour " the
patient is to pander to his unhealthy delusions, while to flatly con-
tradict them is to raise in him a revolt against a contradiction of
personal experiences which are very real to him and to induce in
him a distrust of the person who contradicts. The primary duty
of the physician is to endeavour to persuade the patient that he is
a sick man, and it is therefore absurd to adopt those too common
subterfuges by which it is sought to introduce the doctor to the
patient as somebody whom he is not. From the outset the
physician should assert his position and definitely lay it down that
he is there for the purpose of endeavouring to alleviate symptoms.
It not unfrequently happens that it is a relief to a patient to learn
that he is ill, and it is plainly an enormous step in advance when
he has been further persuaded to submit himself to treatment.
Throughout the illness the same discriminating attitude should be
adopted, and whatever the development of symptoms it must be
sought to explain to the patient that his hallucinations, delusions
and aberrations of conduct are due to illness and must accordingly
so be treated. The instillation of faith and the assurance of hope
are the keynotes of psychotherapy, whether the processes adopted
are called by that name or by some other of a religious connotation.
In the case of those suffering from the syndrome of melancholia
who are sleepless or agitated, sedatives and hypnotics will be
indicated. In certain cases, where there is much restlessness,
potassium bromide, especially in full doses, notwithstanding its
Melancholia. 1297
depressive action, is of considerable use, but it should be given
very tentatively, and of course at once dropped if it has an effect
opposite to the one desired. The bromides may also be given in
combination with chloral as a hypnotic draught at bedtime when
the patient is settled for the night. The various preparations of
opium sometimes have a most striking effect in producing calm.
The tincture of opium or a liquid preparation of one of the
alkaloids, given by the mouth, are the best for our purpose. At
the commencement the tincture may be given in doses of from
5 to 7 min. [U.S.P. 3 to 5 min.] three times a day, and this
amount may be increased from day to day by 2 or 3 rain., until
20 or 30 min. [U.S.P. 12 to 18 min.] are being taken three
times a day. The dosage arid length of time during which the
drug is to be administered will depend upon the effect produced,
and when a condition of increased restfulness has been obtained
tentative efforts may be made to reduce the quantity given. In
practice it is found that in these cases there is but little danger of
inducing a habit, and where this has unfortunately been established
it has been where the drug was administered hypodermically, or
without due medical supervision. Codeine similarly used will
sometimes be found to give better results than opium. Among the
most useful hypnotics in melancholia are paraldehyde, amylene
hydrate and the more soluble forms of veronal. Such little
soluble drugs as sulphonal are, in the constipated state of the
patient's bowels, rather dangerous, and indeed may produce
disastrous symptoms.
Where there is a notable rise in the blood pressure it may be
lowered by the administration of such drugs as trinitrin, erythrol
tetranitrate and sodium nitrite. Erythrol tetranitrate may be
given at first in doses of \ gr. three times a day, the amount being
increased so that at the end of a week 2 or 3 gr. are being given.
With the lowering of the blood pressure it will be found that some
of the mental symptoms are alleviated, perhaps only temporarily,
but at times permanently.
The injection subcutaneously or into the bowel of sterilised
normal salt solution in quantities of \ to 1J pints daily, or on
alternate days, has been much recommended. It is hoped that by
this method urinary excretion may be increased, that toxic sub-
stances retained in the organism may be diluted or their elimination
promoted and that in this way auto-intoxication may be diminished.
As the acute symptoms pass off and as convalescence becomes
established the rtf/iine under which the patient has been living
may be very cautiously and gradually relaxed. The patient should
S.T. VOL. ii. 82
Melancholia.
by this time have learnt that his inclination to suicide represents a
morbid symptom and should have been urged, on feeling any such
inclination, at once to report it to his nurse or doctor. The con-
finement to bed which may have lasted for weeks or months may
be exchanged for rest on a sofa or in an easy chair, while the
amount of exercise taken is gradually increased and made more
interesting in character. At last, when the mental state of the
patient is as it was before he became ill, when his sleep is normal
in amount and quality, when his appetite is good and his bowels
regular and his body weight has reached, or preferably surpassed,
the standard appropriate to his age and height, he may be sent
away for a few weeks' sober travel. It should not, however, be for
several months that the patient returns to his work, properly
prepared on the slightest recurrence of his previous symptoms to
report himself to his medical attendant.
MAURICE CRAIG and E. D. MACNAMARA.
EXHAUSTION PSYCHOSES.
THE symptoms exhibited by patients suffering from the
exhaustion psychoses are varied. There may be confusion,
mania, melancholia, stupor, or katatonia, while hallucinations
are often a marked feature. Treatment will therefore vary
somewhat according to the syndrome present, but whereas the
morbid state is essentially due to exhaustion it is to remedying
that condition that the physician should direct his attention. The
principal indications are to improve the nutrition of the body by
rest and good feeding. The patient should be put to bed, and, in
most cases, a stay there of two or three months will not be found
excessive. Too early abandonment of this method of treatment is
very apt to result in a relapse, and in any case, when it has been
decided that the patient should get up, a careful watch should be
kept on the pulse rate, and upon the mental condition, so that if
the first is unduly accelerated and there is any indication of the
return of the more acute symptoms the patient should be returned
to bed. Food as substantial and in as large quantities as the
stomach can tolerate should be given, and if the patient should
refuse food, speedy recourse must be had to its administration by
the tube. Suicidal attempts must be guarded against, as these
patients are apt to be very impulsive. Aperients are commonly
necessary and may be combined with intestinal antiseptics, such
as salol, sodiurn-sulpho-carbolate or bismuth salicylate, for it is of
importance to endeavour to avoid a condition of auto-intoxication
consequent upon abnormal fermentations occurring in the alimentary
tract. In cases of mental excitement or motor restlessness the
bromides or preparations of opium or hyoscine or hyoscyainine
may be employed, while sleep is best procured by the use of such
drugs as veronal, hedonal, paraldehyde or amylene hydrate. The
wet pack or the warm bath at night are also at times of service,
and careful attention to the skin is important. In all cases any
cause for the exhaustion, menorrhagia, dysentery, etc., should be
treated.
It is more obvious in these cases than in any other class of
mental disorder that treatment directed towards "rousing" and
"distracting" the patient is fundamentally wrong, and it will not
infrequently be found that the misplaced energy of friends has
822
1300 Exhaustion Psychoses.
converted a mild case into one in which the damage is irreparable.
Here also the extreme importance of early treatment cannot be too
much insisted upon. On the recovery of the patient it will be the
duty of the physician to point out to the patient the harmful
character of the conditions which brought about the illness and to
insist that in future the simple rules of life outlined in the section
on Prophylaxis (p. 1279) should be adhered to.
Among the exhaustion psychoses may be placed the insanities of
pregnancy, parturition and lactation, though there may be some
doubt whether the insanity which occurs in the first half of
pregnancy can rightly be so classed. Treatment must be carried
out on the lines indicated above. The prognosis of speedy recovery
in those cases which occur early in pregnancy is so good that,
unless the symptoms are such that it is quite impossible to keep
the patient at home, it is not necessary that she should be sent
away. It is, however, essential that the patient should be relieved
from the worries incidental to the management of a household, and
that she should be carefully tended by skilled persons. So also the
disorder which occurs at or shortly after parturition may be of
brief duration and is analogous to the delirium of an intoxication ;
under such circumstances removal from home is hardly necessary.
The question of abortion may sometimes be raised, and whereas
neither the induction of premature labour nor natural labour result
in anything more than a temporary lull in the symptoms, recourse
to this measure may be deemed inadvisable unless indicated on
other grounds.
MAURICE CRAIG and E. D. MACNAMARA.
1301
PSYCHOSES ASSOCIATED WITH CHANGES IN THE
THYROID GLAND.
IN these psychoses the mental symptoms appear to be a result of
changes in nutrition, brought about by imperfections in the
functions of the thyroid gland. In one variety there are conditions
in which there is but little doubt that the functions of the thyroid
are performed inadequately, and to which the term " hypothyroidism "
has been applied, and in a second variety there are conditions to
which the term "hyperthyroidisin" has been applied, and in which
it is possible that there is an over-activity of the gland. Associated
with hypothyroidism is niyxoedema, while it is at any rate a
tenable hypothesis that exophthalmic goitre is dependent upon
hyper thyroidism .
In rnyxo3dema there is usually a retardation of the mental
processes, but it occasionally happens that states of excitement or
depression occur, with which may be coupled anxiety, restlessness,
delusions of persecution and insomnia. Treatment consists, as in
the other manifestations of myxoedema, of the administration of
preparations of thyroid gland, and among these the most convenient
and efficacious are tablets and tabloids. It has been alleged that
tliyro-iodine is the active principle, but the state of our knowledge
is not yet so far advanced that its use can be recommended in
preference to that of preparations of the entire gland. It is highly
desirable that, whatever the preparation selected, the initial doses
should be small, and that such symptoms as increased frequency of
the pulse rate, increased frequency of the respiration rate, restless-
ness, anorexia, loss of weight, gastro-intestinal disturbance,
rheumatic pains, insomnia and cutaneous eruptions, which are
indications of over-dosage, should be carefully looked for, and, if
present, that the dose should be proportionately diminished. The
administration of the drug should not be pressed with the view of
obtaining a speedy effect, for troublesome symptoms may in this
way be rapidly produced. A long course of treatment rather than
large dosage produces the best effects, and directly the symptoms
are abated an effort may be made to reduce the amount of the
gland which is to be taken. A continuance of administration must,
however, be maintained, and it is as a. rule unwise ever wholly to
discontinue the use of the gland. At the commencement of the
1302 Thyroid Gland Psychoses.
treatment it is as well that the patient should be confined to his
bed, and this is especially the case if the more severe symptoms
of mental disorder are present or if the heart is in any way weak.
It is not uncommon to find that exophthalmic goitre is accom-
panied by mental symptoms. Restlessness, irritability and abulia,
although important symptoms, are seldom regarded as of mental
character, though maniacal and melancholic symptoms attract
attention at once and somewhat seriously aft'ect the prognosis. In
severe cases it is necessary to keep the patient in bed and at the
same time to give a liberal diet with plenty of milk and cream.
Cod- liver oil or malt should be given, while it may occasionally be
found that the bromides or belladonna are of service. Removal of
a part of the gland or a diminution of the amount of blood
supplied to it by ligation of the thyroid arteries has been
practised, but such operations are liable to be attended by sudden
death. An attempt at rational treatment by the administration of
the serum of the blood *>r of the milk of dethyroidectomised goats
and sheep has been made, and it has appeared to us that in some
cases this method of treatment has been productive of good
results. Antithyroidin Moebius may be given in doses of
10 min. three times a day, and the dose may be gradually
increased until about 30 min. are given at each administration.
Thyroidectine prepared from the dried blood of dethyroidectomised
animals may be given in doses of 5 gr. three times a day and be
gradually increased. Rodagen, which is a substance consisting
of the dried milk of dethyroidectomised goats, may be given in
doses of 75 to 150 gr. thrice daily, and of this class of preparation
this is perhaps productive of the happiest results. Cases have been
reported in which large doses of these substances have been
followed by symptoms suggestive of myxoedema, but this has never
happened in our experience.
MAURICE CRAIG and E. D. MACNAMARA.
1303
TOXIC PSYCHOSES.
RENAL inadequacy is frequently accompanied by some degree of
mental ineptitude, and it occasionally happens that more pro-
nounced symptoms occur. States of excitement, states of depres-
sion, of stupor, profound disorientation, hallucinations and
pronounced insomnia, constitute the most prominent of these
symptoms. Treatment must, of course, be directed towards
combating the uraemia from which the patient is suffering, and
the patient being put on a special diet and being kept in bed, and
other emunctory organs being stimulated to perform those
functions properly performed by the kidneys, the symptoms soon
pass away. Indeed, the rapidity of the relief afforded by these
methods is often of material assistance in the formation of a
diagnosis in obscure cases.
Similarly in diabetes the melancholic syndrome occasionally
makes its appearance. Here, too, treatment must be on the lines
proper to the essential character of the disease. In gout the
irritability of the patient is a well-known mental phenomenon.
Some patients are liable, perhaps prior to, or perhaps during an
articular attack, to present symptoms of depression.
Among the important toxic psychoses are to be mentioned those
occurring with acute infective- processes. The fever, which is an
almost invariable accompaniment of the infections, may very
rapidly produce delirium and this delirium may pass into mania,
but the commonest psychoses connected with the infections are
found at subsequent stages, and are not dependent upon, or at any
rate coincident with, the pyrexia. The syndrome characteristic of
the exhaustion psychoses is the most common. There may,
however, be a condition of mental enfeeblement which becomes
more and more pronounced, and of which the prognosis is bad.
Some of these psychoses appear to be dependent upon changes in
the brain ensuing upon a polio-encephalitis, but in others the
anatomical changes accompanying the morbid processes are
unknown. Those symptoms which arise in the initial stages of the
infections, and which are coincident with a high degree of fever,
should be treated as is the delirium which is the more common
accompaniment of these states. The patient is of course in bed,
and hydrotherapeutic measures, such as the continuous bath or the
1304 Toxic Psychoses.
wet pack or cold sponging, are of prime importance, while the
strength must be maintained by the administration of such food
as the patient is capable of assimilating. The condition of the
cardio-vascular system must be continuously observed, and nocuous
action of the toxins upon it must be met by the administration of
stimulants, and the use of alcohol should not be sparing. In the
case of mental symptoms which appear during convalescence, or
when the patient is supposed to have been restored to a normal
state of health, treatment must depend on the particular syndrome
present, and it should be borne in mind that the post-febrile
disorders are only slowly recovered from. The most important
point which we would urge now is that in no infective process
should the stage of convalescence be unduly shortened and that
ample time should be allowed for the restitution of those delicate
nervous structures which have been subjected to the harmful
action of the poison.
MAURICE CRAIG and E. D. MACNAMARA.
1305
DEMENTIA PR^ECOX.
THE diagnosis of this affection may be difficult in the earliest
stages. It is true that in persons who display certain traits
of character, for instance, affected piousness, impulsiveness,
emotionalism, precocious scepticism and cynicism, and who come
of a neurotic stock, the appearance of more acute symptoms may be
anticipated and appropriate prophylactic treatment may in good
time be instituted, but as a rule it is not until the hebe-
phrenic, katatonic or paranoid symptoms have shown themselves
that the patients come under skilled observation. If the presence
of the affection is suspected before the outbreak of serious
symptoms the patient should live strictly in accordance with the
hygienic rules laid down elsewhere, should be educated to some
handicraft or simple outdoor occupation, and his moral develop-
ment most carefully tended ; but if the acute symptoms are
present it will become of the first importance that the general
nutrition should be improved, for it will be found as a rule that
the patient is run down, that his weight is less than it was and that
sleep is bad.
It is desirable that at any rate at first the patient should be con-
fined to his bed, the length of his sojourn there depending upon
the conditions of his nutrition. At times this measure eventuates in
some alleviation of the symptoms, and at any rate when the more
acute symptoms have somewhat subsided the influence of a kindly
though firm discipline is not without effect, and peculiarities of
conduct, shorn of their grosser characteristics, become less
marked. In asylums and even in their own homes such persons
may display activities of considerable use in the humble roles
assigned to them.
MAURICE CRAIG and E. D. MACNAMARA.
1306
THE MENTAL ASPECTS OF HYSTERIA.
THOUGH a preliminary discussion as to the pathogeny of this
disorder might be of value in clarifying our notions as to the
character of treatment to be pursued, the space at our disposal
is sufficient only for a few remarks on those symptoms which
are patently of a mental nature. A condition of what we may call
hyper-suggestibility has been put forward as explanatory of the
phenomena of the affection, and we are willing to agree that
hyper-suggestibility is, at any rate, a very prominent feature in the
production of individual symptoms. The suggestions are some-
times auto- and sometimes heterogenetic, but the problem, to our
minds, only arises at this point and may be summed up in the
inquiry as to why suggestions, whether from within or without,
produce in certain individuals effects which are uncommon and
morbid. It is a mere truism to observe that the patients are
suggestionable, and it is as much in the interpretation put upon the
suggestion as upon the hyper-sensitive condition of affectivity
that we would seek, an explanation. There are mentally disordered
persons who are perpetually being disturbed by the slights which
they fancy are being put upon them by those who are not even
thinking about them at all, and there are, similarly, persons who
are perpetually disturbed by the obtrusion into the field of their
consciousness of sensations, somehow " suggested " to them, which
are not so obtruded upon the consciousness of the normal individual.
That this covers the whole psychic and somatic ground upon which
the symptoms and signs of hysteria become manifest, we do not
pretend, but we do assert that from the therapeutic point of
view it is as well so to regard it. Both prophylactic and curative
treatment must be based on the hypothesis that the appearance
and disappearance of symptoms depend fundamentally upon the
"character" of the individual. We have never known the
phenomena of hysteria to appear in persons in whom has been
developed the faculty of self-control, nor do we know any soil more
favourable for the development of symptoms than that type of
character best exemplified by the term " spoilt child." Prophylaxis
should commence in the education of the child and should be
continued in the adult in the constant endeavour which the healthy
individual makes to restrain himself. Curative treatment also
The Mental Aspects of Hysteria. 1307
essentially consists in the endeavour of the physician to instil into
the patient's mind a reasonable interpretation of the symptoms and
an assurance that with proper regulation of the functions of her
body they will disappear. But education and re-education, as the
education of the adult is sometimes euphemistically termed, must
be patient and continuous. The example of those mothers who
alternately indulgently caress and angrily browbeat their offspring
is to be avoided, and an even temper is best induced in those
whom it is sought to influence by the exhibition of a good example.
Treatment must throughout be carried on in an atmosphere from
which fussy agitation is rigorously excluded, and by persons
with sufficient knowledge and experience calmly and dispassionately
to persuade the patient of the certainty of her cure. It is too often
supposed in uninformed circles that there is an element of
malingering in the symptoms of hysteria and that treatment
should in consequence be punitive in character. This is a funda-
mental error and will lead to therapeutic disaster. There are,
of course, malingerers whose pretended symptoms are akin to those
of hysteria, but we here suppose that such cases have been
excluded and that the diagnosis of hysteria has definitely been
made. As important adjuvants to psycho-therapeutic treatment
isolation, rest and good feeding stand out prominently. Isolation
implies absence from home and relations and friends, and
the consequent withdrawal of influences which in these cases are
seldom otherwise than harmful, and in their place the substitution
of influences which consist in properly devised suggestions made
by properly qualified persons at the proper times and for the proper
length of time. In a few cases the influence of a husband or
relative may be beneficial, and occasional visits may be permitted.
Rest and good feeding are employed in order that the general
health, which is almost invariably at a low level, may be restored.
Drugs may be given if there are any special indications, but
strenuous endeavours must be made that no drug is given for such
a length of time that the patient comes to depend on it and
to regard it as a panacea for her ills. Massage, provided there
is no tendency to restlessness, and hydro-therapeutic measures are
particularly useful at the stage when the patient shows signs of
improvement. The more pronounced mental symptoms of hysteria
consist of delirium, in which hallucinations are a marked feature,
mania, ecstasy, catalepsy, lethargy, mutism, antero-grade amnesia
and somnambulism, and the diagnosis is in main founded upon
some of these symptoms being either preceded or accompanied by
other psychic or somatic manifestations of hysteria. Treatment of
1308 The Mental Aspects of Hysteria.
the acute mental symptoms has been sufficiently indicated under
other heads, and of the less acute must consist of those measures
proper to the treatment of any of the other manifestations.
Hypnotism has at times produced very good results, but we prefer
the methods of re-education and persuasion, for the results,
although to procure them much more time has to be expended, are
built upon a more stable and lasting foundation. It is also true
that hypnotism is not unaccompanied by dangerous risks, for the
already existing hyper-suggestibility of the patient may be increased,
and though the peculiar group of symptoms momentarily existing
may by its means be suppressed, it by no means follows that it
may not crop up in identical or inverted forms and that the last
stage may not be worse than the first. Amputation of the clitoris,
ovariotomy and the performance of mock operations are only here
mentioned to be utterly condemned ; they are useless and of
doubtful morality.
MAURICE CRAIG and E. D. MACNAMARA.
1309
PARANOIA.
THE progress of this disorder is long drawn out, and it is often
very difficult to be precise as to the date of the commence-
ment of symptoms. The temperament of the patient has
perhaps from the first been such that the development of
delusions has seemed not unlikely. An unduly ambitious, vain,
jealous or suspicious nature, by which slights inflicted during
ordinary social intercourse are exaggerated, or perhaps invented,
may lead the unfortunate individual through a preliminary stage,
during which the conduct of others is absurdly interpreted to
another, in which it is supposed that the wrongs from which he
is suffering are the result of organised persecution, and to a still
further stage, in which is evolved the idea that one so molested
cannot but be persecuted because of his intrinsic importance.
Hence arise delusions of grandeur. The treatment of these cases
is not, so far as relief of symptoms is concerned, at all hopeful. It
is very desirable, where the temperament early shows signs of
suspicious morbidity, that education should be specially directed
towards its correction, and the influence of broad-minded persons,
who are habitually capable of rising superior to the rebuffs which
are the lot of every man, is of considerable value. Change of
scene, removal from home surroundings and travel are often useful
in the earliest stages ; while there is, as a rule, no particular indica-
tion for the treatment of any defect in nutrition. In later stages,
when delusions are developed, asylum treatment becomes a
necessity. The patient is in this way placed in conditions in which
relative calm is obtainable, though it is only too likely that before
long, in place of considering some person or body of persons outside
the asylum as responsible for his supposed ills, he will transfer
the responsibility to the asylum officials. But there is perhaps a
yet more important reason why patients suffering from paranoia
should be interned, and that is, that of all persons of unsound
mind they are the most dangerous. When at length the patient
has arrived at a conclusion as to the authorship of his wrongs,
the step is not far to the position in which he resolves to avenge
himself by homicide. Those patients who are pursued by a fear of
being poisoned may refuse to take food and have in consequence to
be fed. Treatment must in short be directed towards the mitiga-
tion of symptoms, since, when once the condition is established,
there is but little hope of recovery.
MAURICE CRAIG and E. D. MACNAMARA.
1310
THE MENTAL ASPECTS OF EPILEPSY.
SOME of the abnormal mental states occurring in connection
with epilepsy are periodic and some are permanent. Of the
periodic states some occur before a fit and some after a fit, while
others occur quite independently of the somatic phenomena.
Among the pre-epileptic symptoms are dreamy states, hallucinations,
delusions, states of extreme excitement, of depression and of general
malaise, accompanied sometimes by tendencies to mistrust of others
and groundless animosity. Among the post-epileptic symptoms are
automatism, in which various criminal acts may be perpetrated,
confusion, intense excitement, depression and delusions. When
the classical symptoms are wholly replaced by mental symptoms, a
condition to which the term " psychic equivalence " is applied, there
may be confusion, automatism, stupor, depression, delirium or
excitement, and it should be remembered that there are epileptics
whose only manifestations are such as these and in whom the more
common symptoms do not display themselves.
Among the permanent mental symptoms are idiocy and imbecility,
occurring where epilepsy has proved itself antagonistic to the
normal growth of the individual, emotional impetuosity, extreme
egoism, valetudinarianism, religiosity, criminality and all degrees of
mental enfeeblement up to fatuous dementia.
The treatment of the mental symptoms of epilepsy will naturally
be essentially the same as the treatment of the somatic symptoms,
with such modifications as their peculiar characters demand. In
the event of certain of the permanent mental symptoms enumerated
above being present it is well nigh impossible to treat the patient
except in an institution. Idiocy, an advanced stage of dementia
and the presence of criminal tendencies render necessary the
protection afforded to the patient and to society in general by
internment ; while the other permanent mental states may or may
not necessitate institutional treatment according to the extent to
which they affect the patient's conduct. Egoism, impulsiveness, and
valetudinarianism, while rendering the individual exceedingly trying
as a member of a household, are yet, unless carried to the utmost
extreme, not considered to justify certification. The periodic mental
states, though often characterised by symptoms of great severity,
are usually of short duration, so that by the time arrangements
The Mental Aspects of Epilepsy. 1311
have been made for certification the patient is well again or,
if he has been received into an asylum or hospital, he is discharged
relieved in a few days. It is in consequence often very difficult in
such cases to decide as to whether to send the patient to an
institution or not. If ample provision for treatment can be made
in the patient's own home, and if it is known by experience of past
attacks that the attack is likely to be a short one, there is then no
particular reason why the patient should be sent away. On the
other hand, there are occasions when the violence of the patient or
the frequency of his attacks is such that it is quite impossible to
keep him at home. In some of the psychic equivalents in which
there is slight confusion, stupor or depression, it is merely necessary
to watch the patient in order to prevent him from doing foolish
things or accentuating his condition by restlessness, starvation or
inattention to the bowels. It must of course be recognised that
patients suffering from the so-called permanent symptoms are also
certain to display periodic symptoms, sometimes somatic and some-
times psychic ; while, conversely, those who at the time they come
under observation only suffer from periodic symptoms are likely
sooner or later, unless the disease is checked, to manifest some
degree of dementia. It will therefore be necessary in advising
treatment to bear prognosis in mind and, so far as is possible, to
arrange a future for the patient in which the stresses of life will
bear but very lightly upon him.
In every case of epilepsy and whatever its manifestations a minute
examination of the history and of the present state of the patient
should be made. There are often present in epileptics minor
bodily defects, and it not infrequently happens, especially in the
young, that when these are remedied the number of the epileptic
manifestations is reduced, and indeed that in some cases no
further manifestation occurs. Morbid conditions of the accessory
cavities of the skull, of the teeth, errors of refraction, circulatory,
gastro-intestinal and urinary disorders should therefore be sought
for and if found remedied. The life of an epileptic should be passed
in as peaceful surroundings as can be obtained. He should be
moderate in food, exercise and work, whether it is mental or
physical. Excesses of all sorts are to be avoided, for a state of
exhaustion appears to favour the occurrence of an attack. The
dietary must be nourishing, and milk may be given in large
quantities, though the amount of meat should be small and purin-
free foods may at times be exclusively taken with advantage.
Alcohol should be forbidden. It is of the greatest importance that
the bowels should be kept well open and indeed that every organ
1312 The Mental Aspects of Epilepsy.
whereby excretion is effected should be stimulated to activity. It
is unnecessary here to enter into minute details as to the drug
treatment of epilepsy. It is sufficient to indicate our belief that at
any rate the periodic psychic phenomena can be mitigated by drugs,
while the permanent mental states are probably beyond their
influence and can only be in part relieved by attention to the
general health of the patient. Of the drugs the bromides are
beyond doubt the most efficacious, and their action may be aided
by removing common salt from the patient's dietary. The extreme
violence of some of the attacks of excitement may be abated by
hyoscine.
MAURICE CRAIG and E. D. MACNAMARA.
1313
OBSESSIVE AND IMPERATIVE IDEAS.
THESE ideas are such as obtrude themselves with undue insistence
upon the consciousness of the individual, interfering with the proper
course of the patient's mental processes and occasionally resulting
in aberrations of conduct. The varieties of ideas are innumerable
and are frequently present to a slight extent among normal persons,
though such persons can put the ideas aside and their conduct is
uninfluenced by them. Obsessive ideas may of course occur as
symptoms among persons suffering from various forms of mental
disorder, but we are here referring to the mental conditions in which
they form the only symptoms, those, for instance, which go by the
names of folie du doute, mysophobia, agoraphobia, nyctophobia and
ereutophobia. Where there is a tendency to such symptoms it will
be found that they become more marked when the patient's general
health is not good and in the case of women during the menstrual
period. It should therefore be the aim of the physician to enquire
minutely into the conditions of the patient's life and to advise the
rectification of such as may appear to him to be faulty, while any
disorder which he may discover should be treated appropriately.
To treat the symptom it may be desirable to place the patient in
such circumstances that the idea is not suggested to him ; for
instance, if the patient has that variety of claustrophobia which
prevents him from entering a train he may spend months in some
part of the country where railway travelling is quite unnecessary, or
such journeys as have to be undertaken may be made by motor-car.
Such a method as this is sometimes the only practicable one, for so
imperative may be the obsession that the patient is unable to carry
on the business routine of his life as he cannot, owing to his
aversion to all sorts of vehicles, get about except by walking.
While the patient is away his general health should be attended
to and various methods of psycho-therapeutics employed. In some
cases which are less well-marked, or where avoidance of incitation
of the idea is impracticable, psycho -therapeutics may be tried with
no adjuvant. Persuasion and suggestion, whether with or without
hypnosis, may be practised and undoubtedly it does happen that
with patience and tact the ideas become less compelling and may
even vanish altogether. We are not convinced that suggestion under
hypnosis is of more value than persuasion, but there are cases in
S.T. VOL. ii. 88
1314 Obsessive and Imperative Ideas.
which it procures comparatively speedy results, though on the
other hand there are many cases in which its beneficial effects are
wholly absent. Another psycho-therapeutic method is that of
psycho-analysis. Sometimes it would appear that the symptoms
are due to the presence of two groups of concurrent and unhar-
monious psychic processes which have been set in action by
emotional disturbance. By the analytic method it is sought to
discover what these processes are. Often their source is unknown
to the patient himself, or if known is not recognised as being the
cause of his symptoms, or if known and recognised is studiously
concealed. By hypnosis, by study of the attentionless associations,
of dreams and of word-reaction times these recondite psychic
transactions are laid bare and can be dealt with in the broad light
of day. It not unfrequently happens that with this exposure and
with the explanation that can thereupon be made the symptoms
disappear.
MAURICE CRAIG and E. D. MACNAMARA.
1315
PERVERSIONS.
THOSE impulses which, apparently without deliberation or
acquired knowledge, lead animals to perform certain actions
which tend towards the preservation of the individual or of
the race to which they belong and which we term instincts, are
sometimes in man remarkable for their exaggerated character or
their absence or perversion. It would be out of place here even to
catalogue the numerous and curious examples of these abnormalities
which from time to time are reported, and it must suffice that we
should name, by way of example, such aberrant instincts as the
exaggerated desire to collect, miserliness and the various varieties
of sexual perversion. These last are the abnormalities about which
advice is most often sought. In such instances the aim of the
physician must be twofold, for, in the first instance, he must
endeavour to place the patient under such circumstances that the
peculiar practice to which he is addicted is difficult or impossible of
performance, and in the second to exercise by the methods of
psycho -therapeutics such an influence that the evil tendency is
eradicated or at least neutralised. Neither aim can be easily or
rapidly realised. A very important feature in treatment is
adequately to fill out the patient's time. Among peasant popula-
tions, where the tending of cattle allows of very frequent intervals
of complete idleness, the criminal annals are full of accounts of
acts which have brought the persons concerned in these occupations
under the cognisance of the law. On the other hand, history
teems with instances of the effect of luxury and idleness upon
urban populations, in which sexual perversion has appeared to be
rather the rule than the exception. It is therefore desirable in
any individual case to recommend that the patient's time should
be filled with useful occupation, for in this way opportunities for
the performance of the particular act are diminished and the
energies necessary for its perpetration are otherwise beneficially
expended. Psycho-therapeutics may consist in the inculcation of
a moral standard higher than that to which the patient has been
used, or to suggestion, made either in the light or profound stages
of hypnosis, that the practices to which the patient is addicted
should be abandoned.
MAURICE CRAIG and E. D. MACNAMARA.
832
1316
MASTURBATION.
MASTURBATION is a frequently occurring symptom among the
insane, and attacks of mental disorder are not uncommonly
regarded as caused by the practice. There can be but little
doubt that neurotic and imaginative individuals are particularly
addicted to masturbation, and that it is also from the ranks of such
that come the victims of mental disorder ; but beyond the common
factor of the neurotic diathesis there is but little real evidence that
the practice stands to the disorder in the relationship of cause and
effect. In the case of the acute or chronic insanities, whether
occurring in males or females, it is only by the closest attention on
the part of the nurses that it can be sought to prevent masturbation.
Local causes of irritation ma}' be removed and sedative drugs may
be given, but will effect but little in the absence of supervision.
Masturbation is common among idiots and imbeciles, and among
these also careful superintendence is all-important.
Of perhaps more importance than the prevention of masturbation
among the insane is the problem of its treatment among the sane.
Although the habit does not, unless in very exceptional cases, lead
to the formidable consequences which are so skilfully portrayed for
the purposes of terrorisation in the literature of charlatanism, yet
its effects are inimical to health. Lassitude of mind and body,
incapacity for work or play, lack of power of attention, anaemia and
loss of weight, are among the common symptoms and may lead in
the predisposed individual to an increased vulnerability to the
attacks of the various agents which cause nervous and mental
breakdown. In the case of the boy or girl addicted to the practice
in whom there is no local irritation and who is of normal mentality
and in whose case the habit has been discovered, it is wise to point
out the possible consequences of its continuance and to appeal to
that sense of decency which is always present in the child who has
been properly brought up. Increased supervision may be necessary,
and the child's time may be filled with the items of a programme
in which there is a judicious admixture of mental and physical
work and of play. In the case of the child in whom the habit has
not been discovered, but in whom it is suspected, it is perhaps on
the whole not advisable directly to tax him or her with the practice.
\\ith a little tact it will probably become manifest whether or no
Masturbation.
the boy or girl has any conception of the subject that is being
indirectly referred to, and further conversation can be regulated
accordingly. "We would recommend reliance being placed on
general maxims, on the inculcation of the duty of keeping the body
fit for its tasks of work and trained for sports, and on the explana-
tion of the fact that acts of impurity diminish its capacities. There
are some who advocate the unrestrained elucidation of sexual
matters to the young, while there are others who would entirely con-
ceal them. For ourselves, we believe that it is idle to lay down any
universal rule. There is a time for all things, and there can be no
doubt that childhood and youth are not the times for the considera-
tion of sexual affairs or for the practice of sexual acts ; nevertheless,
in all cases to make a mystery of such topics will result in some
instances in the fostering of a lascivious pruriency, while to teach
all, without discrimination, the meaning of sexual matters which
are of no interest to the majority will be to awaken in some few a
curiosity which they were better without. We therefore own
ourselves to be eclectic, and recommend that treatment of any
individual case be founded upon the indications presented by that
case. But whether it be determined to enlighten the masturbator,
or, as must not infrequently happen, the potential masturbator,
upon sexual affairs there are, at any rate, modes of life which we
may safely enjoin. The boy or girl should be directed to be an
early riser ; a cold bath may be ordered and life so regulated that
the child has but little time for anything which is not in the day's
routine. Such leisure time as is not given to exercise may well be
spent in learning some interesting craft, for example, carpentering,
and care should be taken that the literature provided is sound and
lacks any sexual soiiprfm. Hypnotism, especially among older
persons, has been useful in some cases.
Among small children, and even among infants, masturbators
are occasionally found, and the practice seems commoner among
females than among males. Among the former a rubbing move-
ment of the thighs followed by flushing, pallor and perspiration,
will often indicate the presence of the habit. All local sources of
irritation must be looked for, and if found, treated ; and for the
rest some simple means must be devised for rendering manipula-
tion by the hands or movement of the thighs impossible. Girls, for
instance, may be put into such splints as cause separation of the
thighs. If the habit is persisted in and is practised quite openly it
may be feared that there is present*some degree of mental defect.
MAURICE CRAIG and E. D. MACNAMARA.
I 3 i8
IDIOCY AND FEEBLE-MINDEDNESS.
THERE are innumerable gradations in the scale of feeble-minded-
ness. At the lowest level of complete idiocy there is a condition in
which there is an absence of even the most elementary instincts.
Further up the scale we find that intelligence is present though
in a rudimentary form, and at the top of the scale we meet with
cases which with difficulty can be differentiated from the normal.
Treatment, which is essentially directed towards the education of
the patient, must manifestly depend upon the receptivity of the
nervous system. So soon as idiocy has been diagnosed educative
efforts should be commenced, and we are of opinion that no case
should be at once dismissed as incapable of improvement. In the
case of an idiot of the lowest grade, in which the diagnosis has been
made at an early age, the first educative efforts are made in the
direction of trying to teach the patient kinsesthetic sensations.
Passive movements and massage tend to impress upon such
sensorium as there may be a recognition of the position of the
limbs. In the next stage the patient may be taught to " feel his
feet " by being held in the upright position upon them and later by
being placed in a go-cart. From lessons in standing the patient
passes to the acquisition of the art of walking, firstly on the flat
and later upstairs. In the meanwhile the education of the hands
is not neglected, and in the first instance the patient is taught to
grasp and handle large objects of different sizes and weights and
gradually to learn to move them from one place to another. The
important senses of heat and cold may be developed by placing the
hands alternately in hot and cold water. The insertion of large
buttons into large button-holes may now be attempted and shortly
followed by such manoeuvres as the lacing of boots and the fixing
of eyes upon hooks, fitting pegs into holes and passing marbles of
various sizes through holes in a piece of wood. The education of
sight, hearing, smell and taste may now be attempted, for instance,
in the case of sight by the insertion of coloured pegs into holes
around which is painted a like colour. If progress has so far been
good the dressing and undressing of dolls may now be taught and
subsequently the putting together of picture puzzles. Reading
may sometimes be taught by the use of wooden letters which are
superimposed upon painted letters of the same colour, while the
patient may be instructed in the elements of writing and the
Idiocy and Feeble-Mi ndedness. 1319
making of straight lines and pot-hooks. Commencing at a very
early age, endeavours are made to educate the movements of the
apparatus of speech and through imitation it is sought to make
the child move the lips and tongue in special directions, to articulate
elementary sounds, short syllables and eventually words and
sentences. When the power of articulate expression has been
acquired an enormous advance has been made and the naming of
various objects and the demonstration of their uses can be
proceeded with apace. It is of very considerable importance
that the feeble-minded person should be taught some handicraft.
Basket-making, mat-making, gardening, boot-making and
carpentering are all suitable occupations, while the selection of
any one will depend upon the capacity of the patient. Games
played in combination with others are of considerable assistance
in introducing the patient to the social amenities and should by
preference be carried on in the open-air.
The control of the sphincters is a matter of much importance
and one in which the feeble-minded are deficient. Much attention
is necessarily devoted to keeping the patient clean in this respect,
and as soon as possible a definite regime should be adopted. In
some cases, at any rate where the patient is capable of sitting up,
it may be necessary to keep him on a nursery commode for long
periods together, while in others he should be placed thereon at
regular intervals which, as time goes on, may gradually be
lengthened. It will be probably found, except in extreme cases,
that regular habits will thus become established.
It is imperative while the above educational efforts are being
carried on that the general health of the child should be carefully
tended. Food should be of a simple character and for the most
part farinaceous. The feeble-minded must be taught properly to
masticate their food, for they exhibit marked tendencies to bolt it,
while many of them eat voraciously and quite out of proportion to
their needs. Cleanliness of person and neatness of dress should
be inculcated, and here also regular habits must be early commenced
and patiently persisted in. Clothing should be light so that the
free movements of the limbs is not interfered with, but it should
be at the same time of warm material, since the patients are
particularly liable to take chill. The periods devoted to sleep
should be long and regular in incidence and the bedroom should be
supplied with the maximum of fresh air. Indeed, so far as is
possible, the patient should live in the open-air and there receive
his lessons and take his meals. Any physical defect which it is
possible to remedy should be attended to. Errors in refraction or
1320 Idiocy and Feeble-Minded ness.
in any of the special senses must be corrected at the earliest
opportunity, since many are feeble-minded owing to defect in the
avenues by which the sensorium is reached, and it will often be
found that progress is far more rapid when such defect is remedied.
If it happens that such defects are irremediable educational efforts
must be directed towards making still more use of the senses which
are not affected. For instance, if the child is deaf an endeavour
must be made to form in the patient's mind associations between
certain ideas and certain movements of the teacher's lips or certain
gestures.
The naso-pharynx should be examined and adenoids or large
tonsils removed. The teeth should be attended to. The prepuce,
if the usual indications for circumcision are present, should be
removed. In certain cases where there is an associated paralysis,
orthopedic surgery is useful, and limbs which have been quite
useless may be brought into such a condition that they may
perform at least some of their functions. At times operations have
been performed upon the brain in the hope of removing pressure
caused by meningeal cicatrices or depressions or thickenings of
bone ; experience unfortunately demonstrates their uselessness.
In the case of cretins much improvement is produced by the
administration of thyroid gland, and in the case of epileptics the
bromides are sometimes beneficial and sometimes harmful.
Elementary notions of right and wrong must be instilled
wherever practicable, and it should be sought to convey to the
mind that certain acts are praiseworthy and others reprehensible.
To effect this kindness and patience are essential qualities in the
teacher, and it is idle to make use of the punishments which are
common in the nursery of the normal child. In most cases a
little experience will enable the teacher to appreciate the likes of
the patient and he may be encouraged in well-doing by their proper
gratification and deterred from ill-doing by the deprivation of
opportunities for satisfying them. It is surprising of how great
progress the feeble-minded are capable when subjected to such a
regime as that outlined above and how small is the residuum in which
no improvement can be effected. It is true that years of patient
endeavour must be passed and that the results may after all appear
but meagre ; nevertheless, for those endowed with courage and
patience, there is ample reward in the gradual unfolding of the stunted
intelligence and the making useful of lives which but for this labour
are of less value than a mere encumbrance upon the earth.
MAURICE CRAIG and E. D. MACNAMARA.
AFFECTIONS OF MUSCLES AND FASCIAE.
INJURIES OF MUSCLES.
Contusions. In contusions of muscles a certain amount of
haemorrhage into the muscle occurs, and, if this effusion of blood is
extensive, very serious impairment of function may follow from
fibrosis and adhesions. Hence every effort should be made
to promote the absorption of the effusion as soon as possible.
In niild cases in which there is but slight effusion the application
of hot fomentations for one or two days, followed by the use of a
simple liniment night and morning, is sufficient. If the pain is not
marked complete rest is not necessary, in fact gentle exercise
assists in the absorption.
In severe contusions, where there is marked effusion, very great
pain is complained of, and as a result of the blow there is often
temporary paralysis of the part. In these cases absolute rest is
indicated both to ease the pain and to assist in the absorption
of the effusion ; in addition, the local application of hot Goulard and
opium fomentations is of great value. Complete rest should be
given for two to three days, after which time local massage should
be ordered ; the rubbing at first should be very gentle and always in
an upward direction, if in a limb. The massage should be persisted
with for two to three weeks ; if the lower limb is affected the
patient is allowed to walk about in about ten days from the time of
the accident. By these means any liability to permanent disability
from muscular impairment due to fibrosis or adhesions is
minimised. In cases in which a definite large haematoma is
formed convalescence may be hastened by incision of the swelling
and evacuation of the clot under strict aseptic precautions. After
evacuation the cavity is irrigated with hot saline solution, the
wound is then sewn up without drainage, firm pressure being
applied by bandaging over a suitable dressing. As soon as the
wound is healed, treatment by massage as described above should
be ordered.
"Wounds of Muscle. Small incised or punctured wounds of
muscle in the direction of the fibres do not require any special
treatment other than that necessary for the wound itself. When,
however, the muscle fibres are divided transversely and the wound
is considerable, an endeavour should be made to unite the ends by
1322 Injuries of Muscles.
suture, so as to restore as far as possible the function of the muscle.
A general anaesthetic having been given, the wound is cleansed by
copious irrigation with a warm solution of biniodide of mercury
(1 in 6,000). The ends of the cut muscles are then isolated,
and the limb is put into the position which relaxes the muscles to
their fullest extent. In order to avoid the sutures cutting out they
must be passed transversely across the muscle fibres, about
f inch from the cut edge, and tied so as to include a bundle
of muscular tissue. Separate sutures are inserted in this way
into each cut end of the muscle. The ends of the sutures are
then tied firmly together so as to approximate the cut ends. As an
additional safeguard one or two mattress sutures may be inserted
after the main sutures have been tied. Chromic catgut is the best
material to employ, as it is absorbed and no irritating foreign body
is left in the muscle. It is advisable to insert a small drainage
tube into the wound for forty-eight hours.
After the operation the muscle is kept fully relaxed for three or
four days ; the position should then be altered slightly each day, so
that in about ten days the muscle is fully extended. Massage and
very gentle passive movements may then be commenced, so as to
prevent as far as possible the formation of adhesions. After three
weeks the patient should be encouraged to perform active move-
ments, but no undue strain should be allowed to fall on the muscle
until at least five weeks after the injury, so as to avoid any
stretching of the new scar tissue.
When very extensive laceration of muscles has occurred, with
possibly injury to or division of main vessels or nerves, the question
of amputation must be considered.
Rupture of Muscles. Subcutaneous rupture of a healthy
muscle is a rare accident, but may occur from a sudden or
unexpected strain or from a blow on the muscle when it is firmly
contracted. In these cases, if the rupture is complete, there is
considerable separation between the parts and also complete loss of
power in the muscle, and the best course to adopt is to cut down
the damaged part and approximate the separate ends with catgut
sutures as described under Wounds of Muscle. When partial
rupture has occurred, the superficial fibres alone being torn, the
part should be immobilised on a splint about a week in such a
position that the muscle is completely relaxed ; after this time
massage should be commenced, to be followed in a few days by
.passive movements; in a fortnight gentle, active movements may
be commenced, and full use of the part may be allowed in three
weeks to a month.
Injuries of Muscles. 1323
In many cases, especially in elderly people, a few deep fibres only
of a muscle are ruptured during some unwonted exertion or from a
sudden strain. The muscles most commonly affected are the calf
muscles and the erector spinal group. In either case there is a
sudden acute pain in the part, often described by the patient as
" like a blow," which may cause him to fall to the ground owing to
the severity of the pain. No other signs are to be made out at the
time of the accident, but later swelling of the part occurs, with
bruising of the tissues, which may take many days to appear.
Complete rest in bed should be ordered until the pain and
swelling have subsided. As soon as this has occurred recovery
may be hastened by local massage and passive movements. The
patients are usually disabled for about ten days. In some cases a
patient is unwilling or unable to lie up ; if this is the case relief
from the pain may be obtained by immobilising the part by the
application of a ham splint, if the lower limb is affected, or firm
strapping in the case of the back : treatment by massage should
be ordered in these cases after the first few days.
Hernia of Muscular Fibres. This condition occasionally
follows the subcutaneous rupture of the deep fascia forming the
muscular sheath ; as a result a gap is left through which muscular
fibres protrude during the action of the muscle. In most cases,
apart from the slight deformity, no inconvenience results from the
accident and no treatment is required. In some few cases either
pain is complained of from nipping of the muscle in the opening or,
the fascial opening being large, the patient desires to be cured of the
resulting swelling. If this is so the best plan is to cut down on the
opening in the fascia, and, after refreshing the edges, to suture
them together with chromic catgut and so close the opening (sec
also Sprains).
C. H. S. FRANKAU.
1324
INFLAMMATORY AFFECTIONS OF MUSCLE*
Acute Simple Myositis. A certain degree of simple inflam-
matory reaction almost invariably occurs around any portion of
muscle which has been injured by contusion ; for this no further
treatment is required other than that for the original contusion,
and no disability from fibrosis or adhesions should occur if the
treatment is adequately carried out.
Acute Suppurative Myositis. In some cases, especially if
there has been extensive extravasation of blood, an infective
myositis may follow an injury, the organisms reaching the part
either through a skin abrasion or by the blood stream. In such
cases early and free incisions into the affected area, with the pro-
vision of adequate drainage, should be made so as to limit as far as
possible the amount of destruction to the muscle involved. During
the later stages contractures of the neighbouring joints, produced
by shrinking of the newly formed scar tissue, are very likely to
occur. Every effort should be made to avoid this complication by
the application of suitable splints or extension apparatus and by
the use of massage and movements as soon as the inflammation
has subsided. In spite of every precaution of this kind it may be
found that even after prolonged treatment some degree of con-
tracture persists ; in such cases the deformity may be benefited or
rectified by subcutaneous division of fibrous bands or even of the
affected tendons, the after-treatment being similar to that described
for tenotomy for talipes, etc. (see Contractures of Joints, and
Talipes).
Rheumatic Myositis. In addition to the usual treatment by
the salicylates or aspirin, great relief may be obtained in these
cases by the local application of a liniment containing a compound
of salicylic acid, such as betulol, i.e., ty. Betulol, gij ; Lin. Saponis,
ad jviij. Fiat linimentum : to be used night and morning.
Dry heat, either in the form of electric light baths or the electric
pad, will also be found to give relief, especially in the more chronic
cases.
Syphilitic Myositis. Gummata of muscle are occasionally
found ; in most cases they react readily to the usual treatment by
potassium iodide and mercury, but they may leave considerable
deformity from a subsequent fibrosis. Such deformities should be
New Growths of Muscle. 1325
treated as described above under Acute Suppurative Myositis, the
constitutional treatment being at the same time persisted with.
Ossifying Myositis. This condition may be limited to one
muscle or group of muscles, or may affect the whole muscular
system. In the localised form the commonest site is the adductor
group, the adductor longus being most often affected and forming
" riders' bone." If no very great disability results no treatment is
indicated in these cases. If, however, the movements of the limb
are much interfered with, the ossified portions may be excised with
great benefit in many cases.
In the generalised form the back muscles are first affected, the
ossification later spreading to other groups of muscles until death
occurs from embarrassment of respiration or from exhaustion.
Unfortunately no treatment has at present been found which is of
any permanent value. The iodides occasionally appear to check
the disease in the early stages for a time ; in the later stages
radiant heat and local counter-irritants will be found to give relief
in some cases.
C. H. S. FRANKAU.
NEW GROWTHS OF MUSCLE.
Innocent New Growths. Lipomata are occasionally met
with growing between the fibres of muscles; they can easily be
enucleated, care being taken to avoid division of muscular fibres
in doing so.
Fibromata are also found ; they should be freely excised, a
wide margin being allowed around the tumour, which is rarely
encapsuled and tends to recur in situ.
Malignant New Growths (Sarcoma). Two varieties may
occur:
(1) The rapidly growing spindle-celled sarcoma, which tends to
rapidly infiltrate surrounding muscles and for which the only
possible treatment in the case of a limb is by amputation.
(2) The slowly growing fibro- sarcoma or " recurrent fibroid
tumour." These tumours should be freely excised in the first
instance, but if recurrence occurs rapidly, amputation of the limb
should be undertaken.
Cysts. Hydatid cysts may occur in muscle. They should be
treated by complete excision when this is possible, and failing this
by drainage.
C. H. S. FRANKAU.
1326
DISEASES AND AFFECTIONS OF TENDONS
AND THEIR SHEATHS.
INJURIES OF TENDONS.
Dislocation of Tendons. The tendons most commonly affected
by this accident are the peronei, which slip forward in front of the
external malleolus at the ankle joint; the accident is usually
associated with tearing of the lateral annular ligament and the
neighbouring fascia with considerable local effusion of blood.
In such cases a good result can only be obtained by operative
treatment; if, however, operation is refused or is contra-indicated
for some reason, the following method may be tried.
After fully everting the foot the displaced tendon is manipulated
into its correct position, the ankle is then immobilised at a right
angle, with the foot slightly inverted, by means of a plaster splint.
This splint is left on for ten days and then removed ; gentle massage
and movements are then commenced, care being taken that the
tendons do not redislocate ; the foot is maintained in an inverted
position in the intervals by an external poroplastic splint. No
attempt at walking should be made for at least three weeks and the
patient should be warned against forcibly everting the foot for a
considerable time afterwards.
If operation is decided upon, a curved incision is made convex
forwards, and a flap of skin turned back so as to expose the peronaeal
groove. The groove is then cleared and deepened if necessary, and
the tendons having been replaced in position the torn lateral
ligament and deep fascia are sutured over it with catgut. The after-
treatment is similar to that given for the non-operative method.
Division of Tendons. The division of a tendon in an open
wound is always followed by loss of function unless the cut ends are
united by suture, and the sooner suture is carried out the better the
ultimate result. An anaesthetic should be given and the wound area
rendered as aseptic as possible, since proper union of the tendon is
hindered or prevented if suppuration occurs. The ends of the
tendon must next be identified ; little difficulty is usually found in
exposing the lower end, as it does not tend to retract. The upper
end may be difficult to find, since marked retraction of the muscle
occurs after division of the tendon ; complete relaxation of the muscle
by suitable manipulation of the limb and forcible squeezing down of
Injuries of Tendons. ! 3 2 7
the muscular belly from above may be effectual in bringing down
the upper end, but more often it is necessary to extend the
original wound upwards to expose the retracted end. As soon as
the ends are found they should be temporarily retained by
pressure forceps and the ends trimmed up if they are at all
ragged. In suturing the cut ends separate sutures should be
inserted into the lateral margins of the two cut ends of the
tendon ; these sutures are passed through the whole thickness of
the tendon and are tied so as to include a small amount of
tissue ; the corresponding ends of the sutures on either side of the
division are then tied together so as to bring the divided ends into
apposition. In a small tendon two such sutures at either end,
inserted into the margins of the tendon, are usually enough ; further
sutures, if necessary, may be inserted in the central portion, if the
cut edges show any tendency to curl up. The wound is then
sutured carefully, a fine tube or catgut drain being left in for twenty-
four hours at one angle, well away from the site of the suture, to
remove any serum or blood effusion. The limb is immobilised on
a splint in such a position that the least possible strain is put upon
the affected tendon. After two or three days the position of the
limb should be changed slightly, and this should be repeated every
day. As soon as the wound is healed, i.e., from eight to ten days,
gentle massage and passive movements should be started. In about
a fortnight the patient may be encouraged to employ active move-
ments. The massage and passive movements should be persisted
with for some weeks so as to avoid any adhesions as far as possible.
In old standing cases, in which the division of the tendon has
occurred some considerable time previously, it is best to expose
the divided tendon by a curved incision, which allows a flap to
be turned back over the site of the division ; the incision must
be free, as in most cases a fairly extensive dissection is necessary
to expose the divided ends which have retracted and in addition
have always contracted adhesions to the sheaths and other sur-
rounding structures. Having identified the ends, they are brought
down in apposition with one another if possible and sutured by the
method described above. If the ends cannot be brought into
apposition, some method of tendon lengthening (see Deformities)
may be employed, or if this is not possible the interval may be
bridged by a network of chrornicised catgut sutures. In either case
the after-treatment is similar to that described above for recent
wounds, with the exception that movements should be somewhat
delayed so as to avoid too great a strain on the new union, which
may be already under considerable tension.
1328 Injuries of Tendons.
Subcutaneous Rupture of Tendons. This is a somewhat rare
accident ; the tendons most commonly affected are the tendo
Achillis, which may be ruptured in dancing ; the patellar ligament,
which may be ruptured by an accident similar to that usually pro-
.ducing fractures of the patella ; and the extensor tendons of the
fingers whicn, being torn through at their attachment to the
terminal phalanx, produce the condition known as " dropped
finger."
In the case of the tendo Achillis usually no operative interference
is necessary. The limb is kept flexed at the knee with the ankle
fully extended by an elastic cord running from a collar of strapping
fastened round the middle of the thigh to a loop or hook fastened
to the sole of the foot by a band of strapping passing over the instep.
By these means the ruptured ends of the tendon are maintained in
fair apposition. The apparatus should be worn for about a fort-
night continuously, after which time it may be removed for a part of
the day and gentle movements at the knee and ankle should be
started. In about three weeks the apparatus may be given up, but
it is not advisable for the patient to put any weight on the limb
for at least a month from the time of the accident, massage and
passive and active movements on a couch being alone allowed.
At the end of a month gentle walking exercise may be allowed
with a stick and this may be gradually increased until full
ordinary power has returned, which usually takes place in seven
or eight weeks. In some cases it will be easily seen that it
is impossible to sufficiently approximate the ends of the tendon,
either owing to excessive separation or owing to the ends
having curled up within the sheath. These cases are best treated
by open operation and tendon suture as described above.
In rupture of the ligamentum patella it is not often possible
to get a good result by non-operative measures, since the torn
ends always tend to curl away from each other ; tendon suture
by open operation is therefore indicated. A curved incision,
convex downwards, should be made, reaching about inch below
the tuberosity of the tibia; a flap is then turned up and the
ends of the tendon having been identified, are brought down
into apposition by fine kangaroo tendon sutures inserted in the
manner described above. It is important to remember that the
accident may have in some cases involved the opening of the
joint by tearing the lower part of the capsule. The after-treat-
ment is exactly the same as after the wiring of a fractured
patella, except that a leather knee splint should be worn for at
least two months, so as to prevent any strain falling on the new
Injuries of Tendons. I 3 2 9
union, which is very likely to stretch. While the splint is being
worn massage and movements to the limb should be continued
so as to prevent any muscular wasting as far as possible.
In cases of "dropped finger" in which the extensor tendon is
torn from its attachment to a terminal phalanx an attempt may
be made to promote union of the tendon by immobilising the
finger in an extended position on a straight splint. This is
successful in some cases, but it is generally more satisfactory to
unite the ends by suture. A straight incision is made from just
above the base of the nail to the middle of the second phalanx ;
the proximal end of the tendon is then sutured to the distal
end, or if, as sometimes is the case, the tendon has actually
been torn from its attachment, to the periosteum and fibrous
tissue at the base of the terminal phalanx. The finger is
immobilised for a few days on a straight splint in an extended
position, after which gentle movements are commenced (see
Deformities).
C. H. S. FRANKAU.
S.T. VOL. ii. 84
1330
AFFECTIONS OF THE TENDON SHEATHS.
Acute Simple Tenosynovitis. For this condition in the early
stages absolute rest for the affected part with the local application
of hot fomentations of Goulard and opium are indicated for the
relief of the pain. Later, as soon as the pain and the swelling
have diminished, gentle local massage and movements should be
ordered. It is most important not to immobilise the part for too
long a time, since troublesome adhesions may result, producing
considerable limitation of the normal tendon movements. The
massage should be continued for some weeks, the patient being
allowed at the same time gradually to return to the normal use of
the limb. Care should be taken that the part is not overstrained
at too early a stage, since by this means another acute attack may
be started, or the condition may lapse into one of chronic tenb-
synovitis.
Chronic Simple Tenosynovitis. Though occasionally follow-
ing an acute attack, this condition more frequently is the result of
some persistent abnormal strain or overuse of the affected tendons ;
thus the extensor tendon sheaths of the wrist are found affected in
washerwomen, typists, and occasionally golfers ; the peronei tendon
sheaths are found affected in chauffeurs or others who frequently
use a foot-brake or clutch-pedal. Consequently the first essential
of treatment to adopt is to avoid the particular strain which has
produced the mischief or to alter the method of application of the
strain (e.g., the " grip " at golf may be altered, or the position of a
brake-pedal may be altered by raising the seat, etc.). In addition
to these measures, local counter-irritation with rest to the part by
means of Scott's dressing and strapping should be ordered, to be
followed, as soon as the original symptoms have diminished, by
massage, so as to restore the part to its normal strength.
Acute Septic Tenosynovitis. An acute suppurative infection
of the tendon sheaths may result from a wound or from the spread
of infection from a neighbouring part, e.g., a theeal whitlow. In
either case incisions should be made as soon as possible so as to
provide free drainage, every endeavour being made to preserve the
tendons, which are very liable to slough in such cases.
Syphilitic Tenosynovitis. A chronic tenosynovitis sometimes
occurs in the secondary stages of syphilis ; it is often symmetrical
Affections of the Tendon Sheaths. 1331
and usually painless. The symptoms speedily disappear under the
usual constitutional treatment, which may be assisted by the local
inunction of Scott's ointment.
In the tertiary stages a gummatous tenosynovitis is found,
affecting most frequently the tendons about the ankle joint. The
condition usually reacts readily to treatment by potassium iodide,
but the action of the tendons may be considerably impaired by the
formation of scar tissue.
Tuberculous Tenosynovitis. In tuberculosis of the tendon
sheaths a single sheath may be affected or a whole group of sheaths
may be involved, as in compound palmar ganglion, in which the
whole flexor tendon sheath is affected above and below the annular
ligament at the wrist. In either case treatment should be carried
out on the following lines :
In the Early Stages. In these cases palliative treatment may
first be tried ; the part should be absolutely rested with, if
possible, open-air or sanatorium treatment. Tuberculin carefully
administered is also of value. If in spite of this the condition does
not improve or tend to progress, operative measures should be
undertaken at once, since if caseation and suppuration occur the
prognosis is much graver. A free longitudinal incision is made, and
the diseased sheath or sheaths are cut away freely. In the case of
the wrist the annular ligament should be preserved if possible ; if it
is found necessary to divide it, it may be possible to suture the cut
edges after clearing away the affected tendon sheaths if the ligament
itself is not yet infected. The wound is sewn up without drain-
age. The general treatment should be continued for some time
subsequently.
When Caseation lias Occurred. Here the chances of preserving
a useful limb are not good. The caseous material should be
evacuated, and as much of the tuberculous granulation tissue as
possible should be curetted away. If possible drainage should
be avoided, and great precautions should be taken to avoid a
superadded infection. The general and constitutional treatment
advised above should be undertaken as soon as the wounds are
healing or healed. When the disease is very extensive, the part
being riddled with sinuses and the joints being affected, the question
of amputation must be considered, since in such cases at best a
useless limb will be the ultimate result. Amputation is essential if
from loss of sleep owing to pain and from the constant discharge
the patient is going rapidly downhill.
Tumours in connection with Tendon Sheaths. Three
varieties of tumours are found in connection with tendon sheaths,
I33 2 Affections of the Tendon Sheaths.
viz. : (1) Simple fibroma ; (2) myeloid sarcoma ; (3) lipoma.
They occur most commonly on the palmar aspect of the fingers,
and in this situation they can easily be removed by making an
incision over the tumour in the long axis of the finger and shelling
it out from the loose fibrous tissue connecting it to the tendon
sheath. It is uncommon to find the sheath itself involved by the
tumour, but if this is so the part of the sheath involved may be
freely excised without ill results, if movements of the affected
tendon are commenced as soon as the wound is commencing
to heal.
Ganglion A simple ganglion is formed by the dilatation of the
synovial sheath of a tendon ; this dilatation may be diffuse, the
whole circumference or a large part of the circumference of the
tendon sheath being involved, or the dilatation may consist of a
protrusion of the synovial membrane through the fibres of the
sheath ; the pouch so formed is connected with the tendon sheath
proper by a pedicle of varying size.
The first variety occurs mainly in adolescents, and palliative
treatment by pressure and counter-irritation by means of Scott's
dressing and strapping is usually sufficient to produce a cure.
In the second variety, and in the first variety if palliative measures
fail, the following methods of treatment may be tried :
(1) Puncture. The surrounding skin having been carefully
sterilised a small area over the centre of the swelling is anaesthetised
by the injection of a few drops of novocaine. The skin is then
drawn to one side so as to produce a valvular opening, and a sharp
tenotome is inserted into the centre of the swelling. The contents
of the ganglion are then expressed partly out of the opening in the
skin and partly into the surrounding cellular tissue. The injection
of a counter-irritant causes much pain and does not appear to do
much good. After expressing the contents firm pressure is applied
by means of bandaging over a sterile dressing. This treatment
will be found efficacious, more especially in the thin -walled variety
of ganglion occurring in elderly people.
(2) Excision. This on the whole is the most satisfactory treat-
ment for the majority of cases in which palliative measures fail.
A curved incision over the most prominent part of the tumour will
usually be found to be the best, allowing a small flap to be turned
back. The ganglion is freed as far as possible by dissection, and if
a pedicle connects it to the tendon sheath this is tied off with catgut
and divided. If the ganglion is diffuse, as much as possible of its
walls is cut away ; this proceeding often freely exposes the tendons,
but no attempt to close in the tendons by the formation of an
Affections of the Tendon Sheaths. 1333
artificial sheath from the remains of the walls of the ganglion, as
sometimes advised, is necessary. The wound in either case is
sutured without drainage, and the part is immobilised for a few
days in a splint. Movements of the tendons should be commenced
at an early period.
C. H. S. FRANKAU.
1334
DISEASES AND AFFECTIONS OF BURS^E.
Acute Bursitis. Acute bursitis almost invariably ends in
suppuration, but an endeavour may be made to prevent this if the
case is seen in the early stages, by rest to the part with the local
application of hot fomentations. If, however, suppuration com-
mences, or has commenced before the case is seen, immediate
incision and drainage are necessary. The incisions should be
made at the most dependent part of the bursa, and usually a
counter-opening is necessary so as to allow the cavity to be irrigated
with saline or some weak antiseptic solution. In the case of the
prepatellar and olecranon burs*e there may be considerable redness
and oedema of the surrounding parts ; these however usually subside
rapidly on dealing with the original focus, but if there is evidence
of extension of suppuration around the bursa further incisions
should be made.
Chronic Simple Bursitis. Chronic inflammation of a bursa
results from long-continued abnormal pressure on the part; in
consequence of this the bursa is at first distended with fluid from
which lymph is deposited in the inner surface of its walls ; the
walls thus become thickened and adhesions may form, producing
loculation. In old-standing cases loose " melon-seed " bodies may
also be produced by the detachment of fragments of lymph.
It follows from this that palliative treatment is very unlikely to
be successful and should only be adopted if operation is refused.
The radical treatment consists in excision of the bursa.
To take for example the prepatellar bursa, which is the most
frequent site of chronic bursitis. After careful sterilisation of the
skin, which in this region is often rough and ingrained with dirt, a
curved incision is made with its convexity directed upwards and
inwards and its uppermost limit extending just above the upper
border of a bursa. This incision is preferable to a vertical or
U-shaped incision, since no pressure falls on the scar on kneeling
afterwards. A flap is then turned downwards and outwards and
the bursa is dissected out entire. It is of no importance if the
bursa is opened, in fact it facilitates removal in many cases. The
wound is sutured without drainage, and after the application of a
suitable dressing the limb is immobilised on a ham splint. The
Diseases and Affections of Bursse. 1335
splint may be removed in two days, and the patient can usually
walk about again in ten days.
Care should be taken, by the use of. a kneeling pad, to avoid any
excessive pressure on the part afterwards, since, unless this pre-
caution be adopted, an obstinate periostitis of the unprotected
patella may result.
If operative measures are contra-indicated or refused, treatment
consists in prevention of any further irritation by avoiding kneeling,
or providing a suitable horseshoe-shaped pad which allows no
pressure to fall on the bursa. At the same time it may be possible
to bring about the absorption of some of the fluid by the application
of local counter-irritants, such as iodine or Scott's dressing. The
treatment by tapping and injection with iodine or pure carbolic
acid is as painful as it is useless.
Syphilitic Bursitis. A gummatous bursitis is occasionally met
with. It is more commonly found affecting the prepatellar bursa,
and, if so, the periosteum of the patella may also be affected. The
cases are somewhat chronic, but no treatment, apart from that by
potassium iodide, is required.
Tuberculous Bursitis. These cases should be treated in the
early stages by absolute rest, with the application locally of
Scott's dressing and the usual general treatment. If these
measures do not succeed, the bursa should be dissected out entire if
possible, or, if this cannot be done, as much as possible of it should
be cut away, the remainder being scraped, so as to remove the
tuberculous pyogenic membrane, and then treated with pure
carbolic acid. The wound is sutured, if possible, without drainage.
In some cases a large chronic abscess alone may be found, the
bursa itself having been destroyed ; these eases should be treated
by evacuation of the abscess under the strictest antiseptic
precautions, the wound being sewn up without drainage after gently
curetting the abscess cavity and irrigating with hot dilute antiseptic
solution.
Injuries of Bursae. A wound involving a bursa is very liable
to become septic, and if this occurs a chronic discharging sinus may
persist at the site of the wound. In such cases the best treatment is
to dissect out the bursa entire if possible, or if this cannot be done
to lay it open freely and, after scraping away the lining membrane
as far as possible, to allow the wound to heal by granulation.
C. H. S. FRANKAU.
A SYSTEM OF TREATMENT.
INDEX.
Abano spa, III. 147
Abdomen, bandaging of, in sho'jk, I. 97
bullet wounds of, II. 248
contusions of, II. 243
diseases of, II. 190, 423
distension of, after abdominal opera-
tions, II. 270
evisceration in, IV. 4 1 7
in peritonitis, II. 638
drainage of, in puerperal sepsis, IV. 300
examination of, in non-operative appen-
' dicitis, II. 424
incision of, in Caesarean section, IV. 387
injuries of, II. 242-256
complicating thoracic injuries, II. 248
convalescence in, II. 244
general considerations and rules for
treatment of, II. 253
incidence of, II. 242
mortality from, II. 243
operation in, II. 254
reaction in, II. 244
table of cases of, II. 242
operations on. See Abdominal opera-
tions.
pains in, in food fever, II. 240
pendulous, complicating pregnancy, IV.
61
stab wounds of, II. 253
supports for, in gastroptosis, II. 319
surgery of, treatment of vomiting in,
1.29
suture of wall of, in ovariotomy, IV. 787
tapping of, in ascites, It. 629
wounds of, penetrating or not, treat-
ment of, I. 565, II. 247
Abdominal belt for umbilical hernia, II.
:,-ll
exercises in gymnastics, III. 226
muscles, rupture of, II. 252
operations, after-treatment, II. 262-
276
anaesthetic, vomiting after, II. 263
anaesthetics in, III. 31
antiseptic precautions in, I. 91
belt worn after, II. 268
care of bladder after, II. 264
bowels after, II. 264
the mouth after, II. 264
S.T.
Abdominal operations (contd^)
clothing in, II. 26"0
complications of, II. 269
involving wound after, II. 272, 273
distension complicating, II. 270
dressings after, II. 266
duration of confinement to bed after,
II. 267
emergency cases, II. 260
feeding after, II. 265
final directions to patients after, II. 268
fixation of time for, II. 257
flatulence after, II. 264
insomnia after, II. 265
intra-peritoneal haemorrhage compli-
cating, II. 275
massage after, II. 268
nervousness and, II. 260
pain after, II. 263
persistent vomiting complicating, II.
269
position of patient in bed after, II. 266
post-operative haematemesis after, II.
275
preparation of alimentary canal in,
II. 258
preparation of patients for, II. 257-261
retention of urine complicating, II.
272
shock complicating. II. 269
skin preparation for, II. 259
thirst after, II. 263
thrombosis complicating, II. 274
uncomplicated cases in, II. 262
visitors to patients after, II. 266
organs, application of vibration to, III.
220
pain complicating typhoid fever, I. 359
supports in constipation in adults, II.
462
wall, incised wounds of, II. 249
sloughing of, complicating abdominal
operations, II. 273
wounds of, II. 245
non-penetrating, II. 246
Abduction splint and pad for the shoulder,
I. 776
Abel (W.), gastro-enterostomy, first per-
formed by, II. 343
A SYSTEM OF TREATMENT.
Abnormalities. See Malformations.
Abortion, IV. 14-22
after-treatment of, IV. 22
complicating pregnancy, IV. 14
incomplete, IV. 21
induction of, by dilatation of the cervix,
IV. 437
by rupturing the membranes, IV. 436
by vaginal Cassarean section, IV. 437
in diseases of pregnancy, IV. 433
maternal indications for, IV. 433
methods of, IV. 436-437
'inevitable, IV. 18
later than first twelve weeks, IV. 20
missed, IV. 22
retained placenta in, IV. 225
prevention of, iy. 14
threatened, IV. 17
Abscess, acute, surgical treatment of,
I. 166-172
alveolar, III. 1174
ano-rectal, II. 600-606
cavities, irrigation and scraping of, I.
175
cerebral, following head injuries, I.
885
complicating typhoid fever, I. 363
drainage of, in pelvic cellulitis, IV. 848
in appendicitis, operation in, II. 419
in connection with tuberculous disease
of the spine, 1. 928-932
in nodule of the auricle, III. 882
in tuberculous disease of hip-joint, I. 757
infective, of scalp, I. 888
infra-mammary, II. 960
intra-cranial, coma and, II. 983
ischio-rectal, complicating pulmonary
tuberculosis, I. 1156
labial, complicating gonorrhoea, I. 229
mammary, II. 958
chronic, II. 962
of areola of nipple, II. 977
of lung, due to foreign bodies in the
bronchus, I. 1061
cf the ovary, IV. 765
of the prostate, II. 922
peri-urethral, II. 895-896
complicating gonorrhoea, I. 226
in the female, IV. 870
psoas, I. 916
pulmonary, I. 1059
retro-pharyngeal, III. 789-790
in diseases of the spine, I. 916
sublingual, II. 133
subphrenic, II. 643-644
supra-mammary, II. 960
tuberculous, methods of treatment of I
173-17ti
vaccine therapy in, III. 264
Accommodation of the eye, errors of, III
528-542
spasm in. III. 542
Accouchement ford in podalic version, IV.
466
A.C.E. mixture as anaesthetic, III. 20
Acetabulum, fracture of, I. 607
Acetanilide, poisoning by, I. 533
Acetone, application of, to cervix uteri in
inoperable cancer, I. 137
in cancer of cervix, IV. 616
preparation of skin by, 1. 73
rubbed into the skin before operation,
I. 84, 88
Acetonuria, TI. 730
Achondroplasia, II. 1227
Achylia, atrophy of the stomach, II. 225-
295
gastrica, II. 368
Acid baths, III. 137
carbolic, antiseptic in typhoid fever, I.
351, 354
gangrene due to, I. 219
in plague, III. 406
in ulcer of the cornea, III. 565
in whooping cough, I. 382
poisoning by, I. 527
diacetic, in the urine in diabetes mellitus,
I. 409, 417
formation of, in diabetes, I. 423
hydrochloric, effect in gastric function,
II. 291
in gastric neurasthenia, II. 356
in typhoid fever, I. 355
hydrocyanic, poisoning by, 1. 530
oxalic, poisoning by, I. 528
oxybutyric in the urine, I. 417
prussic, poisoning by, I. 530
sulphurous, in typhoid fever, I. 355
uric, solvents of, I. 436
Acidity in cancer of the stomach, II. 300
in disordered digestion in the stomach,
II. 370
Acidosis, prevention of, I. 410, 417
Acids, mineral, poisoning by, I. 526
Ackers on epidemic gangrenous proctitis,
III. 437
Acne cheloid, III. 1018
rosacea, III. 1135, 1136
X-rays in, III. 350
scrofulosarum, III. 1151
vulgaris, III. 982-990
after-treatment of, III. 987
general remarks on, III. 982
lotions for, III. 984
ointments for, III. 986
operative treatment of, III. 983
parasiticide applications in, III. 984
powders for, III. 985
Rontgen rays in, III. 349, 987
scarring of skin in, III. 986
soaps for, III. 985
treatment of, internal, III. 987
local, III. 983
vaccine treatment of, III. 989
Aconite and aconitine, poisoning by, I. 532
Aconitine and aconite, poisoning by, 1. 532
in diseases of the heart, I. 1226
Acqui spa, III. 147
Acromegaly, II. 1226-1227
Acromion process, fracture of. I. 586
A SYSTEM OF TREATMENT.
Actinomycosis, drugs in, I. 178
general treatment of, I. 177
local treatment of, I. 177
of Fallopian tube, IV. 800
of the gall bladder, II. 711
of the jaws, II. 109
of the lung, surgical treatment of, I.
1175
of the pharynx, III. 765
of the skull, I. 891
of the spine, I. 919
surgical treatment of, I. 177
Adams-Stokes' syndrome. I. 1237
Adamson (H. G.), the X-rays treatment of
>kin diseases. III. 341-359
Addison's disease, II. 46-48
complicating pregnancy, IV. 50
curative measures in, II. 46
palliative measures in, II. 47
symptoms of. II. 48
(pernicious) an;emia, II. 1-12
Adductors, rupturing of by pressure with
the thumb, I. 945
Adenitis complicating scarlet fever, I. 290
tubercular, III. 757
Adenoids, ana-mia and, II. 14
causes of, I. 49
of the pharyngeal tonsil, III. 732
post-nasal, and Eustachian obstruction,
III. 947
Adenoma, fibrous, of the breast, II. 955
of the prostate, II. 940-949
complication of, II. 944-946
of the sweat glands, III. 1044
Adenomata in goitre, II. <!3
x'haceum, I. 109, III. 991
Adenomatous disease of uterus, leucor-
rha-a in, IV. 570
Adenomyoma of uterus. IV. 662
Adhesions in acute synovitis, I. 742
in ovariotomy, IV. 780
pericardial, I. 1189
Adrenal glands, diseases of, II. 46-48
Adrenalin in asthma, I. 1040
in haemorrhage, I. l'2C>\
in pneumonia, I. 2U1
in vomiting due to heart failure, I. 200
Adrenalin chloride in plague, III. 4(19
Adrenine infusion in shock, I. 98, 102
Agar-agar in constipation in adults, II. 451
Agoraphobia in psychasthenia, II. 1044
Agraphia. restoration in by functional
compensation, II. 1050
Ainhum, III. 4 ('.."
Air bath, compressed, in emphysema, I.
1086
superheated, in gout and gouty con-
ditions, I. 439
cushion in contusions of coccyx, I. 900
complicating labour, IV. 161-162
embolism, I. 1306
fresh, in pleurisy, I. 1093
in pulmonary tuberculosis, I. 1118
hot, therapeutical indications of, III. 324
treatment by, III. 316-326
Air (contd.)
in chlorosis, II. 20
vitiated, poisoning by, I. 534
Air-passages, foreign bodies in, III. 803-
821
upper, catarrh of, climate for, III. 101
Aitken (D. McCrae), surgical treatment of
cerebral palsies of infancy, II. 1157-
1164
Aix-les-Baius spa, III. 147
Aix-la-Chapelle spa, III. 147
Albertine on aortic aneurysm, 1. 1297
Albumen water in marasmus, 1 . 465
preparation of, I. 42
in mercurial poisoning, I. 530
in typhoid fever, I. 342
Albtiminuria. II. 733
complicating diphtheria, I. 201
pregnancy, IV. 30-33
pulmonary tuberculosis, IL 1157
in acute nephritis, II. 797
in pregnancy, IV. 7
in scarlet fever, I. 292
mineral waters and baths in, III. 140
Albumosuria, II. 733
Alcock's apparatus for anaesthetics, III.
14
Alcohol as sterilising agent, I. 72-73
coma from, II. 984
in chronic congestion of the lungs, I.
1079
in diabetes mellitus, I. 423
in dietary of children, I. 62
in fevers, directions for, I. 158
in gout, I. 456
in heart failure, I. 193-200
in infantile weakness, I. 66
in influenza, I. 234
in insomnia, II. 985
in marasmus, I. 466
in pneumonia, I. 260
in pruritus, III. 1098
injection of into nerve trunks, I. 135
in trigeminal neuralgia, II. 1117
intoxication by, in epilepsy, II. 993
natural resistance to disease lowered by,
I. 5, 9
neuritis from, II. 1134
poisoning by, acute, I. 495
tolerance of, I. 499, 539
use of, and anaesthetics, III. 22
Alcoholic gastritis, I. 495-498, II. 353
Alcoholism, I. 495-502
acute, I. 495
chronic, I. 496
complicating cancer of the breast, II.
96(5
inebriety of, I. 499
delirium tremens in, I. 499
dipsomania, I. 497
drugs in, I. 495-497, 500
gastric complications in, I. 495-498, II.
353
hypnotic treatment in. I. 498
nervous disturbance in, I. 496 ; II. 1134
12
A SYSTEM OF TREATMENT.
Alder leaves in cancer, I. 149
Alexander's operation in retroflexion of
the uterus, IV. 681
Alimentary canal, catarrh of, in children.
1.46
injuries of, 250
preparation of in operations, II. 258
system, cancer of, relief of obstruction
in, I. 139
tract, care of, in gout, I. 450
diseases of, II. 190
perversion of functions of in epi-
lepsy, II. 1018
Alkali, exhibition of in diabetes, I. 410,
418
Alkalies, caustic, poisoning by, I. 527
in diabetes mellitus, I. 423
in psoriasis, III. 1114
value of, in gastric derangements in
children, I. 65
Alkaline waters, III. 119
in chronic gastritis, II. 351
Alkaloids in constipation in adults, II.
446
Alkaptonuria. II. 734
Aloes in constipation in adults, 447
Alopecia. III. 992-1004
dependent on morbid conditions of hair
follicles, III. 1000
on the scalp, III. 1000
symptomatic of general diseases, III. 999
Alopecia areata, III. 992-997
general remarks, III. 992
general treatment of, III. 993
local treatment of, III. 994
physical remedies in. III. 996
Alopecia cicatrisata, III. 997
congenitalis, III. 997
hereditaria praematura, III. 998
neurotica, III. 998
pityrodes, III. 1003
seborrhoic dermatitis, III. 1004
oily type of, III. 1003
or calvities, III. 1001
senilis, III. 998
Alum, powdered, in haemorrhage, I. 1261
Aluminium plate in fractures of jaws, II.
114
Alveolar abscess, III. 1174
chronic, III. 1175
echinococcus disease, III. 523
Amaurotic family idiocy, II. 1244
Amblyopia, III. 543-546
congenital, III. 543
toxic, 111. 543
Amblyoscope. Worth's, in strabismus, III.
652
Amelies-les-Bains spa. III. 147
Amenorrhcea, IV. 725-735
constipation in, IV. 726
drugs in, IV. 727-728
primary, permanent, IV. 730
temporary, IV. 725
secondary, IV. 731
lactation in, IV. 731
Ammonia, acetate of, in whooping cough,
I. 380
poisoning by, I. 527
Ammonium, benzoate of, in arterio-
sclerosis, I. 1294
hippurate of, in arterio-sclerosis, I. 1294
tartrate in opacity of the cornea, III.
572
Amoebic hepatitis. II. 676
Ampulla of Vater, cancer of, II. 714
Amputations, I. 789-872
at the elbow-joint, I. 820-824
at the knee-joint, I. 859-861
at the wrist-joint, I. 813-816
by a racket incision, I. 796
by flaps of skin and muscle, I. 796
by the circular method, I. 794, 795
conditions essential for good flaps in, I.
792
control of haemorrhage in, I. 798
dangers and complications after, I.
803
Faraboeuf's, I. 855, 858
for gunshot fracture, I. 562
for inflammatory condition, including
gangrene, I. 790
for new growths, I. 791
general considerations, I. 789
Guyon's, I. 850
in acute suppnrative synoviti?, I. 744
in aneurysm, I. 1303
in ' disease of the ankle and tarsus, I.
774
in gangrene, I. 214-217
instruments for, I. 799
interscapulo thoracic, T. 830
in traumatic cases, I. 789
in uncontrollable haemorrhage. I. 559
irregular forms of, I. 797
Lord Lister's, I. 852
modified circular, I. 795
neuromata, I. 112
of fingers, sites for, I. 804
of the fingers, I. 804-813
of the foot, I. 836-850
of the knee-joint in tuberculous disease,
1.771
of the toes, I. 834-836
osteo-periosteal method of, I. 801
periosteum in, I. 800
Pirogoffs, I. 848
Stokes's, I. 863
stump, pain in, I. 792
Teale's, I. 851
technique in, I. 797
through the arm, 824-827
forearm, I. 816-820
through the leg, I. 850-859
the thigh, I. 862-866
vitality of flaps in, I. 791
Amyl nitrite in asthma, I. 1039
in hsemothorax, I. 564
Amylic alcohol in inoperable cancer,
137
Amyotonea congenita, II. 1245
A SYSTEM OF TREATMENT.
Anaemia, acute rheumatism in, I. 15
Addison's (pernicious), II. 1-12
and abdominal operations, II. 258
and haemorrhoids, II. 616
aplastic, II. 37
associated with ulceration, I. 372
Bright's disease and, II. 17
cancer in, II. 16
caused by pulmonary tuberculosis, II.
13
climate for, III. 92
complicating tuberculosus peritonitis,
II. 646
convalescence from, II. 15
due to actual loss of blood, II. 18-19
dnc to some definite malady, II. 13-17
heart disease in, II. 15
in ailing children, II. 14
in pulmonary tuberculosis, I. 111 1 .*
in rheumatism in childhood, I. 279
intestinal parasites and, II. 15
mineral waters and baths in, III. 143
of the labyrinth, III. 967
of the larynx, III. 822
oxygen inhalations in, II. 9
pernicious, anti-streptococcus serum in,
II. 8
arsenical waters in, II. 5
bone-marrow in, II. 9
complications of, II. 10
convalescence in, II. 11
diet in, II. 2
drugs in, II. 3
gastro-intestinal antiseptics in, II. 6
Grawitz method in, II. 9
infusion in, II. 9
intestinal antiseptics in, II. 8
iron in, II. 5
oral antiseptics in, II. 6
rest in, II. 1
vaccine treatment of, II. 7
with atrophy of the stomach, II. 293
plumbism and, II. 16
septic states in, II. 16
severe, in post-partum hemorrhage,
IV. 222
syphilis and, II. 17
tropical, II. 15
Anaemic obesity, I. 468, 472
Anaesthesia, difficulties anddangers arising
during. III. 33
general, in foreign bodies in the air
passages, III. 813
infiltration, in treatment of cysts, I. 108
in relation to shock, I. 95
in sprains, I. 740
intravenous, III. 35
local, in foreign bodies in the air
passages, III. 813
method of, in malignant disease of
upper jaw, II. 117
in operations on jaws, II. 117
of the pharynx, III. 782
spinal, for relief of pain, I. 136
treatment of after-effects, III. 35
Anaesthetic, bichlorinated chlorate of
methyl as, III. 13
chloroform as, III. 13
.choice of principles of, III. 21
in craniotomy, IV. 405
in decapitation, IV. 413
in operation for cleft palate, II. 149
in radical operation for cancer of breast.
II. 968
in version, IV. 462
mixtures with chloroform, III. 19
nitrous oxide as, III. 2
trichlormethane as, III. 13
vomiting after abdominal operations,
II. 263
complicating gynaecological surgery,
IV. 489
Anaesthetics, III. 1-39
administration of, antiseptic precau-
tions during, I. 83
in certain special operations, III. 26
choice of, in empyema generalised in
lower part of thorax, I. 1 101
diabetes and, III. 24
for the reduction of dislocations, III. 33
general, III. 1
in common use and methods by
which administered, III. 2
in abdominal operations, III. 31
in evisceration, IV. 416
in excision of the eye, III. 30
in exophthalmic goitre, II. 59
in hypertrophy of the pharyngeal tonsil,
III. 734
in labour, IV. 376-381
conclusions on, IV. 380
in operations for cancer of the breast,
III. 31
for empyema, III. 30
for intestinal obstruction, III. 32
for mature cataract, III. 622
upon the genito-urinary passages,
III. 32
upon the rectum, III. 32
in perforation of the intestine, II. 551
local, teeth extraction under, III. 1190
in pregnancy, III. 24 ; IV. 58, 375-376,
489
teeth extraction under, III. 1190
Anaesthetist, methods of, at operations, I.
83
Analgesia, local, III. 38
spinal, III. 36
Anderson (Edith McC.), management of
the sick room, I. 26-43
Andrews (H. Russell), abscess of the ovary,
IV. 765
affections of the breasts during preg-
nancy and the puerperium, IV. 330-
336
chronic ovarian pain, IV. 766
hernia of the ovary, IV. 767
intra-ligamentary tumours, IV. 768-
770
malignant ovarian tumours, IV. 770
A SYSTEM OF TREATMENT.
Andrews (H. Russell) (contd.*)
ovarian tumours discovered during
labour, IV. 773-7 74
discovered during pregnancy, IV.
771-772
discovered during puerperiutn, IV. 774
ovariotomy, IV. 775-795
prolapse of the ovary, IV. 796
suppurating ovarian cysts, IV. 797-798
Anencephalus of newborn child, IV. 357
Aneurysm, amputation in, I. 1303
aortic, chloroform inhalations in, 1. 1299
haemorrhage in, I. 1300
iodide of potassium in, I. 1298
measures which aim at producing a
cure in, I. 1297
measures which aim at the relief of
symptoms, I. 1299
medical treatment of, I. 1297
pain in, I. 1299
rest in, I. 1299
subcutaneous injection of gelatine in,
I. 1298
tracheotomy in, I. 1299
Tufnell's treatment of, I. 1297
venesection in, I. 1299
arteriorrhaphy in, I. 1303
arterio-venous, I. 1305
of the orbit, III. 662
of the scalp, I. 893
cirsoid, of the scalp, I. 893
compression in, I. 1302
diffuse, I. 1304
excision in, 1. 1301
femoral, I. 1304
general treatment of, I. 1301
glnteal, I. 1304
intra-cranial, I. 1304
intra-orbital, I. 1304
introduction of foreign bodies to procure
coagulation in, I. 1302
ligature for, I. 1302
of hepatic artery, II. 667
of renal artery, II. 752
popliteal, I. 1304
sciatic, I. 1304
simple of the scalp, I. 893
subclavian, I. 1304
summary of, I. 1303
surgical treatment of, I. 1301-1305
traumatic in gunshot wounds, I. 560
Angina, acute membranous, III. 771
pectoris, I. 124fi
attacks of, I. 1251
in gout and gouty conditions, I. 443
neurosis of, I. 1252
palpitation and, I. 1252
streptococcus, III. 771
Vincent's, III. 771
Angiokeratoma. III. 1151
Angioma of the auricle, III. 879
of lingual tonsil, III. 762
of the umbilicus in newborn child, IV.
37o
Angiomata of the scalp, I. 893
Angioneurotic oedema. II. 1228-1229
Angiotripsy in haemorrhage, I. 1257
Aniline eczema, I. 117
poisoning by, I. 533
Animal food, II. 192
in gout, I. 451.
foodstuffs (Bunge), II. 74:>
Anisometropia, III. 528-529
eyes used alternately in, III. 528
one eye permanently excluded from
vision in, III. 529
simultaneous binocular vision in, III.
529
Ankle, dislocations of, I. 731
tuberculous disease of, 1. 772-77.1
Ankle-joint, suction glass for, in hyper-
aernic treatment. III. 59
Syme's disarticulation at, I. 845
Ankylosis in gunshot injuries of joints, I.
562
in tuberculous disease of the hip-joint,
I. 761-763
of hip-joint, osteotomy in, I. 764
of the jaw, II. 105, 106
Ankylostomiasis. III. 487
beta-naphtbol in, III. 492
eucalyptus in, III. 491
prophylaxis of, III. 487
routes of entry in, III. 489
thymol treatment of, III. 490
Ankylostomum duodeuale, expulsion of, I.
522
Annulus migraus, II. 126-129
Anodyne fomentations in acute rheuma-
tism, I. 269
Anodynes for relief of pain, I. 134
Ano-rectal area, diseases of, II. 593-612
Anorexia and cancer of the stomach, II.
298
nervosa neurasthenia, II. 1C42
Anthelmintic treatment of taeniasis in-
testinal, III. 518
Anthracene purgatives in constipation in
adults. II. 447
Anthrarobin in psoriasis. III. 1119
Anthrax complicating pregnancy, IV. 49
cutaneous, I. 179
malignant pustule, I. 179
intestinal, I. 179
methods of examination in, I. 180
respiratory, I. 179
sclavo serum in, I. 179
treatment of, I. 179
Antibodies in serum therapy, III. 259
Anti-coli serum in bacillus coli injections,
III. 271
Antidotes and poisons, I. 526-535
Antifebrin in diseases of the heart, I. 1225
Antimony, acute poisoning by, I. 529
Antimonyl tartrate in trypanosomiasis,
111.421
Anti-pneumococcus serum, III. 285
Antipyretic treatment of typhoid fever,
I. 348. 351
Antipyretics, use of in pyrexia, I. 159
A SYSTEM OF TREATMENT.
Antipyrin. dosage of, in children's diseases,
I. 67
in influenza, I. 234
poisoning by, I. 533
Antirabic serum injection in rabies, I.
265
Antiscorbutics in scurvy, I. 476
Antisepsis in surgical technique, 1. 84-92
Antiseptic solutions in gynaecological
operations, IV. 484
treatment of typhoid fever, I. 352
Antiseptics, composition and strength of,
I. 76, 81
definition of, I. 161
in chronic dilatation of the stomach, II.
312
in pernicious anaemia. II. 6
intestinal, I. 387
in chlorosis, II. 28
in pernicious anaemia, II. 8
Anti-streptococcus serum, III. 290
in cellulitis, I. 183
in infective endocarditis, I. 205
in pelvic cellulitis, IV. 849
in pernicious anasmia, II. 8
in scarlet fever, I. 288
in septic arthritis, I. 291
Antitoxic serum in tetanus, I. 329
therapy, III. 259
Antitoxin, intravenous injection of, dosage
of, I. 191
method of administration, I. 191
prophylactic use of, I. 192
treatment of diphtheria, I. 189-192
sequelas of, I. 193
Antitoxins in chronic rhinitis, III. 709
in serum therapy, III. 259
Antrum, suppuration of, in acute inflam-
mation of middle ear, III. 897
Anuria, calculous, II. 755
complicating diphtheria, 1. 201
Anus, abrasion of, in constipation in chil-
dren, II. 436
abscess of, II. 600
artificial, in fistulas of the intestines, II.
488
diseases of, II. 593-625
fissure of, II. 597
in constipation in children, II. 436
operative treatment for, II. 598
fistula of, II. 606-610
complications of, II. 608
due to tuberculosis, II. 609
imperforate, in newborn child, IV. 362
infective ulcerative proctitis, II. 610
ischio-rectal abscess of, II. 601
after-treatment, II. 603
malformations of, II. 613
pelvi-rectal abscess of, II. 604
pruritus of, II. 593 ; III. 1102-1105
retro-rectal abscess of, II. 604
subcutaneous abscess of, II. 600
sub-mucous abscess of, II. 604
Aorta, abdominal, ligature of, for
anenrysm, I. 1304
Aorta (fontd.)
aneurysm of, medical treatment of, I.
1297
.thoracic, surgery of in aneurysm, I.
1303
Aperient waters, in constipation in adults,
II. 466
Aperients in constipation in children, II.
437
in prevention of lead poisoning, I. 514
Aperiosteal method of amputation, I. 801
Aphakia, III. 530
Aphasia and other speech defects of cere-
bral origin, II. 1143-1149
hysterical, II. 1147
of cerebral origin, II. 1143-1149
speech restoration in, by functional
compensation, II. 1147
syphilitic, II. 1144
temporary, II. 1145
Aphonia, application of vibration in, III.
219
hysterical, III. 842
Aplastic anasmia, II. 37
Apomorphine in dipsomania, I. 497
Aponeuroses, chronic rheumatism of, I.
484
of external oblique, division of in in-
guinal hernia, II. 501
Apoplexy, cerebral, II. 1070
Apparatus, surgical, sterilisation of, I. 80-
83
Appendicectomy, after-care of patients
from, II. 268
incision through sheath of rectus muscle,
II. 413
muscle-splitting incision, II. 412
Appendicitis, II. 401-425
abscess in, II. 404
operation in, II. 419
acute cases of, II. 402
in children. II. 405
and enteric fever, II. 411
and pregnancy, II. 406 ; IV. 54
cases of diffuse and general peritonitis
and, II. 423
chronic, II. 409
closure of the wound in, II. 416
desperate cases of, II. 405
fulminating, II. 405
in children, statistics of at St. George's
Hospital, II. 406
in elderly patients, II. 406
indications for operation in, II. 401
intussusception of the appendix in, II.
422
non-operative, II. 422-425
acute cases of, II. 423
prophylactic treatment of, II. 424
subacute cases of, II. 423
operations for, II. 411
in acute cases, II. 418
special difficulties in, II. 417
perforative, and Bier's treatment, III.
44
A SYSTEM OF TREATMENT.
Appendicitis (contd.~)
quiescent appendix in, II. 407
statistics of in St. George's Hospital, II.
402
subacute cases of, II. 407
with symptoms of general peritonitis,
II. 405
Appendicostomy for chronic constipation,
II. 470
for chronic mucous colitis, II. 571
in constipation in adults, II. 468
in ulcerative colitis, II. 576
Appendix and tuberculous peritonitis, II.
411
dyspepsia, II. 409
in a hernial sac, II. 410
intussusception of, in appendicitis. II.
422
isolation of, II. 413
malignant disease of, II. 411
quiescent, in appendicitis, II. 407
removal of, II. 414
during laparotomy, II. 410
in quiescent stage, II. 411
when abscess is present in appendi-
citis, II. 421
Apraxia, II. 1150-1152
Arc light, concentrated, III. 199
use of, III. 186 ; 190
Areola, abscess of, II. 977
Argeles-Gazost spa, III. 147
Argyrol, installations of, in pyelitis, II. 804
Arm, amputation through, I. 824-830
brawny, of breast cancer, lymph-angio-
plasty in, I. 144
fractures of, I. 586, 596
modified circular amputation through,
I. 825
Armour (Donald), abscess in connection
with tuberculous disease of the spine,
I. 928-932
diseases of the spine, I. 912-921
infective lesions of bones of the skull,
1. 889891
surgical diseases of the scalp and
cranium, I. 888
surgical treatment of tumours of the
brain, II. 1204-1207
tumours of the scalp, I. 892-896
spinal cord, II. 1221-1225
Arrowroot, preparation of, I. 42
Arsacetin in syphilis, I. 321
iu trypanosomiasis, III. 421
Arsanilates in trypanosomiasis. III. 419
Arsenic, dosage of, in children's diseases,
I. 68
in cerebro-spinal syphilis, II. 1067
in chlorosis, II. 27
in chorea, II. 1258
in diabetes mellitus, I. 424
in Hodgkin's disease, I. 1343
in intermittent hydrarthrosis, I. 749
in leukaemia, II. 39
in pellagra, I. 523
in pernicious anaemia, II. 3
Arsenic (contd.}
in psoriasis. III. 1111
in syphilis, I. 321
tolerance of, I. 503
tiisulphide of, in ^rvpanosomiasis, III
421
Arsenical dermatitis, I. 117
neuritis, II. 1138
poisoning, acute, I. 543, 529
chronic, I. 504
waters, III. 122
in pernicious antenna, II. 5
Arsenious acid in trypanosomiasis, 111.
421
Arseniuretted hydrogen, poisoning by, I.
535
Arsenophenylglycin in trypanosomiasis,
III. 418
Arterial tension, high, I. 1281
headache from, II. 1034
Arteries, compression of in hasmorrhage,
I. 799
diseases and affections of, 1. 1255-1308
in gouty subjects, I. 436
effect of shock on blood pressure in, 1. 93
gangrene due to gradual obliteration of,
1.215
to sudden obliteration of, I. 215
gluteal, injuries to, I. 1276
haemorrhage from. I. 1255-1277
injuries of, I. 1255-1277
intercostal, wounds of, I. 1026
lacerated wounds of, I. 1280
ligation of in gunshot wounds. I. 559
in inoperable cancer, I. 136
mesenteric. embolism by, I. 1307
palmar, wounds of. I. 1276
primary haemorrhage of, I. 1270
sciatic, injuries to, I. 1276
senile changes of, cerebral thrombosis
due to, II. 1178
subcutaneous injuries of, I. 1278
suture of, in injuries to, I. 1279
wounds of, 1. 1278-1280
See also under Artery.
Arterio-capillary fibrosis, I. 1288
Arteriorrhaphy in aneurysm, I. 1303
Arterio-sclerosis, I. 1287-1295
causes of hypertension in, I. 1289
diet in, I. 1290
exercise in, I. 1291
general treatment of } I. 1290-1292
hygiene of the skin in, I. 1291
medicinal treatment of, I. 1292
oedema and hydrothorax in, I. 1294
spa treatment of, I. 1291
surgical aspects of, I. 1296
Arterio-venous aneurysm, I. 1305
communications in gunshot wounds, I.
560
Arterio-visceral-sclerosis. I. 1287
Artery, axillary, excision of. in aneurism,
I. 1304
brachial, hemorrhage from, 1. 1275
femoral, injuries of, I. 1276
8
A SYSTEM OF TREATMENT.
Artery (contd.)
fneual, rupture of, II. S7ti
gangrene due to mechanical obstruction
of, I. 215
hepatic, aneuiysm of, II. 667
iliac, ligature of, for aneurysm, I. 1304
innominate, ligature of for aneurysm,
I. 1303
internal mammary, wounds of, I. 1025
middle meningeal, haemorrhage from,
I. 1275
palatine, haemorrhage from, I. 1275
renal, aneurysm of, II. 752
subclavian, haemorrhage from, I. 1275
See also under Arteries.
Arthralgia, I. 781-784
Arthrectomy in disease of the ankle and
tarsus, I. 773
Arthritis, acute suppurative, I. 742-745
general treatment of, I. 744
local treatment of, I. 742
adhesions of, in hemiplegia, II. 1187
arthrotomy in, I. 745
bursae and cysts in association with, I.
749-750
chronic, I. 745-748
complicating scarlet fever, I. 290
typhoid fever, I. 363
deformans, I. 391-399
climate for, I. 392
diet in, I. 393
electrical treatment, I. 398
local treatment of, I. 396
localised foci in, I. 391
medicinal treatment of, I. 395
surgical measures in, I. 397
treatment by natural thermal baths,
I. 397
electro-therapeutics in, I. 746
enteric, I. 784
fibrolysin in, I. 748
gonorrhceal, I. 781-783
vaccine therapy of, III. 281
hydro-therapeutics in, I. 745
in haemophilia, I. 786
in syringomyelia, I. 786
infective, I. 741
local applications in, I. 748
mineral waters and baths in, III. 142
neuropathic, I. 785
pneumococcal, I. 783-784
rheumatoid, chronic rheumatism and,
1.483
complicating pregnancy, IV. 57
massage in, III. 208
treatment of by counter irritation of
the spine, I. 405-407
Arthrotomy in chronic synovitis and
arthritis, I. 745
Ascariasis, III. 493
prophylaxis of, III. 493
santonin in, III. 494
Ascites, II. 626-631
cardiac, II. 630
complicating pregnancy, IV. 55
Ascites (contd.)
diaphoresis in, II. 628
diet in, II. 626
diuretics in, II. 627
general treatment of, II. 626
operative measures in, II. 631
pain in, II. 627
paracentesis in, II. 628
purgatives in, II. 627
removal of, II. 627
special forms of, II. 630
tapping abdomen in, II. 629
Ascitic fluid in tuberculous peritonitis,
removal of, II. 647
Asepsis in operative treatment of fractures,
1.636
Aspergillosis, pulmonary, 1. 1116
Asphyxia in cut throat, II. 164
local, II., 1238-1241
of the newborn child, IV*. 350-355, 473
Schultze's artificial respiration in,
IV. 352
treatment of, IV. 351
Aspiration in hasraatoma, I. 545
in joint affections, I. 755
in pleural effusion, I. 1095
of tuberculous abscess, I. 174
Aspirin in acute rheumatism, I. 271, 278
in chronic rheumatism, I. 490
in influenza, I. 233
Association method in hysteria, II. 1011
Asthma, I. 1035-1042
application of vibration in, III. 216
cardiac, I. 1253
climate for, I. 1037
diet in, I. 1036
in children, I. 1041
physical exercises in, III. 251
pneumatic treatment of, I. 1042
spasmodic, III. 691
treatment in the intervals of the
paroxysms, I. 1041
of the aetiological factors of, I. 1035
of the paroxysms of, 1038-1041
Astigmatism, III. 530
irregular, III. 533
Astragalus, dislocation of, I. 733
excision of, 1. 775
fracture of. I. 633
Atazia of the vocal cords, III. 841
in hemiplegia, II. 1188
Ataxy, locomotor, II. 1085-1092
physical exercises in, III. 256
Atelectasis and collapse of the lung, 1.
1063-1065
in newborn child, IV. 361
Atmospheric influences, 1. 534, 1118
children susceptible to, I. 63
Atomiser for spraying nasal cavities, III.
696
Atoxyl in cancer, I. 149
in pellagra, I. 522
in syphilis, I. 321
in trypanosomiasis, III. 420
in undefined tropical fevers, III. 411
9
A SYSTEM OF TREATMENT.
Atresia, congenital, of the pylorus, II. 344
superficial, of the vulva, IV. 513
Atrophy, muscular, in hemiplegia, II.
1187
myotonic, II. 1252
of' the nails, III. 1082
progressive muscular, II. 1081-1082
Atr opine, hypodermic injection of, before
operation, I. 84
in acute iritis, III. 584
in alcoholism, I. 501
in asthma, I. 1038
in constipation in adults, II. 446
in diabetes insipidus, I. 429
in diphtheritic paralysis, I. 200-201
in diseases of the heart, I. 1226
in hypermetropia, III. 536
in hyperopia, III. 536
in nocturnal enuresis, II. 75
in pneumonia, I. 262
poisoning by, I. 532
Atticotomy in acute inflammation of the
middle ear, III. 917
Attie punch forceps, III. 916
Atwater and Bryant, food analyses of, II.
192
Aural probe, III. 908
snare, III. 909
vertigo, operation on, indication for,
III. 974
Auricle, abscess in lobule of, III. 882
angeioma of, III. 879
blackheads of, III. 881
cervical, III. 876
comedones of, III. 881
cysts of, III. 879
dermatitis of, phlegmonous, III. 881
dermoid cysts of, III. 879
diseases of, III. 880
local, III. 880-882
eczema of, III. 880
erysipelas of, III. 880
fibromata of, III. 879
foreign bodies in, III. 888
herpes of, III. 880
keloids of, III. 879
lupus of, III. 881
new growths of, III. 878
noma of, III. 882
perichondritis of, III. 881
Raynaud's disease of, III. 880
rodent ulcer of, III. 879
tophi of, III. 880
Auricles, accessory, III. 876
Auricular fibrillation of the heart, I. 1231
Auscultation in normal labour, IV. 130
Auto-inoculation, guides to the control
of, I. 1162
in vaccine therapy, III. 264
regulation of in pulmonary tuberculosis,
I. 1121
Auto-intoxication, I. 386-390
in epilepsy, II. 993
Auto-massage in constipation in adults,
II. 463
Automatism in epilepsy, II. 1005
Auvard's three-bladed cephalotribe in
craniotomy, IV. 410
Axilla, in small-pox, immunity of, I. 303
Axillary artery, excision of, in aneurysm,
I. 1304
cellulitis, I. 183
Azoo'spermia, sterility in, IV. 848
Babes and Vasilin on atoxyl in pellagra, I.
522
Bachman on strophanthus, I. 1223
Bacillary plugs, embolism by, I. 1306
Bacilluria, II. 751
complicating typhoid fever, I. 361
in typhoid fever, I. 346
Bacillus serogenes capsulatus, gangrene
due to, I. 582
coli infections, acute and chronic, III.
272
anti-coli serum in, III. 271
serum therapy in, III. 271-272
vaccine therapy in, III. 271-272
Bacon fat in dietary of children, I. 59
Back (Ivor), circumcision, II. 880-881
diseases of bone, I. 695-712
diseases of the scrotum, II. 900
diseases of the testicle, II. 901-910
extravasation of urine, II. 893-894
fistulas of the urethra, II. 894
injuries of the urethra, II. 882-885
peri-urethral abscess, II. 895-896
stricture of the urethra, II. 886-892
Back, contusions of, I. 898
hot-air apparatus for, III. 323
suction apparatus for, in hyperaeniic
treatment, III. 60
wound of, I. 901
Bacterial decomposition and gout, I. 450
food poisoning, I. 507-510
Bactericidal serum therapy, III. 259
Bacterio-therapeuties of diphtheria, III.
273-279
Bacteriology of puerperal infection, IV.
284
Bacteriolysins in serum therapy, III.
259
Baden-Baden spa, III. 147
Baden- Weiler spa, III. 147
Bagneres de Bigorre spa, III. 148
Bagnoles de 1'Orne spa. III. 148
Bagnoli spa, III. 154
Bagshawe (A. G.) trypanosomiasis, III.
417-422
Bailey, (H. C.), on strophanthus, I. 1222
Bainbridge (S.), on trypsin in cancer, I.
151
Bains-les-Bains spa, III. 148
Balance movements for scoliosis. III. 244
Balanitis. II. 874
Ball (Sir Charles), method of operation for
pruritus ani, II. 597
Ballance's operation in diseases of the
mastoid process, III. 928, 929
10
A SYSTEM OF TREATMENT.
Ballantyne (J. W.), management of
puberty and the menopause, IV. 498-
503
the general management of pregnancy,
IV. 1-13
Balneotherapy in arthritis deformans, I.
397, 439
See also Baths un<1 Mineral Waters.
Balsams, urinary, I. 225
Bandages, after abdominal operations, II.
2(17
for control of haemorrhage, I. 798, 1259
for fractures of lower jaw, I. 87; II.
101
Bandaging in treatment of ulcers, I. 371
value of in shock, I. 97
Banting's treatment of obesity, I. 468, 471
Barbados tar in water itch, III. 486
Bardswell, on diet in tuberculosis, II. 203
Bareges spa, III. 149
Barium, salts of, poisoning by, I. 529
Barker's flushing spoon, use of, I. 175
Barker's solution, injection of, for spinal
analgesia, III. 37
Barley water in infant feeding, IV. 347
preparation of, I. 42
Barr's antipyretic treatment in typhoid
IVver, I. 350
Barwell (Harold), diseases of the crico-
arytenoid joint, III. 823
injuries of the larynx, III. 825-826
injuries and malformations of the nose,
III. 671-677
leprosy of the nose, pharynx, and
larynx, III. 780
lupus of the larynx, III. 838-839
of the pharynx, III. 781
and tuberculosis of the nares, III.
687-688
of the naso-pharynx, III. 742
new growths of the larynx (benign),
III. 846-852
paroxysmal or vasomotor rhinorrhrea,
III. 689-691
perichondritis of the larynx, III. 861-862
stenosis (cicatricial) of the larynx, III.
863-867
tuberculosis of the larynx, III. 870-875
of the pharynx, III. 793-794
Barwell-Lake epiglottis punch, III. 875
Basedow's disease, climate for, III. 99
Bashford (E. F.), on cancer in mice, 1. 132
Basilar meningitis, chronic, I. 253-255
Bath, cabinet light, III. 187
combined double-light, III. 320
douche, III. 127
electric, III. 101
large, for recumbent position in radiant
heat therapy, III. 318
for sitting position in radiant heat
therapy, III. 317
light, III. 187
local light, III. 195
portable limb, for radiant heat therapy,
III. 316
Bath (contd.)
portable trunk in radiant heat therapy,
III. 319
radiant heat, duration of, III. 325
reflector, in radiant heat therapy, III.
321
spa, III. 148
Baths, acid, III. 137
cold, in eclampsia, IV. 37
in impotence, I. 231
reaction to, III. 113
use of, I. 36
continuous, I. 38
creosote, in bronchiectasis, I. 1044
vapour, in pulmonary tuberculosis, I.
1149
effervescent, III. 131
electrical, in chronic synovitis and
arthritis, I. 747
for chlorosis, II. 26
for infants and children, I. 47
for osteo-arthritis, I. 402
general action of, III. 112
hot air, I. 37, III. 128
in atony of the stomach, II. 289
in gouty joints, I. 397, 439
in obesity, I. 470
kinds of, and their uses, III. 124
local hot air, III. 128
local light, III. 194
marine, III. 129, 130
mineral, in diseases of the heart, I.
1210
mud, III. 136
peat, III. 135
sand, III. 136
special in chorea, II. 1263
sub-thermal, III. 113
sulphur, III. 133
superheated air, in gout and gouty
conditions, I. 439
temperature of, I. 36, 38, 47
thermal, III. 124
in arthritis deformans, I. 397
Turkish, in acute gout, contra-indi-
cated, I. 441
value of in children's diseases, I. 69
vapour, III. 129
warm, effect on nervous system, I. 70
Battaglia spa, III. 148
Battle's fbcision in appendicitis, II. 412
Bavarian splint, I. 574
Bayly (H. Wansey), the clinical patho-
logy of syphilis in relation to treat-
ment, I. 325-228
Bazin's disease, III. 1151
Beard, ringworm of, III. 1130
Beatson (Sir O.) on oophorectomy in
mammary cancer, I. 150
Beaunis' method of hypnotism, III.
164
Beckmann's post-nasal curette, III. 734
Bed, confinement to, after abdominal
operations, II. 267
in acute bronchitis, I. 1050
11
A SYSTEM OF TREATMENT.
Bed (contd.')
petition of patient in, after abdominal
operations, II. 266
preparation of for operation, I. 30
Bedclothes, heavy, to be avoided, I. 45
Bedding, disinfection of, I. 162
Bedmaking, instructions as to, I. 30
Bedrooms, disinfection of during and
after contagious complaints, I. 164
Bedsores, avoidance of, I. 157
in myelitis, II. 1218
in paraplegia, II. 1199
prevention of, I. 365
and treatment of, I. 31
in injuries of the spine, I. 910
Bed-wetting, II. 75-77
Beds, double and single, choice of, I. 26
Beef, chemical composition of, II. 192
essence, preparation of, I. 43
inspection of, in the tropics, III. 385
raw, essence, preparation of, I. 42
Beef-tea custard, preparation of, I. 43
peptonised, preparation of, I. 42
salted, as a stimulant, I. 158
Beer in gouty conditions, I. 456
Bell (W. Blair), fistulae of the uterus, IV.
664-668
hermaphroditism and pseudo-herma-
phroditism, IV. 865-867
injuries of the uterus, IV. 707-710
malformations of the uterus, IV. 711-
717
sub-involution of the uterus, IV. 720-724
Belladonna, applications in spinal sprain,
I. 900
dosage of in children's diseases, I. 68
in constipation in adults, II. 446
in epilepsy, II. 998
in exophthalmic goitre, II. 55
in nocturnal enuresis, II. 75
in small-pox, I. 305
in vomiting due to heart failure, I. 200
in whooping cough, I. 381
poisoning by, I. 532
Bell's nerve, injuries of. II. 1112
treatment of spina bifida, I. 912
Bellingham on aortic aneurysm, I. 1297
Belt for gastroptosis, II. 320
for movable kidney, II. 788
use of, after abdominal operations, II.
268
Bennett (Norman C.), dental surgery, III
1164-1194
Bennett (Sir William H.), varicocele I
1323-1327
varicose veins, I. 1309-1322
Benzene compounds, poisoning by treat-
ment of, I. 533
Beraneck's tuberculin, III. 293
Berger's amputation, I. 146
operation, re-section of clavicle, followed
by division of main vessels and nerves
I. 831-834
Bergmann's post - aural operation in
diseases of mastoid process, III. 922-923
Beri-beri, III. 414-416
neuritis in. II. 1139
Berkeley (Comyns), craniotomy, IV. 403-
412
decapitation, IV. 413-415
evisceration, IV. 416
fibroids, IV. 634-663
forceps, IV. 417-432
induction of abortion and premature
labour, IV. 433-445
infusion set for haemorrhage, I. 1264
obstetric operations, IV. 373-374
on connection between leucoplakia
and cancer, I. 119.
spondylotomy, IV. 451
version or turning, IV. 461-473
Berkeley's infusion apparatus, IV. 478
self-containing retractor, IV. 477
table, IV. 480
vaginal clamp, IV. 481
Bernheim's method of hypnotism, III. 164
Berries, chemical composition of, II. 196
Berry (James), affections of the lips, II.
96-98
cleft palate, II. 147-156
harelip, II. 85-95
Besridka, on serum therapy of scarlet
fever, I. 287
Beta-naphthol in ankylostomiasis, III. 492
Bex spa, III. 148
Beyea's operation for gastroptosis, II. 324
Bezold's rnastoid abscess, III. 932
Bicarbonate of Soda. See Soda.
Bier's hyperagmic treatment by means of
cupping glasses, III. 56
by partial vacuum, III. 56
by suction apparatus, III. 56
" heated air," III. 61
in acute abscess, I. 168-182
in whitlow, I. 169
induced hyperasmia, III. 40-68
in infective lesions of scalp, I. 888
in tuberculous joints, I. 751
methods and rules of, III. 43, 45
passive, induced by elastic constriction,
III. 46
Big heel, III. 465
Bigelow's method in dislocations, I. 724
Bile on constipation in adults, II. 454
stagnation of, and cholelithiasis, II.
682
Bile ducts, cancer of, obstruction due to,
I. 143
catarrh of, infective, II. 704
congenital obliteration of, II. 673
croupous inflammation of, II. 702
diseases of, II. 680
fistulas of, II. 699
inflammation of, II. 699-709
injuries of, II. 680
perforation of, II. 707
primary malignant disease of, II. 713
stricture of, II. 706
tumours of, II. 713-715
cystic, II. 713
12
A SYSTEM OF TREATMENT.
Bile (contd.)
typhoid infection of, I. 353
passages, injection of, and choleli-
thiasis, II. 683
wounds of, II. 680
Bilharzia disease, III. 498-500
general treatment in, III. 499
medicinal treatment of, III. 499
preceding carcinoma, I. 119
prophylaxis of, III. 498
Biliousness, effect of chalky water in, II.
345
Binder in third stage of labour, IV. 125
Biniodide solution for actinomycosis, I.
177
Birth, injuries of newborn child, IV. 3(53
marks, III. 1077-1081
paralysis, brachial, II. 1110
Bismuth, carbonate of, in acute gastritis,
II. 352
dressing, ineffective, I. 78
emulsion of, injection into abscess
cavities, I. 176
in achylia, II. 294
in chronic dilatation of the stomach, II.
314
in typhoid fever, I. 354
injection of, in fistulous tracks in
empyema, I. 1110
mixture in vomiting, I. 507, 509
Blacker (G.), menorrhagia and metror-
rhagia, IV. 751-7tU
Blackheads of the auricle, III. 881
Blackwater fever, III. 386-389
local applications in, III. 389
stimulants in, III. 389
use of morphia in, III. 388
Bladder, acquired sacculation of, in
vesical calculus, II. 854, 864
calculus of, II. 852-857
cancer of, II. 871
fistula due to, I. 142
palliative operations for, II. 873
care of, after abdominal operations, II.
264
complications, in gynaecological sur-
gery, IV. 487, 496
control of, in children, I. 53
in typhoid fever, I. 362
diseases of, II. 852
diverticula of, II. 864
ectopia, II. 866
extrophy of, in newborn child, IV. 360
female, calculi in, IV. 733
in supra-pubic cystotomy, IV. 734
diseases of, IV. 868, 875
displacements of, IV. 875
fissure of neck of, IV. 883
foreign bodies in, IV. 875
fistulae of, at the umbilicus in adults, II.
279
in infants, II. 278
gun shot wounds of, I. 566
hydronephrosis due to obstruction in,
II. 772
Bladder (contil.~)
in abdominal operations, II. 259
in gynaecological surgery, IV. 487, 496
inflammation of, complicating typhoid
fever, I. 361
injuries to, II. 252
intestine and, fistulas between, II. 491
papilloma of, single, II. 870
papillomata of, multiple, II. 871
plastic closure of, in ectopia vesicae, II.
866
rupture of, II. 868
after treatment, II. 869
sacculi of, II. 854, 864
separation of, in Wertheim's operation,
IV. (506
sphincter of, troublesome in tabes
dorsalis, II. 1090
weakness in disseminated sclerosis,
II. 1075
tuberculosis of, II. 820, 824
tumours of, I. 119, 120 ; II. 870-873
washing out of, I. 910
wounds of, II. 868-869
Blake's tympanic syringe, III. 912
Bland-Button (J.), actinomycosis of Fallo-
pian tube, IV. 800
cancer of Fallopian tube, IV. 801-803
chorion-epithelioma of F'allopian tube,
IV. 804
diseases and affections of the Fallopian
tubes, IV. 799-823
hernia of the Fallopian tube, IV. 804
hydatids of the broad ligaments, IV.
820-821
inflammation of the Fallopian tube
(salpiugitis), IV. 805-815
papilloma of the Fallopian tube, IV. 816
preventive treatment of salpingitis, IV.
815
thrombosis of the veins of the broad
ligaments, IV. 822-823
tubal pregnancy, IV. 78-88
tuberculous diseases of the Fallopian
tubes (tuberculous salpingitis), IV.
817-819
tumours of the broad ligaments, IV. 823
Blankets, disinfection of, I. 162
Blastomycetic dermatitis, III. 1005
Blepharitis of the eyelids, iii. 577
Blepharospasra, clonic, II. 1047
Blindness, snow, of the conjunctiva, III.
560
Blistering in chorea, II. 1262
Blisters, application of, I. 36
in counter-irritation in rheumatoid
arthritis, I. 405
in iritis, III. 586
in joint affections, I. 748
value of in children's diseases, I. 69
Blondel (Raoul) on lacto serum, I. 1295
Blood, action of arc light bath on, III. 191
anaemia due to actual loss of, II. 18-19
circulation of, effect of massage on, III.
204
13
A SYSTEM OF TREATMENT.
Blood circulation (coittd.')
effect of shock on, I. 94
in Bier's hyperaemic treatment. III.
42
coagulability of, effect of animal serum
on, I. 129
coagulation of, encouragement of, in
haemophilia, II. 32
cont, differential, in pelvic cellulitis,
IV. 826
deficiency of lime salts in, IV. 721
direct transfusion of, in haemorrhage, I.
1269
diseases of, II. 1-45
effusion of in fractures, I. 570
elimination of noxious materials from,
I. 7
in normal puerperium, IV. 258
massage in, III. 207
transfusion of in pellagra, I. 523
See also Transfusion.
Blood cysts of neck, II. 167
Blood-forming organs, diseases of, II.
1-45
Blood mole complicating pregnancy, IV.
59
Blood-pressure, I. 1281-1286
effect of infusion in, I. 98, 102
high, I. 1281
relief for, I. 10
in cerebral compression, I. 880
in gouty subjects, I. 436
influence of shock on, I. 93
low, I. 1284
Blood stasis, torsion-clamp method of in
elephantiasis scroti, III. 509
Blood states, abnormal, cerebral throm-
bosis due to, II. 1179
Blood-vessels, division of in Berger's
operation, I. 831
injuries to large, I. 1030
ligature of, I. 1254
in amputations, I. 801
special, wounds of, I. 1274
Blue light, use of, III. 187
bath, III. 193
pill in gout, I. 432, 436
in gouty complications, I. 443-446
Blumfield (J.), anaesthetics, III. 1-39
Body, causes of loss of natural resistance
to disease in, I. 5
Boeck, multiple benign sarcoid of, III.
1152
Boiling, disinfection by means of, I. 161
sterilisation by, I. 72
of instruments, directions for, I. 27, 30
Boils, ceridine in, III. 1008
complicating diabetes mellitus, I. 425
general treatment of, III. 1007
ionic medication of. III. 184
local treatment of, III. 1009
nuclein in, III. 1008
sulphur in, III. 1007
vaccine treatment of, III. 1008
yeast in, III. 1006
v. Bokay on intubation, III. 804
Bone-grafting in| sarcoma of jaws, II.
115
Bone-marrow in pernicious anaemia, II. 9
Bones, cancer of, spontaneous fractures
in, I. 146
deformities of in children, I. 56
in rickets, I. 481
direct union of, in fracture of the
jaws, II. 102
diseases of, I. 695-712, 756, 772
complicating typhoid fever, I. 363
fracture of, in extraction of teeth, III.
1188
infective lesions of, I. 889
injuries of, I. 568-633
necrosis of following abscess, I. 167, 171
in burns, I. 541
vaccine therapy in, III. 264
sarcoma of, Coley's fluid in. I. 153
section of, I. 800
spread of, I. 124, 711
tuberculosis of, I. 704
tumours of, I. 708
Bonney (Victor), after-treatment and post-
operative complications of gynaeco-
logical surgery, IV. 487-497
carcinoma of body of uterus, IV. 575-
581
the cervix, IV. 582-617
chorio-carcinoma (chorion epithelioma,
deciduous malignum), IV. 618-619
connection between cancer and leuco-
plakia, I. 117
general points in the technique of
gynaecological operations, IV. 474-
486
puerperal infection, IV. 282-323
sarcoma of the uterus, IV. 718-719
Bonney's dissecting forceps, IV. 476, 477
needles, IV. 477
vaginal clamp, IV. 481
Boracic dressings in burns and scalds, I.
541
fomentations in cellulitis, I. 181
Borax in thrush, II. 123
Boric gauze and wool, I. 78
Bormio spa, III. 148
Bossi's dilator in accidental haemorrhage
during pregnancy, IV. 26
metallic dilator in eclampsia, IV. 39
Bottle-feeding of infants, II. 221
Botulism, I. 510
Bouchard, on auto-intoxication, I. 386
Bougie, black elastic oesophageal, II.
172
conical-ended black elastic oesophageal,
II. 172
Eustachian, in patency of Eustachian
tube. III. 949
gum-elastic, in inducing of premature
labour, IV. 437
Schrotter's hollow vulcanite, III. 865
silk web oesophageal, II. 172, 173
sterilisation of, I. 92
14
A SYSTEM OF TREATMENT.
Bourbon-lAchambauld spa, III. 148
Bourbon-Lancy spa. III. 148
Bourbonne-les-Bains spa, III. 148
la Bourboule spa, III. 152
Bowels. Sre. Intestines.
Bow-leg and genu varum, I. 1*62
Bowls and dishes, preparation of, I. 72
Bowman's spoon for cataract, III. 628
Boxwood screw wedges in fibrous anky-
losis of the jaws, II. 106
wedge for fibrous ankylosis of the jaw,
II. 106
Brachial artery, hemorrhage from, I.
1376
birth paralysis, II. 1012, 1110; IV.
365
neuralgia, II. 1121
plexus, injuries of, II. 1012, 1110
Bi aid's method of hypnotism, III. 160, 163
Brain, abscess of, complicating diseases
of the ear, III. 939-941
following head injuries, I. 885
anaemia of, due to shock, I. 94
apoplexy of, II. 1070
compression of, I. 878, 880
concussion of, I. 878
contusion of, I. 878
direct drainage from, in meningitis, I.
252
diseases of, II. 1143
aphasia in. II. 1143-1149
electro-therapeutics in, III. 109
paraplegia in, II. 1195
speech defects in, II. 1143
embolism of, II. 1167
exhaustion of the vasomotor centres in,
I. IK;
gouty conditions of, I. 447
iiunshot injuries of, I. 562
hsemorrhage of, II. 1168-1176
hernia of, II. 1190
injuries of, I. 878-884
oedema of, in injuries of the head, I.
884
palsies of, in infancy, II. 1055-1058,
1153-il5C,
surgical treatment, II. 1059-1066,
1157-1164
syphilis of, headache from, II. 1034
thrombosis of , II. 1177-1180
syphilitic.-. II. 1068
tumours of,
fits in, II. 1202
in children, II. 1068, 1166
intra-cranial, localised, II. 1202. 1203
medical treatment, II. 1200-1203
optic neuritis in, II. 1201
palliative operations in, II. 1204
radical operations in, II. 1205
surgical treatment of. II. 1204-1207
Bramwell's method of hypnotism. 1 1 1 . 1 65
Branchial cysts of neck, II. 167
dermoids, I. 110
fistulas of neck. II. lilt',
Brand cancers of cattle, I. 117
Brandy in collapse and diarrhoea, I. 28. 37.
508
Brawny arm of cancer of breast, treat-
ment of, I. 144
Bread, chemical composition of, II. 195
cleansing of walls by, I. 163
food in diabetes, I. 413
\n diet for gout, I. 454
in dietary of children, I. 59
rye, gangrene from use of, I. 219
Breakfast, abuse of, in dietary of children,
I. 62
Breast, abscess of, II. 958
affections of, in pregnancy, IV. 330-336
in the puerperium, IV. 330-336
atrophic scirrhus of, II. 964
cancer of, after-treatment in radical
operations for, II. 972
age of patient and, II. 965
anaesthetics in operations for, III. 31
axillary dissection in radical operation
for, II. 970
both, II. 965
chronic alcoholism and, II. 966
chronic bronchitis and, II. 966
cirrhosis and, II. 966
complications of, I. 145, 146
diabetes and, II. 966
drainage after radical operation for,
II. 971
dressings after radical operations for,
II. 972
exploration of tumour in, II. 968
incision in radical opera f ion for, II.
969
oophorectomy in, I. 150
operations for, II. 967
palliative operations for, IF. 973
position of patient in radical opera-
tion for, II. 968
pregnancy and. II. 965
preparation of patient for radical
operation for, II. 967
radical operation for, II. 967
radium therapy in, III. 313
recurrent, II. 974
spread of, I. 126
suture of wound after radical opera-
tion for, II. 971
care of, in normal puerperium, IV.
266
chronic abscess of, II. 962
cysts of, II. 952-954
multiple, II., !>.v_>
operation for, 1 1. 953
simple, II. 952
with intra-cystic growths, II. 954
diseases and affections of, II. 952-981
duct papilloma of, II. 954
fever in puerperal sepsis, IV. 315
fibro-adenomata of, II. '.'55
operation for, II. 955
galactocele of, II. 953
hydatid cysts of. II. '.'54
hypertrophy of II. 957
15
A SYSTEM OF TREATMENT.
Breast (
iii normal puerperium, IV. 258
inflammation of, II. 958-962
infra-mammary abscess of, II. 960
malignant disease of, II. 963-975
enlargement of supra - clavicular
glands in, II. 964
indications for operation, II. 963
results of operative treatment, II. 963
management of, in pregnancy, IV. 330
massage of, for painful engorgement,
IV. 332
mastitis of, chronic interstitial, II. 961
chronic lobar, II. 961
neuralgia of, II. 976
operations upon, preparations for, I. 89
painful engorgement of, in the puer-
perium, IV. 331
persistent sinuses of, II. 960
removal of, in malignant disease of, II.
971
sarcoma of, II. 975
suction apparatus for, in hyperasmic
treatment, III. 60
supra-mammary abscess of, II. 960
treatment 'of. when patient is not going
to suckle the infant, IV. 330
tuberculosis of, II. 981
tumours of, operative diagnosis of, II.
979-980
doubtful, II. 979
Breast-feeding, contra-indications to, in
normal puerperium, I V. 269
in normal puerperium, IV. 266
of infants, II. 215
of the new-born child, IV. 340
Breath, chronic foetor of, II. 127
Breathing, children to be instructed as to,
1.49
exercises, III. 227
in pulmonary diseases, III. 249
Brehmer on pulmonary tuberculosis, I.
1121
Brewis, (N. T.), endometritis, IV. 620-631
erosion or adenomatous disease of the
cervix, IV. 632-633
hypertrophy of the cervix, IV. 700-706
Brides les-Bains spa, III. 149
Brides-Salins spas, III. 149
Bridge of Allan spa, III. 149
Bright's disease, acute, II. 796-797
acerbations in, II. 798
chronic, II. 798
decapsulation in, II. 799
epistaxis in, I. 15
in anasmia, II. 17
Brine baths, III. 130
Briscoe (J. C.), Broncho-pneumonia, I.
1066-1073
Broad ligaments, diseases of, IV. 836-839
ribroids of , I V . 653
false, IV. 652
hydatids of, IV. 836-837
tumours of, IV. 839
veins of, thrombosis of, IV. 838-839
Bromide acne, II. 997
Bromides, combinations of, in epilepsy,
II. 996
dosage of, in children's diseases, I. 67
in epilepsy, II. 995
in diseases of the heart, I. 1225
in epilepsy, II. 993
in small-pox, I. 305
Bromine, new preparations of, II. 997
Bromism in epilepsy, II. 994
Bromoform in whooping cough, I. 382
Bronchi, diseases of, I. 1035-1075
empyema ruptured into, I. 1106
foreign bodies in, abscess due to, I.
1061
Bronchial catarrh, complicating influenza,
I. 239
Bronchiectasis, I. 1043-1048
methods of treatment of, I. 1047
surgical treatment of, I. 1048
Bronchiectatic cavities of the lung, I.
1061
Bronchitis, I. 1049-1058
acute, general measures, I. 1050
chronic, 1. 1054-1058
climatic treatment of, I. 1055
complicating cancer of the breast, II.
966
general measures in, I. 1054
medicinal treatment of, I. 1056
physical exercises in, III. 251
vaccine treatment of, I. 1056
complicating gynecological surgery,
IV. 494
whooping cough. I. 378, 384
in injuries of the spine, I. 909
in measles, I. 245
in myelitis, II. 1216
medicinal measures in, I. 1051
peculiar forms of, I. 1058
plastic, I. 1058
putrid, I. 1058
sicca, I. 1058
sub-acute, I. 1053
Broncho-pneumonia, I. 1066-1073
complicating gynaecological surgery,
IV. 494
small-pox, I. 308
diet in, I. 1068
drugs in, I. 1068
general management in, I. 1066
special symptoms in early stages of, I.
1069
treatment in the later stages of, I.
1070
Bronchorrhoea serosa, I. 1058
Bronchoscope, Briinings, III. 810
introduction of, in foreign bodies in the
air passages, III. 816
Bronchoscopy, description of, III. 803-821
Brophy's operation in cleft palate, II.
149
Broths for young children, I. 58
Brow presentation, forceps in, IV. 422
in labour, IV. 137-139
16
A SYSTEM OF TREATMENT.
Brown (W. Carnegie), ankylostomasis
(uncinariasis, hookworm disease), III.
487-482
ascariasis. oxyuriasis and trichocephalis,
III. 493-497
dracontiasis (infection by guinea-worm,
filaria medinensis), III. 501-502
leprosy, III. 447-453
oriental sore, III. 454-456
sprue. III. 442-446
hvniusis, intestinal, III. 517-520
trichiniasis (trichinosis, trichiuelliasis),
III. 524-527
uln-rating granuloma of the pudenda,
III. 457-458
yaws (fnmibcKsia tropica), III. 4<U
Brace (J. Mitchell), principles of treat-
ment. 1. 1-25
Bruce (W. Ironside), X-ray treatment of
diseases other than skin diseases,
111. 360-368
Briinings bronchoscope, III. 806
dilatable bronchoscope, description of,
III. 810
direct laryngoscope, III. 849
forceps, description of, III. 808
hand lamp, description of, III. 810
cesophagoscope for foreign bodies in the
oesophagus, II. 187
Brunton (Sir T. L.), on arterio-sclerosis,
I. 12114
Bryant's splint, I. 617
suspension apparatus for fractures of
femur, I. 616
Bubo, climatic, III. 467
parotid, II. 131
plague, III. 405
suppurating, complicating chancre, I.
3i:>
Buckley (Charles W.), rheumatism
(chronic), I. 483-491
(muscular), I. 492-494
Budd on incidence of gout, 1. 448
Bulbar palsy, II. 1061
acute, II., 1061
progressive, II. 1061
Buller's shield for gonorrhoeal ophthalmia
in the adult, III. 555
Bullet wounds. See Wounds, gunshot.
Burns, continuous baths for, I. 38
scars of, the seat of carcinoma, I. 117
and injuries by electricity, I. 547-549
and scalds, I. 540-544
general treatment of, I. 543
immediate treatment of, I. 540
local treatment of the burnt areas in,
1. 540
and treatment of contractions, I. 543
of the conjunctiva, III. 547
of the external ear, III. 888
of the oesophagus, II. 188
Burrows' solution in erysipelas, I. 210
Bursse and cysts in association with
arthritis, I. 749-750
chronic rheumatism of, I. 484
Bursae (fontd.~)
diseases of, IL 1334-1335
prepatellar, chronic bursitisof, II. 1334
.wounds of, II. 1335
Bursal cyst of neck, II. 168
Bursitis." acute, II. 1334
chronic simple, II. 1334
syphilitic, II. 1335
tuberculous, II. 1335
Bury (Jndson S.), acute anterior polio-
myelitis, II. 1055-1058
facial paralysis, II. 1093-1095
Butlin (Sir H. T.) on mortality from
operations on jaws, II. 117
on operations on the tongue, II. 140,
143
Butyl chloral in infantile diseases, I. 67
Buxton spa, III. 149
Buzzard (E. Farquhar), caisson disease,
II. 1208-1209
cerebro-spinal syphilis, II. 1063-1069
general paralysis of the insane, II. 1077^
1080
haematomyelia, II. 1210-1211
hemiplegia, II. 1181-1190
myelitis, II. 1212-1218
Cachexia, relief of in inoperable cancer, I.
132
saturnine, in lead poisoning, I. 514
strumipriva complicating operation for
goitre, II. 70
Caecal region, growths in, excision of, II.
580
Caecostomy for cancer of the colon, II.
584
in chronic mucous colitis, II. 571
valvular, in chronic mucous colitis, II.
571, 573
Caecum, cancer of, relief of obstruction in,
I. 141
Caesarean hysterectomy, IV. 398-402
mortality from, IV. 401
operation of, IV. 399
operation for contracted pelvis, table of
mortality of, IV. 402
section. IV. 382-398
abdominal, in eclampsia, IV. 40
incision in, IV. 387
after-treatment of, IV. 396
ethical standpoint of, IV. 394
extraction of child in, IV. 390
extra-peritoneal, IV. 397
in accidental haemorrhage during
pregnancy, IV. 25
in contracted pelvis, IV. 383
complicating labour, IV. 170, 171
in eclampsia, IV. 384
in libro-myomata of the uterus, IV.
384
in ovarian tumours, IV. 384
in placenta praevia, IV. 385
mortality from, IV. 401
17
A SYSTEM OF TREATMENT.
Caesarean section (contd)
preparation of patient in, IV. 385
removal of placenta in, IV. 391
repeated, danger of, IV. 395
sterilisation in, IV. 394, 396
stitching the uterus in, IV. 391
time of operating in, IV. 386
uterine incision in, IV. 388
vaginal, for inducing abortion, IV.
437
in forcible methods of delivery,
IV. 444
Caffeine citrate for relief of pain, I. 134
in diseases of the heart, 1. 1227
in influenza, I. 233
Caigrer (F. Foord) and H. E. Cuff, diph-
theria, I. 187-202
general treatment of infectious diseases,
I. 157-160
scarlet fever, I. 281-294
typhus fever, I. 365-367
^Caisson disease, 1. 1306 ; II. 1208-1209
preventive measures, II. 1208
remedial measures, II. 1208
Calabar bean, poisoning by, I. 533
Calcareous deposits of the tympanic
membrane, III. 892
waters, III. 120
Calcium chloride in haemorrhage, I. 1261
lactate in acute alcoholism, I. 495
in haemophilia, II. 34
in haemorrhage, I. 1261
permanganate of in lead colic, I. 513
Calculous disease, diet in, II. 207
Calculus, II. 753-766
anuria in, II. 755
operations for, II. 757
bilateral renal, II. 765
in a solitary kidney, II. 766
nephrectomy for, II. 765, 779
pancreatic, II. 724-725
prophylactic treatment, II. 753
prostatic, II. 918
complicating prostatic adenoma, II.
945
renal, cases unsuitable for operation, II.
758
colic and, II. 755
haematuria and, II. 755
hydronephrosis with, II. 773
nephrolithotomy for, II. 759, 764
operative treatment of, II. 758
pyelolithotomy for, II. 763, 764
salivary impacted, causing simple paro-
titis, II. 157
and inflammation of parotid gland,
II. 159
ureteral, II. 846-851
vesical, II. 852-857
in female bladder, IV. 876
litholapaxy in, II. 854, 855
median perineal lithotomy for, II.
856
mineral waters and baths in, III. 140
operations for, II. 854
18
Calculus vesical (contd.~)
preventive treatment of, II. 853
removal of through urethra, IV. 876
supra-pubic lithotomy for, II. 856
Callard diabetic food, I. 414, 418, 421
flour, I. 421
Callus, formation of, massage and, I.
579
Calomel in acute gastritis, II. 347
in acute gout, I. 432
in acute rheumatism, I. 270
in amoebic dysentery, III. 432
in syphilis. I. 318
in typhoid fever, I. 353
Caloric value of foods, II. 198
table of values, II. 198
Calvities or alopecia seborrhoica, III.
1001
Cameron (Samuel J.), amenorrhcea and
scanty menstruation, IV. 725-735
Camphor, compound tincture of, use of,
I. 245
in chronic congestion of the lungs, I.
1079
liniment in bronchitis, I. 245
Cancer a deux, I. 120
aetiology of, I. 116-119
alder leaves in, I. 149
and anaemia, II. 16
atoxyl in, I. 149
cataphoresis in, I. 153
chronic irritation as a cause, I. 118
Coley's fluid in, I. 152
diagnosis of, I. 121
drug treatment of, I. 148
electrical methods in, I. 153
exploratory incision in, I. 121
ferments in treatment of, I. 151
fulguration in, I. 154
gastric, II. 296-301
general principles of treatment of, I.
116-156
haemorrhage from stomach in, II. 329
infection of, I. 120
inoperable, treatment of, by control of
discharge, haemorrhage and ulcera
tion, I. 136
by empirical remedies, I. 147
by palliative removal of growth, I.
131
by relief of cachexia, I. 132
by relief of obstructions, I. 138
by relief of pain, I. 133
by relief of special symptoms, I. 144
by vaccines, I. 133
irradiation in, I. 155
Keith methods in, I. 149
local infection in same individual, I.
120
lymphatic permeation of, I. 125
mammary, spread of, I. 126
metastatic growths of, I. 124
of alimentary system, I. 139-142
of ampulla of Vater, II. 714
of biliary passages, I. 143
A SYSTEM OF TREATMENT.
Cancer (contd.)
of bladder, II. 871
of bones of the skull, I. 895
of both breasts, II. 9G5
of cervix uteri, IV. 567, 582 617
of colon, II. 578-584
of corpus uteri, leucorrhcea in, IV. 570
of female urethra, IV. 872
of Fallopian tube, IV. 801-803
of glands, I. 1350
of jaws, II. 112
mortality of, II. 117
of pancreas, II. 729
of prostate, II. 933
of respiratory organs, I. 142
of tongue, operative treatment, II. 141-
144
of urinary organs, I. 142
of uterus, IV. 570, 575-581
oophorectomy in, I. 150
operability of, I. 122
operations on, complications of, I. 128
organo-therapy in, I. 149
pain in, relief of, I. 133
pathological anatomy of, I. 123
placental extract in, I. 150
post-operative treatment of, I. 129
pre-cancerous conditions, I. 116-119
preventive treatment of, I. 116-121
primary, of the vagina. IV. 553
radical treatment of operable, I. 123
radium in, I. 155
recurrence of, I. 123
secondary of the umbilicus, II. 281
serum treatment of. I. 152
soamin in, I. 149
sijuamous cell, eczema preceding, I. 117
ovarian dermoids the seat of, I. 110
synthetic preparations in, I. 149
thymus extract in, 1. 150
thyroid extract in, I. 150
vaccine therapy of, 1. 152
vegetable preparations for, I. 148
violet leaves in, I. 149
X-ray treatment in inoperable, I. 155
Cancer-cell injection of operation area in
vaginal hysterectomy, IV. 600
Cancer-cells, growth of, inhibition of, I.
129
Cancer-houses, I. 120
Cancroin, valueless, I. 152
Cancrum oris, II. 124-125
complicating measles, I. 247
typhoid fever, I. 357
and noma, gangrenous, I. 219
Canines, lower, extraction of, III. 1183
upper, extraction of, 1181
Cannula for venous infusion, subcutaneous,
IV. 222
Cantharides plasters in counter-irritation
for rheumatoid arthritis, I. 405
poisoning by, treatment of, I. 532
Cantlie (James), abscess of the liver,
surgical aspects of, II. 648-656
Capsule forceps for cataract, III. 626
Caraate or piiita, III. 477
Carbohydrates, digestion of, II. 191
effect in rickets, 1. 479, 481
food-tables, showing percentages of, I.
411, 419
foods arranged in order of value in, 1 1.
197
in diabetes mellitus, I. 422
in dietetics, II. 201
in typhoid fever, I. 342
Carbolic acid antiseptic in typhoid fever,
I. S51, 354
in pruritis, III. 1098
in ulcer of the cornea, III. 565
in whooping cough, I. 382
poisoning by, I. 527
sterilisation with, I. 72
fomentations, gangrene following, I.
168, 170
gauze and wool, I. 78
Carbon dioxide in port-wine stains, III.
1078
poisoning, I. 534
solid, in lupus erythematosus, III.
1071
rodent ulcer treated by, I. 115
in warts, III. 1157
snow in small capillary naevi, III.
1078
monoxide poisoning, I. 534
Carbonic acid poisoning, I. 534
Carbuncles, I. 888 ; III. 1012-1014
complicating diabetes mellitus, I. 425
general treatment of, III. 406, 1012
in plague, III. 406
ionic medication of, III. 184
local treatment of, III. 1013
vaccine treatment of, III. 1013
Carcinoma. See Cancer.
Garden's operation, I. 862
Cardio-vascular disease in insomnia, II.
1019
Cardiolysis in pericarditis, I. 1189
Cardiospasm of the stomach, II. 357
Carlsbad water in acute gastritis, II. 347,
352
Carneous mole complicating pregnancy,
IV. 59
Carpets, disinfection of, I. 162
in sick room, cleansing of, I. 26
use of in nursery, I. 44
Capillary haemorrhage, I. 1272
Carotid artery, common, excision of, in
aneurysm, 1. 1303
wounds of, I. 1274
external, excision of, in aneurysm, I.
1303
wounds of, I. 1274
internal, excision of, in aneurysm, I.
1303
wounds of, I. 1274
Carpus, fractures of, I. 604
Carr (J. Walter), whooping cough, I. 376-
385
' Carriers " of disease, I. 336
19 22
A SYSTEM OF TREATMENT.
" Carrion's fever," III. 459
Carr's splint, I. 603
Carton's catheter, IV. 115
Caruncle of the female urethra, IV. 872
vascular, of the meatus urinarius, IV.
512
Cascara sagrada in constipation in adults,
II. 448
Caseation in tuberculous disease of the
knee-joint, I. 768
Castellammare spa, III. 149
Castor oil enema, I. 32
in constipation in adults, II. 448
Cataphoresis in arthritis and synovitis, I.
746
in cancer, 1. 153
in gout and gouty conditions, I. 441
Cataract, III. 607-641
after-, III. 634
complicated capsular opacities, III.
637
simple capsular opacities, III. 634
complete milky, III. 608
complicated, III. 641
complications by presentation of
vitreous humour, III. 628
extracting, bandages for eyes after, III.
631
immature, Smith's operation for, III.
621
juvenile, III. 607
lamellar, III. 608
curette evacuation of lens in, III. 613
discission of the lens in, III. 611
linear extraction of lens in, III. 613
operative treatment of lens in, III. 611
mature, delivery of the lens in, III. 626
general treatment, III. 633
iridectomy for, III. 624
operations for, III. 622
anfesthetic in, III. 622
position of patient and surgeon in,
III. 623
post -operative treatment of, III. 630
preparation of patient in operation
for, III. 622
solutions for use in, III. 623
preliminary iridectomy in, III. 619
refraction and, III. 618
secondary, III. 641
senile, III. 615
ante-operative treatment, III. 616
artificial maturation of, III. 620
immature, operations to extract, III.
620
monocular, III. 615
shrunken malformed lenses in, III 607
toilet after. III. 627
traumatic, III. 638
Catarrh, avoidance of in infants and
children, I. 46, 52
chronic endo-cervical in nulliparse, IV.
566
conjunctival, III. 551
gastric, alkalies in, I. 64
Catarrh, gastric (contd.)
diet in, II. 209
or acute indigestion, I. 506-507
mineral waters and baths in, III. 143
nasal, in young children, I. 49
naso-pharyngeal, III. 739-741
of upper air passages, climate for, III.
101
pituitous, I. 1058
spring, of the conjunctiva, III. 560
Catgut ligatures, sterilisation of, I. 72
suture, continuous, in operation for
inguinal hernia, II. 506
Cathcart (George C.), stammering, III.
327-330
voice production, III. 331-340
Catheter, Carton's, IV. 115
Eustachian, for patency of Eustachian
tube, III. 948
for nasal feeding, I. 33
for rectal feeding, I. 29
Jacques's, in cancer of the stomach, II.
306
passing of, I. 40
in females, I. 40
sterilisation of, I. 92, 909
ureteral, drainage by in pyonephrosis.
II. 815
Caton, on cardiac lesions in rheumatism,
I. 278
Cattle, cancer in, I. 117
Caustic alkalies, poisoning by, I. 527
fluids, injuries to stomach by, II. 284
Caustics in cancer, I. 148
of cervix, IV. 616
Cauterets spa, III. 149
Cauterisation in cancer of cervix, IV. 615
in lupus, III. 1149
of granulations in chronic inflammation
of the middle ear, III. 908
Cautery, galvano, in haemorrhage, I. 1258,
1260
in haemorrhoids, II. 619
Cautley (Edmund), hypertrophic stenosis
of the pylorus, II. 337-341
laryngeal spasm in children, III. 827-
830
night terrors, II. 1036-1037
rickets, I. 478-482
tetany in children, II. 1272-1273
Cavernositis, II. 874
Cellulitis, axillary, I. 183
causes of, L 181
cervical, complicating scarlet fever, I.
290
chronic atrophic form of, IV. 851
complicating gynecological surgery, IV.
493
constitutional treatment of, I. 182
Lud wig's angina, I. 183
of the orbit, III. 661
pelvic, IV. 322-838
abscess cavities in, drainage of, IV. 832
anti-streptococcus serum in, IV. 833
diseases of pelvic bones in, IV. 836
20
A SYSTEM OF TREATMENT.
Cellulitis, pelvic (contd.')
inflammation virulent in, IV. 847
moderate acute infection in, IV.
827
parametritis, chronic in, IV. 834
remote in, IV. 833
summary of treatment, IV. 837
suppuration in, IV. 828
vaccine treatment of, IV. 837
Centanni's method in rabies, I. 265
Cephalhsematoma of newborn child, IV.
363
Cephalhsematomata on head, injuries in
the infar.t, I. S8C>
Cephalotribe, Auvard's three-bladed in
craniotomy, IV. 408, 411
difficulties of, IV. 409
in craniotomy, IV. 408, 409
merits of, IV. 410
Cerebellum, diseases of, in children, II.
1168-1166
disorders of, II. 1246
Cerebro spinal fluid, escape of, in spina
bifida, I. 913
meningitis, I. 250
paraplegia, II. 1196
Ceresole-Reale spa, III. 149
Ceridine in boils, III. 1008
Cerumen, hypersecretion of, in the meatus,
III. 884
Cervical auricle, III. 876
forceps for post-partum haemorrhage,
IV. 221
Cervix uteri, acetone applied after
curetting, I. 137
adenomatous disease of, IV. 632-633
amputation of, in prolapse of uterus,
IV. 1!)4, 199. 695
atresia of. IV. 158, 712
complicating labour, IV. 158
cancer of, IV. 582-617
acetone in, IV. 616
appearance of early, IV. 585
caustics for, IV. 616
cauterisation in, IV. 615
complicating labour, IV. 160
curative treatment, IV. 584
differential diagnosis in, IV. 589
early diagnosis in, IV. 584
fibroids of, IV. 159
fulguration in, IV. 617
leucorrhoea in, IV. 567
ligature of arteries in, 1. 13(5
operative cure of, IV. 591
palliative treatment, IV. til")
preventive treatment, IV. 582
radical abdominal operation in, IV.
601
radical hystero-vaginectomy in, IV.
till
radium in, IV. 615
relief of symptoms in, IV. 617
retardation of growth in, IV. 615
signs established in, IV. 587
symptoms of. IV. .">s.~>
Cervix, cancer of (contd.~)
total abdominal hysterectomy in, IV.
600
vaginal hysterectomy in, IV. 593
after-treatment, IV. 596
technique of operation, IV. 593
Wertheim's operation in, IV. 601
congenital hypertrophy of, IV. 716
conical, IV. 713-716
dilatation of, in dysmenorrhoea, IV. 762
in forcible methods of delivery, IV.
442
in induction of premature labour,
IV. 439
in sterility, IV. 854
endometritis of, IV. 627
erosion of, IV. 632-633
fibroid of, anterior, hysterectomy in,
IV. 651
central, hysterectomy for, IV. 648
polypus of, IV. 658
posterior, hysterectomy for, IV. 652
gonorrhoea of, leucorrhoea in, IV. 566
hypertrophy of, IV. 700-706
incision of, in eclampsia, IV. 40
incomplete removal of, in vaginal
hysterectomy. IV. 600
inflammation of, acute, leucorrhoea in,
IV. 566
chronic, leucorrhoea in, IV. 566
injuries of. IV. 707
laceration of, severe, IV. 189
sterility in, IV. 857
leucorrhrea from, IV. 566
mucous polypi of, IV. 567, 662
podalic version in, IV. 468
rigidity of, IV. 159
stenosis of, IV. 715
supra-vaginal portion, hypertrophy of,
IV. 703, 705
vaginal portion, amputation of in endo-
metritis, IV. 630 ; hypertrophy of,
IV. 700, 701
Chalazia of the eyelids, III. 578
Chalybeate waters, III. 122
in chlorosis, II. 26
Championniere (Lucas), on massage in
fractures, I. 578
on fractures of clavicle, I. .~>S t
Chancre, syphilitic, I. 316
of the tongue, II. 134
soft, I. 315
Chantemesse'sserum in typhoid fever, 1. 347
Chapman on diet in tuberculosis, II. 203
Chappa, III. 466
Charcot's disease of joints, I. 785
Charles (Sir R. H.), elephantiasis scroti,
III. 504-516
sunstroke, I. 53ii-.r>3'.i
Charwomen's dermatitis, III. 1030
Chatel Guyon spa, III. 1411
Chaulmoogra oil in leprosy. III. 44!i
Cheatle (G. L.), on extension of rodent
ulcers, I. 123
surgical technique, I. 71-92
21
A SYSTEM OF TREATMENT.
Cheese, chemical composition of, II. 194
Cheiropompholyx, III. 1015-1016
Cheloid or acne cheloid, III. 1018
Cheloids, causes and treatment of, I. 113
of the scalp, I. 893
" Chelsea Pensioner," in rheumatism, I.
490
Cheltenham spa, III. 149
Chemotherapy, general principles of, III.
417
Chest,
-clapping exercise in pulmonary diseases,
III. 252
contusions of, I. 1025
deformities of, due to incorrect breath-
ing, I. 50
empyema following injury to, I. 1027
generalised in the lower part of, I.
1101
expansion exercises for spinal curva-
tures, III. 237
foreign bodies in, I. 1027
injuries of the contents of, I. 1028-1031
new growths of, I. 1034
penetrating gunshot wounds of, I. 564
stab wounds of, II. 253
voice production and, III. 333
wounds of, I. 1025-1028
Cheyne's (Sir Watson), operation for mal-
formation of the nose, III. 674
Chian turpentine in cancer, I. 148
Chianciano spa, III. 149
Chicken-pox, malignant form of, I. 185
prophylaxis of, I. 186
treatment of, I. 186
Chilblains, III. 1019-1020
Child, newborn. See Infants.
Children, acute appendicitis in, II. 405
bronchitis in, I. 1052
rheumatism in, I. 268, 271
ailing, anaemia in, II. 14
antiflexion of uterus in, IV. 670
asthma in, I. 1041
baths for, directions as to, I. 47
brain tumours in, II. 1166
care of, I. 44-70
the digestion in, I. 45
the feet in, I. 57
cerebellar conditions in, II. 1165-1166
clothing of, directions as to, I. 50 ; IV.
339
colic in, II. 428-431
constipation in, II. 432-438
centra-indications to excisions in, I.
770
control of the bladder and bowels in,
I. 53
cookery for, directions for, I. 59
deafness in, causes of, III. 979
educational treatment of, III. 981
surgical treatment of, III. 980
diarrhceal diseases of, II. 471-478
dietary suitable for, I. 58-81 ; II. 202
digestive system of, derangements of,
causes of, I. 64
Children (contd.~)
diseases of, external applications in, I.
69
dosage of medicines for, I. 66
^exercises for, I. 51, 57
fat, not always healthy, I. 59
fatigue in, to be avoided, I. 56
foreign bodies in the ear of, III. 889
gonorrhoeal salpingitis in, IV. 807
" hardening " of, danger of, I. 46, 50
hip joint, disease in, I. 754
hygiene of, I. 44-70
laryngeal spasm in, III. 827-830
management of, during anaesthetics,
III. 25
multiple papillomata in, III. 851
muscular atrophy in, family form of,
II. 1247
ponos in, III. 440
postures of, I. 56
premature, treatment of, IV. 372
pyelitis in, II. 805
rest for, I. 56
rheumatism in, I. 276-279
sleep of, amount required, I. 54
tetany in, II. 1272-1273
tumours of the kidney in, II. 836
vulvitis in, IV. 560
vulvo-vaginitis in, IV. 528, 560
See also Infants.
Chill, avoidance of, after baths and packs,
I. 38
in infants and children, I. 46, 50, 52,
53
and food fever, II. 236
Chinosol in syphilitic ulcers, II. 136
Chittenden on food values, I. 450
on over-nutrition, I. 451
Chittenden's diet tables, II. 200
Chloasma, III. 1017
Chloral in diseases of the heart, I.
1225
hydrate in asthma, I. 1040
in epilepsy, II. 996
in restlessness of fever, I. 244
poisoning, treatment of, I. 530
use of, in diseases of children, I. 67
in morphinism, I. 518
Chloralamide in insomnia, I. 366
of scarlet fever, I. 286
in simple insomnia, I. 159
Chloretone in children's diseases, I. 67
Chloride in opacity of the cornea, III.
572
of sodium, ionisation with, I. 488
Chlorine in typhoid fever, 1. 354
ions, III. 184
solution, mouth wash of, I. 285
Chloroform, anaesthetic mixtures with,
III. 19
as anaesthetic, III. 13
in convulsions, I. 292
in eclampsia, IV. 36
inhalation of, in aortic aneurysm, I.
1299
22
A SYSTEM OF TREATMENT.
Chloroform (contd.)
Junker's inhaler for administration of,
III. 16
poisoning, delayed, in fatty liver, II.
669
treatment of, I. 531
Chloroma of the bones of the skull, I. 895
Chlorosis, II. 20-31
arsenic in. II. 27
baths for, II. 26
chalybeate waters in, II. 26
constipation in, II. 30
diet in, II. 29
digitalis in, II. 27
emetics in, II. 28
general principles in, II. 20, 30
intestinal antiseptics in, II. 28
iron preparations in, II. 21
manganese in. II. 27
marriage and, II. 31
mineral waters and baths in, III. 143
organic iron compounds in, II. 24
quinine in, II. 27
rest in, II. 20
salt in, restricted, II. 28
scale preparations in, II. 24
spas for, II. 26
sulphur in, II. 27
sunshine in, II. 20
theocin-sodium acetate in, II. 27
wines in, II. 25
Cholangiostomy, intrahepatic, I. 144
Chlorotic thrombosis, I. 1331
Cholangitis. II. 701
infective, II. 704
suppurative, II. 705
Cholecyst-enterostomy in biliary cancer,
I. 143
in cholelithiasis, II. 694, 695
Cholecystitis, catarrhal, II. 700
obliterative, II. 701
phlegmonons, acute, II. 704
Cholecystostomy in biliary cancer, I. 143
for cholelithiasis, II. 686, 693
.Cholelithiasis, II. 682-685
after treatment, II. 695
biliary colic in, II. 684
cholecystenterostomy in, II. 694, 695
cholecystotomy for, II. 686, 693
cholelithotrity and, II. 695
diet in, II. 683
enlargement of the pancreas and, II.
694
general treatment, II. 682
intermittent hepatic fever in, II. 684
intervisceral fistula and, II. 695
malignant disease and, II. 695
prophylaxis of, II. 682
spa treatment of, II. 683
surgical treatment of, II. 686-697
Cholelithotrity and cholelithiasis, II. 695
Cholera, III. 423-427
anti-choleraic vaccination of, III. 423
convalescence in, III. 427
diseases of the intesiines in, III. I.'."
Cholera (contd.}
personal hygiene in, III. 424
prophylactic measures in, III. 423
stage of collapse in, III. 426
invasion in, III. 425
reaction in, III. 427
treatment of an attack of, III. 425
diarrhoea in, III. 425
discharges in, III. 427
vaccine therapy in, III. 273
Cholesteatoma, III. 934
Chondrodystrophia fatalis, II. 1227
Chondroma of the scalp, I. 893
Chopart's disarticulation at the mid-
tarsal joint, I. 840
operation, comments on, I. 842
disarticulation in, I. 842
flaps in, I. 842
incision in, I. 842
indications for, I. 840
superficial landmarks in, I. 841
Chordee and painful erections of the
penis complicating gonorrhosa, 1. 226
Chorea, II. 1257-1263
blistering in, II. 1262
care of the bowels in, II. 1261
convalescence of, II. 1262
diet in, II. 1261
Huntingdon's, II. 1249
hypnotism in case of, III. 174
in children, ergot in, I. 68
massage in, II. 1263
medicinal measures in, II. 1257
nursing in, II. 1262
rest in, II. 1260
spa treatment in, II. 1263
special baths in, II. 1263
Chorea gravidarum. complicating preg-
nancy, IV. 51
Chorio-carcinoma of the uterus, IV. 618-
619
Chorion-epithelioma of Fallopian tube, IV.
804
of the uterus, IV. 618-619
Choroid, diseases of, III. 597
rupture of, III. 597
tumours of, III. 597
Choroiditis, III. 597
Chromidrosis, or coloured sweating, III.
1021
Chrysarobin in alopecia areata, III. 995
in psoriasis, III. 1117
Chyluria in tilariasis. III. 503
(non-parasitic), II. 752
Cicatricial oedema of larynx, III. 863-876
Cicatrix. formation, after amputation, I.
793, 795
Cider in gout, I. 467
Ciliary body, diseases of, III. 583, 592-
596
inflammation of, III. 592
vitreous opacities in, III. 593
paracentesis of anterior chamber, III.
593
tumours of, III. 596
23
A SYSTEM OF TREATMENT.
Cinchona in alcoholism, I. 501
Circulation, disorders of, Zander treatment
in, III. 371
enfeebled, cerebral thrombosis due to,
II. 1178
in tra- cranial venous, vascular tumours
in communication with, I. 894
Circulatory system, diseases of, climate
for, III. 97
electro-therapeutics in, III. 109
massage and the, III. 209
Circumcision, II. 880-881
Circumflex nerve, injuries of, II. 1111
Cirrhosis hepatic, II. 631
Citrated milk, II. 225
Citrates in influenza, I, 223
Clamp for haemorrhoids, II. 619
Clarke (Ernest), errors of refraction and
accommodation, III. 528-542
Claudication, intermittent, II. 1234-1236
serum treatment of, II. 1235
Claustrophobia in psychasthenia, II. 1044
Clavicle, dislocation of, I. 714
fractures of, I. 583, 680
in newborn child, IV. 354, 366
resection of in Berger's operation, I.
831
Cleaves (Margaret), on "light energy,"
III. 191
Cleft palate, II. 147-156
Cleidotomy in contracted pelvis compli-
cating labour, IV. 171
in craniotomy, IV. 412
Climate, conditions unfavourable for
abdominal operations, II. 257
diseases induced by, I. 5
effect of, in dietetics, II. 200
for anaemia, III. 92
for arthritis deformans, I. 392
for asthma, I. 1037
for Basedow's disease, III. 99
for catarrh of upper air passages, III.
101
for diabetes, III. 96
for diseases of the circulatory system,
III. 97
of digestive system, II. 351 ; III.
98
of the heart, III. 97
of the kidney, III. 101
for exophthalmic goitre, III. 99
for gout, III. 93
for Graves's disease, III. 99
for nervous ailments, III. 99
for obesity, III. 92
for rheumatism, III. 94
for rheumatoid conditions, III. 94
for rickets, III. 96
for tuberculosis, III. 100
in atony of the stomach, II. 289
in chronic bronchitis, I. 1055
in exophthalmic goitre, II. 56
in gastric disorders, II. 351, 354, 360
in gout and gouty conditions, I. 460
in liypertrophic emphysema, I. 1083
Climate (contd.)
of tropics, adaptation of habits to, III.
376
pulmonary tuberculosis and, I. 1118
Climates, classification of, III. 85
tropical, varieties of, III. 375
warm, diseases of, III. 375-516
where heat demand is large, III. 88
is medium, III. 87
is small, III. 86
See also Tropical diseases, and Tropics.
Climatic bubo, III. 467
demand, law of, in climatology, III. 71
Climatology, III. 69-102
climatic requirements in disease and,
III. 91
law of climatic demand in, III. 71
individual response in, III. 78
local requirement in, III. 83
Clinical phenomena of disease, I. 15
Clitoris, hypertrophy of, IV. 514
Clothing, disinfection of, I. 161
during pregnancy, IV. 8
faulty, in spinal curvatures, III. 236
for infants ano! children, I. 50 ; JV. 339
in abdominal operations, II. 260
in arthritis deformans, I. 393
in chronic bronchitis, I. 1055
rheumatism, I. 485
in rickets, I. 478-
in the tropics, III. 377
Clover's crutch for retained placenta, IV.
232
in lacerations of the genital tract, IV. 188
inhaler, Hewitt's modification of, III. 7
Club-foot, bar on outside edge of sole and
inside brace for, I. 954
case of neglected, I. 956
congenital, I. 951
shoe, I. 953
Coagulation, locally, encouragement of,
in haemophilia, II. 32
Coal-tar derivatives in typhoid fever, I. 352
Cocaine in whooping cough, I. 311
poisoning by, I. 532 ,
Cocainisation, for foreign bodies in air
passages, III. 816
Cocainism, I. 505, 532
Coccydynia or coccygovynia, I. 900, 921
Coccyx, contusions of, I. 900
fracture of, I. 608
Cochlea, removal of, operation for, III
973-974
Cocoa, chemical composition of, II. 197
in typhoid fever, I. 343
Codeine in constipation in adults, II. 446
in diabetes insipidus, I. 429
mellitus, I. 424
Cod-liver oil, dosage of, for children, I. 66
in rickets, I. 479
inunction of, I. 70
Cceliac disease, II. 426-427
Coffee as antidote in poisoning, I. 530,
532, 534
in typhoid fever, I. 343
A SYSTEM OF TREATMENT.
Coin catchers, II. 185
Colchiciiie pills in gout, I. 433, 4:'..",
poisoning by, treatment of, I. 533
Colchicum in gout, I. 433, 435
poisoning by, I. 533
Cold, exposure to, cause of rheumatism, I.
277, 279, 484
in haemorrhage, I. 1260
in sprains, I. 737
protection from, necessary to young
children, I. 50
Cold baths for children, directions as to,
I. 47
in eclampsia, IV. 37
in typhoid fever, I. 348
use of, I. 36
pack in cutaneous inelasticity, I. 69
use of, I. 37
sponging in fever, I. 244
in hyperpyrexia, I. 160
Colds. See Catarrh.
Colectomy in constipation in adults, II. 468
Coley's fluid, dosage of, III. 298
in cancer and sarcoma, I. 152
in epithelioma of tongue, II. 144
in inoperable sarcoma, I. 920
in malignant tumours, III. 298
in sarcoma of jaw, II. 1 18
prophylactic use of, I. 130
Coli-bacilluria in anaemia, II. 14
Colic, biliary, and cholelithiasis, II. 684
from foods containing curds, II. 231
in children, II. 428-431
in lead poisoning, I. 512
renal and calculus, II. 755
Colitis, II. 562-569
chronic mucous, II. 570
mucous, appendicostomy for, II. 571
caecostomy in, II. 571
valvular caecostomy in, II. 571-573
complicating gastroptosis, II. 321
haamorrhagic, 11. 574
membranous, II. 563
surgical treatment of, II. 570
ulcerative, II. 568, 576
diet in, II. 211
in mercurial poisoning, t. 530
Collapse and anaesthetics, III. 24
cause of, I. 94
following sudden suppression of drugs,
1.516
in abdominal injuries, II. 244
in emergency cases of abdominal opera-
tions, II. 260
in food poisoning, I. 509
in marasmus, I. 467
intravenous infusion in, I. 104
mustard bath for, I. 3S
saline injections in. I. 33
treatment of, I. 94, 1U4
Colles's fracture, I. 602
of radius, I. 578
Collier (James), aphasia and other speech
defects of cerebral origin, I. 1143-
1149
Collier (James) (cunfd.)
apraxia, If. 1150-1J52
migraine aQ d other forms of periodic
headache, II. 1027-1035
treatment to facilitate restoration of
speech faculties by functional com-
pensation, II. 1049-1051
Collodion, dressing with, method of, I. 89
flexile, use of, in bedsores, I. 911
in small-pox, I. 305
in wounds, I. 552
Colon, abnormalities of, chronic consti-
pation due to, II. 470
adhesions of, II. 559
non-operative treatment in, II. 559
operative treatment, II. 560
bacillus peritonitis, II. 641
cancer of, II. 578-584
caecostomy for, II. 584
colotomy for, II. 581
excision of growths in csecal region,
II. 580
immediate anastomosis in, II. 579
left, inguinal colotomy for, II. 581
lumbar colotomy in, II. 583
palliative operations for, II. 580
Paul's operation for, II. 580, 584
relief of obstruction in, I. 141
resection of the growth, II. 579
short-circuiting operation for, II. 580
congenital abnormalities of, II. 585
dilatation of, II. 585
acute obstruction in, II. 585
colotomy for, II. 586
non-operative treatment, II. 585
operative treatment, II. 586
resection in, II. 586
hypertrophy of, II. 585
diseases of, II. 559-592
chronic constipation due to, II. 470
mineral waters and baths in, III. 139
exclusion of, in constipation in adults,
II. 468
hyperplastic tuberculosis of, II. 590
in enteroptosis, surgery of, I. 431
multiple polypi of, II. 588
perforation of, II. 558
in pericolitis, II. 576
tuberculosis of, II. 590
ulcer of, with perforation, II. 589
volvulus of, II. 591
operation for shortening mesocolon
in, II. 592
Colostomy in cancer of intestines, I. 141
Colotomy in cancer of the colon, II. 581
in congenital dilation of the colon, II.
586
left inguinal, for cancer of the colon,
11.581
lumbar, in cancer of the colon, II.
583
Colpo-perineorruaphy, posterior, in pro-
lapse of uterus, IV. 694
Colporrhaphy, anterior, IV. 549
in prolapse of uterus, IV. 694
A SYSTEM OF TREATMENT.
Colpotomy in tubal pregnancy, IV. 87
Coma, II. 982-985 .
alcoholic, II. 984
associated with intra-cranial abscess
and tumour, II. 983
cerebral haemorrhage and, II. 984
diabetic, 1. 424 ; II. 983
epileptic, II. 983
following morphia poisoning, II. 984
in heat stroke, II. 985
malarial, II. 985
urasrnic, II. 982
Combretum sundiacum in opium smoking,
1.518
Comedones, III. 1022-1023
local procedure for, III. 1022
of the auricle, III. 881
Rontgen rays in, III. 1023
Complications and sequelae of disease, I.
22
Compresses, changing of, I. 36
Conception, retention of products of, sub-
involution of uterus by, IV. 721
Concretions of the stomach, II. 359
See also Calculi.
Concussion of brain in cranial fractures,
1.877
Condiments in obesity, I. 472
Condurango in anorexia of gastric cancer,
II. 298
Condylomata, acuminate, of the vulva, IV.
511
Congenital abnormalities of the colon, II.
585-587
absence of the tympanic membrane,
III. 891
affections of the heart, I. 1254'
alopecia, III. 997
amblyopia, III. 543
amyotonia, II. 1245
anteflexion of the uterus, IV. 670
atresia of the meatus, III. 882
pylorus, II. 344
cystic disease of kidney in foetus com-
plicating labour, IV. 180
goitre complicating labour, IV.
180
defects of the newborn child, IV. 355-
363
dilatation of the colon, II. 585
elevation of the shoulder, I. 985
hydronephrosis, II. 772
hypertrophy of cervix, IV. 716
of the colon, II. 585
malformations of the penis, II. 875-
87
of the umbilicus, II. 277
of the ureter, II. 774
of the vagina, IV. 541
myotonia, II. 1252
obliteration of the bile-ducts, II.
673
perforations of the tympanic membrane,
III. 891
ptosis, III. 650
Congenital abnormalities (contd.~)
syphilis in newborn child, IV. 369
and jaundice, II. 672
varix, I. 1310
webs of the meatus, III. 882
Congestion, passive. See Bier's treat-
ment.
Conjunctiva, burns of, III. 547
diseases of, III. 547-562
general rules in, III. 548
prescriptions in, III. 548
pterygiurn of, III. 561
snow blindness of, III. 560
spring catarrh of, III. 560
symblepharon of, III. 548
tuberculosis of, III. 560
tumours of, III. 561
wounds of, III. 547
xerosis of, III. 561
Conjunctivitis, catarrhal, III. 551
complicating influenza, I. 239
small-pox, I. 309
diphtheritic, III. 557
electric, III. 560
in measles, 1. 246
phlyctenular, III. 552
Connell (Arthur), diseases of the lym-
phatic glands, I. 1339-1340
injuries of the spleen, II. 79-80
lymphatic vessels, I. 1351-1352
new growths of glands, I. 1350
surgical treatment of spleen, II. 81
of tuberculous glands, I. 134S
Connell (K.), on acid urine in typhoid
fever, I. 346
Constipation after abdominal operations,
II. 264
and insomnia, II. 986
and modifications of diet in simple
digestive disorders, II. 231
auto-intoxication and, I. 387
chronic, appendicostomy for, II. 470
due to abnormalities of the colon, II.
470
due to disease of colon, II. 470
ileo-sigmoidostomy for, II. 470
massage in, III. 21 1
complicating diabetes mellitus, I.
426
typhoid fever, I. 358
ulcer of the stomach, II. 381
constitutional, II. 445
cumulative, II. 445
diet in, II. 212
in adults, II. 439-469
abdominal supports in, J I. 462
alkaloids in, II. 446
amount of fluid for enemata in, II.
454
castor oil in, II. 448
choice and dosage of purgatives in,
II. 445
dietetic treatment of, II. 441
electrical treatment, II. 464
enemata in, II. 452, 457
26
A SYSTEM OF TREATMENT.
Constipation in adults (i-nntd.)
exercise in, II. 459
general indications for the use of
eiiemata in, II. 457
glycerine suppositories in, II. 453
hydrotlierapy in. II. 459
hygiene of the bowels in, II. 439
indications for purgatives in, II. 444
intestinal lavage in, II. 467
massage in, 11. 462
medicinal treatment of, II. 444
mercurial purgatives in, II. 450
natural aperient waters in, II. 466
operative treatment of, II. 467
psychotherapy in. 11.411
removal of impacted faeces in, II. l"i'
saline purgatives in, II. 449
short-circuiting operations for, II.
467
spa treatment of, II. 465
substaiices which increase the bulk of
the faeces in, II. 45(1
suppositories in, II. 452
Swedish gymnastics in, II. 459, 460
^ynthfsised purgatives in, II. 449
varieties of enemata in, II. l.">4
vegetable purgatives in, II. 447
in amenorrhoaa, IV. 726
in atony of the stomach, II. 287
in cancer of the stomach, II. 300
in children, II. 432-438
anal fissure in, II. 436
atonic dilatation of the bowel in, H.
435
local causes of, II. 434
overloaded condition of sigmoid in,
II. 435
prevention of, II. 432
spasmodic contraction of sphincter
ani in, II. 436
in chlorosis, II. 30
in general paralysis of the insane, II.
1079
in insomnia, II. 1018
in newborn child, IV. 368
in secretory disorders of the stomach,
II. 363
intestinal, electricity in, II. 464
eneuiata in, II. 457
intractable, II. 445
mineral waters and baths in. III. 139
neurasthenic, electricity in, II. 465
senile, II. 4 15
symptomatic, II. 444
Constitution, bodily, causes of weakness
of, I. r>
Consumption, pulmonary, I. 1117-1126
Contacts, plague. III. 402
Contagious diseases, disinfection of bed-
rooms during and after. I. l<>4
Contractions following burns and scalds,
l. :>4:<
wounds, 1. 555
Contrexeville spa, III. 149
Contusions and hcematoma, I. 545-546
Convalescence, cautions as to, I. 22
from acute rheumatism, I. 273
from anaemia, II. 15
from influenza, I. '-'85
from typhoid fever. I. 364
from whooping cough, treatment
during, I. 384
in acute bronchitis, I. 1053
in chorea, II. 1262
in pernicious anaemia, II. 11
management of. I . L'L'
in children, I. lit
protracted, mineral waters and baths
in, III. 146
quinine during, I. 65
Convulsions, chloroform in, I. 292
in measles, I. 246
in newborn child, IV. 371
infantile, II. 986-989
rapidly repeated, II. 988
warm baths in, I. 70
Cookery for children, directions for, I. 59
for the sick room, I. 42
Cooking, effect on food, II. 198
Coolie itch, III. 486
Cooper's modification of Lisfranc's
amputation, I. 840
Copper, salts of, acute poisoning by, I. 529
Coracoid process, fracture of, I. 586
Corn preparations, chemical compositions
of, II. 195
Cornea, conical, III. 563
dermoid of, III. 563
diseases of. III. 563-573
herpes frontalis and, III. 571
interstitial keratitis of, III. 568
Mooren's ulcer of, III. 566
opacities of, III. 571
phlyctenular ulceration of, III. 567
rodent ulcer of, III. 566
sclerosing keratitis of, III. 570
tuberculous keratitis of, III. 569
ulcer of, III. 563
complicating small-pox, I. 309
vascular, keratitis of, III. 570
Corner (Edred M.), abdominal injuries,
II. 242-256
peritonitis, II. 632-642
subphrenic abscess, II. 643-644
Cornflour, preparation of, I. 42
Corns, III. 1024-1025
Coronoid process, fracture of, I. 598
Corpus cavernosum, thrombosis of, I.
1331
Corrosive poisoning, I. 526
Corrosives, atrophy of stomach from
ingestion of. II. 294
Corsets, avoidance of, in gastroptosis, II.
319
for movable kidney, II. 789
Costo-transversectomy in abscess in con-
nection with tuberculous disease of the
spine, I. 931
Cotton good*, disinfection of, I. 161
wool jackets in bronchitis, I. 245
27
A SYSTEM OF TREATMENT.
Cough and abdominal operations, II. 258
extra-pulmonary in pulmonary tuber-
culosis, I. 1144
in emphysema, I. 1087
in measles, relief of, I. 245
in pulmonary tuberculosis, I. 1144
intermediate cause of, in pulmonary
tuberculosis, I. 1146
intra-pulmonary, I. 1147
nervous laryngeal, III. 841
relief of, in pleurisy, I. 1094
Counter-irritation in joint affections, I.
748
of the spine in treatment of rheumatoid
arthritis, I. 405-407
use of, in children's diseases, I. 69
Cow-pox, Jennerian, I. 311
Cow's milk in infant feeding, II. 219
Coxa valga, I. 959
Coxa vara, I, 958
Cradling described, I. 37
Craft palsies, II. 1267
Craig (M.). cocainism, I. 505
dementia praecox, II. 1305
exhaustion psychoses, II. 1299-1300
idiocy and feeble-mindedness, II. 1318-
1320
insomnia, II. 1014-1024
mania, II. 1284-1289
masturbation, II. 1316-1317
melancholia, II. 1290-1298
mental aspects of epilepsy, II. 1310-
1312
mental aspects of hysteria, II. 1306-
1308
mental diseases, II. 1274-1283
morphinism, I. 516-520
obsessive and imperative ideas, II. 1313-
1314
paranoia, II. 1309
perversions, II. 1315
psychoses associated with changes in
thyroid gland, II. 1301-1302
toxic psychoses, II. 1303-1304
Cramp, hammerman's, II. 1267
telegraphist's, II. 1266
writer's, II. 1264
hypnotism in case of, III. 174,
175
Cranial bones, indentations of, in infants,
I. 886
meningocele, II. 1194
puncture in hydrocephalus, II. 1191
Cranioclasm operation of, cranioclast in.
IV. 407
Cranioclast, dangers of, IV. 409
in craniotomy, IV. 406
merits of, IV. 410
Craniotomy, IV. 403-412
anaesthetic in, IV. 405
Auvard's three-bladed cephalotribe in,
IV. 410
cephalotribe in, IV. 408, 409
merits of, IV. 410
cleidotomy in. IV. 412
Craniotomy (tvntd.)
cranioclast in. IV. 406
crotchet in, IV. 411
crushing in, IV. 4(M>
extraction in, IV. 406
of after-coming head, IV. 412
of the body in, IV. 411
forceps in, IV. 411
in breech presentation, IV. 406
in brow presentation, IV. 405
in face presentation, IV. 405
in vertex presentation, IV. 405
indications for, IV. 403
instrumental crushing, IV. 406
perforation in, 405
dangers of, IV. 405
version in, IV. 411
vertebral hook in, IV. 411
Cranium. See Skull.
Craw-craw, III. 468
Cream in infant feeding, II. 227
Creams in pruritus, III. 1099
Creasy (Eliot) on static wave currents in
arthritis, I. 746
Crede's method of expression in post-
partum haemorrhage, IV. 218
Cremation of infected material, I. 161, 164
Creosote as anti-pyretic, I. 352
baths in bronchiectasis, I. 1044
vapour bath in pulmonary tuberculosis,
I. 1149
Cresolene vapour in whooping cough, I.
379
Cretinism and myxoedema, 1 1. 72
Crico-arytenoid joint, III. 823
Crile's apparatus for use of ether adminis-
tration, III. 27
Croft's splint, I. 629
for fractures, I. 565
Crotchet in craniotomy, IV. 411
Croup in measles, I. 245
Croupons inflammation of the bile ducts
II. 702
of the gall bladder, II. 702
Crashing clamp for removal of the ap-
pendix. II. 414
Crypto-menorrhcea, IV. 732
Crystalline lens, delivery of, III. 626
discission of in cataract, III. 611
linear extraction of, III. 613
operative treatment of, III. 611
shrunken malformed, III. 607
spoon delivery of, III. 628
Cubitus valgus at the elbow-joint, I. 938
Cudowa spa, III. 149
Cuff (H. E.) and F. Foord Caiger. diph-
theria, I. 187-202
general treatment of infectious dis-
eases, I. 157-160
scarlet fever, I. 281-294
typhus fever, I. 365-367
Cunningham (H. H. B.), diseases and
affections of the external ear, III.
876-889
tympanic membrane, III. 891-893
28
A SYSTEM OF TREATMENT.
Cupping, method of, I. 35
glasses for hyperaamic treatment, III.
56
Curettage, after - treatment of, IV.
626
application of acetone after, I. 137
danger of, IV. 626
in acute endometritis, IV. 621
in chronic endometritis, IV. 622
in menorrhagia, IV. 758
in metrorrhagia, IV. 758
leucorrhosa after, IV. 627
Curette evacuation of lens in lamellar
cataract, I1L 613
flushing, IV. 621
Roulte's pattern for retained placenta,
IV. 227
for cataract, III. 625
loup, IV. 624
narrow loup, IV. 625
Roux's, IV. 624
Currents, high frequency and static in
arthritis, I. 746
Curtains, disinfection of, I. 162
Gushing' s method in cranial fracture, I.
882
Cushny on auricular fibrillation, I. 1232
on drugs for diseases of the heart, I.
1212
Custards, preparation of, I. 42. Ill
Cut throat, II. 164 ; III. 825
Cyanide gauze and wool, double, I. 75
powder and paste, I. 74
Cyanides, poisoning by, I. 530
Cyanogen, percentage of, in cyanide
gauze, I. 76
Cyclitis, III. 592
traumatic, III. 595
Cyclophoria of ocular muscles, III. 648
Cycloplegia, III. 534
Cyllin in gastric dilatation, II. 315
Cysticercosis, III. 522
Cystinuria, II. 734
Cystitis, II. 858-860
acute, II. 858
chronic, II. 859
complicating adenoma of the prostate,
II. 944
gonorrhoea, I. 228
gynaecological surgery, IV. 496
the puerperium, IV. 272
in bilharzia disease, III. 500
in female, IV. 881-883
in injuries of the spine, I. 909
in myelitis, II. 1217
in pregnancy, IV. 272
in the puerperium, IV. 273
mineral waters and baths in, III.
140
tuberculous, II. 861-863
complicating pulmonary tuberculosis,
I. 1156
primary source of infection in, II.
861
vaccine therapy in, II. 860
Cystocele of the vagina complicated by
ulceration, IV. 547
operative treatment, IV. 549
. palliative treatment of, IV. 547
of uterus, surgical treatment of, IV. 693
Cystostomy in carcinoma of the bladder,
II. 873
in vesical cancer, I. 143
Cystotome for cataract, III. 625
Cystotomy, suprapubic for calculus in
female bladder, IV. 877
Cysts and bursse in association with
arthritis, I. 749-750
dental, of the gums, III. 1193
dentigerous, of maxillary alveolus, III.
719
of the auricle, III. 879
of the breast, II. 952-954
of lingual tonsils, III. 762
of muscle, II. 1325
of the neck, II. 167
of the scalp, 1. 892
of the vagina, IV. 531-532
of the vulva, IV. 511
sebaceous, III. 1140
surgical treatment of, I. 108-111
Daily notes in sanatorium treatment of
pulmonary tuberculosis, I. 1132-1142
Dakin (W. E.), accidental haemorrhage
during pregnancy, IV. 23-29
placenta praevia in pregnancy, IV. 65-69
Damp, cause of chronic rheumatism. I. 484
Daniels (C. W.), beri-beri, III. 414-416
blackwater fever, III. 386-389
chronic dysentery, III. 433-436
dengue fever, III. 390
epidemic dropsy, III. 416
Japanese river fever, III. 390
kala azar, III. 391
malaria. III. 392-398
Malta fever, III. 399-400
phlebotomus fever (' sand fly " fever),
III. 400
relapsing fevers, I. 266-267
undefined tropical fevers, III. 410-411
yellow fever, III. 412-413
Darier's disease, III. 1026
Davos, climate of, III. 84
Dax spa, III. 149
Dead, disposal of, I. 164
Deaf-mutism, III. 979-981
diagnosis of, III. 980
pathology of, III. 979
prognosis of, III. 980
Deafness, due to disturbance of cochlea
division of eighth nerve, III. 977
hysterical, and the labyrinth, III. 968
in adults, educational treatment of, III.
981
in children, causes of, III. 979
educational treatment of, III. 981
surgical treatment of, III. 980
in otosclerosis, III. 956
29
A SYSTEM OF TREATMENT.
Decapitation, foetal difficulties of, IV. 415
in contracted pelvis, IV. 415
operation of, steps of, IV. 413
sepsis in, IV. 415
Deciduoma malignum of the uterus, IV.
618-619
Decortication of lung in empyema, I. 1108
Deformities, acquired, of the lips, II. 96
of the lower limb, I. 958-970
after amputation in disease of the
ankle and tarsus, I. 774
after excision of the knee-joint, I. 771
due to spinal and nerve paralysis, I.
988-990
in tuberculous disease of the hip-joint,
I. 759-761
of the knee-joint, I. 767, 769
of the upper limb, I. 935-943
rachitic, 1. 970-972
recuperative factors in, I. 11
Degeneration, amyloid, I. 462
Deglutition in diphtheritic paralysis, I.
201
Delirium in typhoid fever, I. 362
tremens in chronic alcoholism, I. 499
Delstanche's malleus extractor, III. 915
otomasseur, III. 952
Dementia praecox, II. 1305
Dengue fever, III. 390
Dent (C. T.), obstruction of the intestine,
II. 528 540
Dental cysts of the gums, III. 1193
forceps, III. 1180-1187
neuralgia, II. 1114
surgery, III. 1164-1194
Deny's bouillon nitre" tuberculin, III. 293
Deodorants, definition of, I. 161
Depilatories in hypertrichosis, III. 1047
Dermatitis artefacta, III. 1027
blastomycetic, III. 1005
following external applications, I. 486
herpetiformis, III. 1028
occupation, III. 1029
phlegmonous, of the auricle, III. 881
seborrhoeic, III. 1004, 1143
X-ray, III. 1161
preceding cancer, I. 117
Dermatophiliasis, III. 481
Dermatosis, chronic, preceding cancer, I.
116
Dermoid cysts, I. 109
of the auricle, III. 879
of the cornea, III. 563
of floor of mouth, II. 145
of neck, II. 168
of the scalp, I. 892
of the tongue, II. 145
Desmoid fibroma, I. 113
Desquamation, infectivity of, I. 288
De Wecher's forceps scissors for traumatic
cataract, III. 639
Dextrocardia in newborn child, IV. 361
Dhobie's itch, III. 478
Diabetes and anaesthetics, III. 24
cancer complicating, I. 128
Diabetes (contd.~)
climate for, III. 96
coma in, II. 983
complicating cancer of the breast, II.
966
pulmonary tuberculosis, I. 1158
drugs in, I. 423
gangrene in, I. 217
in gout and gouty conditions, I. 446
insipidus, I. 428-429
complicating pregnancy, IV. 55
drugs in, I. 428-429
general treatment of, I. 428
polyuria of, I. 428
prophylaxis of, I. 428
mellitus, I. 408-427
alcohol in, I. 423
alkalies in, I. 423
coma of, I. 424
complicating pregnancy, IV. 54
complications of, I. 425-427
constipation in, I. 426
dietetic and hygienic treatment of, I,
409
exercise in, I. 422
gangrene complicating, I. 426
nephritis complicating, I. 426
oatmeal treatment of, I. 421
opium in, I. 424
pregnancy in, I. 425
prophylaxis of, I. 408
neuritis in, II. 1131
ulcers complicating, I. 373
xanthoma in, III. 1160
Diabetic foods, I. 414, 419
mastoiditis, III. 932
Diacetic acid in urine in diabetes, I. 409,
417
Diaphoresis in ascites, II. 628
Diaphragm, absence of half of, in new-
born child, IV. 361
rupture of, I. 1028
wounds of, II. 253
Diaphragmatic hernia, I. 1028
Diarrhoea, acute in adults, II. 479
caused by mushroom poisoning, II.
480
chronic in adults, II. 480
complicating diabetes mellitus, I. 426
sprue, III. 445
tuberculous peritonitis, II. 645
typhoid fever, I. 358
in children, II. 471-478
lienteric form of, II. 477
in cholera, III. 425
in food poisoning, I. 509
in measles, I. 246
in pellagra, I. 522
in pernicious anasmia, II. 4
infantile, acute summer, II. 473
preventive treatment of, II. 472
of the hills, III. 438
septic, in children, baths in, I. 69
Diet for infants and children, I. 58-61
errors of, in anaemia, I. 14
30
A SYSTEM OF TREATMENT.
Diet (cuntd.')
in acute bronchitis, I, 1051
dysentery. III. 429
endocarditis, I. 1191
fevers, II. 202
gout. I. 434
rheumatism, I. 270
in amoebic dysentery, III. 43D
in arterio-sclerosis. I. 1290
in arthritis deformans, I. 393
in ascites, II. 626
in asthma. I. 1036
in atony of the stomach, II. 289
in broncho-pneumonia, I. 1068
in calculous disease, II. 207, 753
in cancer of the stomach, II. 297
in childhood, II. 202
in chlorosis, II. 29
in cholelithiasis, II. 683
in chorea, II. 1261
in chronic bronchitis, I. 1055
diffuse parenchymatous nephritis,
II. 794
dilatation of the stomach, II. 313
gastritis, II. 350
gout, I. 455
in constipation, II. 212
in adults, II. 441
in diabetes mellitus, I. 409
in diarrhoeal diseases in children, II.
474
in diphtheria, I. 188
in disease. II. 202
in diseases of the heart, I. 1206
of the intestines, II. 208
of the stomach, II. 208
in eczema, III. 1032
in epilepsy. II . !>'.''.'
in exophthalmic goitre, II. 55
in gastric neurasthenia, II. 355
in gastroptosis, II. 320
in gout, II. 207
alimentary tract factors, I. 450
animal food, I. 451
articles to be avoided, I. 455
digestibility of food, I. 448
fruits in, I. 454
general principles, I. 447
meals, selections for, I. 455
purin-free, I. 452
saccharine food, I. 453
starchy food, I. 453
in gouty conditions, I. 446
in gynecological surgery, IV. 488
in haemophilia, II. 35
in haemorrhoids, II. 616
in hill diarrhoea, III. 438
in infectious diseases, I. 158
in inflammation of the stomach, II. 345
in jaundice, II. 671
in later infancy, II. 231
in marasmus, 1. 465
in measles, I. 244
in melancholia, II. 1292
in membranous colitis, II. 566
Diet (co/itd.')
in myelitis. II. 1216
in nephritis, II. 204
in normal puerperium, IV. 269
in obesity, I. 470, 472 ; II. 212
in osteo-arthritis, I. 400
in pericarditis, I. 1180
in peritonitis, II. 640
in pernicious anaemia, II. 2
in plague, III. 403
in pleurisy, I. 1094
in pregnancy, IV. (>
in psoriasis, III. 1110
in pulmonary tuberculosis, I. 1119
in rheumatism (chronic), I. 486
in rickets, I. 479
in scarlet fever, I. 283
in scurvy, I. 475
in secretory disorders of the stomach,
II. 361
in simple digestive disorders, constipa-
tion and. II. 231
in sprue, III. 442-443
in treatment of contracted pelvis in
labour, IV. 174
in the tropics, III. 378
in tuberculosis, II. 203
in typhoid fever, I. 340 ; II. 202
in typhus fever, I. 366
in ulcer of the stomach, II. 376
in ulcerative stomatitis. II. 122 .
in whooping cough, I. 379
modifications of, in simple digestive
disorders. II. 230
purin-free. in epilepsy, II. 1000
regulation of, before abdominal opera-
tions, II. 258
tables of, for diabetics, I. 414
vomiting, and, II. 231
Dietary, sick room. I. 42
Dietetics, principles of, II. 190-213
proportion of different foods in, II. 200
Diets. Chittenden's tables of, II. 200
Dieulafoy on surgical treatment of hsema-
temesis, II. 332
Digestion, aids to, II. 289, 291, 315, 322
care of, in infants and children, I. 45
disorders of, due to excessive drugging,
I. 64
electro-therapeutics in, III. 110
massage and, III. 211
modifications of diet in, II. 230
symptoms of, II. 370-374
in rickets, I. 479
milk as a cause of disorders of, I. 61
Digestive organs, disorders of, massage
and, III. 211
Zander treatment in, III. 372
system, climate for, III. 98
effect of excess of food on, I. 8
Digitalis in art eric-sclerosis, I. 1294
in chlorosis, II. 27
in diseases of the heart, I. 1213
in exophthalmic goitre, II. 55
in heart failure, I. 260
31
A SYSTEM OF TREATMENT.
Digitalis (contd.)
method of administration of, I. 1219
poisoning by, I. 533
preparations of, I. 1219
Digits, supernumerary, in newborn child,
IV. 363
union of, in newborn child, IV. 362
Dilatation, therapeutic significance of, I.
U
Dilating bag, use of, in accidental
haemorrhage during pregnancy, IV.
25
Dilator, glass, in vagiuismus, IV. 862
graduated metal, IV. 623
for retained placenta, IV. 226
modified Sims', IV. 623
Dionin in iritis, III. 586
Diphtheria, I. 187-202
acute inflammation of middle ear in,
III. 902
age as a factor in, I. 190
antitoxin treatment of, I. 189-192
dosage of, I. 190; 111.275
intravenous injection of, I. 191
method of administration, I. 191
prophylactic use of, I. 192
sequelae of, I. 193
standardisation of, III. 274
therapeutic value of, III. 276
value of, in prophylaxis, III. 279
bacj:erio-therapeutics of, III. 273-279
bacteriology of, I. 188, 189
complications of, cardiac, I. 199
effect of anti-toxin in, III. 278
otitis media, I. 202
paralysis, I. 200
pregnancy, IV. 49
renal affections, I. 201
conjunctivitis in, III. 557 .
diet in, I. 188
drugs in treatment of, I. 193
general management of, I. 187
hsemorrhagic, I. 187, 199
isolation in, duration of, I. 187
laryngeal, I. 194-199
intubation in, I. 198
tracheotomy in, I. 195
local treatment of, I. 193
measles associated with, I. 243
nasal discharge in, I. 190
neuritis after, II. 1138
of the meatus, III. 883
of the vulva, IV. 523
remedial treatment of, I. 189-194
return cases of, I. 188
serum, dangers and ill-effects of, III.
297
limitations of, III. 300
stimulants in, use of, I. 193
Diplopia, paralytic, of ocular muscles. III.
649
Dipsomania. I. 497
pseudo-, I. 498
Discussion needle for cataract, III.
611
Disease, acute, I. 20
indications for treatment, I. 20
causes of, complexity of, I. 6
control of, I. 3
specific, avoidance and removal of, I.
6, 7
natural reaction to, I. 8
chronic, I. 21
indications for treatment, I. 20
climatic requirements in, III. 91
clinical phenomena of, I. 15
complications and sequelae of, I. 22
diet in, II. 202
incipient, mineral waters and baths in,
III. 146
insect-borne, protection from, in the
tropics, III. 379
intercurrent complicating pernicious
anaemia. II. 11
local, of obscure origin, III. 465-469
malignant, X-rays in, III. 362
natural resistance to, I. 3, 5
prevention of, methods of. I. 4
principles of the treatment of, I.
1-25
processes of, conservative, I. 10
specific causes of, I. 4
terminations of, I. 21
X-ray treatment of, III. 360-368
Disinfectants, definition of, I. 161
for typhoid cases, I. 339
poisoning by, I. 527
Disinfection by spraying, I. 103
in amputations, I. 797
in plague, III. 401, 402
of bedrooms during and after con-
tagious complaints. I. 164
of clothes, I. 161
of leather goods, I. 162
of premises, I. 162
of stools. I. 164
of utensils, 1 . 40
preparatory to operation, methods of,
I. 27, 30
with hot air, I. 162
See also Sterilisation.
Dislocations. I. 713-733
congenital, of the elbow, I. 936
in newborn child, IV. 366
nerve injuries, complicating, II. 1102
of ankle and foot, I. 731-733
of the clavicle, I. 714
of the elbow, I. 721
of the fingers, I. 723, 938
of the head of the radius, I. 936
of hip. I. 724, 943
of the jaw, II. 104
of the knee, I. 728, 949
of the shoulder-joint, I. 715, 935
of the spine, I. 902-905
of the teeth, III. 1177
of the ulnar nerve, II. 1113
of the wrist, 1. 723, 937
reductions of, anaesthetics for, III.
33
32
A SYSTEM OF TREATMENT.
Distension, flatulent, complicating gynae-
cological surgery, IV. 4!)<)
Diuretic waters, III. 120
Diuretics in ascites, II. 627
Diver's paralysis, I. 130(5
Diverticula, of the oesophagus, II. 189
vcsical. II, 8(>4
Dixon (W. E.) on drills in haemorrhage, I.
12U1
Dobbie (Nina L.). physical exercises, III.
2:> 7
Ddderlein's method of pubiotomy, IV.
44S, 44!)
Dominici (H.), radium therapy, III. 303-
816
Dominici's tubes in radium therapy, III.
3i C,
Donovan's solution in syphilis, I. 321
Dosage of medicines for children, I. 66
Douche bath, III. 127
for infants and children, I. 48
sub-thermal, III. 127
hot-air, in hyperasinic treatment, III.
66
in chronic synovitis and arthritis, I. 746
in meuorrhagia, IV. 756
in metrorrhagia, IV. 756
in puerperal sepsis, IV. 310-311
in rctroversion of the uterus, IV. 673
in vaginal leucorrhcea, IV. 561
Scotch, in gouty joints, I. 439
tube, intra-uterine, IV. 298
vaginal, I. 39
Douglas, pouch of, in posterior cervical
fibroid, IV. 652
Dover's powder in pneumonia, I. 259
in sleeplessness, I. 159, 186
Dowsing radiant heat bath, I. 747
Doyen's gag. III. 7:i5
serum in cancer. I. 152
Doyne (R. W.), amblyopia and functional
diseases of the eye, III. 543
diseases of the choroid, III. 597
of the conjunctiva, III. 547-562
of the optic nerve, III. 645
of the orbit, III. 661-663
of the retina. III. 642-644
glaucoma, III. 602-606
injuries of the eyeball, III. 656 660
Dracontiasis (infection by guinea-worm
tilaria mediuensis), III. 501
prophylaxis of, III. 501
Drainage of the pericardium, I. 1188
of wounds, I. 551 >
after amputation, I. 802
surgical, methods of in acute abscess,
1. 167, 170
tubes, cyanide gauze to be used with,
I. 80
See also Lumbar puncture.
Draughts, avoidance of in nurseries, I. 45
witli young children. I. ~>'2
Dressings after abdominal operations, II.
266
application of, I. 86
Dressings (cnt<l.) -
in burns and scalds, I. 541, ">48
in gynaecological surgery, IV. 488
in ovariotomy, IV. 804
in wounds, I. 554
of wounds after amputation, I. 802
surgical choice of materials for, I. 79
materials for, I. 74-80
Drink, cold water, in fevers, I. 158
imperial, composition of, I. 258
in the tropics, III. 378 '
in typhoid fever, I. 343
Droitwich spa, III. 150
Dropped finger, II. 1329
Dropsy due to heart failure, digitalis in,
I. 1220
epidemic, III. 416
of the gall bladder, II. 710
Drowsiness, condition of, and anaesthetics,
III. 23
Drug eruptions, III. 1031
Drugs after abdominal operations, II.
270
allied narotic, use of and anaesthetics,
III. 22
anti-pyretic, in typhoid fever, I. 351
antiseptic, in plague, III. 406
collapse following sudden suppression
of, I. 516
diabetes mellitus, I. 423
dosage of, for children, I. 66
during pregnancy, IV. 9
hypnotic, I. 500
in insomnia, II. 1021
impotence due to use of, I. 231
in acute catarrhal pharyngitis, III. 766-
767
diarrhoea in adults, II. 480
dysentery, III. 429
laryngitis, III. 833
nephritis, II. 796
rheumatism, I. 270
yellow atrophy of the liver, II. 657
in alcoholic neuritis, II. 1135
in alcoholism, I. 495, 497, 500
in amoebic dysentery, III. 430
in amenorrhcea, IV. 727
in arthritis deformans, I. 395
in ascariasis, III. 494
in ascites, II. 627
in atony of the stomach, II. 290
in bilharzia disease, III. 499
in blackwater fever, III. 388
in broncho-pneumonia, I. 1068
in cancer, I. 148
of the stomach, II. 298, 299
in cardiac ascites, II. 631
diseases, I. 1211-1227, 1243
in catarrhal jaundice, II. 673, 674
in chancre of the tongue, II. 134
in chorea, II. 1257
in chronic dilatation of the stomach, II.
314
diarrhoea in adults, II. 482
dysentery, III. 435
33 3
A SYSTEM OF TREATMENT.
Drags, in chronic (contd.)
gastritis, II. 351
interstitial nephritis, II. 792
laryngitis, III. 836
simple ulcer of the stomach, II. 328
in colic, I. 512
in conjunctival diseases, III. 548
in constipation in adults, II. 4f4
in children, II. 436
in cystitis, IV. 274, 275
in diabetes insipidus, I. 429
in diarrhoeal diseases in children, II.
472, 475
in disseminated sclerosis, II. 1073
in dysmenorrhrea, IV. 745
in eczema, III. 1032
in epilepsy, II. 997
in exophthalmic goitre, II. 55
in food fever, II. 239
in gastric atony. II. 290
in gastric neurasthenia, II. 356
in -gastroptosis, II. 321
in goitre, II. 62
in gonorrhoeal arthritis, I. 783
in haemorrhagic tendency of portal
cirrhosis of the liver. II. 663
in haemorrhoids, II. 616
in headache, I. 514
in hill diarrhoea, III. 438
in hypersecretion of the stomach, II.
367
in hypertrophic biliary cirrhosis, II.
664
in hysteria, II. 1012
in impotence, II. 912
in infantile hypertrophic stenosis of
the pylorus, II. 339
in inflammation of the stomach, II. 346
in insanity of lactation, IV. 279
in insomnia, II. 988
in jaundice, II. 671
in Kala Azar, III. 391
in laryngeal spasm in children, III.
828
in laryngitis stridulosa, III. 829
in leprosy, III. 449, 450
in malaria, III. 392
in mania, II. 1287, 1288
in marasmus, I. 466
in meningitis, I. 253
in menorrhagia, IV. 754
in metrorrhagia, IV. 754
in migraine, II. 1029
in morphinism, I. 519
in myelitis, II. 1215
in obesity, I. 470
in Oriental sore, III. 455
in osteo-arthritis, I. 401
in oxyuriasis, III. 495
in paralysis agitans, II. 1270
in pellagra, I. 522
in pernicious anaemia, II. 3
in ponos, III. 440
in portal cirrhosis of the liver, II. 660
in pruritus ani. II, 595
Drugs (contd.)
in pruritus of the vulva, IV. 517
in puerperal sepsis, IV. 313
in pulmonary embolism, IV. 325
in pyelonephritis, infective. II. 808
in rheumatism in childhood, I. 278
(chronic) I. 490
(muscular) I. 493
in rhinorrhoea, III. 689
in rickets, I. 479
in salivary diseases, II. 130
in secretory disorders of the stomach,
II. 363
in simple acute rhinitis, III. 701
parotitis, II. 157
in splenomegaly, II. 82
in sprue, III. 444
in sympathetic ophthalmitis, III. 600
in syphilitic cirrhosis of the liver, II.
665
in syphilis, I. 317, 319, 324
in tabes dorsalis, II. 1088
in tetanus in puerperium, IV., 327
in tinnitis, III. 972
in trachoma, III. 557
in trichiniasis, III. 526
in trichocephaliasis, III. 496
in trigemiual neuralgia, II. 1116
in tuberculous peritonitis, II. 645
in tumours of the spinal cord, II. 1222
in typhoid fever, I. 351
in ulcer of the stomach, II. 378
in uraemia, II. 837
in urethritis in the puerperium, IV. 329
in uterine fibroids, IV. 634
inertia, IV. 253
in vasomotor neuroses, II. 1242
in vomiting. I. 512
in whooping cough, I. 380
in yellow fever, III. 412
for albuminuria during pregnancy. IV.
31
for chilblains, III. 1019
for paralytic distension after abdominal
operations, II. 271
for stone in the ureter, II. 846-851
Dubois' apparatus for anaesthetics, III. 14
method of hypnotism, III. 166
Dubreul's method of disarticulation at
wrist joint, I. 815
Dunbar's pollantin antitoxic serum, III.
286-287
Duodenum, ulcer of, II. 375-381
diet in, II. 211
surgical treatment, II. 391-394
with perforation, II. 396-398
Dupuytren's contraction, I. 942
exercises in, I. 490
enterotome, II. 489
fracture, I. 629
splint, I. 630
Dura mater, incision of in compression
I. 883-885
Durham's tracheotomy tubes, use of.
I. 196
34
A SYSTEM OF TREATMENT.
Dust and pulmonary tuberculosis, I. 1118
carrier of typhoid, I. 336
inhalation of, causing pneumokoniosis,
I. 1115
Dusting powders for intertrigo, IV. 529
for vulvitis, IV. 520
Dyschezia, electricity in, II. 464
enemata in, II. 457
with weak abdominal muscles, elec-
tricity in, II. 465
Dysentery, acute, III. 428-432
general treatment of, III. 428
medicinal treatment of, III. 429
serum treatment of, III. 430
amoebic, III. 430
calomel in, III. 432
diet in, III. 430
general treatment of, III. 430
medicinal treatment of, III. 430
other treatments of, III. 431
prophylaxis of, III. 4:52
bacillary, III. 428
chronic, III. 433-436
serum treatment of, III. 279
vaccine treatment of, III. 279, 280
Dysmenorrhcea, IV. 736-750
drugs in, IV. 745
in puberty, IV. 501
membranous, IV. 738
palliative treatment, IV. 742
prophylaxis of, IV. 742
spasmodic, sterility in, IV. 847
surgical treatment, IV. 746
Dyspareunia, IV. 839-842
carunclo of urethra in, IV. 841
in diseases of the fallopian tubes, IV.
841
in diseases of uterus, IV. 844
Dyspepsia, acute, or acute gastric catarrh,
I. 506-507
ami tropical liver, II. 678
appendix, II. 4()'.i
atonic, of stomach, II. 286
complicating artificial pneumothorax,
I. 1170
diet in, II. 208
forms of, I. 388
gouty, and acidity, I. 442
in acne vulgaris, III. Stss
in the menopause, IV. "> (| l
infant ilc. <-aiiM'> of. I. 54
mineral waters and baths in, III. 139
IUTVOUS, 1 1. 354
Dysphonia spastica, III. 841
Dyspnoea and ana'sthetics, III. 23
complicating acute endocarditis, 1. 1193
in emphysema, I. 1087
in goitre, II. 67
in pulmonary tuberculosis, I. 1138
Dystrophy, muscular, II. 12.">o-1251
Ear, application of vibration to, 111. '2\~>
cough in pulmonary tuberculosis, I.
1145
Ear (coidd.)
diseases of, III. 876"-889
brain abscess in, III. 939-941
complicating typhoid fever, I. 363
int racranial complications in, III.
937-943
intra-venous complications in, III.
937-943
meningitis in, III. 937-939
thrombosis of the sigmoid sinus in,
III. 941-943
See alto Otitis Media,
external, burns of, III. 888
diseases of, III. 876-889
foreign bodies in, III. 889-890
frost-bite of, III. 888
haematoma of, III. 888
malformations of, III. 876
wounds of, III. 887-888
fistulas of, III. 877
internal, syphilis of, III. 978
middle, diseases of, non-suppurative
and Eustachian obstruction, III.
944-953
patency of Eustachian tubes in, III.
947-951
dry catarrh of, in Eustachian tube,
III. 944
inflammation of, acute, III. 894-903
before perforation of tympanic
membrane, III. 894
in diphtheria, III. 902
in enteric fever, III. 902
in measles, III. 902
in scarlet fever, III. 902
local treatment, III. 894
paracentesis in, III, 895
perforation of tympanic membrane
in, III. 896
secondary to infectious diseases,
III. 902
suppuration of antrurn in, III. 897
of mastoid cells in, III. 897
chronic, atticotomy in, III. 917
aural polypi and, III. 909
cauterisation in, III. 908
epitympanic suppuration, III. 912
granulations in, III. 908
ossiculectomy in, III. 913
removal of incus in, III. 915
of malleus in, III. 914
of malleus, incus and outer attic
wall in, III. 913
of stapes in, III. 916
suppurative, III. 904-918
complicating influenza, I. 239
polypi of, III. 909
after-treatment of , III. 911
suppuration of, paroxysmal, vertigo of
labyrinth and, III. 960-961
telephone, III. 880
tuberculosis of, III. 935-!3i>
Ears, care of, in infants and children, I. 48
examination of, in epilepsy, II. 991
projecting, III. 878
35
32
A SYSTEM OF TREATMENT.
Eaux-Bonnes spa, III. 150
Eaux-Chaudes spa, III. 150
Eberth coli bacilli in typhoid fever, I. 345
Ecchymoses of the tympanic membrane,
III. 891
Echinococcus disease, alveolar, III. 523
Echolalia in psychasthenia, II. 1045
Eclampsia, Bossi's metallic dilator in, IV.
39
Caesarean section in, IV. 384
abdominal, IV. 40
chloroform in, IV. 36
cold baths in, IV. 37
decapsulation of kidneys in, IV. 37
forceps in, IV. 421
in pregnancy, IV. 34-41
incision of cervix in, IV. 40
lumbar puncture in, IV. 38
massage of the heart in, IV. 37
morphia in, IV. 36
nitro-glycerine in, IV. 37
obstetrical treatment of, IV. 38
oxygen in, IV. 37
pilocarpine in, IV. 37
rectal injection of glucose in, IV. 37
saline infusion, intravenous in, IV. 35
subcutaneous in, IV. 35
thyroid extract in, IV. 37
venesection in, IV. 36
veratrum viride in. IV. 37
Ectopia of the testis, II. 904
vesicse. II. 866-867
diversion of the urinary stream in,
II. 866
plastic closure of bladder in, II. 866
Ectropion of the eyelids, III. 581
Eczema, III. 1032-1036
chronic. X-rays in. III. 351
complicating diabetes mellitus, I. 425
diet in, III. 1032
in gout and gouty conditions, I. 445
infantile, III. 1035
local treatment of, III. 1033
medicines for, III. 1032
occupations causing, I. 117
of the auricle, III. 880
of the meatus, III. 886
of the nails, III. 1082
vulva, ointments for, IV. 530
Edmunds on auricular fibrillation, I.
1232
Effervescent baths, III. 131
Effleurage in massage, III. 203
Effusion, aspiration in, 755
Egg diet in gastric ulcer, II. 210
wine preparation of, I. 43
Eggs, chemical composition of, II. 194, 206
children's dietary to include, I. 59
Egypt as a winter resort, I. 461
Erblich's ' 606 " in syphilitic affections of
the vulva, IV. 521
specific for syphilis, I. 322
Eicken (Carl von), foreign bodies in the
air-passages, with a description of
bronchoscopy, III. 803-821
Einhorn's spray apparatus in chronic
gastritis, II. 349
Elastic constriction, passive hypertemia
induced by, III. 46
oesophageal bougie, II. 172
conical-ended black, II. 172
Elbow, congenital dislocation of, I. 936
dislocations of. I. 721
posterior moulded splint for, I. 600
tuberculous disease of, I. 777-779
Elbow-joint, disarticulation at, I. 820-
824
by anterior elliptical incision, I. 820
by a circular incision, I. 823
by a racket incision, I. 821-823
fracture of, I. 596
Electric baths, III. 104
in joint affections, I. 747
conjunctivitis, III. 560
light, exposure to, I. 548
in gout and goutj' conditions, I. 439
methods in cancer. I. 153
shock, I. 547
Electricity in acute anterior polio-myelitis,
II. 1056
in arthritis deformans, I. 398
in atony of the stomach, II. 288
in cancer, I. 153
in constipation in adults, II. 464
in craft palsies, II. 1268
in diabetes insipidus, I. 428
in disseminated sclerosis, II. 1074
in dyschezia, II. 464
with weak abdominal muscles, II.
465
in facial paralysis, II. 1094
in gastric neurasthenia, II. 354
in intestinal constipation, II. 464
in melancholia. II. 1294
in menorrhagia, IV. 762
in metrorrhagia, IV. 762
in neurasthenic constipation, II. 465
in paralysis of lead poisoning, I. 513
in paraplegia, II. 1198
in pruritus, III. 1101, 1104
in rheumatism (chronic), I. 488
in sterility, IV. 857
in tabes dorsalis, II. 1091
injuries and burns from, I. 547-549
local in electrotherapeutics, III. 106
Electro-therapeutics, III. 103-110
in chronic synovitis and arthritis, I.
448, 746-748
in digestive disorders, III. 110
in disorders of circulatory system, III.
109
in nervous disorders, III. 108-109
in skin diseases, III. 110
localised electrisation in. III. 106
statical treatment in, III. 106
Electrolysis in adenoma sebaceum, III.
<)!>!
in hypertrichosis, III. 1048
in small capillary naevi, III. 1079
of the Eustachian tube, III. 950
36
A SYSTEM OF TRK.ITM li\~I .
Elephantiasis arabuni of the vulva. l\'.
611
of leg, III. 516
palliative treatment of, III. 516
radical treatment of, III. 516
of vulva, III. 615; IV. 511
scroti, III. 504-516
bandage for after operation, III. 515
cardinal rules in, III. 504
flaps to penis in operation for, III.
511
operating without the cord in, III.
513
operation for, III. 504
dressing in, III. 513
naps in, III. 509
penis dressing in, III. 513
perineal dressings in operation for,
III. 513
pubic dressings in operation for, III.
513
sutures in operation for, III. 513
X-rays in. III. 353
Elliotson (J. M.) and practice of mes-
merism, III. 159
Elster spa, III. 150
Embolism, air, complicating labour, IV.
161-162
by bacillary plugs, I. 1306
by fibrinous particles, I. 1306
by parenchymatous cells, I. 1 306
by tumour-cells, I. 1306
cerebral, II. 1167
excluding cerebral embolism, I. 1306-
1308
fat, I. 1306
gangrene due to sudden obliteration of
arteries by, I. 215
of arteria centralis retina, III. 644
of the kidneys, I. 1308
of the mesenteric arteries, I. 1307
of the spleen, I. 1307
pulmonary. I. 1307
after abdominal operations, II. 275
complicating gynaecological surgery,
IV. 494
the puerpeiium, IV. 324-325
prevention of, IV. 324
Emetics in chlorosis, II. 28
in poisoning, I. 529
Emphysema, acute vesicular, I. 1088
atrophic, I. 1088
compensatory, I. 1088
hypertrophic, palliative treatment of, T.
1084
preventive treatment of, I. 1082
interstitial, I. 1089
physical exercises in. I IF. 251
varieties of, I. 1082-1089
Empirical remedies for cancer, I. 147
Empiricism, reasons for, I. 1
Empyaema. I. 1099-1100
anesthetics in operations for, III. 3n
complicating pulmonary tuberculosis. I.
1158
Empyaema (contd.)
double. I. 1 Hit;
failure to heal of an, I. Hot!
fistulous tracks in, injections in, I. 1110
following injury of the chest, I. 1027
generalised, after-treatment of, I. 1104
drainage in, I, 11 <>4
in the lower part of the thorax, 1. 1 101
operation for, I. 1103
localised, I. 1106
of the gall bladder, II. 710
ruptured into a bronchus, I. 1106
simple, of gall bladder, II. 702
treatment of, I. 90
tuberculous, I. 1108
want of expansion of lung in, I. 1107
Ems spa, III. 150
Encephalocele of foatus complicating
labour, IV. 180
of newborn child, IV. 357
Encephalopathy, saturnine, in lead poison-
ing, I. 514
Endocarditis, acute, I. 1190-1193
after-care of, I. 1192
complications of, I. 1193
medicinal measures in, I. 1191
in acute rheumatism, I. 272-274
infective, malignant or ulcerative,
bactericidal sera in, I. 20
bacterial vaccines in, I. 206
drugs in, I. 204
non-specific measures in, I. 203-207
prophylaxis of, I. 202
sero-vaccines in, I. 206
specific measures in, I. 204, 207
synopsis of treatment of a case, I. 207
Endomastoiditis, purulent, III. 920
suppurative, chronic indications for
operation in, III. 922
Endometritis, IV. 620-631
acute, IV. 620
curettage in, IV. 621
irrigation in, IV. 620
leucorrhrea in. IV. 568
amputation of vaginal portion of cervix
in, IV. 630
cervical, IV. 627
vaccine treatment in, IV. 630
chronic, IV. 622
curettage in, IV. 622
leucorrhoea in, IV. 569
corporeal, vaccine treatment in, TV. 630
gonorrhoeal, leucorrhcea in, IV. 569
importance of general treatment, IV.
630
Schroeder's operation in, IV. 629, 630
senile, leucorrhoea in, IV. 57u
sterility in, IV. 845
Endothelioma of the prostate, II. 932
operability of, I. 122
Endotoxins in serum therapy, III. 259
Enemata as solvents in constipation in
adults, II. 456
before abdominal operations, II. 261
chemical stimulation of, II. 452
A SYSTEM OF TREATMENT.
Enemata (eontd.)
general indications for, in constipation
in adults, II. 457
high, in constipation in adults, II. 454
in children, II. 436, 437
in chronic dysentery, III. 433
in constipation in adults, II. 452
in dyschezia, II. 457
in removal of impacted faeces, II. 459
low, in constipation in adults, II. 455
mechanical stimulation of, II. 452
methods of giving, 1. 31
of cold water in typhoid fever, I. 355
rectal, in constipation in adults, II.
454
thermal stimulation of, II. 452
varieties of, in constipation in adults,
11.454
various, I. 32
Engine-driver's eczema, I. 117
English (T. Crisp), affections of the nip-
ples, II. 977-978
appendicitis, 11.401-425
diseases and affections of the breast, II.
952-981
operative diagnosis of doubtful tumours
of breast, II. 979-980
the preparation of patients for abdomi-
nal operations, II. 257-261
the treatment of patients after abdomi-
nal operations, II. 262-276
tuberculosis of the breast, II. 981
Enteric. See Typhoid Fever.
Enteritis, acute, in adults, II. 479-480
chronic, in adults, II. 480-482
infective, in newborn child, IV. 367
Enteroclysis in haemorrhage, I. 1268
Enteroptosis, general treatment of, I.
430
(Glenard's disease), I. 430
surgical treatment of, I. 431
mechanical support in, I. 430
Enterotome, Dupuytren's, II. 489
with key, Groves', II. 489
Enterotribe, Gray's, I. 1258
Entropion of the eyelids, III. 580
Enuresis. nocturnal, II. 75-77
belladonna in, II. 75
minute supervision in, II. 75
peripheral irritation and, II. 75
thyroid extract in, II. 76
Epidemic dropsy, III. 416
gangrenous proctitis, III. 437
Epidermolysis bullosa, III. 1036
Epididymitis, II. 906
complicating adenoma of the prostate,
II. 945
gonorrhoea, I. 227
tubercular, complicating pulmonary
tuberculosis. I. 1157
Epiglottis punch, Lake-Bar well's, III.
875
Epilation in hypertrichosis, III. 1048
Epilepsy, II. 990-1007
acute exhaustion after fit in, II. 1005
Epilepsy (<wtf<7.)
alcoholic, I. 499 ; II. 993
and anesthetics, III. 25
arrest of fit in, II. 1003
associated conditions in, II. 991
automatism in, II. 1005
belladonna in, II. 998
bromides in, II. 993
coma in, II. 983
combinations of bromides and other
remedies in, II. 996
complications of, II. 1002
confirmed, II. 1006
diet in, II. 999
drugs in, II. 997
duration of treatment of, II. 998
examination of ears in, II. 991
eyes in, examination of, II. 991
features of, unfavourable for treatment,
II. 1006, 1007
genital organs, examination in, II. 992
hygienic treatment of, II. 1001
idiopathic, II. 990
introspection in, II. 990
mania, acute, in, II. 1005
marriage in, II. 1002
mental aspects of, II. 1310-1312
miscellaneous methods of treatment of,
II. 999
new preparations of bromine in, II.
997
nose examination in, II. 991
of infective origin, II. 992
of recent origin, II. 993
of toxic origin, II. 993
opium in, II. 998
organotherapy in, II. 999
perversion of functions of alimentary
tract in, II. 1018
viscera in, II. 1018
prodromata in, II. 1002
purin-free diet in, II. 1000
reflex, II. 991
seizure of fit in, II. 1003
self -abuse in, II. 992
serotherapy in, II. 999
solanum carolineuse in, II. 998
stomach examination in, II. 992
strychnine in, II. 998
surgical treatment of, II. 1007
teeth examination in, II. 992
tobacco intoxication in, 1 1. 993
zinc salts in, II. 998
Epileptiform convulsions in electric shock,
I. 848
Epiphora in fractures of the jaws, II.
100
Epiphysial line of knee-joint, primary
disease at, I. 768
Epiphysis, separation of, in fractures,
I. 590, 599
in newborn child, IV. 366
Epiphysitis, acute, I. 698
Episiotomy in second stage of labour,
IV. 115
38
A 'SYSTEM OF TREATMENT.
Epispadias in congenital malformations of
the penis, II. 875
Epistaxis, III. G(i4-66<;
complicating typhoid fever, I. 357
due to constitutional conditions, III.
664
severe organic nasal disease, III. 665
immediate arrest of, III. 666
in chronic Bright's disease, I. 15
permanent arrest of, III. 666
relief from high blood-pressure by, I.
10
Epithelial odontomes of the jaws, II. 112
Epithelioma, embryonic, radium treat-
ment of, 111. 309
in X-rays, III. 348
of the lip, II. 97
of the scalp, I. 892
of the scrotum, II. 900
of the skin, III. 1037-1038
of the tongue, II. 138-144
of the vulva, IV. 515
primary, of the umbilicus, II. 281
Epitympanic suppuration with perfora-
tion of membrana tlaccida, III. 912
Epulis, cause of, I. 113
myeloid, of jaw, II. 110
of the gums, III. 1193
Erasion in lupus, III. 1149
in tuberculous disease of the knee-
joint, I. 769, 770
Ergot, acute poisoning by, I. 510, 533
dosage of in children's diseases, I. 68
gangrene, I. 219
in rnenorrhagia, IV. 754
in metrorrhagia, IV. 754
Ergotism. I. 510. 533
Erichsen (Sir J. E.) on shock from burns
and scalds, I. 540
Ernst's kidney truss, II. 787
Erysipelas, I. 209-211
complicating pregnancy, IV. 49
typhoid fever, I. 357
constitutional treatment of, I. 211
ichthyol in, I. 210
iron perchloride in, I. 211
Kraske's method in, I. 210
lead lotion in, I. 210
local treatment of, I. 209
multiple incisions in, I. 210
of scalp, I. 888
of the auricle, III. 880
of the vulva, IV. 524
prophylaxis of, I. 209
vaccine therapy of, I. I'll
Erythema induration, III. 1151
multiforme, III. 1038
nodosum, I. 212-213
convalescent stage, I. 213
eruptive stage, I. 212
prodromal stage, I. 212
Erythrasma, III. 475, 1039
Erythromelalgia, II. 1230-1231
Escharotics in Framboesia tropica, III
402
Esdaile (James), and mesmerism, III. 160
method of hypnotism, III. 163
Eserine or physostigmine, poisoning by,
I. 533
Esmarch's bandage, I. 798
compression with, in haemorrhage, I.
1259
Esophoria of ocular muscles, III. 646
Essences, food, preparation of, I. 42
Esthiomene of the vulva, IV. 508
Estlander's operation for empyema, I.
1107
Ether, closed method of administration,
III. 7
drop-bottle, III. 11
ethylic, as anaesthetic, III. 6
open method of administration, III. 9
preceded by ethyl chloride as anaes-
thetic, III. 11
nitrous oxide as anesthetic, III. 11
semi-open method of administration,
III. 11
Ethmoidal sinus, III. 727-728
Ethyl chloride, administration of, from
small bag and face piece, III. 18
preceded by ether as anassthetic, 1 1 1. 1 1
ether as anaesthetic, III. 6
oxide as anaesthetic, III. 6
Eucaine in sciatica, II. 1026
Eucalyptus in ankylostomiasis, III. 491
in bronchitis, I, 245
oil, inunction of in scarlet fever, I. 288
Europeans, physiological effect of tropical
regions on, III. 375
Eustachian bougies in patency of Eusta-
chian tube, III. 949
catheter for patency of Eustachian tube,
III. 948
tube, electrolysis of, III. 950
mucous membrane of, III. 951
obstruction of, and adenoid post-nasal
growths, III. 947
and adhesions in naso-pharynx, III.
947
and chronic catarrhal otitis media,
III. 944
hypertrophic rhinitis, III. 946
mucopurulent nasal catarrh, III.
946
iKiso-pharyngeal catarrh, III. 946
non-suppurative middle ear
disease, III. 944-953
and dry catarrh of middle ear, III.
944
and naso-pharyngeal catarrh, III.
91.-)
and oto-fibrosis, III. 944
and tumours of the naso-pharynx,
III. 947
functional tests in, III. 944
general treatment, III. 945
nasal catarrh and, III. 945-947
prophylaxis, III. 945
patency of, and diseases of middle
ear, III. 947-951
39
A SYSTEM OF TREATMENT.
Evaux les-Bains spa, III. 150
Eve's operation for gastroptosis, II. 323
Evian-les-Bains spa, III. 150
water in obesity, I. 470, 471
Evisceration of foetus, IV. 416
anaesthetic in, IV. 416
difficulties in, IV. 416
operation for, steps of, IV. 416
Ewart's treatment in typhoid fever, I. 34-
Excision. centra-indications to in tuber
culous disease of the knee-joint, 1. 770
in tuberculous disease of the knee
joint, I. 769
of joints in gunshot wounds, I. 562
of the knee-joint, deformity after, I. 771
Excitement in general paralysis of the
insane, II. 1079
sleeplessness caused by, I. 54
Excretal diseases and their dissemination
in the tropics, III. 383
Exercises, abdominal, in defective meta-
bolism, III. 255
after spinal injury, I. 908
after the administration of tuberculin,
I. 1139
amount of food in, II. 199
and constipation in adults, II. 459
breathing, III. 227
during arthriiis deformans, I. 392
excessive, a cause of strain, I. 8
for flat foot, I. 968 .
for infants and children, I. 51
for spinal curvature in children, I. 57
Fraenkel's, in tabes dorsalis, II. 1091
fundamental, III. 225
graduated, in pulmonary tuberculosis.
I. 1159
in adhesions of the colon, II. 559
in arterio-sclerosis, I. 1291
in diabetes, I. 422
mellitus, I. 422
in diseases of the heart, I. 1208
in pregnancy, IV. 7
in pulmonary tuberculosis, I. 1123
in treatment of rheumatism (chronic"),
1.489
of obesity, I. 469
influence of, in dietetics, II. 199
introductory, III. 224
muscular, physiological effect ol , III.206
physical, III. 222
arch-flexions in, III. 225
derivative, III. 226
double curves in for scoliosis, III. 247
for knock-knee, III. 235
for kyphosis, III. 236
for lordosis, III. 239
for scoliosis, III. 241
for spinal curvature, III. 236
for talipes, III. 233
for wry-neck. III. 233
four-footed, III. 248
in asthma, III. 251
in cardiac affections, III. 249
in chronic bronchitis, III. 251
Exercises, physical (contd.)
in chronic nervous diseases, 111. 2.">ij
in defective metabolism. III. 254
in emphysema, III, 251
in flat-foot, III. 234
in orthopaedic cases, III. 233
in pulmonary affections, III. 249-254
movements to exercise muscles in
scoliosis, III. 248
passive stretching movements in, for
scoliosis, III. 247
remedial, III. 227
respiratory, necessary in voung children,
1.50
stage in sanatorium treatment of pul-
monary tuberculosis, I. 1129. 1135
Exertion in acute rheumatism. I. 273
Exhaustion, acute, after fit in epilepsy,
II. 1005
and anesthetics. III. 24
in sanatorium treatment of pulmonary
tuberculosis, I. 1138
psychosis, II. 1299-1300
Exophoria of ocular muscles, III. 647
Exostoses of the meatus, III. 883
Exotoxins in serum therapy, III. 259
Expectoration, serous or albuminous in
hydrothorax, I. 1092
Extension, method of, in tuberculous
disease of the hip-joint, I. 753
External applications in diseases of chil-
dren, I. 69
Extremities. See Limbs.
Eye, accommodation and refraction of,
errors of, III. 528-542
spectacles for. III. 542
application of vibration to. III. 215
care of, in measles, I. 246
diseases of, III. 528-573
complicating small-pox, I. 309
functional, III. 543-546
examination of, in cataract, III. 617
in epilepsy, II. 991
excision of, anesthetics for, III. 30
liquid pollantin serum for, III. 287
muscles of, diseases of, III. 646-655
powdered pollantin serum for, III. 287
spasm of accommodation in, III. 542
Eyeball, enucleation of, III. 658
mules, operation for. III. 660
gunshot wounds of, III. 657
injuries of, non-perforating, III. 656
operation for enucleation in, III. 658
perforating, III. 657
wounds of, III. 656-660
Eyelids, blepharitis of, III. 577
chalazia of, III. 578
diseases of, III. 577-582
ectropion of, III. 581
entropipn of. III. 580
hordeola of, III. 579
ptosisof, III. 579
trichiasis of, III. 580
xanthelasma of, III. 582
Eyestrain, III. 534
A SYSTEM OF TREATMENT.
Face, application of vibration to, III. 220
deformity in fractures of jaw, II. 99
dressings for, I. 88
gunshot wounds of, I. 563
hemorrhage from, I. 1275
hemiatrophy of, II. 1232
operations on, and auajsthetics, III. 26
palsy of, in newborn child, IV. 365
paralysis of, II. 1093-1095
presentation in labour, IV. 140-143
spasm of, II. 1047
Facial nerve, injuries of, II. 1108
neuralgia II. 1127: III. 170
Faecal fistula;, IV. 535
Faeces, analysis of, II. 190
impacted, in constipation in adults, II.
452
removal of by enemata, II. 4.")9
substances which increase the bulk of,
in constipation in adults, II. 450
Fallopian tubes, actinomycosis of, IV. 800
cancer of, IV. 801-803
chorion-epithelioma of, IV. 804
diseases of, IV. 799-819
il\ sjmreunia and, IV. 841
lia'inatosalpinx of, IV. 810
hernia of, IV. 804
hydrosalpinx of, IV. 824
inflammation of, IV. 805-814
salpingostomy in, IV. 825
sterility in, IV. 845
leucorrhcea from, IV. 571
papilloma of, IV. 816
removal of, sterility in, IV. 856
salpingitis of, acute, IV. 810
chronic, IV. 813
complicating cancer of the uterus,
IV. S14
septic infection of, in salpingitis, IV. 807
tuberculous diseases of, IV. 817-819
Familial diseases, II. 1244
Family amaurotic idiocy, II. 1244
Fango baths in arthritis deformans, -I.
398
Farabceuf's method of amputation of the
toes, I. 835
through the leg, I. 855, 858
subastragaloid disarticulation, I. 843
comments on, I. 845
incision in, I. 843
Faradism of kidneys in diabetes insipidus,
I. 429
use of, in sprains, I. 739
Farinaceous food for children, I. 59, 62
in gout, I. 452
Fasciae, affections of, II. 1321
Fat diet in diabetes, I. 419
embolism, I. 1306
food in rickets, I. 479
foods arranged in order of value in, II.
197
in dietary of children, I. CO
milk modified by, II. 223
processes in lipoma, I. 107
value of, in dietetics, 11. 201
Fatigue in children to be avoided, I. 56
in migraine, II. 1027
Fats, digestion of, II. 191
inunction of, I. 70
not digentible during typhoid fever, I.
342
Fauces, ulceration of, in scarlet fever, I.
284
Favus, III. 1040
of the nails, III. 1082
Feeble-mindedness, II. 13181320
Feeding after abdominal operations, II.
265
after operation, directions for, T. 29
artificial, of infants, I. 59
methods of, I. 29, 33
forced, when to avoid, I. 64
improper, and diarrhceal diseases in
children. II. 471
of newborn child, frequency of, IV.
341
subcutaneous, in shock, I. 103
See also Diet, Food.
Feet, care of, in children, I. 57
in infants and children, I. 46, 48
protection of, in children, I. 50
Femoral artery, injuries of, I. 1276
thrombo-phlebitis in puerperal sepsis,
IV. 321
thrombosis, complicating gynaecological
surgery, IV. 494
Femur, Bryant's suspension apparatus, in
fracture of, I. 616
fractures of, I. 609-620
condyle of, I. 619
great trochanter of, I. 612
in children, I. 577
in newborn child, IV. 366
neck of, I. 609, 611
produced by direct violence, I. 670
separation of, epiphyses in, I. 612, 620
torsion or spiral, I. 664
T-shaped or inter-condyloid, I. 619
osteo-sarcoma of, I. 870
rotation of, after reposition of the head,
I. 946
Fenton's uterine dilator, IV. 478
vulsellum, IV. 476
Fenwick (W. Soltau), atony of the
stomach, II. 286-292
atrophy of the stomach (achylea), II.
293-295
cancer of the stomach, II. 296-301
chronic dilatation of the stomach
(pyloric stenosis), II. 312-315
dilatation of the stomach, II. 310-311
displacements of the stomach, II. 318-
322
hemorrhage from the stomach, II. 325-
330
inflammation of the stomach, II. 353
nervous diseases of the stomach, II.
:;:.4-358
parasites and concretions of stomach,
II. 3.V.I
11
A SYSTEM OF TREATMENT.
Fenwick (W. Soltau) (contd.)
sea-sickness, II. 395
secretory disorders of the stomach, II.
360-369
symptoms of disordered digestion in
the stomach, II. 370-371
ulcer of the stomach and duodenum, II.
375-381
Fermentation, gastric, prevention of, II.
627
Ferments in treatment of cancer, I. 151
Fetor in cancer of cervix, IV. 617
Fever, acute early, in puerperal sepsis,
IV. 317
blackwater, III. 386-389
breast, in puerperal sepsis, IV. 315
continued, in puerperal sepsis, IV. 317
dengue, III. 390
early slight, in puerperal sepsis, IV.
314
enteric. See Typhoid,
food, II. 233-241
in measles, I. 244
intermittent hepatic, in cholelithiasis,
II. 684
Japanese river, III. 390
malarial, III. 392-398
Malta, 111. 399-400
Mediterranean, III. 399
non-septic, in puerperal sepsis, IV. 315
phlebotomus, III. 400
puerperal. See Puerperal Sepsis,
rheumatic. See Rheumatism,
"sand fly," 111.400
tropical, undefined, III. 410-411
undulant, III. 399
yellow, III. 412-413
Fevers, acute, diet in, II. 202
subinvolution of uterus in, IV. 720
eruptive, cold sponging contraindicated,
I. 160
general treatment of, I. 157-160
infections, management of convales-
cence, I. 65
relapsing, 1. 266-267
tropical, III. 386-422, 410
Fibrinous particles, embolism by, I. 1306
Fibro adenomata of the breast, II. 955
Fibrocystic disease of the jaws, JI. 112
Fibroids of broad ligament, IV. 653
false, hysterectomy in, IV. 654
true, enucleation in, IV. 653
cervical anterior hysterectomy in, IV.
651
central hysterectomy in, IV. 648-649
complicating labour, IV. 159
hysterectomy in, IV. 649
posterior, hysterectomy for, IV. 652
Paget's recurrent, I. 114
pedunculated, abdominal myomectomy
in, IV. 658
polypi, uterine, IV. 658-661
vaginal enucleation in, IV. 660
sessile, abdominal hysterectomy in, IV.
658
Fibroids (c-ontd.)
uterine, IV. 634. <;<;;{
drugs in, IV.'<>34
hysterectomy in, IV. 639
abdominal, in, IV. 641
indications for, IV. 637
sub-total in, IV. 643
total, in, IV. 647
leucorrhcea in, IV. 570
myomectomy in. IV. 658-G63
pain in, IV. 638
preliminary considerations, IV. 634
pressure symptoms in, IV. 638
removal of, IV. C>35
should ovaries be removed in ? IV.
639
vaginal hysterectomy in, IV. 655-
658
Fibrolysin in adhesions of the colon, II.
660
in cheloids, I. 113
in chronic rheumatism. I. -I'.io
synovitis and arthritis, I. 748
in disseminated sclerosis, II. 1074
in tabes dorsalis, II. 1086
Fibroma of the female urethra, IV. 872
of the gums, III. 1193
of the prostate, II. 950-951
Fibromata mollusca, characteristics of, I.
112
of muscle, II. 1325
of the auricle, III. 879
of the jaw, II. 109
pharyngeal, I. 113
simple, of the scalp, I. 893
situation of, I. Ill
subcutaneous, I. Ill
varieties of, I. 112
Fibrosis, arterio-capillary, I. 1288
Fibrositis, I. 483
rheumatic, II. 1121
Fibrous ankylosis of the jaws, II. 106
epalis of the jaw, II. 109
Fibula, congenital defects of, I. 950
fracture of, I. 622-632
involving the ankle-joint, I. 628
Pott's fracture of, I. 629
torsion or spiral fracture of, I. 657
Filaria lymphangiectasis, III. r>lii
medinensis in the tropics, III. 384
infection by, III. 501
volvulus in chappa, III. 466
Filariasis, III. 503
chyluria in, III. 503
complicating pregnancy, IV. T>1
hydrocele in, III. 516
lymph scrotum in, III. 503
lymphangitis in, III. 503
oichitis in, III. 503
Fingers, amputations of, I. 804-813
sites for, I. 804
steps for, I. 808-810
congenital contraction of, I. 938
dislocation of, I. !>H<S
contractures of, I. 911
42
A SYSTEM OF TREATMENT.
Fingers (contd.)
disarticulation of, by racket incision, I.
806
dropped, II. 1329
infective abscess of, I. 16'J
paralysis of, in lead poisoning, I. 513
supernumerary, in new-born, IV. 363
surgery of, I. 170-171
Finney's operation for pyloric stenosis, II.
316
Finsen, red liuht treatment of small-pox,
I. 307
light in lupus. III. 1117
in lupus erythematosus, III. 1071
in rodent ulcer. III. 1134
Fires in sick room, I. 26
open, in nurseries, I. 1 1
Fish, chemical composition of, II. 193
in dietary of children, I. 60, 61
inspection of, in the tropics, III. 385
Fissure, anal. II. .V.7
Fistula and sinus, general and local treat-
ment of, I. 299-301
Fistulae, aerial, of neck, II. 166
anal, II. 606-610
aural, III. 877
between bladder and intestine, II. 491
intestine and female generative
organs, II. 491
biliary, II. 698, 6!)!
gastric, II. 699
branchial, of neck, II. 166
cervical, II. 166-167
complicating operation for goitre, II.
69
faecal, IV. .~>35
gastro-colic, II. 490
intervisceral, and cholelithiasis, II. 695
intestinal, II. 483-492
median cervical, II. 167
mucous, of the gall-bladder, II. 698
pathological surface, II. 699
peri-renal, II. 767-769
peritoneal, II. 280
recti-urethral, and acute prostatitis, II.
923
renal, II. 767-769
treatment of, II. 768
resulting from infective processes of
uterus, IV. r,r,s
salivary, and inflammation of parotid
gland, II. 160
supra-pubic, failure of closure of, com-
plicating adenoma of prostate, II. 915
tlivn>-i:los-:il. of neck, 11.167
thyroid. II. lf,7
tracheal, III. 799
umbilical, acquired, II. 281
mvteral, II. 842-845 ; IV. 6C.7
uretcro-vaginal, IV. 5:i4
urinary, IV. .":$.">
at the umbilicus, in adults, II. 279
in infants. II. 278
uterine. IV. 664-668
from malignant growths, IV. 668
Fistulse (conttl.)
utero-iutestinal. IV. 667
utero-vesical. IV. 666
vaginal. IV. :>:tt-536
vesico-cervical. IV. 737
vesico-vagiual, IV. 533 ; IV. 878-881
operation for, IV. 736
vitello-intestinal, II. 278
Fits in tumours of the brain, II. 1202
Flannel underclothing for children, I. 50
Flaps, amputation, 1/791, 800
vitality of, in amputations, I. 791
Flat-foot. 1. 967
exercises for, I. 968
inflammatory, I. 969
in rickets, I. 482
physical exercises in, III. 234
traumatic, I. 970
Flatulence, after abdominal operations,
II. 264
from foods containing curds, II. 231
in disordered digestion of the stomach,
11.371
Flexner's anti-meningitis serum, clinical
results of, III. 276
in meningococcus infection, III. 275
serum in meningitis, I. 254
Flies, carriers of typhoid fever. I. 336
Flour, starch-free, I. 421
Flours, chemical composition of, IT. 195
Floury foods in infant feeding, II. 229
Fluid diet in infectious diseases, I. 158
food necessary for young children, I. 53
Flushing curette, IV. 621
Foetor oris, II. 127
Foatus, amencephalus of, complicating
labour, IV. 180
body of, extraction of in craniotomy,
IV. 411
chondrodystrophia of, II. 1227
condition of, forceps in, IV. 425
congenital septic disease of kidney in,
complicating labour, IV. 180
goitre of, complicating labour, IV.
180
ceptic hygroma of, complicating
labour, IV. 180
death of, IV. 14
induction of premature labour in, IV.
436
decapitation of, 413-415
deformities of, causing obstruction to
labour, IV. 176-181
diseases of, causing obstruction to
labour, IV. 176-181
distress of. forceps in, IV. 421
encephalocelc of, complicating labour
IV. 180
enlargement of, complicating labour,
IV. 179-181
general, complicating labour, IV. 176
evisceration of, IV. 416
in impacted shoulder presentation,
IV. 416
extraction of, in craniotomy, IV. 406
43
A SYSTEM OF TREATMENT.
Foetus (contd.')
forceps to hasten delivery in interests
of, IV. 421
head of, position of blades of forceps to,
IV. 431
hydrocephalus of, complicating labour,
IV. 179
indications of, for induction of pre-
mature labour, IV. 434
large, induction of premature labour
and, IV. 436
malposition of, forceps in, IV. 421
measures for resuscitating, in forceps,
IV. 425
monstrosities of, complicating labour,
IV. 180
presentations of, forceps in, IV. 421-422
syphilis of, complicating pregnancy,
IV. 77
urethra of, imperforate, complicating
labour, IV. 180
Fb'hn wind of Switzerland, III. 75
Folliclis, III. 1151
Fomentations, anodyne, in acute rheu-
matism, I. 269
in chronic rheumatism, I. 486
and stupes, I. 35
Food, administration of, in aphthous
stomatitis, II. 121
amount and character of, bodily health
and, I. 451
amount required in different circum-
stances, II. 199
animal, in gout, I. 451
articles to be avoided by gouty, I. 455
canned, chemical composition of, II.
192
carrier of typhoid, I. 337
daily quantity of, for children, I. 63
digestibility of, in gout, I. 448
excess of, effect on digestive system, I.
8
gastro-intestinal derangement due to,
II. 232-241
in the tropics, III. 378
in typhoid fever, I. 341
materials, chemical composition of, II.
192
nitrogenous, causing gout, I. 448
preserved, chemical composition of, II.
192
purin-free, I. 452
refusal of, in general paralysis of the
insane, II. 1079
requirements in muscular work, II. 200
solid, forbidden before an operation, I.
27
starchy, effect on young children, I. 58-
61
total value of, II. 199
fever, II. 233-241
drugs in, II. 239
poisoning, I. 506-511
bacterial or ptomaine, I. 507-510
from tinned food, I. 510
Foods, analyses of, II. 1!)2
animal (Buuge), II. 7-15
ash percentage in, II. 745
caloric value of, II. 1 98
common, arranged according to value in
protein, carbohydrate and fat, II.
197
composition of, II. 192
containing no starch in infant feedinsr,
II. 229
floury, in infant feeding, II. 2:?'.)
oxalic acid in, II. 744
prepared, in infant feeding, II. 227
proportion of, in dietetics, II. 200
tables of, showing percentage of carbo-
hydrates, I. 411
tinned, metallic poisoning from, I. 510
Foot, amputations of, I. 836-850
dislocations of, I. 733
everted, I. 967
Faraboeuf's subastragaloid disarticula-
tion of, I. 844 '
hollow or contracted, I. 963
hot-air apparatus for, III. 325
inversion exercise for flat foot, III. 235
madura, III. 485
suction glass for, in hypersemic treat-
ment, III. 59
weak, I. 967
Foramen ovale, neuralgia in, II. 1119
rotundum, alcohol injection into for
neuralgia, II. 1020
neuralgia in, II. 1118
Forceps, action of, IV. 431
anaesthesia and, IV. 425
Attie punch, III. 916
axis-traction, IV. 429-431
Bonney's dissecting, IV. 476, 477
Briinings', III. 808
capsule, for cataract, III. 626
choice of, IV. 422
condition of cervix and, IV. 424
the child, and, IV. 425
uterus and, IV. 424
craniotomy, cranioclast used as, IV.
407
dangers of delivery by, IV. 430
dental, III. 1180-1187
for delay in labour,*IV. 418
for grasping the tonsil, III. 753
for oblique head, IV. 431
for removal of foreign bodies in the
gullet, II. 184
Hartmann's, III. 908
in abnormal obliquity of uterus, IV.
420
in ante-partum hasmorrhage, IV. 420
in brow presentation, IV. 422
in craniotomy, IV. 411
in delay of after-coming head, IV. 422,
430
in eclampsia, IV. 421
in exhaustion of mother, IV. 420
in expression of the cord, IV. 421
in foetal distress, IV. 421
44
A SYSTEM OF TREATMENT.
Forceps (contd.}
in heart disease during labour, IV. -120
in locked twins. IV. 422
in malposition of child, IV. 421
in measures for resuscitating the child,
IV. 425
in mento-anterior presentation of face,
IV. 421
in occipito-posterior presentation, IV.
421
in post-partum haemorrhage, IV. 42ti
in prolapse of child's arm, IV. 422
in prolapse of the cord. IV. 421
in rigidity of pelvic floor, IV. 420
in threatened rupture of perineum, IV.
420
in transverse head, IV. 432
Lake's larjngeal punch, III. 874
Lane's tissue, I. 1256
long curved, application of, IV. 426,
J2S
Luc's nasnl, III. IW3
Mackenzie's luryngeal, III. 847
methods of applying. IV. I2!-430
ossophageal, II. 184-185
I'aterson's laryngeal, III. 848
position of blades of, to foetal head,
IV. 431
position of blades of, to maternal pelvis,
IV. 431
position of child and patient, IV. 424
pressure. IV. 476
relative advantages of, IV. 432
ring. IV. 475, 47>;
round ligament, IV. 481
scissors, De Wecker's, III. 639
Thomson Walker's, for calculus, II. 760
to assist delivery in the interests of the
mother. IV. 419-420
toothed dissecting in lacerations of
cervix, IV. 189
in operations on tonsil, III. 752
use of, in disproportion between child
and maternal pelvis, IV. 417-419
indications for, IV. 417
uterine, with pledget of wool, IV. 625
Walchers position in, IV. 424
Whistler's laryngeal, III. 848
Forearm, amputation through, I. 816-820
circular amputation through, I. 819
fractures of the bones of, I. 596-603
modified circular amputation of, I. 816
paralysis of extensor muscles of, electro-
therapeutics in, III. 107
suction glass for, in hyperaemic treat-
ment, III. 58
varix of, I. 1321
Foreign bodies in the air-passages. III.
803-821
cocainisation in. III. 81(5
general anu'sthesiu in. III. S13
instruments for removal of, III. 80(
introduction of the bronchoscope, TIT.
816
local anaesthesia in. III. 813
Foreign bodies (contd.)
position of patient in the direct
method, III. 814
technique of direct method for, III.
814, 818
in the auricle, III. 888
in the bronchus, abscess due to, I. 1061
in the chest, I. 1027
in the external ear, III. 888-889
in the female bladder, IV. 875-876
in the intestines, II. 493-497
in the meatus, III. 888
in the nose, III. 667
in the oesophagus, II. 184-189
in the stomach, II. 285
in the urethra, II. 884
in the vagina, IV. 537
introduction of, in aneurysm, I. 1302
Forlauini's method of artificial pneumo-
thorax, I. 1170
Formalin gas, fumigation by means of, I.
163
spray, disinfection by, I. 120
Formamint tabloids in diphtheria, I. 194
Foruncles. See Furuncles.
Fothergill (W. E.), cysts of the vagina,
IV. 531-532
fistula; of the vagina, IV. 533-536
foreign bodies in the vagina, IV. 537
infections of the vagina, IV. 538-539
injuries of the vagina, IV. 540
malformations of the vagina, IV. 541-544
prolapse of the vagina, IV. 545-552
tumours of the vagina, IV. 553-554
Foulerton on thymus extract in cancer,
I. 150
Fournier (Prof.), on treatment of syphilis,
I. 317
Fowler's position for administration of
fluids per rectum in peritonitis, II. 635
solution, dosage of in children's diseases,
1.68
Fox (R.Fortescue), hydrology, III. 111-147
index of spas, III. 147-158
Foz (Wilfrid S.), adenoma sebaceum, III.
991
blastomycetic dermatitis, III. 1005
cheloid or acne cheloid, III. 1018
chilblains, III. 1019-1020
corns, III. 1024-1025
Darier's disease. III. 1026
epithelioma, III. 1037-1038
erythrasma, III. 1039
favus. III. 1040
hydradenomata, or adenoma of the
sweat glands, III. 1044
icthyosis and xeroderma, III. 1053
innocent t umours of the skin (myomata),
in. ior>7
K a post's disease (xeroderma pigmen-
tosuin). III. 1057
lentigo (freckles), III. 1058
inolluscum contagiosum, III. 1073
molluscum fibrosum : von Reckling-
hausen's disease, III. 1074
A SYSTEM OF TREATMENT.
Fox (Wilfrid S.) (contd.)
mycosis fungoides, III. 1076
naevi moles, birth marks. III. 1077-1081
pediculosis, III. 1086-1087
pityriasis versicolor, III. 1095
ringworm, III. 1125-1131
rodent ulcer, III. 1132-1134
rosacea. acne rosacea rhinophyma, III.
1135-1136
scabies, III. 1137-1138
sebaceous cysts. III. 1140
seborrhrea, III. 1141-1142
seborrhoeic dermatitis, III. 1142
tuberculides, III. 1146-1152
urticaria angioneurotic oedema, lichen
urticatis, urticaria pigmentosa, III.
1154-1156
warts (verrncae), III. 1157-1159
xanthoma, III. 1160
X-ray dermatitis. III. 1161-1163
Fracture-dislocations of the spine, I. 902-
905
Fractures, I. 568-633
accurate apposition of fragments in, I.
639
badly united, operative treatment of, I.
650
callus formation in, I. 579
causes of displacement in, I. 570
Collis', I. 578
complications, &c., of, Zander treatment
in, III. 374
compound, general principles of treat-
ment of, I. 581-583
extension principle in, I. 577
fragments in, apposition of, I. 642
gangrene following, I. 582
general principles of treatment of, I.
568-~633
greenstick, I. 570
gunshot, I. 561
immobolisation in, I. 572
impacted, I. 570
instruments used in the operative treat-
ment of, I. 637-651
local treatment of, I. 569
massage and passive movements in, I.
577
nerve injury in, II. 1101
redema in, I. 578
of bone in extraction of teeth, III. 1188
of the head in infants, I. 886
of the larynx, III. 825
of the long bones in newborn child, IV.
365
of the teeth, III. 1177, 118&
operative treatment of, I. 634-693
painful action of tendons in, I. 578
pelvic, I. 605
pulley extension apparatus for, I. 576
reduction of, I. 569, 571
retentive apparatus, forms of, I. 573
septic, I. 561
septicaemia following, I. 581
setting of, I. 571
Fractures (contd.}
splints for. various. I. 573-575
spontaneous, in cancer, I. 146
stiff joints following, massage in, III.
207
suppuration following, I. 582
water pillows for, I. 31
Fraenkel's exercises in tabes dorsalis, II.
1091
Fragilitas ossium, I. 712
Framboesia tropica, III. 461
constitutional treatment of, III. 4V2
local treatment of, III. 462
prophylaxis of, III. 461
Frank's operation for malignant stricture
of the oesophagus, II. 177
Frankau (C. H. B.), affections of the tendon
sheaths. II. 1330-1333
cranial meningocele, II. 1194
diseases and affections of bursae, II.
1334-1335
hernia cerebri, II. 1190
inflammatory affections of muscles, II.
1324-1325
injuries of muscles, II. 1321-1323
injuries of tendons, II. 1326-1329
new growths of muscle, II. 1325
surgical treatment of aneurysm, I.
1301-1305
surgical treatment of epilepsy, II.
1007
urethritis, chronic (gleet), II. 877-879
Franzenslad spa. III. 150
Fraser (J. S.), eustachian obstruction
and chronic non-supurative middle-
ear disease. III. 944-953
otosclerosis. III. 954-957
Freckles, lenrigo, III. 1058
Freeland (J. B.), management of the
newborn child, IV. 337-372
Freeman (John), on vaccine therapy of
whooping cough, I. 383
Freezing, destruction of rodent ulcer by,
I. 115
French (Herbert), Addison's pernicious
anaemia. II. 1-12
anaemia due to actual loss of blood, II.
18-19
anaemia due to some definite malady,
II. 13-17
aplastic anaemia, II. 37
chlorosis, II. 20-31
chorea, II. 1257-1263
haemophilia, II. 31-36
mental diseases in pregnant women, IV.
4(5-58
Friction and massage, II. 204
Friedreich's disease, II. 1248
Frontal sinus, III. 728-730
inflammation of complicating influenza,
I. 239
suppuration of, III. 729
Frost-bite of the external ear, III. 888
Fruit, digestion of, in young children, I.
53, 62
46
A SYSTEM OF TREATMENT.
Fruit (i-initif. )
incautious use of, in children, I. 53
in gout, I. 454
in sprue, III. 443
in typhoid fever. I. 344
Fruits, chemical composition of, II. 196
Fuchs' myoputhic ptosis, III. 650
Fuel-workers' era-ma, I. 117
Fulguration in cancer, I. 1.">1
of cervix uteri, l\ T . 617
Fumigations in asthma, I. 1039
with formalin gas, I. 163
with sulphurous acid gas, I. 162
Fundal grip in palpation in normal labour.
IV. 98
Funic souffle in normal labour, IV. 104
Furuncles or boils, III. 1006-1011
Gag in operation for cleft palate, II. 150
powerful screw, in fractures of the jaw,
II. Ki7
Galactocele in the puerperium, IV. 336
of the breast, II. 953
Galbiati's knife for symphysiotomy, IV.
4."i 7
Gall bladder, actinomycosis of, II. 711
catarrh of, chronic, II. 700
cirrhosis of, hypertrophic, II. 664
croupous inflammation of, II. 701'
diseases of, II. 680
distension of, II. 710
dropsy of. If. 710
cmpvema of, II. 710
fistula? of, II. 698
gangrene of, II. 7n|
liydatidsof. II. 711
hydrops of, II. 710
hypertrophy of, II. 710
inflammation of, II. 699-709
followed by cancer, I. 119
injuries of, II. 680
mucous fistula? of, II. 698
new growths of, II. 711
perforation of, II. 707
sarcoma of, II. 712
simple empyema of, II. 702
stricture of, II. 706
tumours of, II. 710-712
Gall-stone scoop, II. 688
Gallant's corset for movable kidney, II.
789
Gallic acid in haemorrhage, I. 1261
Galvanism in gout. I. l:i'.i
in s| trains. I. 73H
of kidneys in diabetes insipidus, I. 429
Galvano-cautery in chronic infections of
the tonsil, III. 751
in haemorrhage, I. 12.">8
Game, chemical composition of. II. 193
Games for young children. I. .":.'
Ganglion of tendon sheaths, II. 1332
Gangrene. I. 214-220
acute spreading traumatic. I. 219
after injuries of arteries, I. 1279
Gangrene
amputation in, I. 216, 790
carbolic, I. 219
diabetic, I. 217, 426
"due to ergot, I. 219
to gradual obliteration of the main
arteries, I. 215
to mechanical obstruction of a main
arterial trunk, I. 215
to sudden obliteration of the main
arterial, I. 215
following carbolic fomentations, I. 168,
170
fractures, I. 582
from direct crushing, I. 214
general treatment of, I. 214
in arterio-sclerosis, I. 1296
in Kaynaud's disease, II. 1240
moist, complicating diabetes mellitus,
1.426
of the gall bladder, II. 704
of the lung, I. 1090
senile, I. 215
symmetrical, I. 218
Gangrenes, specific, I. 219
Gangrenous proctitis, epidemic, III. 437
Gardiner (F.), cheiropompholyx, III.
1015-1016
chloasma, III. 1017
dermatitis artefacta, III. 1027
herpetiforms, III. 1028
(occupation), III. 1029-1030
diseases of the nails, III. 1082
drug eruptions, III. 1031
eczema, III. 1032-1036
epidermolysis bullosa, III. 1036
erythema multiforme, III. 1038
herpes febrils, III. 1042
zoster, III. 1043
melanoderma, III. 1073
milium, III. 1073
monilithrix, III. 1075
morphcea, III. 1075
pemphigus, III. 1088, 1089
pityriasis rubra, III. 1093
pilaris, III. 1092
prurigo, 111. 1096
purpura, III. 1124
sclerodermia, III. 1139
sycosis, III. 1144, 1145
trichorrhexis nodosa, III. 1145
tylosis, III. 1153
vitiligo, III. 1159
Garrod (A. E.), urinary disorder, II.
730-750
Gaseous poisons, treatment of, I. 534-535
Gasserian ganglion, excision of, for tri-
geminal neuralgia, II. 1117, 1128
injection of alcohol, II. 1119
Gastem spa, III. 150
Gastrectomy in gastric cancer, I. 140
partial, for cancer of the stomach, II.
308
for hour-glass stomach, II. 334, 336
statistics of, II. 303
47
A SYSTEM OF TREATMENT.
Gastric juice, diminution of, II. 293
Gastritis, acute simple, II. 345, 348
toxic, II. 348
alcoholic, II. 353
chronic, II. 294, 348
general treatment of, II. 348
'medicinal treatment of, II. 351
diet in, II. 345, 350
general treatment in, II. 345
medicinal treatment of, II. 346
phlegmonous, II. 353
Gastro-enterostomy for hour-glass stomach,
II. 334
for hypertrophic pyloric stenosis, II.
342, 343
for relief of obstruction in cancer of
alimentary system, I. 140
in ulcer of the stomach, II. 386
statistics of, II. 302
Gastro-gastrostomy for hour-glass stomach,
II. 334
Gastro-intestinal antiseptics in pernicious
anaemia, II. 6
derangements due to food, II. 233-
241
form of gout, I. 447
post-operative haemorrhage, I. 1276
temperature in pulmonary tuberculosis,
I. 1139
Gastro-jejunostomy for pyloric stenosis,
II. 316
in haematemcsis, II. 333
Gastroliths, II. 359
Gastrolysis for hour-glass stomach, II. 334
for pyloric stenosis, II. 316
simple, II. 336
Gastroplasty for hour-glass stomach, II.
334
Gastroptosis, II. 319
accompanied by myasthenia, II. 321
belt for, II. 320
diet in, II. 320
medicinal treatment of, II. 321
surgical treatment of, II. 323-324
Gastrostomy, feeding after, method of, I.
33
for malignant stricture of the oesopha-
gus, II. 176
for relief of obstruction in cancer of
alimentary system, I. 139
mortality of, II. 305
Gastrotomy for foreign bodies in the
oesophagus, II. 187
in the stomach, II. 285
Gaurain's portable stand, with spinal
board, I. 751
method in abscesses, I. 757
Gauze, antiseptic, use of in operations, I.
85-86
for surgical dressings, varieties of, I.
74-78
plugging after abdominal operations,
11.267
strips in drainage of acute abscess, I.
167, 170
Gelatine in hasmorrhage, I. 1262
injection of, in haamophilca, II. 34
subcutaneous injections of, in aortic
aneurysm, I. 1298
Genital organs, care of, in children, I. 48
examination of, in epilepsy. IV. 992
female, and intestine fistulas between,
II. 491
obesity and, I. 473
male, diseases of, II. 874
passages, dilation of, in symphysio-
tomy, IV. 454
tract, lacerations of, amputation of cer-
vix in, IV. 194
Clover's clutch in, IV. 188
complicating labour, IV. 188-213
non-haemorrhagic discharges from,
IV. 555-574
re-sterilisation of, after piobable in-
fection in puerperal sepsis, IV. 290
slower sterilisation of, in puerperal
sepsis, IV. 289
Genito-urinary organs, physical defects of,
I. 231
passages, anaesthetics in operations on,
III. 32
symptoms in paraplegia, II. 1199
system in typhoid fever, I. 361
Genu recurvatum, I. 949
valgum, or knock-knee, I. 959
varum and bow-leg, I. U62
Geographical pathology, III. 375-516
tongue (annulus migrans), II. 126-129
Gibbons (K. A.), dysmenorrhoea, IV. 73(5-
750
dyspareunia, IV. 839-842
sterility, IV. 843-859
vaginismus, IV. 860-864
Gigli's saw in pubiotomy, IV. 447, 450
wire saw in fractures of the jaws, II.
106
Gingivitis in svphilis, I. 318
marginal, III. 1191
Glanders, III. 670
acute, I. 222
chionic, I. 222
differential diagnosis, I. 221
incubation period, I. 222
parotid inflammation of, II. 157-163
Glands, adrenal, diseases of, II. 46-48
axillary, removal- of in malignant dis-
ease of the breast, II. 972
carcinoma of, I. 1350
of, metastatic growths, I. 124, 126
caseating tuberculous, in mediastina,
I. 1177
enlarged, application of vibration in,
III. 218
cervical, complicating influenza, I.
239
lymphatic, diseases of, I. 1339-1340
diseases secondary to infective pro-
cesses, I. 1339
tuberculous disease of, I. 1344
lymphosarcoma of, I. 1350
48
A SYSTEM OF TREATMENT.
Glands (contd.)
new growths of, I. 1350
salivary, diseases of, II. 130-131, 157-163
injuries of, II. 157-163
sublirigual, inflammation of, II. 158
submaxillary, inflammation of, II. 158
supra-clavicular, enlargement in malig-
nant disease of the breast, II. 96-1
tuberculous, operative procedures for,
I. 1348
surgical treatment of, I. 1348
Glandular affections in measles, I. 246
Glaucoma, III. 602-606
acute idiopathic, III. 602
chronic, III. 604
intermittent, III. 604
Gleason'a operation on the nasal septum,
III. 681
Gleet, II. 877-870
Glenard's disease (enteroptosis), I. 430
general treatment, I. 430
mechanical support in, I. 430
surgical treatment of, I. 431
Glenoid cavity, fracture of, I. 585
Glossina palpalis and sleeping sickness,
III. :?s;{
Glossitis, acute parenchytnatous, II. 133
inveterate chronic, in syphilitic affec-
tions of the tongue, II. 136
Glottis, oedema of, complicating cut throat,
II. 165
Gloves, sterilised rubber, use of, in labour,
IV. 288
use of in operations, I. 81
Glucose, rectal injection of, in eclampsia,
IV. 37
solution in hemorrhage, I. 1267
Gluteal arteries, injuries to, I. 1276
Glycerine and belladonna in glandular
affections, 1. i-Mii
enema, I. 32
suppositories in constipation in adults,
II. 4.-.:<
Glycosuria in diabetes, diet in, I. 413-416
in gout and gouty conditions, I. 446
mineral waters and baths in, III. 140
Goat's milk, micrococcus melitensis in,
III. 384
Goitre, II. 62-71
application of vibration in, III. 216
complications after the operation for,
11.68
during operation for, II. 68
cystic, congenital, complicating labour,
IV. 180
exophthalmic, II. 54 -.~>7
after-treatment of, II. 60
climate in, II. 56: III. 99
complicating pregnancy, IV. 57
diet in, II. 55
drugs in, 1 1. ">
Mot-bius's anti-thyroid serum in, II.
56
rest in, II. 54
results of surgical treatment of, II. 60
I
4'J
Goitre, exophthalmic (contd.)
surgical treatment of, II. 57, 58-61
X-rays in, III. 366
general treatment of, II. 62
indications for operation in, I. 67
local treatment of, 1 1. 63
medicinal treatment of, II. 62
operations for, details of, II. 65, 70
operative treatment of, II. 63
resection-enucleation for, II. 65
results of operative treatment of, II. 70
Gonococcus in salpingitis, IV. 815
infections, serum therapy of, III. 280-
281
Gonorrhoea, I. 223-230
abscesses complicating, I. 226
acute, vaccine therapy of, III. 280
chronic, vaccine therapy of, III. 281
complications of, I. 225-230
epididymitis in, I. 227
injections in, I. 224
Janet's method of urethral irrigation
in, I. 224
lymphangitis in, I. 226
oedema of prepuce in, I. 225
of cervix uteri, leucorrhcea in, IV. 566
sterility due to, I. 227
urethral irrigations in, I. 224
complicating the puerperium, IV. 329
urethritis in, I. 281
vaccine therapy of, I. 225, III. 280
zinc astringent solutions in, I. 224
Gonorrhoeal arthritis, I. 781-783
local treatment, I. 781
serum therapy in, I. 783
vaccine therapy in, I. 782, III. 281
endometritis, leucorrhosa in, IV. 569
ophthalmia, I. 228
in the adult, III. 555
peritonitis, II. 642
rheumatism, I. 228
salpingitis in children, IV. 807
vaginitis, IV. 564
vulvitis, IV. 524
chronic, IV. 561
general measures in, IV. 524
in women, IV. 560
local treatment, IV. 525
treatment of by vaccines, IV. 527
warts complicating gonorrhoea, I. 226
Gooch's splinting, I. 573
Goodall (E. W.), measles, I. 243-247
rubella, I. 280
Gossage (Alfred M.), achondroplasia
(chrondrodystrophiafoetalis), II. 1227
acroniegaly, II. 1226-1227
angioneurotic oedema, II. 1228-1229
cerebellar, conditions in children, II.
1165-1166
chronic basilar meningitis, I. 253
erythromelalgia. II. 1230-1231
hvpertrophic pulmonary osteo-arthrc-
pathy, II. 1233
infantile convulsions, II. 986-989
leontiasis ossea, II. 1236
A SYSTEM OF TREATMENT.
Gossage (Alfred M.) (contd.*)
osteitis deformans, Paget's disease, II.
1237
osteogenesis imperfecta, II. 1237
Raynaud's disease, II. 1238-1241
Goulard's lotion in sprains, I. 738
Goundou, III. 469
Gout, I. 432-461
acidity in, I. 442
acute, calomel in, I. 432
colchicum in. I. 433
diet in, I. 434
lotions in, I. 433
massage in contra-indicated, I. 438
affections of the throat in, III. 775
alcohol in, I. 456
angina pectoris in, I. 443
cardiac form, I. 447
manifestations, I. 443
cataphoresis in, I. 441
causes of, I. 448
cerebral form of, I. 447
chronic, baths in, I. 439
diet in, I. 455
salts and solvents in, I. 434-436
climate for, III. 93
complications of, I. 442-447
diabetes in, I. 446
diet in, II. 207
alimentary tract factors, I. 450
animal food, I. 451
articles to be avoided, I. 455
digestibility of food, I. 448
fruits in, I, 454
general principles, I. 447
meals, selections for, I. 455
purin-free, I. 452
saccharine food, I. 453
starchy food. I. 453
dyspepsia in, I. 442
eczema in, I. 445
electric light baths in, I. 439
gastro-intestinal form of, 447
general principles of treatment, I.
432
glycosuria in, I. 446
hepatic torpor in, I. 442
hyperchlorhydria in, I. 442
insomnia of, I. 444
irregular, I. 442-447
lithium salts in, I. 435
local treatment of joints in, I. 438
metastatic, I. 447
mineral waters in, classification of value
of, I. 460
and baths in, III. 140
neuritis in, I. 444 ; II. 1130
phlebitis in, I. 444, 1330
preventive treatment of, I. 437-461
prostatitis in, II. 926
pseudo-angina in, I. 444
retrocedent, I. 447
sciatica in, I. 444
subacute, I. 434-436
colchicum in, I. 434
Gout (contd.}
superheated air baths, I. 440
uric acid solvents in, I. 436
von Graefe's cataract knife, III. 623
Grafting, epithelial in avulsion of scalp,
I. 875
Grain poisoning, I. 506, 510
Grant (Dundas), on injection of alcohol
for relief of pain, I. 135
Granulating surfaces in burns and scalds,
treatment of, I. 542
wounds, I. 554
Granulations in chronic inflammation of
the middle ear, III-. 908
Granuloma, infective, III. 447
ulcerating, of the pudendum, III. 457-
"458
Granulosis rubra nasi, III. 1041
Graves' disease. See Goitre, exophthalmic.
Grawitz method in pernicious anaemia, 1 1. 9
Gray's enterotribe, I. 1258
Green protective, value of, I. 79
Greenstick fracture, I. 570
Greville non-luminous bath, I. 747
Grey oil injections in syphilis, I. 319
Griffith's mixture in chlorosis, II. 22
Grimsdale (Harold B.), diseases and
affections of the cornea, III. 563-573
diseases and affections of the eyelids,
III. 577-582
diseases and affections of the lacrymal
gland, III. 556-558
Gritti's transcondyloid amputation
through thigh, I. 862
Groves (Ernest W. Hey), affections of the
umbilicus, II. 277-281
fistulas of the intestines, II. 483-492
foreign bodies in the intestines, II. 493-
497
fractures of the jaws, II. 99-119
perforation of the intestine, II. 550-
558
Groves' enterotome with key, II. 489
Gruel, preparation of, I. 42
Grunbaum (Otto), diseases of the adrenal
glands (Addison's disease), II. 46-48
Guaiacum in osteo-arthritis, I. 401
resin in chronic rheumatism, I. 490
in gout, I. 435, 438
Guerin's fracture of the jaw, II. 100
Guillotine, removal by, in chronic affec-
tions of the tonsil, III. 751
Guinea worm, infection by, III. 501
Gullet, forceps for removal of foreign
bodies in, II. 184
Gumma, intra-cranial, in cerebro-spiual
syphilis, II. 1067
of the trachea, III. 801
Gums, care of, in scarlet fever, I. 294
dental, cysts of, III. 1193
diseases of, dental origin, III. 1191
epulis of, III. 1193
fibroma of, III. 1193
laceration of, in extraction of teeth, III.
1188
50
A SYSTEM OF TREATMENT.
Gunshot wounds. See under Wounds.
Gunzberg's test in poisoning, I. 526
Gurjem oil in leprosy, III. 450
Guthrie (Thomas), syphilis of the larynx,
III. 868-869
of the naso-pharynx, III. 743
of the nose, III. 714-715
of the pharynx, III. 791-792
Guyon's supra-malleolar amputation, I.
850
Gymnastics, educational. III. 223
in deformities of the spine, I. 981
remedial, III. 227
Swedish, in constipation in adults, II.
459, 460
Si't- iilxo Kxercises.
Gynaecological operations, antiseptic solu-
tions in, IV. 484
directions to nurse in, IV. 485
examination of patent before, IV. 474
garb of surgeon and assistants in, IV.
4 S3
instruments for, IV. 475
ligature, material for, IV. 482
retentive apparatus for, IV. 481
special apparatus for, IV. 481
sterilisation in, IV. 483
swabs in, IV. 483
technique of, IV. 474-486
surgery, after-treatment, IV. 487-489
bladder in, IV. 487
bladder, complications of, IV. 496
bowels in, IV. 487
cardiac failure in, IV. 494
cellulitis in, IV. 493
complications in parietal wound in,
IV. 495
of, post-operative, IV. 489-497
diet in, IV. 488
distension in, IV. 490
dressings in, IV. 488
femoral thrombosis in, IV. 494
haemorrhage in, IV. 491
insomnia in, IV. 490
intestinal obstruction in, IV. 493
pain in, IV. 490
parotitis in, IV. 495
peritonitis in, IV. 492
position of patient in, IV. 487
pulmonary complications of, IV. 494
pulse in, IV. 487
respiration rate in, IV. 487
rest in bed in, IV. 489
shock in, IV. 491
temperature in, IV. 487
vomiting in, IV. 489
Gynaecology, light treatment in, III. 201
Habits, vicious, natural resistance to
disease lowered by, I. 5, 9
Hsematemesis. gastro-jejunostomy, II.
333
in cancer of the stomach, II. 300
medicinal treatment of, II. 328
Haematemesis
post-operative, complicating abdominal
operations, II. 275
surgical treatment of, II. 332
Hsematocele, II. 913
Haematoma and contusions, I. 545-546
complicating operation for goitre, II. 69
wound after abdominal operations, II.
272
increasing diffused, in injuries of
arteries, I. 1278
in varicose veins, IV. 90
of the external ear, III. 888
of the scrotum, II. 900
of the spermatic cord, II. 917
of the sterno-mastoid in newborn
child, IV. 305
of the vulva, IV. 522
Haematomata, subaponeurotic, in contu-
sions of the scalp, I. 873
Haematomyelia, I. 904 ; II. 1210-1211
acute stage of, II. 1210
stage of repair in, II. 1211
Haematoporphyrinuria, II. 735
Haematosalpinx of Fallopian tube, IV. 810
Haematuria, II. 736
and chronic interstitial nephritis, II.
799
in acute nephritis, II. 797
in scurvy, I. 475, 477
post-operative, in renal calculus, II. 762
renal, and calculus, II. 755
Haemophilia, II. 31-36
arthritis in, I. 786
diet in, II. 35
encouragement of coagulation locally,
II. 32
internal remedies for, II. 34
iron in, II. 36
local pressure in, II. 33
local vaso-constriction in, II. 33
Haemoptysis in pulmonary tuberculosis, I.
1150
mild, in pulmonary tuberculosis, 1. 1150
moderate, in pulmonary tuberculosis, I.
1151
severe cases of, in pulmonary tubercu-
losis, I. 1154
Haemorrhage, accidental after labour, IV.
28, 29
complicating pregnancy, IV. 23-2!)
after amputations, I. 803
after extraction of teeth, III. 1189
after ovariotomy, IV. 793
angiotripsy in, I. 1257
ante-partum, forceps in, IV. 420
podalic version in, IV. 466
antiseptic action of, I. 7
arterial, I. 1255-1277
as symptom of cancer of cervix, IV.
585
cerebellar, II. 1174
cerebral, II. 1168-1176
coma in, II. !i*l
effects of, II. 1169
51 42
A SYSTEM OF TREATMENT.
Haemorrhage, cerebral (eontd.*)
factors underlying production of. II.
1169
in asphyxia of newborn child, IV.
353
in newborn child, IV. 364
meningeal, II. 1072
results of, I. 880
superficial, II. 1170
traumatic, II. 1170
cold in, I. 1260
complicating adenoma of the prostate.
II. 945
gynaecological surgery, IV. 491
operation for goitre, II. 68
perineal prostatectomy in adenoma
of prostate, II. 948
pernicious anaemia, II. 10
concealed, after labour, IV. 28
before labour, IV. 27
severe, IV. 28
control of, in amputations, I. 798
in disarticulation at hip joint, I. 866
in inoperable cancer, I. 136
in malignant disease of upper jaw,
II. 116
cutaneous, in jaundice, II. 671
effect of decreased coagulability on, I.
128
Esmarck's bandage in, 1. 1259
external, severe, in labour, IV. 27
slight, after labour, IV. 28
before labour, IV. 26
extradural, in injuries of the head, I.
880
forci -pressure in, I. 1256
from the ear, III. 886
from varicose vein, I. 1276
from wounds, arrest of, I. 550
gastric. II. 325-330
complications of, II. 331
surgical treatment of, II. 331-333
gastro-intestinal post-operative, 1. 1276
general treatment of, I. 15-29
haemorrhoids and, II. 616
heat in, I. 1260
horse serum in, III. 262
immobility in, I. 1262
in aortic aneurysm, I. 1300
in cancer of cervix, IV. 617
in chronic simple ulcer of stomach, II.
327
in colitis, II. 574
in contusions and haematoma, limita-
tion of, I. 545
in cut throat, II. 164
in gunshot wounds, I. 559
in naevi of the lips. II. 97
in operation for cleft palate, II. 150
in portal cirrhosis of the liver, II. 663
in uterine fibroids, IV. 637
in Wertheim's operation, IV. 607
in wounds of parotid gland, II. 162
of the scalp, I. 874
of the tongue, II. 132
Haemorrhage (co/itd.')
internal, in abdominal injuries, II. 244
signs of, I. 29
intestinal, complicating typhoid fever,
I. 359
into the spinal canal in injuries of the
spine, I. 904
intra-cerebral, purgation in, II. 1171
treatment of, general, II. 1171
surgical, II. 1173
venesection in, II. 1172
intra-cranial, in head injuries in the
infant, I. 886
in infants, I. 886
treatment of, surgical, II. 1175
intra-dural, in injuries of the head, 1. 882
intra-peritoneal, complicating abdomi-
nal operations, II. 275
laryngeal, III. 824
meningeal, I. 880 ; II. 1170
mixed, after labour, IV. 28
severe, in labour, IV. 28
mucous, in jaundice, II. 671
parenchymatous, I. 1272
pharyngeal, III. 776-777
pontine, II. 1175
position in, I. 1262
post-operative, treatment of, I. 87
post-partum, IV. 29
bi-inanual compression of uterus in,
IV. 220
complicating labour, IV. 214-223
compression of fundus in, IV. 219
Crede's method of expression in, IV.
218
exciting causes of, IV. 215
external, IV. 216
forceps in, IV. 426
in placenta prsevia, IV. 68
predisposing causes, IV. 215
severe anaemia in, IV. 222
shock in, IV. 222
primary, of arterial origin, I. 1270
reactionary, I. 1272
rest in, complete, I. 1262
rubber tourniquet for, I. 1258
saline infusion in, I. 1262
secondary, I. 1272
in gunshot wounds, I. 559
in haemorrhoids, II. 619
of the cord in newborn child, IV
370
special, I. 1274-1277
styptics in, I. 1261
surgical methods in, I. 1255
varieties of, 1270-1277
torsion in, I. 1257
transfusion of blood in, I. 1269
vaginal, in newborn child, IV. 371
venous, I. 1271
Hsemorrhagic diphtheria, I. 187-199
small-pox, I. 310
Haemorrhoids, II. 615-620
cautery in, II. 619
clamp for, II. 619
52
A SYSTEM OF TREATMENT.
Haemorrhoids (contd.')
complicating pregnancy, IV. 42
diet in, II. 616
external, II. 615
haemorrhage and. II. 616
in the female urethra, IV. 729
internal, II. 615
operations in, II. 618
pregnancy, IV. 42
pain in, II. 617
radical operation for, II. 620
secondary haemorrhage in, II. 619
thrombosed, complicating pregnancy,
IV. 42
Haemostasis in amputation through the
arm, I. 824
in disarticulation through shoulder-
joint, I. 827
Haemostat. Ion<*. for faucial and pharyn-
geal use, III. 784
Haemothorax, 1. 1090
amylnitritc in, I. 564
in injuries of the thorax. I. 1029
Hair, care of, in sick room, I. 28
growth of, excessive, III. 1046
piedra disease of, III. 476
Hairballs, gastric, II. 359
Hair-follicles, alopecia dependent on
morbid conditions of, III. 1000
Hall (Arthur J.), diseases of salivary
glands, II. 130-131
geographical tongue (annulus migrans),
II. 126-129
stomatitis, II. 120-125
Hallux flexus, I. 965
valgus, I. 965
Halsted's operation for inguinal hernia,
II. 507
Hamel (Gustav), massage. III. 203-212
the Zander treatment, III. 369-374
treatment by radiant heat and hot air,
III. 316-326
Hamilton Irving's box, II. 943, 944
Hamman-Meskoutine spa, III. 150
Hamman-B'irha spa, III. 151
Hammerman's cramp, II. 1267
Hammerschlag on pubiotomy, IV. 449
Hammer toe, I. 966
cause of, I. 57
Hands, contractures of, I. 941
disinfection of, in normal labour, IV.
106
hot-air chamber for, in hyperaemic
treatment, III. 63
sterilisation of, I. 81
in puerperal sepsis, IV. 288
Hanging in physical exercises, III. 230
Handley (Sampson), on lymphangioplasty,
I. 144
on open-air methods in inoperable
cancer, I. 133
on spread of mammary cancer, I. 126
on trypsin treatment in ossophageal
cancer, I. 140
Hanot's disease. II. 664
' Hardening " of children, dangers of, I.
46. 50
Harelip, II. 85-95
after-treatment in operations for, II.
93
double, 11.89
premaxillary bones in, II. 92
in newborn child, IV. 357
nostril and, II. 90
operations and anaesthetics, III. 28
preliminary considerations of, II. 85
secondary operations for, II. 94
single, II. 86
premaxillary bones and, II. 91
Harris (Wilfred), neuralgia, II. 1114-1126
nystagmus, II. 1140-1141
occupation neuroses, and craft palsies,
II. 1264-1268
tetany, II. 1271
tics and spasms, II. 1047-1049
Harrison's rubber tooth cleanser, II. 128
Harrogate spa, III. 151
Hartmann's forceps, III. 908
Haward (J. Warrington), phlebitis and
thrombosis, I. 1328-1338
on embolism following operation for
appendicitis, II. 274
Hay (John), arterio-sclerosis, I. 1287-1295
Hay fever, III. 690
Hazeline suppository in haemorrhoids, II.
617
Head, diathetic neuralgia of, II. 1024
diseases and injuries of, I. 873-887
foetal, after-coming, delay of, forceps in,
IV. 422, 430. 432
injuries of, in the infant, I. 886-887
infection following, I. 884-885
level of, to be lowered in shock, I. 97
neuralgia, diathetic, affecting, II. 1122
toxic, affecting, II. 1122
oblique, forceps in, IV. 431
pain in, hypnotism in case of, III.
172
position of, in X-ray application for
ringworm. III. 356
preparation of for operation, I. 87
toxic neuralgia of, II. 1024
transverse, forceps in, IV. 432
varix of, I. 1321
Headache from cerebral syphilis, II. 1034
from chronic hydrocephalus, II. 1034
from disease of nasal accessory cham-
bers, II. 1033
of skull bones, II. 1033
from errors of refraction, II. 1033
from gross intra-cranial disease, II.
1034
from high arterial tension, II. 1034
from inter-cranial tumour, II. 1034
from ocular conditions, II. 1033
from renal disease, II. 1034
from uraemia, II. 1034
in fever, relief of, I. 159
in lead poisoning, I. 514
in yellow fever, III. 412
53
A SYSTEM OF TREATMENT.
Headache (contd.)
neuralgic, accompanied by soreness of
the scalp, II. 1116
periodic, II. 1027-1035
forms of, II. 1033
Head-nodding in nystagmus, II. 1141
Heart affections complicating influenza,
I. 241
scarlet fever, I. 293
block, I. 1237
congenital affections of, I. 1 254
continuous irregularity of, I. 1231
dilatation of, I. 1240
compensatory, I. 10
diseases of, climate for, III. 97
complicating pregnancy, IV. 52
rheumatism, acute, I. 272
consciousness of, I. 1245
dropsy in, I. 1243
drugs in, I. 1211, 1243
during labour, forceps in, IV. 420
following diphtheria, I. 193
in anaemia, II. 15
in typhoid fever, I. 364
physical exercises in, III. 249, 253
principles of treatment of, I. 1194-
1254
remedial measures in, I. 1203-1211
subjective phenomena in, I. 1245
symptoms as indications for treat-
ment, I. 1227
vascular, mineral baths in, III. 137
what to treat, I. 1194
effect of lithium salts on, I. 435
thyroid extract upon, II. 49
extra systoles of, I. 1230
failure, I. 1195
causes of, I. 13
complicating gynaecological surgery,
IV. 494
difficulty in estimating effects of
remedies in, I. 1197
in chronic simple ulcer of the stomach,
II. 329
in diphtheria, I. 199
in pneumonia, I. 260
threatened, in acute bronchitis, I.
1052
fatty degeneration of, 1. 1 242
febrile affections of, acute, I. 1242
gout and gouty conditions of, I. 443,
447
gunshot wounds of, I. 565
hypertrophy of, I. 1241
irregular action of, I. 1228-1237
irregularity of, in arterio-sclerosis, I.
1295
lesions in rheumatism in childhood, I.
278
massage of, in eclampsia, IV. 37
myocardial affections of. I. 1240
right, dilatation of, complicating acute
endocarditis, I. 1193
rupture of, I. 1030
sinus irregularity of, I. 1228
Heart (contd.')
stimulation of. by massage, III. 254
valvular defects of, I. 1239
diseases of. and anaesthetics, III. 23
wounds of, I. 1030
Heat, excessive, and tropical liver, II.
677
baths in osteo-arthritis, I. 403
exhaustion, I. 537
flushes in the menopause, IV. 502
in haemorrhage, I. 1260
iritis and, III. 585
prickly, III. 470
radiant, treatment by, III. 316-326
indications of, III. 324
treatment of chronic rheumatism, I.
486
use of, in sprains, I. 737
value of foods, II. 191, 198
Heath's tonsil guillotine, III. 752
Heat-shock. I. 537
Heat-stroke, I. 538
coma in, II. 985
Heated air, hyperaemic treatment by, III.
61
Hebosteotomy in contracted pelvis, com-
plicating labour, IV. 171
Hebra, pityriasis rubra gravis of, III.
1151
Hectine in syphilis, I. 323
Heel. big. III. 465
painful, II. 1025
neuralgia in, II. 1123
raising exercise for flat foot, III. 235
Hegar's dilators in hypertrophic pyluric
stenosis, II. 343
Hellebore, black, poisoning by, I. 533
white or green, poisoning by, I. 533
Hellier (J. B.), diseases, affections and
injuries of the vulva, IV. 505-530
infections of tuberculous or doubtful
nature of vulva, IV. 508
injuries of vulva, IV. 509-510
innocent tumours of vulva, IV. 511-512
malformations of vulva, IV. 513-514
malignant disease of vulva, IV. 515-516
pruritus vulvas, IV. 517-519
syphilitic affections of vulva, IV. 520-
521
varix and haematoma of vulva, IV. 522
vulvitis and forms of dermatitis affect-
ing the vulva, IV. 523-529
Helouan spa, III. 151
Hemiatrophy. facial, II. 1232
Hemiplegia, II. 1181-1190
arthritic adhesions in, II. 1187
ataxis in, II. 1188
contractures in, II. 1187
general considerations of, II. 1181
involuntary movements in, II. 1188
length of treatment in, II. 1189
muscular atrophy in, II. 1187
of children, II. 1181-1190
pain in, II. 1188
paralysis in, II. 1184
54
A SYSTEM OF TREATMENT.
Hemiplegia (contd.)
spastic, of upper limb, II. 1064
spasticity in, II. 1186
symptomatic treatment of, II. 1184
vasomotor disturbances in, II. 1189
Henbane, poisoning by, I. 532
Hepatitis, amrebic, II. 676
Hepatoptosis of the liver, II. 659
Hereditary alopecia, III. 998
spastic paraplegia, II. li'l'.i
Hermaphroditism, IV. 865-867
in newborn child, IV. 362
pseudo-, IV. 865-867
uterus masculinus in, IV. 881
Hernia, II. 498-527
cerebri, II. 1190
diaphragmatic, 1. 1028 ; II. 515
direct inguinal, II. 508
femoral, II. 509-511
operation for, II. 509, 510
>t rangulated, II. 522
general considerations, II. 498
gluteal, II. 514
in newborn child, IV. 358
inllamed, IT. 515
inguinal, II. 500-509
external incision in operation for, II.
501
ligature of sac in operation for, II.
503
of newborn child, IV. 359
operations for, other than Bassin's
method, II. 507
sac of direct, II. 503
separation of external oblique apo-
neurosis in operation for, II. 502
separation of sac from cord in opera-
tion for, II. 502
strangulated, II. 521
suture of conjoined tendon to Pou-
part's ligament in operation for,
II. 504, 505
interstitial, II. 508
labial, IV. 512
lumbar, II. 515
obstructed, II. 515
obturator, II. 514
of muscular fibres, II. 1323
of the Fallopian tube, IV. 804
of the lung, I. 1027
of the ovary, IV. 767
of the testis, II. 901
operative treatment, II. 498
palliative treatment of, II. 523
by trusses, II. 498
perincal, II. 515
preventive treatment, II. 499
scar complicating gynaecological sur-
gery, IV. 496
sciatic, II. 514
strangulated, II. 516-523
after-treatment of, II. 519
causes of, II. 520
of newborn child, IV. 359
umbilical, II. 511-514
Hernia, umbilical (contd.~)
after-treatment of operations for, 1 1.
513
of newborn child, IV. 358
operation for, II. 512
strangulated, II. 523
vaginal, II. 515
ventral, II. 514
Hernial sac, appendix in, II. 410
Herpes complicating pregnancy, IV. 56
febrils, III. 1042
frontalis and cornea, III. 571
of the auricle, III. 880
of the meatus, III. 885
of the pharynx, III. 778
of the tympanic membrane, III. 891
post, neuralgia, II. 1122
zoster, II. 1096-1097 ; III. 1043
acute stage, II. 1096
pain in, III. 1043
prodromal stage, II. 1096
pustulation in, III. 1043
sequelae of, II. 1096
Herringham (W. P.), nephritis, acute, II.
796-797
nephritis, chronic diffuse parenchyma-
tous, II. 794-795
chronic interstitial, II. 792-793
uraemia, II. 837-839
Hertz (Arthur F.), constipation in adults,
II. 439-469
Heterophoria of ocular muscles, III.
646
Hett (G. Seccombe), acute tonsillitis, III.
747-749
chronic infections of the tonsil, III.
750-759
diseases and affections of the lingual
tonsil, III. 760-763
diseases and affections of the uvula
III. 744-746
syphilis, tuberculosis and tumours of
tonsil, III. 756-759
Hewitt's artificial airway, III. 8
modification of Clover's inhaler, III. 7
Key's modification of Lisfranc's amputa-
tion, I. 840
Hiccough after ovariotomy, IV. 792
in peritonitis, II. 639
spasm, II. 1048
High-frequency and static wave currents
in chronic synovitis and arthritis, I.
746
currents, III. 105
Hill diarrhoea, III. 438
Hill's (Leonard), manometer, I. 1281
Hilton's method in acute abscess, I. 167
Hip, congenital dislocation of, I. 943
deformities of in cerebral palsies of in-
fancy, II. 1160
dislocations |of, I. 724
flexion deformity of, II. 1062
internal rotation of, II. 1062
joint, disarticulation at, I. 866-872
by anterior racket incision, I. 871
55
A SYSTEM OF TREATMENT.
Hip joint, disarticulation at (contd.}
indications for, I. 866
Jordan's modified method, I. 868
tuberculous disease of, I. 752-765
Hodge's pessary in retroflexion of uterus,
IV. 680
Hodgen's splint, I. 614
Hodgkins' disease, I. 1340-1343
general treatment of, I. 1341
medicines for, I. 1343
surgical treatment of, I. 1341
X-rays in, I. 1342
Holland (Eardley), management of the
normal puerperium, IV. 256-271
Holmes (Gordon), amaurotic family idiocy,
II. 1244
amyotonia congenita, II. 1245
cerebral palsies of infancy, II. 1153-
1156
chronic disorders with cerebellar
symptoms, II. 1246
family form of muscular atrophy in
children, II. 1247
family periodic paralysis, II. 1247
Friedreich's disease, II. 1248
hereditary spastic paraplegia, II.
1249
Huntingdon's chorea, II. 1249
muscular dystrophies, II. 1250, 1251
myotonia atrophica, II. 1252
myotonia congenita, II. 1252
pcroneal muscular atrophy, II. 1253
sub-acute combined degenerations of
the spinal cord, II. 1083-1084
syringomyelia, II. 1219-1220
Holt (Emmett), on atropine in bed-wetting,
11.75
on modified milk in infant feeding,
II. 225
on phenazone in whooping cough,
1.382
Homatropine in cataract, III. 618
Homburg spa, III. 151
Hood (Wharton), on sprained joints, I.
739
Hookworm disease, III. 487
Hopogan in hyperchlorhydria, I. 442
Hordeola of the eyelids, III. 579
Border (T. J.), infective endocarditis, I.
203-208
purulent meningitis, I. 249-253
tuberculous meningitis, I. 248-249
Horn's catgut, sterilisation of, I. 72
sebaceous, I. 109
Horsehair sutures, I. 86
Horse serum in haemophilia, I. 787
in serum therapy, III. 261
irritating effects of, I. 193
normal, in infective endocarditis, I.
207
Hot air apparatus for the back, III. 323
for the shoulder, III. 323
baths, I. 38 ; III. 128
chambers for hyperaemic treatment, III.
62-64
Hot air (contd.)
disinfection by means of, I. lf>2
douche in hyperaemic treatment, III. 65
thermal douche bath, III. 127
treatment by, III. 316-326
Hot bottles, use of, I. 29, 34
, pack, use of, I. 38
water bottles, use of, I. 29, 34
Houseworkers' dermatitis. III. 1030
Housing in the tropics, III. 379
Huggard (William R.), climatology, III.
69-102
Hullux rigidus, I. 965
Humerus, fractures of, I. 586-592
anatomical neck of, I. 587
capitellum of, I. 595
condyles of, I. 592-594
in newborn child, IV. 365
lower extremity of, I. 592
separation of epiphyses in, I. 590. 593,
599
shaft of, I. 590, 681
surgical neck of, I. 589
T-shaped, I. 595
tuberosities of, I. 588
Hunger, sleeplessness caused by, I. 54
Huntingdon's chorea, II. 1249
Hutchinson (Jonathan), affections of the
tongue, II. 132-146
Hutchison (R.) on food values, II. 198
Hydatid cysts of the breast, II. 954
of the broad ligaments, IV. 820-821
of the gall bladder, II. 711
of the liver, II. 669
of the lung, surgical treatment of. I.
1175
of neck, II. 169
of the scalp. I. 892
of the skull, 'I. 894
disease, prophylaxis of. III. 521
of the spine, I. 918-919
Hydatidiform mole. IV. 59
Hydradenomata of the sweat glands, III.
1044
Hydramnios. acute, complicating preg-
nancy, IV. 44
chronic, in pregnancy, IV. 43
complicating pregnancy, IV. 43-44
olego, complicating pregnancy, IV. 44
Hydrarthrosis, intermittent, I. 748
Hydrastis canadensis, in menorrhagia, IV.
771
in metrorrhagia. IV. 771
Hydrencephalocele of newborn child, IV.
357
Hydrocele, II. 914-916
encysted of the spermatic cord, II. 917
filarial. III. 516
of the canal of Nuck, IV. 512
of neck, II. 169
of newborn child, IV. 360
palliative treatment, II. 914
radical cure by open operation, II. 916
Hydrocephalus, II. 1191-1192
chronic, headache from, II. 1034
56
A SYSTEM OF TREATMENT.
Hydrocephalns (contd.'}
cranial puncture on, II. 1191
in spina bih'da. I. 915
lumbar puncture in, II. 1191
medicinal treatment of, II. 1191
of fietus complicating labour, IV. 179
of newborn child, IV. 3,">i!
operation in. II. 1193
surgical treatment of, II. 1193
various drainage devices in, II. 1191
Hydrochloric acid, effect in gastric func-
tion. II. 291
in gastric neurasthenia, II. 386
in typhoid fever, I. 355
Hydrocyanic acid poisoning, treatment
.-,f. I. .-,30
Hydro-electric baths in arthritis defor-
mans. I. 31(8
Hydrology. III. 111-147
(Miit ra-indications for, III. 137
doctrine of ions in. III. 1 14
indications for, I II. 137
medical, definition of, III. Ill
Hydronephrosis. II. 770-779
congenital. II. 772
due to obstruction in bladder, II. 773
to obstruction in bony pelvis, II. 772
to obstruction in the urethra, II. 772
general observations on, II. 777
nephrostomy for, II. 779
results of plastic operations for, II. 779
with aberrant vessels of kidney, II. 773
with calculus, II. 773
with movable kidney, II. 772
Hydropathy in disseminated sclerosis, II.
1(174
in tabes dorsalis, II. 1092
Hydropericardium, I. 1185
Hydroperitoneum, complicating cancer, I.
146
Hydrophobia. I. 264, 265
antirabic serum in, I. 265
Pasteur's inoculation method in, I.
264
Hydrops of the gall bladder, II. 710
Hydrosalpinx of Fallopian tube, IV. 808
Hydro-therapy in chronic synovitis and
arthritis, I. 745
in constipation in adults, II. 459
in insomnia, II. 985, 1017
in pruritus. III. 1100
in rickets, I. 478
Hydrothorax, I. 1091. 1092
and arterio-sclerosis, I. 1294
complicating cancer. I. 146
paracentesis in. I. 1091
Hygiene and care of infants and children,
I. 44-70
personal, in cholera, III. 424
in the tropics, III. 375-385
Hygroma, cystic, of foetus, complicating
labour, IV. 180
of lymphatic vessels, I. 1351
of neck, II. Hi'.t
of newborn child, IV. 358
Hymen, atresia of, IV. 513
im perforate, IV. 541
Hyoscine in morphinism, I. 517
Hyoscyamine or hyoscine (scopolamine),
poisoning by, I. 532
Hyperacidity of the stomach, II. 360
Hypersemia, active, in joint affections, I.
747
Bier's treatment, III. 40-68
of the labyrinth, III. 967
of the larynx. III. 822
passive. See Bier's treatment.
Hypersemic treatment. See Bier's hyper-
agmic treatment.
Hypersesthesia of the labyrinth, III. 967
laryngeal, III. 845
of 'the phaiynx, III. 782
Hyperchlorhydria, I. 519
in gout and gouty conditions, I. 442
Hyperidrosis. or excessive sweating, III.
1044, 1045
X-rays in, III. 359
Hypermetropia, III. 536
atropine in, III. 536
Hyperopia. III. 536
atropine in, III. 536
Hyperphoria of ocular muscles, III. 647
Hyperplasia. chronic, of the mucous
membrane of the upper respiratory
tract, III. 774
Hyperpyrexia, cold water sponging in, I.
160
complicating acute rheumatism, I. 273
scarlet fever, I. 289
in injuries of the spine, I. 908
in typhoid fever, cold bath treatment,
I. 348
Hypersecretion of the stomach, II. 364
Hypertension. I. 1281
case of, I. 1282
causes of. in arterio-sclerosip, I. 1289
Hypertonic salt waters, III. 119
Hypertrichosis, III. 1046-1052
depilatories in, III. 1047
electrolysis in, III. 1048
epilation for, III. 1048
Rontgan rays in, III. 1047
Hypertrophy of the breasts, II. 957
of the heart, I. 1241
promotion and maintenance of, I. 13
recuperative process of, I. 10
Hypnotics in alcoholism, I. 500
Hypnotism and treatment by suggestion,
III. 159-179
cases of, III. 177
conclusions, III. 175
author's method (J. F. Woods), III.
166
Beaunis' method of, III. 164
Bernheim's method of, III. 164
Braid's method of, III. 163
Bramwell's method of, III. 165
brief historical introduction, III. 159
Dubois' method of, III. 166
Esdaile's method of, III. 163
57
A SYSTEM OF TREATMENT.
Hypnotism (contd.)
in alcoholism, I. 498
in insomnia, II. 989, 1021
in morphinism, I. 519
Liebault's method of, III. 164
Luy's method of, III. 165
Mesmer's method of, III. 163
methods of inducing. III. 163
Richet's method of, III. 165
stages of, III. 177
Vorsin's method of, III. 165
Wetterstrand's method of, III. 164
Hypochondriasis, sexual, in impotence,
I. 232 ; II. 912
Hypodermic injection in vaccine therapy,
III. 265
syringe in cases of collapse, I. 28, 37
Hypodermoclysis, continuous, in haemor-
rhage, I. 1268
in haemorrhage, I. 1267
Hypogastrium, prominence of, in third
stage of labour, IV. 120
Hypospadias, in congenital malformations
of the penis, II. 875
in newborn child, IV. 362
Hypothermal baths, III. 126
douche bath, III. 127
Hypotonic waters, III. 115
Hysterectomy, abdominal, in uterine
fibroids, IV. 641
instruments for, IV. 642
preparation of patient in, IV. 641
total, in cancer of cervix, IV. 600
bladder reflected in, IV. 645
broad ligaments, clamped in, IV. 642
divided in, IV. 646
Cassarean, IV. 398-402
mortality from, IV. 401
operation of, IV. 399
for anterior cervical fibroid, IV. 651
precautions in, IV. 652
for central cervical fibroid, IV. 648, 649
precautions in, IV. 650
for cervical fibroid, IV. 649
for false broad ligament fibroid, IV.
654
for posterior cervical fibroid, IV. 652
for uterine fibroids, indications for, IV.
687
in accidental, haemorrhage during preg-
nancy, IV. 25
in menorrhagia, IV. 763
in metrorrhagia, IV. 763
in puerperal sepsis, IV. 302
in tubal pregnancy, IV. 87
in uterine fibroids, IV. 639
sub-total in uterine fibroids, IV. 643
precautions in, IV. 646, 648
total abdominal in cancer of uterus,
IV. 579
in uterine fibroids, IV. 647
uterine vessels, clamped in, IV. 643
uterus amputated in, IV. 644
vaginal, cancer-cell infection of opera-
tion area, IV. 600
Hysterectomy, vaginal (contd.')
division of broad ligament in, IV.
598, 599
in accidental haemorrhage during
pregnancy, IV. 26
in cancer of cervix, IV. 593
results of, IV. 597
in cancer of uterus, IV. 578
in fibroids, IV. 655-658
in prolapse of uterus, IV. 693
instruments for, IV. 655
limits of operation and percentage
operability, IV. 597
opening utero-rectal pouch in, IV. ~>W
utero-vesical pouch in, IV. 595
operation by ligature only, IV. 655
precautions in, IV. 657
reflecting mucous membrane in, IV.
594
results of, IV. 599
transfixing lower part of broad liga-
ment in, IV. 597
Hysteria, II. 1008-1013
aphasia in, II. 1147
association method in, II. 1011
drugs in, II. 1012
mental aspects of, II. 1306-1308
persuasion method in, II. 1012
physical methods in, II. 1012
prophylactic treatment of, II. 1012
psycho-analysis in, II. 1010
spasm of, II. 1049
suggestion in, II. 1009
Hysterical joint disease, I. 787
Hystero-vaginectomy in cancer of uterus,
IV. 580
operation, complications of, IV. 612
dangers of, IV. 612
difficulties of, IV. 612
limits of, IV. 613
results of, IV. 613
technique of, IV. 612
radical, in cancer of cervix, IV. 611
ice-bags, application of, I. 36
in chronic simple ulcer of the stomach,
II. 328
Ice compressors, I. 36
poultice in pneumonia, I. 259
uses of, in sprains, I. 738
Ichthyol in erysipelas, I. 210
in pruritus, III. 1099
Icterus, II. 670-675
in the newly born, II. 672 ; IV. 369
See also Jaundice.
Icthyosis, III. 1053
Ictus laryngea, III. 841
Ideas, imperative, II. 1313
Idiocy, II. 1318-1320
amaurotic family, II. 1244
Ileo-oolostomy in cancer of colon, I. 141
Ileo-sigmoidostomy in cancer of colon, I.
141
for chronic constipation, II. 470
58
A SYSTEM OF TREATMENT.
Immunity, insufficiency and loss of, I.
8, 11
Impetigo, III. 1054-1056
general remarks on, III. 1054
local treatment of, III. 1054
Implanation cysts. I. 110
Impotence, II. ! 11 -HI 2
physical causes, I. 231 ; II. 911
physical, 1.231 ; II. 911
sexual hypochondriasis in, II. ill 2
symptomatic, I. 231 ; II. 911
Incandescent light, concentrated, III. 1%
blue, III. 197
red, III. l'.)S
use of, III. 186
Incisors, lower, extraction of, III. 1183
upper, extraction of, III. 1181
Incubation period of whooping cough, I.
377
Incus, removal of, in chronic inflammation
of middle ear, III. 915
Index finger, amputation at metacarpo-
phalangeal articulation of, I. 811
Indicanuria, II. 737
Indigestion. Xee Dyspepsia.
Individuality of patient, appreciation of,
1.25
Industrial plumbism, prevention of, I. 514
See also Occupations.
Inebriety, chronic, I. 499-502
Infantilism, II. 71
Infants, artificial feeding of, I. 58
biliary cirrhosis in, III. 439
breast feeding of. II. 215
care of the mouth in, II. 120
cerebral palsies of, II. 1055-1058, 1153-
1156
surgical treatment of, II. 1059-1066,
1157-11154
treatment of lower limbs in, II. 1159
of upper limbs in, II. 11(52
convulsions of, II. 986-989
rapidly repeated, II. 988
eczema in, III. 1035
exercise for, I. 51
feeding of, II. 214-232 ; IV. 344
breast feeding best in, II. 215
citrated milk in, II. 225
condensed milk in, II. 227
cream in, II. 227
diluted milk in, II. 222
dried milk in, II. 228
floury foods in, II. 229
in marasmus, I. 46(5
milk composition in, II. 221
diluted by adding fat in, II. 223
by adding sugar in, II. 223
predigested milk in, II. 226
prepared foods in, II. 227
sterilisation of milk in, II. 220
top milk diluted by adding lactose, II.
224
whey in, II. 227
whole milk in, II. 221
with cow's milk. II. 219
Infants, feeding of (contd.~)
with foods containing no starch, II.
229
hygiene and care of, I. 44, 70
hypertrophic stenosis of pylorus in, II.
338
inflammation of the umbilicus in, II.
279
injuries to the head in, I. 886-887
management of during anaesthetics, III.
25
mastitis in, II. 960
newborn, absence of half diaphragm
in, IV. 361
ancncephalus of, IV. 357
angioma of the umbilicus in, IV. 370
asphyxia of, IV. 350-355
cerebral hemorrhage in, IV. 353
atelectasis in, IV. 361
bath of, IV. 337
birth injuries of, IV. 363-366
brachial palsy in, IV. 365
breast, feeding of, IV. 340
cephalhaematoma in, IV. 363
cerebral haemorrhage in, IV. 364
cleft palate in, IV/357
congenital defects of, IV. 355-363
syphilis in, IV. 369
constipation in, IV. 368
convulsions in, IV. 371
cystic hygroma of, IV. 358
dextrocardia in, IV. 361
diseases of, IV. 366-372
dislocations in, IV. 366
encephalocele of, IV. 357
epiphyseal separation in, IV. 366
extrophy of bladder in, IV. 360
facial palsy in, IV. 365
feeding of, IV. 341
fracture of, clavicle of, IV. 354
long bones in, IV. 365
ribs in, IV. 354
skull of, IV. 364
frequency of feeding of, IV. 341
hpematoma of the sterno-mastoid in,
IV. 365
harelip in, IV. 357
hermaphroditism in, IV. 362
hernia in, IV. 358
hydrencephalocele of, IV. 357
hydrocele in, IV. 360
hydrocephalus of, IV. .356
hypospadias in, IV. 362
icterus in, II. 672
imperforate anus in, IV. 362
infective enteritis in, IV. 367
intussusception in, IV. 371
jaundice in, IV. 369
management of, IV. 337-372
marasmus in, IV. 370
mastitis in, IV. 371
melasna in, IV. 370
meningocclc of, IV. 357
naevus in, IV. 3(53
non-descent of the testicle in. IV. 360
59
A SYSTEM OF TREATMENT.
Infants, newborn (contd.*)
ophthalmia neonatorum in, IV. 366
phimosis of, IV. 360
prepuce of, IV. 339
rickets in, IV. 371
rupture of the cord in, IV. 366
scurvy in, IV. 371
secondary hemorrhage of the cord
in, IV. 370
sepsis of the cord in, IV. 370
spina bifida in, IV. 361
strophulus in, IV. 371
supernumerary digits in, IV. 363
talipes in, IV. 362
tongue tie in, IV. 358
union of digits in, IV. 362
vaginal haemorrhage in, IV. 371
paralysis of, nerve anastomosis in, II.
1059-1060
pyelitis in, II. 805
urinary fistulas at the umbilicus of, II.
278
weaning of, II. 218
<Se also Children.
Infection, avoidance of at operations, I. 83
a principle of treatment, I. 7
following head injuries, I. 885
in gunshot wounds, I. 557
prevention of, I. 557
means of, in tetanus, I. 329
of wounds, I. 555
puerperal, IV. 282-323
Infectious cases, nursing of, I. 41
diseases, acute inflammation of middle
ear, secondary to, III. 902
cold water drink in, I. 158
diet in, I. 158
general treatment of, I. 157-160
nursing of, I. 41
remediable treatment of, I. 159
Infective lesions of bones, I. 889
of the scalp, I. 888
Inflammation, conservative factor of,
I. 10
in non-operative appendicitis, II. 423
Influenza, I. 233-242
bronchial catarrh in, I. 239
cardiac affections complicating, I. 241
chronic, I. 237
complications of, I. 239-242
conjunctivitis complicating, I. 239
convalescent stage of, I. 235
drugs in, I. 233, 234
enlarged cervical glands in, I. 239
frontal sinusitis complicating, I. 239
gastric, I. 236
inflammation of trachea in, III. 798
jaundice complicating, I. 241
mastoiditis in, III. 933
meningitis complicating, I. 241
middle ear disease in, I. 239
nephritis complicating, I. 241
neuralgia following, I. 242
neuritis complicating, I. 241
pharyngitis complicating, I. 239
Influenza (contd.*)
pneumonia complicating, I. 240
prophylaxis of, I. 237
relapsing, I. 235
vaccine therapy in, I. 235, 238
Infra-orbital foramen, alcohol injection
into for neuralgia, II. 1118
Infusion, apparatus for, I. 99, 100
in shock^ I. 98-103
human blood, I. 102
intra-peritoneal, 1. 101
normal saline, I. 98
rectal, I. 99
subcutaneous, I. 99
methods of, I. 98, 100
Injections, intramuscular in malaria, III.
395
intra-spinal, in labour, IV. 379
intra-tracheal, I. 1149
Injuries. See, Wounds.
Inman (A. C.), bacterio-therapeutics of
diphtheria, III. 273-279
meningococcus infection, serum therapy
of, III. 282-283
micrococcus catarrhalis infections,
serum therapy of, III. 282-283
pneumococcus infections, III. 285-286
staphylococcus infections, vaccine
therapy of, III. 288-289
tuberculosis, III. 290-295
tumours, malignant, III. 298-299
typhoid fever, III. 299-300
Inoculation of plague, point of, III. 405
preventive, in plague, III. 284
in typhoid fever, I. 348 ; III. 299
treatment of rabies, Pasteur's method,
I. 264
Insane, general paralysis of, II. 1077
Insanity, II. 1274-1283
and anaesthetics, III. 25
of lactation, IV. 279
of pregnancy, IV. 45
puerperal, IV. 277-278
Insecticides in the tropics, III. 383
Insects, diseases disseminated by, in the
tropics, III. 379
Insomnia, IT. 1014-1024
aetiology of, II. 1014
after abdominal operations, II. 265
application of, vibration in, III. 221
cardio-vascular disease and, II. 1019
chloralamide in, I. 286, 366
complicating gynaecological surgery,
IV. 490
constipation in, II. 1018
general measures in, II. 1016
hydrotherapeutic measures in, II.
1017
hypnotic drugs in, II. 1021
hypnotism in, II. 1021
in children, causes of, I. 54
in gout and gouty conditions. I. 444
in pneumonia, I. 259
in the menopause. IV. 502
simple, hypnotics for, I. 159
60
A SYSTEM OF TREATMENT.
Insomnia (cantd.)
special causes of, II. 1018
toxic, causes of, II. 1015
Instruments employed in amputations of
fingers, I. 804
for abdominal operations, IV. 482
for decapitation, IV. 418
forgynascologicaloperati.ins. IV. 175
for mastoid operation, III. 921
for ovariotomj', IV. 776
for vaginal operations, IV. 482
in abdominal hysterectomy. IV. 642
iu vaginal hysterectomy, IV. 655
preparation of, in obstetric operations,
IV. 374
and sterilisation of, I. 28-30
required in vaginal hysterectomy, IV.
593
sterilisation of, in puerperal sepsis, IV.
288
surgical, for removal of foreign bodies
in the air passages, III. 806
sterilisation of, I. 72
with sterile case in normal labour,
IV. 95
Insufflations, dry, in puerperal vaginitis,
IV. 563
Insufflator for powders to the nose and
throat, III. 697
Intensive baths, III. 126
Inter-arytenoideus muscles, paralysis of,
III. 1844
Interscapulo-thoracic amputation, I. 830
Intertrigo. dusting powders for, IV. 529
Intestinal obstruction, II. 528-540
ainesthetics in operation for, III. 32
cancerous, relief of, I. 142
complicating gynaecological surgery,
IV. -lies
tract, bacterial decomposition in, 1.
450
Intestines, abscesses, with fistulas, II. 485
and bladder, fistulas between, II. 491
and female generative organs, fistulae
between, II. 491
anthrax of, I. 179
antiseptics in typhoid fever, I. 353-356
auto-intoxication arising in, I. 387
bi-mucous fistula? of, II. 490
cancer of, relief of obstruction in, I.
140
care of, after abdominal operations, II.
264
constipation in, enemata for, II. 1."
control of bowels in children, I. 53
dilatation of atonic in infantile con-
stipation, II. 435
diseases of, II. 401
diet in, II. 208
in cholera, III. 425
empty, treatment, in typhoid fever, I.
344
fistula? of, II. 483-492
abscess with, II. 485
anastomosis operations in, II. 487
Intestines, fistulae of (contd.~)
and artificial anus, II. 488
non-operative treatment, II. 484
plastic operations for, II. 486
simple external, II. 483
foreign bodies in, II. 493-4'.i7
cases associated with obstructive
symptoms. II. 495
causing inflammatory symptoms,
II. 494
without definite symptoms, II. 493
gunshot wounds of, I. 565
haemorrhage from complicating typhoid
fever, I. 359
hygiene of, in constipation in adults,
II. 439
in gynaecological surgery, IV. 487
in normal puerperium, IV. 266
injury of, in ovariotomy, IV. 785
internal fistula? of, II. 490
lavage of, in constipation in adults, II.
467
paralytic distension following opera-
tions, II. 271
perforation of, II. 550-558
after-treatment, II. 555
anaesthetic in, II. 551
complicating typhoid fever, 1. 359
incision in, II. 552
location of the lesion in, II. 552
mortality after operation for, II. 556
operation for, II. 551
peritoneal toilet in, II. 554
suture of, II. 552
preparation of in abdominal operations,
II. 259
tajniasis in. III. 617-520
typhoid, perforation of, II. 550
Intoxications, I. 495-502
Intracranial aneurysm, I. 1304
complications of ear disease, 937-943
disease, headache from, II. 1034
Intramuscular injections in syphilis, I.
318
Intraperitoneal haemorrhage complicating
abdominal operations, II. 275
Intratracheal injections in bronchiectasis,
I. 1046
Intratympanic operations, III. 952
Intravenous anaesthesia, III. 35
complications of ear disease, III. 937-943
injection of antitoxin, dosage of, I. 192
in syphilis, I. 320, 322
in tetanus, I. 330
Intubation in laryngeal diphtheria, I. 198
in stenosis of the larynx, III. 865
instruments for, III. 804
Intussusception. II. 541-549
acute, 11. 541
after-treatment of, II. 549
closure of abdominal wound in, II. 546
in newborn child, IV. 371
of appendix, II. 422
steps of the operation in, II. 543
when irreducible, II. 546
61
A SYSTEM OF TREATMENT.
Inunctions in diseases of children. I. 70
in syphilis, I. 319
Iodide of potassium. See Potassium.
Iodides, dosage of in children's diseases,
1.67
in cerebro-spinal syphilis, II. 1065
in chronic rheumatism, I. 490
in inveterate chronic glossitis, II. 136
Iodine, applications of, I. 35
applied to the skin before operations, I.
27
in chronic rheumatism, I. 487
in goitre, II. 62
in syphilis, I. 321
ions, III. 184
in rheumatism. I. 488
preparation of skin with, I. 74
use of, in radical operation for cancer
of breast, II. 967
lodipin in inveterate chronic glossitis, II.
136
lodoform gauze, composition of, I. 77
lodo-glycerin solution, injection of in
spina bifida, I. 913
lodolysin in chronic rheumatism, I. 491
Ionic medication, III. 180-185
in cancer, I. 153
in chronic rheumatism, I. 488
in leucorrhcea, IV. 573
of boils, III. 184
of carbuncles, III. 184
of chronic synovitis, III. 185
of lupus erythematosus, III. 184, 1070
of lupus vulgaris, III. 184, 1150
of rodent ulcer, III. 184, 1133
of trigeminal neuralgia, III. 184
of warts, III. 184
Ions, conversion of, I. 437
doctrine of, in hydrology, III. 114
mineral waters containing, I. 458
Ipecacuanha in chronic dysentery, III. 435
in undefined tropical fevers, III. 411
in whooping cough, I. 380
Iridectomy in mature cataract, III. 624
preliminary, in cataract, III. 619
Iris, diseases of, III. 583-592
injuries of, III. 591
prolapse of, III. 591
tumours of, III. 592
Iritis, acute, III. 583
blisters in, III. 586
complicating small-pox, I. 309
dionin in, III. 586
general treatment of, III. 583
heat in, III. 585
internal treatment of. III. 587
leeches in, III. 586
lotions in. III. 586
recurrent, III. 589
rheumatic, III. 587
serous, complicating gonorrhoea, I. 229
special varieties of, III. 587-589
syphilitic. III. 588
tuberculous, III. 589
vaccine therapy of, III. 281
Iron, contra-indicated in gastric derange-
ments, I. 65
in atrophy of the stomach, II. 294
in chlorosis, II. 21-25
perchloride of, in erysipelas, I. 211
peroxide of, hydrated, in arsenical
poisoning, I. 504
Irritability in general paralysis of the
insane, II. 1079
Irritant poisoning. I. 528-530
Irritation, chronic, as a cause of cancer,
I. 118
counter, in chronic synovitis and
arthritis, I.*748
Irwln and Houston, on vaccine therapy in
typhoid fever, I. 346
Ischaemic paralysis or Volkmann's con-
tracture, I. 940
Ischia spa, III. 151
Ischio-rectal abscess of the anus, II.
601
Ischl spa, III. 151
Isolation in diphtheria, I. 187
in influenza, I. 236
Isotonic waters, III. 115
Itch, coolie, III. 486
Dhobie's, III. 478
water, III. 486
Itching or pruritus, III. 1097-1101
Jaborandi, poisoning by, I. 533
Jackson (Chevalier), new growths of the
laryngo-pharynx, III. 786
of the larynx (malignant), III. 853-
857
of the nasal cavities, III. 692-698
of the pharynx, III. 699-700
Jacques's catheter in cancer of the
stomach, II. 306
Jaffrey (F.), dislocations, I. 713-733
wounds of joints, I. 735-736
Janet's method of urethral irrigation, I.
224
Japanese river fever, III. 390
Jaundice, II. 670-675
and abdominal operations, II. 258
cancer complicating, I. 128
catarrhal, II. 672, 673
chronic haemolytic, II. 674
complicating influenza, I. 241
pregnancy, IV. 53
congenital syphilis and, II. 672
cutaneous haemorrhage in, II. 671
diet in, II. 671
due to biliary cancer, I. 143
in newborn child, II. 672 ; IV. 369
infective, of intestinal origin, II. 672
of umbilical origin, II. 673
mucous haemorrhage in, II. 671
physiological, of newborn infants, II.
672
pruritus in, II. 670
special forms of, II, 672
symptomatic treatment of, II. 670
62
A SYSTEM OF TREATMENT.
Jaw, abnormal development of, III. 1165
ankylosis of, II. 105
benign growths of, II. 109
central myelomata of, II. Ill
cysts of, simple. II. 110
development of, retarded by incorrect
breathing, I. 411
dislocation of, II. 104
treatment of old unreduced cases of,
II. 104
recent cases of, II. 104
epithelial odontomes of, II. 112
fibrocystic disease of, II. 112
fibromata of, II. 109
fibrous ankvl'isis of, II. 186
fractures of, I. 563 ; II. 99-119
dental displacement in. II. 99
epiphora and, II. 100
prevention of facial deformity in, II.
'.lit
ramus of. II. 103
severe grades of extra-articular adhe-
sions in. II. 107
Guerin's fracture of, II. 100
inHaiumatory diseases of, II. 107
lower, fracture of, II. 100
with and without displacement, II.
101
malignant disease of, II. 113
restoration of continuity of, II. 114
malignant disease of, II. 112
mortality of operations on, II. 117
morbid growths of, II. 110
necrosis of, II. 108
curative treatment of, II. 108
prophylactic treatment of, II. 108
operations on, and anaesthetics, III. 26
osteoma of, II. 109
specific infective diseases of, II. 109
upper, fracture of, II. 99
malignant disease of, II. 115
control of haemorrhage in, II. 116
diagnostic operations in, II. 115
limitations of operation in, II. 115
method of anaesthesia in, II. 117
partial or modified operation in, II.
116
removal of lymph glands in II. 116
results of operations for, II. 117
routine operation in, II. 118
treatment, other than operative, II.
118
separation from skull in fractures, II.
100
Jejunostomy for cancer of the stomach,
II. 305
for hour-glass stomach, II. 334
in intestinal cancer, I. 140
Jejunum, perforation of, II. 557
Jez method in typhoid fever, I. 317
Jigger or sand flea (dermatophiliasis).
III.' 481
Johannisbad spa. III. 151
Joints, adhesions in. anaesthetics in
operations for. III. 32
Joints (eontd.')
care of in rheumatism in childhood, I.
279
Charcot's disease of, I. 785
chronic rheumatism of, I. 484
condition of in acute rheumatism, I.
274
diseases of, complicating typhoid fever,
1.363
electro-therapeutics in, I. 746-748
nervous mimicry of, I. 786
non-traumatic, massage in, III. 208
functional derangements of, Zander
treatment in, III. 373
gouty enlargement of, I. 436
local treatment of, I. 438
gunshot wounds of, I. 562, 735
inflammation of. See Arthritis,
mal-positions of, in arthritis deformans,
I. 397
pain in, in fracture, I. 577
sprained, I. 739
stiff, following fractures, massage in,
III. 207
stiffness in, in fractures, I. 577
surgical diseases of, I. 741-788
swelling of, in gout and gouty condi-
tions, I. 438
syphilitic, disease of, I. 784
tuberculous, I. 750-752
Bier's treatment in, I. 751
general treatment of, I. 750
operative treatment of, I. 752
tuberculin in, I. 750
vaccine therapy in, I. 750
wounds of, I. 734-736
Jones (Bence), protein in urine, II. 749
Jones (H. Lewis), electro-therapeutics,
III, 103-110
ionic medication, III. 180-185
Jones (Eobert), surgical treatment of
cerebral palsies of infancy, II. 1157-
llt>4
elbow halter of, I. 777
Jordan (Furneaux), method of disarticu-
lation modified, I. 868
Jothion in chronic rheumatism, I. 488
Jumping exercises in gymnastics, III. 226
Junker's apparatus for anaesthetics, III. 14
inhaler for administration of chloro-
form, III. 16
metal tube for use with, III. 17
Junket, preparation of. I. 4i'
Kala azar, III. 391
Kangri cancer of Kashmir, I. 117
Kaolin in leucorrhoea, IV. 573
insufflations in leucorrhoea, IV. 572
Kaposi's disease, III. 1057
Karlsbad spa. III. 151
Keating-Hart on fulguration in cancer,
I. i:.4
Keith (George and Skene), on treatment
of cancer, I. 149
63
A SYSTEM OF TREATMENT.
Kelly (A. Brown), acute catarrhal pharyn-
gitis, III. 766-767
acute membranous angina, III. 771
acute septic inflammation of the
pharynx and larynx, III. 772-773
chronic catarrhal pharyngitis, III. 768-
769
haemorrhage, pharyngeal, III. 776-777
herpes of the pharynx, III. 778
pemphigus of the pharynx, III. 788
retro-pharyngeal abscess, III. 789-790
ulcerative pharyngitis, III. 795-796
Keloid in wounds, I. 556
of the auricle, III. 879
Ker (Claude), on stimulants in typhus
fever, I. 367
on treatment of lobular pneumonia, I.
245
Keratitis, interstitial, of the cornea, III.
568
sclerosing, of the cornea, III. 570
tuberculous, of the cornea, III. 569
vascular, of the cornea, III. 570
Keratosis obturans of the meatus, III. 885
of the pharynx, III. 779
pharyngo, of lingual tonsil, III. 762
Kerion. Rontgen rays in, III. 1129
Kerr (J. M. Munro), Caesarean section and
Caesarean hysterectomy, IV. 382-402
Kidney belt for movable kidney, II. 788
Kidneys, aberrant vessels of, hydrone-
phrosis with. II. 773
amyloid disease of, II. 839
bilateral calculi of, II. 765
calculus in solitary, II. 766
decapsulation of, in chronic Bright's
disease, II. 799
in eclampsia, IV. 37
diseases of, II. 730
anaesthetics in, III. 24
associated with vascular disease,
cerebral thrombosis due to, II.
1178
climate for, III. 101
complicated by cancer, I. 128
diphtheria, I. 201
headache from, II. 1034
effect of protein on, II. 204
elimination of infection by, I. 10
embolism of, I. 1308
failure of, in poisoning, I. 530, 532
fistulae of, II. 767.
granular, water allowance in, II. 206
growths of, dangers of nephrectomy in,
II. 833
results of, nephrectomy for, II. 833
hydronephrosis of, II. 770-779
injuries to, II. 250
with external wound, II. 783-784
operative treatment, II. 783
without external wound, II. 780-782
operations for, II. 780
results of operation, II. 781-784
movable, II. 785-791
corset for, II. 789
Kidneys, movable (conttl.)
hydronephrosis with. II. 772
operative treatment, II. 789
palliative treatment, II. 786
results of operative treatment, II.
790
selection of cases of, II. 785
truss for, II. 787
nephritis of, non-tuberculous, II. 824
of foetus, congenital cystic disease of,
complicating labour, IV. 180
perinephritic abscess of, II. 801
secretion of in diabetes insipidus, I.
428
stone in. See Calculus, renal,
surgery of, in vesical cancer, I. 143
tuberculosis of, II. 819-829
after-results, of nephrectomy for, II.
828
bilateral, II. 823
nephrotomy for, II. 828
partial nephrectomy for, II. 822
primary results of nephrectomy for,
II. 827
tuberculin treatment of, II. 820
tumours of, in adults, II. 830-835
operation for, II. 831
in children, II. 836
statistics of, II. 836
Kilian's bronchoscopy, III. 806
operation for malformation of the
nasal septum. III. 6S2
Kirstenrs lamp. III. 811
Kissengen spa, III. 151
Kitasato's bacillus in tetanus, I. 329
Klebs-Loffler bacillus in diphtheria, I.
188
Knee, congenital dislocation of, I. 949
contraction of, I. 950
dislocations of, I. 728
hot-air apparatus for, III. 325
leather splint for, I. 766
Knee-bending exercise for flat foot, III.
236
Knee-joint, disarticulation at, I. 859-861
by an anterior elliptical incision, I.
861
indications for, I. 859
hot-air chamber, in hyperaeuiic treat-
ment, III. 64
Miller's disarticulation at, I 861
tuberculosis of, I. 765-772
amputation in, I. 771
caseation and suppuration in, I. 768
deformity after excision, I. 771
excision and erasion in, I. 769
flexion deformity of, I. 767
rest and fixation in, I. 7<!.~>
synovial effusion in, I. 767
weight extension in, I. 767
Kneeling in physical exercises, III. L'29
Knock-knee or genii valgum, I. i5!>
physical exercises for, III. 235
Koch's new tuberculin. III. 293
old tuberculin, III. 293
64
A SYSTEM OF TREATMENT.
Kocher's gastro-duodenostomy for pyloric
stenosis, II. 316
reduction of dislocations, I. 716
Koenig. on infiltrating tuberculosis, I.
890
on mortality of cancer of jaw, II. 118
Koenig' s long flexible silver tracheotomy
tube, II. 74
Kb'rners flap in operation for diseases of
mast process, III. 924
Kraske's method in erysipelas, I. 210
Kraurosis of the vulva, IV. 508
Krause's operation for prurititis ani, II.
597
Kreuznach spa, III. 151
Kronig on pubiotomy, IV. 448
Kronlein's suggestive anaesthesia, II. 117.
Kuhn's mask, I. 1148
Kiister's post-aural operation in diseases
of mastoid process, III. 922, 923
Kyphosis, physical exercises for, III. 236
Kyphotic pelvis complicating labour, IV.
173
Labia, abscess of, complicating gonorrhoea,
I. 229
Labial hernia, IV. 512
Labour, abnormalities of, excluding mal-
presentations, IV. 157
abnormalities of maternal soft parts in,
IV. 157-160
air embolism in, IV. 161-162
anaesthetics in, IV. 376-381
atresia of the cervix in, IV. 158
carcinoma of cervix in, IV. 160
complications of, excluding malpresen-
tations, IV. 157-
contracted pelvis and, IV. 163-175
diagnosis of, IV. 103
diet in treatment of contracted pelvis,
IV. 174
exhaustion of uterus in, IV. 250-251
exostoses of pelvic bones and, IV. 174
false, IV. 103
fibrinous polypus of placenta in, IV.
228
forceps in, dangers of, IV. 430
to hasten delivery in interests of
child, IV. 421
to hasten delivery in interests of
mother, IV. 420
forcible methods of delivery in, dangers
of, IV. 444
by dilatation of cervix, IV. 442
funic souffle in, IV. 104
haemorrhage, accidental after, IV. 28,
29
from shortness of cord after, IV. 29
concealed, after and before, IV. 27, 28
external, after, before and during, IV.
26-28
mixed, after, IV. 28
post-partum, in, IV. 29, 214-223
severe, mixed, before, IV. 28
S.T. I
Labour (contd.)
hypodermic medication in, IV. 378
induction of. IV. 433-437
"intra-spinal injection in, IV. 379
inversion of uterus in, IV. 182-187
ky photic pelvis and. IV. 173
lacerations of genital tract in, IV. 188-
213
malacosteon pelvis and, IV. 172
malposition of cervical canal in, IV.
157
management of, obstetrical bag in, IV.
93
normal, auscultation in, IV. 103
dilatation of os in, IV. 103
management of, IV. 91-127
palpation in, IV. 97, 98
show in, IV. 103
sterile instruments in, IV. 95
uterine souffle in, IV. 104
oblique pelves and, IV. 173
obstruction of, by cystic diseases of
foetus, IV. 180
by deformity of the foetus, IV. 176-
181
by diseases of the foetus, IV. 176-181
local enlargement of tetus, IV.
179-181
laceration of perineum in, IV. 204
of vagina in, IV. 201, 204
of vulva in, IV. 204
osteomalacic pelvis and, IV. 172
ovarian tumours complicating, IV.
773-774
pains of, IV. 103
paralysis associated with, IV. 280
placental polypus in, IV. 228
post-partum haemorrhage in, IV. 29,
214-223
precipitate, IV. 224
premature induction of, dilatation of
cervix in, IV. 439
foetal indications for, IV. 434
for habitual death of foetus, IV. 436
for large foetus, IV. 436
in contracted pelvis, IV. 434
in diseases of pregnancy, IV. 434
in prolongation of pregnancy, IV.
436
insertion of gum-elastic bougie in,
IV. 437
maternal indications for, IV. 434
methods, IV. 437-445
rupture of membranes in, IV. 437
presentations in, breech, IV. 128
brow, IV. 137-139
deformity following, IV. 143
face, IV. 140-143
impacted, IV. 135
neglected, IV. 152
occipito- posterior, IV. 144-146
prolapse of arm in, IV. 151
Schatz's method in, IV. 141
special management of, IV. 128-156
transverse, IV. 150-153
5
A SYSTEM OF TREATMENT.
Labour, presentations in (cowtd.)
twins, IV. 154-156
vaginal examination in, IV. 141
prolapse of the cord in, IV. 147-149
leg in, IV. 149
limbs in, IV. 149
pseudo-osteomalacic pelvis and, IV. 172
pubiotomy in, IV. 446-450
rarer forms of contracted pelvis in, IV.
172-175
retention of placenta complicating, IV.
225-237
rigidity of cervix in, functional, IV.
158
organic, IV. 159
Roberta's pelvis and, IV. 173
rupture of uterus in, IV. 238-247
incomplete, involving perineal coat
only, IV. 242
limited to lower segment, IV. 240-241
severe lacerations of cervix in, IV. 189
spondylolisthetic pelvis and, IV. 173
stages of, first, breech presentation in,
IV. 129
management of, IV. 109
second, breech presentation in, IV.
130
delivery of after-coming head in
breech presentation, IV. 132,
133
episiotomy in, IV. 115
management of, IV. 110
nuchal position of the arm in, IV.
132
rupture of membranes in, IV. 112
support of the perineum in, IV.
113
third, IV. 117
binder in, IV. 125
change of shape of uterus in, IV.
120
control of uterus in, IV. 118
examination of afterbirth in, IV.
123
expression of placenta in, IV. 121
expulsion of placenta in, IV. 119
failure of cord to pull up with
uterus in, IV. 120
increased mobility of uterus in,
IV. 120
lengthening of cord in, IV. 119
ligature of cord in, IV. 117
perineum in, IV. 126
prominence of the hypogastrium in,
IV. 120
retention of placenta in, IV. 229
rising of the fundus in, IV. 120
succenturiate placenta in, IV. 124
vulval pad in, IV. 125
spondylotomy in, IV. 451
sterilised rubber gloves in, IV. 288
symphysiotomy in, IV. 452-460
tonic contraction of uterus in, IV. 248-
249
transverse presentation in, IV. 152
Labour (contd.}
turning in, IV. 461-473
unavailing at term, in extra-uterine
pregnancy, IV. 87
uterine inertia in, IV. 252-255
vaginal examination in, IV. 104
version in, IV. 461-473
Laburnum, poisoning by, I. 533
Labyrinth, anaemia of, III. 967
concussion of, III. 968
destruction of, paroxysmal vertigo
associated with, III. 961
diseases of, acute, III. 958-966
chronic, III. 967-976
hyperaemia of, III. 967
hypersesthesia of, III. 967
hysterical deafness and, III. 968
injuries of, III. 969
Menier's disease of, III. 970
necrosis of, III. 965-966
paroxysmal vertigo of vasomotor
origin, III. 958-960
suppuration of, III. 958-966
tinnitis of, III. 971-973
vertigo of, paroxysmal, and middle ear
suppuration, III. 960-961
Labyrlnthitis, infective, acute. III. 961-
962
vestibulotomy, double in, III. 962
inferior in, III. 962, 963
Lack (H. Lambert), epistaxis, III. 664-666
neuroses of the pharynx, III. 782-783
rhinitis, acute and chronic. III. 701-712
Lactic acid in leucorrhoea, IV. 571
ferment preparations in leucorrhcea, IV.
571
Lacrymal gland, blocking of excretory
passages of, III. 556
diseases and aflEections of, III. 556-558
lacrymation and, III. 556
Lacrymation and lacrymal gland. III. 556
Lactation, insanity of, IV. 279
in secondary amenorrhoea, IV. 747
Lactose, top milk diluted by, in infant
feeding, II. 224
use of in prolonged pyrexia, I. 158
Lacto-serum injections in arterio-sclerosis,
I. 1295
Lake-Barwell epiglottis punch, III. 875
Lake (Eichard), chronic diseases and
affections of the labyrinth, III. 967-
976
nerve deafness or deafness due to dis-
turbance of cochlea division of eighth
nerve, III. 977-978
polyneuritis of the auditory nerve and
affections simulating this condition,
III. 977
syphilis of the internal ear, III. -978
Lake's laryngeal punch forceps, III. 874
Lamalou spa, III. 152
Lamb, chemical composition of. II. 193
Lamblia intestinalis in chronic dysentery,
III. 436
Lamellar cataract, III. 608
66
A SYSTEM OF TREATMENT.
Laminectomy in gunshot injuries, I. 5f>4
in injuries of the spine, I. 906
Landry's paralysis, II. 1080
Lane (J. Ernest), sonorrhoea. I. 223-230
impotence. I. 231-232 ; II. 911-912
soft chancre, I. 315
syphilis, I. 316-324
Lane (W. Arhuthnot), the operative treat-
ment of fractures, I. 634-693
on care of the feet in children, I. 57
on care of nasal passages in children, I.
49
on spinal deformity in children, I. 56
Lane's continuous subcutaneous infusion
apparatus, I. 99
Lange's method in sciatica, II. 1026
Laparotomy, removal of appendix during,
II. 410
Lardaceous disease (albuminoid or amyloid
degeneration), I. 462
Laryngectomy, for new growths of the
larynx, III. 856
partial, for new growths of the larynx,
III. 855
Laryngismus stridulus. III. 827
Laryngitis. III. 831-837
acute, III. 831
chronic, III. 834
complicating measles, I. 245, 247
stridulosa, III. 828
Laryngo-pharynz, new growths on, III.
78(5
Laryngoscope, Bruning's direct, III. 849
Laryngotomy in epithelioma of tongue,
II. 140, 143
in sarcoma of the tongue, II. 145
Larynx, anaemia of, III. 822
cancer of, relief of obstruction in, 1. 142
diphtheria of, I. 194-199
diseases of, III. 803-872
fractures of, III. 825
growths of (benign), III. 846-852
malignant, III. 853-857
extrinsic cases, III. 854
intrinsic cases, III. 853
laryngectomy for, III. 855, 856
palliative treatment of, III. 856
thyrotomy in, III. 854
haemorrhage from, III. 824
hyperaemia of, III. 822
hyperaesthesia of, III. 845
ictus of, III. 841
leprosy of, III. 780
lupus of, III. 838-839
multiple papillomata of, in children,
III. 851
muscles of, intrinsic, paralysis of, III.
841-844
nervous cough of, III. 840
neuralgia of, III. 845
neurosis of, III. 840-845
motor, III. 840
sensory, III. 844
oedema of, III. 858-860
acute inflammatory, III. 858
Larynx, oedema of (contd.)
acute passive, III. 860
non-infective inflammatory, III. 860
secondary inflammatory, III. 859
operations on, III. 846
pachydermia of, III. 846, 850
perichondritis of, III. 861-862
phonetic spasm of, III. 841
septic inflammation of, III. 772
singers' nodules of, III. 851
spasm of, in children, III. 827-830
spasmodic affections of, III. 840
stenosis of, cicatricial, III. 863-867
fixed dilatation in, III. 864
intermittent dilatation in, III. 865
intubation in, III. 865
tracheo-laryngotomy in, III. 866
syphilis of, III. 868-869
tuberculosis of, III. 870-875
curative local treatment of, III. 873
general treatment of, III. 871
indications for treatment in, III.
870
injection of alcohol for relief of pain
in, 1. 135
palliative local treatment of, III, 872
ulceration of, complicating typhoid
fever, I. 361
vertigo of, III. 841
wounds of, III. 825
Larva migrans, III. 482
Lassitude in sanatorium treatment of
pulmonary tuberculosis, I. 1138
Lasts, for weak foot, I. 967
Latham (Arthur), acute endocarditis, I.
1190-1193
bacilluria, II. 751
bronchitis, I. 1049-1058
congenital affections of the heart, 1. 1254
general principles of serum therapy
and vaccine therapy, III. 258-270
pulmonary tuberculosis, I. 1117-1126
rheumatic fever (acute), I: 268-275
serum therapy, summary of doses in,
III. 301-302
tuberculosis (acute), I. 332-334
tuberculosis, tuberculin therapy of, III.
291-298
tul)erculous disease of lymphatic glands,
I. 1344-1347
tuberculous peritonitis, II. 645-647
tumours of the lung, I. 1174
vaccine therapy, summary of doses in,
III. 301-302
Latham (P. W.), on treatment of acute
rheumatism, I. 268
on the treatment of rheumatoid arth-
ritis by counter-irritation of the
spine, I. 405-407
Laurvek spa, III. 152
Lavage, gastric, in atony, II. 288
in cancer of stomach, II. 296
in chronic dilatation, II. 312
in chronic gastritis, II. 349, 353
in hypersecretion, II. 367
67 52
A SYSTEM OF TREATMENT.
Lavage, gastric (contd.')
in infantile hypertrophic stenosis oi
the pylorus, II. 338
in secretory disorders of the stomach
II. 361
intestinal, in constipation, II. 467
Lavey spa, III. 152
Lawson (Arnold), cataract, III. 607-641
diseases and affections of the iris and
ciliary body, III. 583-596
sympathetic ophthalmitis, III. 598-601
Lawson (David), sanatorium treatment of
pulmonary tuberculosis, I. 1127-1158
Lazarus-Barlow's solution in haemorrhage,
I. 1267
Lead colic, I. 512
Lead in pruritus, III. 1099
lotion in erysipelas, I. 210
salts of, poisoning, I. 529
unsuitable remedy for children, I. 67
Lead neuritis, II. 1137, 1139
Lead poisoning, I. 512-515
dropped-wrist, due to, I. 991
paralysis in, I. 513
prevention of, I. 514
saturnine encephalopathy in, I. 514
Leamington spa, III. 152
Leather goods, disinfection of, I. 162
Lednc's ionisation in rheumatism, I. 488
Leeches, application of, I. 35
in iritis, III. 586
Leg, amputations through, I. 850-859
bowing of in rickets, I. 481
constant pain in, hypnotism in case of,
III. 172
elephantiasis of, III. 516
exercises in defective embolism, III. 255
protection of, in children, I. 50
See also Fractures.
Legg (T. P.), foreign bodies in the
oesophagus, II. 184-189
goitre, II. 62-71
inflammation of parotid gland, II. 157-
163
injuries and diseases of neck, II. 164-
170
malignant disease of thyroid, II. 73-74
simple stricture of cssophagus, II. 171-
183
surgical treatment of inflammatory
affections of thyroid, II. 53
surgical treatment of exophthalmic
goitre, II. 58-61
Leitch (A.), on vaccine treatment of
cancer, I. 152
Letter's cold coil apparatus, III. 919
tubes in sprains, 1. 738
Lembert's suture, II. 282
Lemonade, preparation of, I. 42
Lenhartz diet, II. 210
Lenk spa, III. 152
Lens. See Crystalline lens.
Lentigo (freckles), III. 1058
Leontiasis ossea, II. 1236
Leopold on pubiotomy, IV. 449
Lepine (R.), on pregnancy in diabetes, I .
425
Leprosy, III. 447-453
general treatment of, III. 448
local treatment of, III. 450
medicinal treatment of, III. 449
Nastin treatment of, III. 452
of the larynx, III. 780
of the nose, III. 780
of the pharynx, III. 780
prophylaxis of, III. 447
serum treatment of, III. 451
surgical treatment of, III. 450
Leptothrix, III. 1058
Leube (V.) diet, II. 210
Lencocytosis, artificial, in peritonitis, II.
637
promotion of, in infective endocarditis,
1.204
Leucomata of the tongue, II. 137
Leucoplakia, preceding carcinoma, I. 117
Leucorrhoaa, IV. 555-574
after curettage, IV. 627
as an increase of altered secretions, IV.
558
as an increase of the physiological
secretions, IV. 556
as a simple increase of normal secre-
tions, IV. 557
due to general diseases, IV. 557
due to pathological changes in the
mucosa, IV. 559
from affections of cervix, IV. 566
from affections of corpus uteri, IV.
568
from Fallopian tubes, IV. 571
from operations, IV. 570
ionic medication in, IV. 573
kaolin in, IV. 572
lactic acid in, IV. 571
lactic ferment preparations in, IV.
571
milk, IV. 559
normal secretions in, IV. 556
of menopause, IV. 557
of pregnancy, IV. 557
post-menstrual, IV. 557
post-sexual, IV. 557
replacing menstruation, IV. 557
uterine, IV. 565
spa treatment in, IV. 571
vaccine treatment in, IV. 572
vaginal, IV. 561
due to tumours, IV. 557
vulvar, IV. 559
yeast in, IV. 572
Leukaemia, II. 38-42
general treatment, II. 38
lymphatic, II. 41
medicines in, II. 39
pseudo-, II. 42
spleno-medullary, II. 38
complicating pregnancy, IV. 55
X-rays in, III. 363
X-rays application in, II. 39
68
A SYSTEM OF TREATMENT.
Leukoplakia buccalis, II. 126
of the tongue, II. 137
Levico spa, III. 152
Lichen planus, III. 1061-1064
chronic, X-rays in, III. 351
general treatment, III. 1061
local treatment, III. 1063
prognosis in. III. 1061
Lichen scrofulosorum, III. 1151
urticatis. III. 1154-1156
Lichenification, III. 1059-1060
general treatment of, III. lo.v.i
local treatment of, III. 1059
Rontgen rays in, III. 1060
Liebeault and mesmerism, III. 161
method of hypnotism, III. 164
Ligamentum patella, rupture of, II. 1328
Ligation of arteries in haemorrhage, 1. 559
Ligatures, catgut and silk, sterilisation of,
I. 72
in ovariotomy, IV. 776
material for gynaecological operations,
IV. 482
Light, arc, III. 186
concentrated, III. 199
bath, III. 187
and projector, III. 188
blue incandescent lamp in, III. 193
blue, III. 187
cabinet, III. 187
concentrated incandescent, III. 196
energy, concentrated, treatment by, III.
196
exposure of the body to, IIP. 187
incandescent, III. 186
red, III. 187
incandescent lamp in, III. 193
therapeutic effect of, III. 189
treatment by various forms of, III.
186
general exposure to, III. 187
in gynaecology, III. 201
in pulmonary tuberculosis, III. 201
in small-pox. I. 307
local, treatment by, III. 194
precautions in giving. III. 189
Lillingston (Claude) and 8. Yere Pearson,
the treatment of pulmonary tuber-
culosis by the induction of an arti-
ficial pneumothorax. 1. 1164
Limbs, diathetic neuralgia of, II. 1024
extremities, application of vibration to,
III. 220
foetal prolapse of, in labour. IV. 149
involuntary movements of, in hemi-
plegia, II. 1188
lower and upper, varix of, I. 1311-1320
lower, acquired deformities of, I. 958-
970
congenital deformities of, I. 943-958
in cerebral palsies of infancy, II.
1159
neuralgia, diathetic affecting, II. 1122
toxic, affecting, II. 1122
toxic neuralgia of, II. 1024
Limbs (contd.)
upper, deformities of, I. 935-943
in cerebral palsies of infancy, II. 1162
paralytic deformities of, I. 990
spastic hemiplegia of, II. 1064
See alao Arm and Leg.
Limp, intermittent, II. 1234-1236
Linen, small, disinfection of, I. 161
Lingual tonsil, benign tumours of, III. 762
diseases of, III. 760-763
chronic abscess of, III. 762
malignant diseases of, III. 762
tonsillotome, III. 761
tonsillitis, acute, III. 760
chronic, III. 761.
Liniments in arthritis deformans, I. 396
in chronic rheumatism, I. 487
in joint affections, I. 748
salicylate, in muscular rheumatism, I.
493
Linseed poultices, I. 33
Lint, value of, I. 79
Lipomata, diffuse, thyroid extract in, 1. 108
length of incision required in, I. 107
of muscle, II. 1325
of the scalp, I. 893
of the vulva, IV. 511
surgical treatment of, I. 106
Lipcmatosis, symmetrical, I. 108
Lips, acquired deformities of, II. 96
carcinoma of, I. 124
diseases of, II. 85-98
epithelioma of, II. 98
inflammation of, II. 96
new growths of, II. 97
wounds of, II. 96
Lipuria, II. 737
Lisdoonvarna spa, III. 152
Lisfranc's amputation of the foot, I. 836
Cooper's modification of, I. 840
Hey's modification of, I. 840
Skey's modification of, I. 840
disarticulation of the metatarsus, I. 837-
839
Lister's (Lord) amputation, I. 852
head and neck bandage, I. 87
methods of, I. 80
strong solution, preparation of, I. 73-81
transcondyloid amputation, I. 862
Listen's splint for fracture of the femur,
I. till-617
in hip disease, I. 754, 762
Lithium, ionisation with, I. 488
Litholapaxy, in vesical calculus, II. 854, 855
Lithotomy, median perineal, for vesical
calculus, II. 856
supra-pubic for vesical calculus, II. 856
vaginal, IV. 877
Lithuria, II. 738
Little's palsy, I. 886
Liver, abscess of, intra-hepatic, II. 648
needle in search of pus in, II. 650
operations for, II. 652
by abdominal incision, II. 654
when pus is supra-hepatic, II. 652
69
A SYSTEM OF TREATMENT.
Liver, abscess of (contd.}
pulmonary complications of, II. 655
pus in, II. 649
sub-hepatic, II. 649
supra-hepatic, II. 648
surgical aspects, II. 648
symptoms which suggest operation in,
II. 649
trans-thoracic operation by incision,
II. 654
trans-thoracic operation by trocar
and cannula, II. 652
acute yellow atrophy of, II. 657-658
amyloid, II. 675
aneurysm of hepatic artery of, II. 667
anomalies of, II. 659
cirrhosis of, II. 631, 660-665
common, II. 660-663
complicating cancer of the breast, II.
966
haemorrhage in, II. 329
infantile, III. 439
portal, II. 660-663
early stages of, II. 660
hsemorrhagic tendencies in, II. 663
late stages of, II. 662
prophylactic treatment of, II. 660
degeneration of, II 668
diseases of, II. 648
mineral waters and baths in, III.
139
enlargement of complicating typhoid
fever, I. 360
gunshot wound of, II. 251
fatty, II. 668
functional derangement of, II. 668
hepatoptosis of, II. 659
hydatid cysts of, II. 669
enucleation in, II. 669
incision and drainage in, II. 669
injuries of, II. 250
lardaceous, II. 675
linguiform of, II. 659
obstruction of veins of, II. 667
partial hepatoptosis of, II. 659
Riedel's lobe of, II. 659
secondary malignant growths of, II. 679
suppurative pylephlebitis of, II. 666
syphilitic cirrhosis of, II. 665
tear of, II. 250
torpor of, in gout and gouty conditions,
1.442
tropical, II. 676-678
and malaria, II. 676
dyspepsia and, II. 678
excessive heat and, II. 677
over-eating and over-drinking, II. 677
tumours of, II. 679
vascular diseases of, II. 666
wandering, II. 659
Llandrindod spa, III. 152
Llangammarch spa, III. 152
Llanwrytd spa, III, 152
Llewelyn (L. Jones), arthritis deformans,
I. 391-399
Llewelyn, (L. Jones) (contd,.')
osteo-arthritis, I. 400-403
spondylitis deformans, I. 404
Lochia in normal puerperium, IV. 257,
262
Lockyer (Cuthbert) inversion of uterus in
labour, IV. 182-187
lacerations of the genital tract in
labour, IV. 188-213
post-partum haemorrhage, IV. 214-223
retained placenta, IV. 225-237
rupture of the uterus, IV. 238-247
Locomotor ataxy, II. 1085-1092
Loeche-les-Bains spa, III. 152
Longhurst's combined chloroform tube
and tongue depressor, III. 29
Lordosis, physical exercises for, III. 239
Loreta's operation, II. 317
stretching operation in hypertrophic
stenosis of the pylorus, II. 339, 342
Lotheissen's operation for femoral hernia,
II., 511
Lotions after cataract extraction, III. 633
boiled water in preparation of, I. 73
evaporating, I. 36
in acute gout, I. 433
in herpes zoster, II. 1096
in iritis, III. 586
for pruritus, IV. 530
for vulvitis, IV. 530
Love (James Kerr), deaf mutism, III.
979-981
Low (G. C.), acute dysentery, III. 428-
432
Bilharzia disease, III. 498-500
cholera, III. 423-427
diseases of obscure origin, III. 465-469
epidemic gangrenous proctitis, III. 437
filariasis, III. 503
hill diarrhoea, III. 438
infantile biliary cirrhosis, III. 439
ponos, III. 440-441
tropical liver, II. 676-678
Luc's nasal biting forceps, III. 693
Lucae's pressure probe in massage of
tympanic membrane, III. 952
Lucan spa, III. 152
Lucca spa, III. 152
Luchon spa, III. 152
Ludwig's angina, treatment of, I. 183
Luff (Arthur P.), gout and gouty con-
ditions, I. 432-461
Lumbago, mineral waters and baths in,
III. 142
Lumbar puncture, II. 1025-1026
in cerebral concussion, I. 879
in eclampsia, IV. 38
in hydrocephalus, II. 1191
in meningitis, I. 251
in tuberculous meningitis, I. 249
methods of, I. 251-252
Lunacy in pellagra, I. 523
See also Insanity and Mental diseases.
Lungs, abscess of, I. 1059
following pneumonia, I. 1060
70
A SYSTEM OF TREATMENT.
Lungs, abscess of (contd.)
surgical treatment of, I. 1060-1062
actinomycosis of, surgical treatment of,
I. 1175
aspergillosis of, I. 1116
atelectasis and collapse of, I. 1063-1065
collapse of, I. 1065
congestion of, acute, I. 1076
chronic, I. 1077
hypostatic, I. 1079
and oadema of, I. 1076-1081
decortication of, in empyema, I. 1108
diseases of, I. 1059-1175
breathing exercises in, III. 249
complicating gynaecological surgery,
IV. 494
physical exercises in, III. 249
effect of ammonia on, I. 527
embolism of, after abdominal opera-
tions, II. 275
complicating the puerperium, IV.
324-325
expansion of, correct breathing neces-
sary for, I. 49
in generalised empyema, I. 1104
gangrene of, I. 1090
hernia of, I. 1027
hydatid cyst of, I. 1175
hypcracute or fulminating forms of
oedema of, I. 1080
injuries to, I. 1028
oedema of, I. 1081
and congestion of, 1. 1076-1081
operation when hepatic abscess has
burst through, II. 655
tuberculosis of, I. 1117-1126
See also Tuberculosis, Pulmonary,
tumours of, I. 1174
surgical treatment of, I. 1175
want of expansion of, in empyema, I.
1107
Lupus, III. 1146
cauterisation in, III. 1149
crusted and ulcerated, X-rays in, III. 352
erasion in, III. 1149
excision in, III. 1146
Finsen light in, III. 1147
frequent source of carcinoma, I. 117
ionisation in, III. 184, 1150
of the auricle, III. 881
of the larynx, III. 838-839
of the nares, III. 687
of the naso-pharynx, III. 742
of the pharynx, III. 781
of the tonsil, III. 757
of the vulva, IV. 508
pyrogallic acid in, III. 1150
radium in, III. 1150
Rontgen rays in, III. 352, 1148
salicyclic acid in, III. 1150
scarification in, III. 1141)
silver nitrate in, III. 1150
vaccine therapy of, III. 1150
verrucosus, X-rays in, III. 352
Vienna paste in, III. 1150
Lupus erythematosus, III. 1065-1072
direct causes, III. 1066
Finsen light in, III. 1071
general treatment, III. 1066
ionic medication of, III. 184
ionisation in, III. 1070
local treatment, III. 1067
predisposing causes, III. 1065
radium in, III. 1071
solid carbon dioxide in, III. 1071
Luxeuil-les-Bains spa, III. 153
Luy's method of hypnotism, III. 165
Lying-in, length of in normal puerperium,
IV. 270
Lymph, flow of, increase of, I. 438
Lymphadenoma, I. 1341-1343
Lymphangiectasis, cavernous, of the lym-
phatic vessels, I. 1351
cystic, of lymphatic vessels, I. 1351
rllarial, III. 516
simple, of lymphatic vessels, I. 1351
Lymphangioma of neck, II. 169
proper of lymphatic vessels, I. 1352
Lymphangiomatous tumours of the scalp,
I. 893
Lymphangioplasty in brawny arm of
cancer, I. 144
Lymphangitis, acute, complicating gonor-
rhoea, I. 226
filarial, III. 503
of lymphatic vessels, I. 1352
Lymphatic glands, carcinoma of, 1. 124, 125
diseases of, I. 1339-1344
secondary to infective processes, I.
1339
removal of in malignant disease of
upper jaw, II. 116
sarcomatous secondary deposits of, I.
135
tuberculous disease of, I. 1344
general measures in, I. 1345
tuberculin in, I. 1346
varicose, III. 516
leukaemia, II. 41
system, anatomy of, and permeation
theory, I. 126
vessels, I. 1351-1352
cavernous lymphangiectasis of, 1. 1351
cystic hygroma of, I. 1351
cystic lymphangiectasis of, I. 1351
diseases of, I. 1339-1340
lymphangioma proper of, I. 1352
lymphangitis of, I. 1352
simple lymphangiectasis of, 1. 1351
Lymphorrhoea of lymphatic vessels, I.
1351
Lymphosarcoma of glands, I. 1350
McBurney's incision in appendicitis, II.
411
MacCormac (Sir W.) on cancerous secon-
dary growths, I. 125
Macdonald (Sydney G.), calculus of the
bladder, II. 852-857
71
A SYSTEM OF TREATMENT.
Macdonald (Sidney G.) (contd)
cystitis, II. 858-860
diverticula and sacculi of the bladder,
II. 864-865
ectopia vesicae, II. 866-869
injuries of the bladder, II. 868-869
tuberculous cystitis, II. 861-863
tumours of the bladder, II. 870-873
McEwen's operation for inguinal hernia,
II. 507
Maclntyre's splint in fractures of the
femur, I. 618
Mackenzie (Hector), pleurisy and effusion
(sero-fibrinous), I. 1093-1098
Mackenzie (James), general treatment of
diseases and affections of the heart, I.
1194-1254
Mackenzie's laryngeal forceps, III.
847
McKenzie's pillar separator in operations
on tonsil, III. 752
Mackintosh sheets, use of, I. 30, 31
Mackintoshes, arrangement of before
operation, I. 84
MacLeod (J. M. H.), acne vulgaris, III.
982-990
alopecia, III. 992-1004
boils or furuncles, III. 1006-1111
carbuncles, III. 1012-1014
chromidrosis or coloured sweating, III.
1021
comedones, III. 1022-1023
granulosis rubra nasi, III. 1041
hyperidrosis or excessive sweating, III.
1044-1045
hypertrichosis, III. 1046-1052
impetigo, III. 1054-1056
leptothrix, III. 1058
lichenification, III. 1059-1060
lichen planus, III, 1061-1064
lupus erythematosus, III. 1065-1072
parapsoriasis, III. 1085
pityriasis rosea, III. 1090-1091
pruritus or itching, III. 1097-1101
pruritus ani, III. 1102-1105
pruritus vulvae, III. 1106-1108
psoriasis, III. 1109-1123
sporotrichosis, III. 1143
tropical skin diseases, III. 470-486
verruga Peruviana, III. 459-460
Macnamara (E. D.), cocainism, I. 505
dementia praecox, II. 1305
exhaustion psychoses, II. 1299-1300
idiocy and feeble-mindedness, II. 1318-
1320
insomnia, II. 982-992, 1014-1024
mania, II. 1284-1289
masturbation, II. 1316-1317
melancholia, II. 1290-1298
mental aspects of epilepsy, II. 1310-
1312
mental aspects of hysteria, II. 1306-
1308
mental diseases, II. 1274-1283
morphinism, I. 516-520
Macnamara (E. D.) (contd.*)
obsessive and imperative ideas, II.
1313-1314
paranoia, II. 1309
perversions, II. 1315
psychoses associated with changes in
thyroid gland, II. 1301-1302
toxic psychoses, II. 1303-1304
Macrodactyly, I. 943
Maddox (E. E.), diseases and affections of
the ocular muscles, III. 646-655
Madeling's deformity of the wrist. I. 939
Madura foot, III. 485
Maggots in the nose, III. 669
Magnesium in arsenical poisoning, I. 504
peroxide, in hyperchlorhydria, I. 442
sulphate of, in constipation in adults,
II. 449
in lead poisoning, I. 514
in tetanus in puerperium, IV. 326
Mail-carts for young children, use of, I.
52
Maize diet, cause of pellagra, I. 521
Malacosteon pelvis complicating labour,
IV. 172
' Maladie de Woillez," I. 1076
Malaria, III. 392-398
after-treatment of, III. 397
coma in, II. 985
complicating pregnancy, IV. 48
intramuscular injections in, III. 395
medicinal prophylaxis of, III. 392
mineral waters and baths in. III. 143
neuritis in, II. 1131
prevention of, III. 380
prophylaxis of, III. 392
quinine in, III. 392-394
rectal administration of quinine in, III.
396
spleen in, II. 81
treatment of an attack of, III. 394
tropical liver and, II. 676
Male fern in bilharzia disease, III. 499
Malformations of the anus, II. 613
of the colon, II. 582-587
of the external ear, III. 876
of the meatus, III. 882
of the nails, III. 1082
of the nasal septum, III. 678
of the nose, III. 671-677
external and internal, III. 672-673
of the oesophagus, II. 189
of the teeth, III. 1165
of the tympanic membrane, III. 891
of the uterus, IV. 711-717
of the vagina, IV. 541-544
of the vulva, IV. 513-514
Malignant cyst of the neck, II. 169
degeneration of simple tumours, I. 119
disease, aetiology of, I. 116-119
and cholelithiasis, II. 695
of the appendix, II. 411
of the auricle, III. 878
of the breast, II. 963-975
of the lingual tonsil, III. 762
72
A SYSTEM OF TREATMENT.
Malignant disease (contd.)
of the nasopharynx, III, 700
of the penis, II. 877-878
of the uvula, III. 746
of the vulva, IV. 51 5-5] 6
X-rays in, III. 362
See also Cancer, Sarcoma and
Tumours.
epulis of the jaw, II. 110
growths, fistula; of uterus from, IV.
668
in the lower pharynx, III. 786
of the maxillary antrum, III. fi'.'i; -
of the meatus, III. 883
of muscle, II. 1325
of the nasal cavities, III. 694
of the oro-pharynx, III. 785
of the rectum, II. 625
ovarian tumours, IV. 770
stricture of the oesophagus, II. 175
tumours, Coley's fluid in, III. 292
of the tonsil, III. 758
Malignant pustule, I. 179
Malingering in spinal injuries, I. 901
Mallet finger, I. 943
Malleus incus, removal of, III. 913-915
Malta fever, III. 399-400
Mammary artery, internal, wounds of, I
1025
Manganese in chlorosis, II. 27
Mania, II. 1284-1289
acute, in epilepsy, II. 1005
delirious, acute, II. 1289
medicinal treatment of, II. 1287
puerperal, hypnotism in case of, III.
173
Manometer, Leonard Hill's, I. 1281
Marasmus, I. 463
dietetic treatment of, I. 466
drugs in, I. 466
following measles, I. 247
in spina bifida, I. 915
in newborn child, IV. 370
prophylaxis of, I. 463
sea water, injections in, I. 467
Marching, equipment for, I. 536
Margate, climate of, III. 84
Marienbad spa, III. 153
Marine baths, III. 129
Marriage and chlorosis, II. 31
and epilepsy, II. 1002
and female sterility, IV. 843
Martigny spa, III. 153
Martin's rubber bandage for ulcers, I.
371, 372
splint for fracture of the jaws, II. 114
mercurial instrument for test of blood
pressure, I. 1281
Masks, use of, in surgical operations, I. 81
Mason's gag in anaesthetics, III. 2
Massage, III. 203-212
abdominal in membranous colitis, II.
565
after abdominal operations, II. 268
callus formation and, I. 579
(contd.*)
effleurage in, III. 203
friction and, III. 204
in acute anterior poliomyelitis, II. 1056
in acute gout, contra-indicated, I. 438
in adhesions of the colon, II. 559
in alopecia areata, III. 996
in arthritis deformans, I. 398
in atony of the stomach, II. 287
in chorea, II. 1263
in constipation, II. 463
in facial paralysis, II. 996, 1094
in flat foot, I. 969
in fracture of head of radius, I. 599
in non-traumatic joint affections, III.
208
in paraplegia, II. 1198
in diseases of the heart, I. 1210
in fractures, I. 577-579
in orthopaedic cases, III. 233
in osteo-arthritis, I. 402
in pulmonary tuberculosis, I. 1139
in Raynaud's disease, I. 218
in rheumatism (chronic), I. 488
(muscular), I. 494
in sprains, I. 737, 740
in tabes dorsalis, II. 1091
in varix of lower extremities, I. 1312
of the breasts for painful engorgement,
IV. 332
of the neck, III. 209
of the tympanic membrane, III. 952
of the tympanic ossicles, III. 952
of the uterus, in retroversion, IV. 673
petrissage and, III. 204
tapotement and,. III. 204
therapeutical indications of, III. 206
vibration, III. 204
vibratory, in chronic rhinitis, III. 709
Mastitis at puberty, II. 960
chronic interstitial, II. 961
lobar. II. 961
lobular, II. 961
in infants, II. 960
in newborn child, IV. 371
in the puerperium, IV. 334-335
Mastoid abscess, Bezold's, III. 932
antrum, opening of, Schwartze s opera-
tion, III. 898
cells, inflammation of, acute primary,
III. 919
suppuration of, in acute inflammation
of middle ear, III. 897
operation, III. 920-921
instruments for, III. 921
preparation of patient, III. 920
periostitis. III. 919
process, diseases of, III. 919-932
after-treatment of operation cases,
III. 927
Ballance's operation in, III. 929
Bergmann's post-aural operation in,
III. 922, 933
Kuster's post-aural operation in, III.
922, 923
73
A SYSTEM OF TREATMENT.
Mastoid process (contd.~) -
Schwartze's post-aural operation in,
III. 922, 923
Stacke's post-aural operation in, III.
922, 923, 926
Mastoiditis, diabetic, III. 932
influenzal, III. 932
latent, III. 933
Masturbation, II. 1316, 1317
in epilepsy, II. 992
Matas (Rudolf), on haemorrhage, I. 1266,
1270
Matas's operation in traumatic aneu-
rysms, I. 560
Metatarsals, fracture of, I. 633
Matico, infusion in epidemic gangrenous
proctitis, III. 437
in haemorrhage, I. 1261
Matlock Bath, III. 153
Maxillary alveolus, dentigerous cyst of,
III. 719
antrum, malignant growths of, pallia-
tive treatment, III. 697
sinus, III. 721-727
suppuration of, III. 721
Mayer's tonsil enucleator, III. 753
Mayo's operation for umbilical hernia, II
513
scissors, IV. 476, 477
Meals, arrangement and composition of,
for diabetes, I. 414, 419
in obesity, I. 471
daily number of, for children, I. 62
hypersecretion and, II. 209
nature of, and gout, I. 449, 455
Mealies, chemical composition of, II. 195
Measles, I. 243-247
acute inflammation of middle ear in, III.
902
bronchitis and, I. 245
cancrum oris complicating, I. 247
care of eyes in, I. 246
croup and, I. 245
diarrhoea and, I. 246
diet in, I. 244
fever and, I. 244
glandular affections in, I. 246
. laryngitis complicating, I. 245, 247
lobular pneumonia in, I. 245
marasmus following, I. 247
otorrhoea in, I. 246
quinine in convalescence from, I. 65
stomatitis and, I. 246
Meat broths in typhoid fever, I. 342
diet in gout, I. 452
in sprue, III. 443
dietary for children, directions for, I. 59
extracts in typhoid fever, I. 342
Meatus, congenital atresia and webs of,
111. 882
cutaneous diseases of, III. 884
diphtheria of, III. 883
diseases of, III. 883
eczema of, III. 886
exostoses of, III. 883
Meatus (contd.)
fibroid polypi of, III. 882
foreign bodies in, III. 888
granulations of, III. 882
hypersecretion of cerumen in, III. 884
herpes of, III. 885
inflammations of, III. 885
keratosis obturans of, III. 885
malformations of, III. 882
malignant growths of, III. 883
neuroses of, III. 884
new growths of, III. 882
otalgia of, III. 884
otomycosis of, III. 886
otitis externa, circumscripta of, III. 885
croupous, III. 884
diffusa of, III. 886
haemorrhagic, III. 886
papillomata of, III. 883
secretion of, deficient, III. 885
stenosis of, III. 882
syphilis of, III. 883
vascular caruncle of, IV. 512
Medical sciences, advance of, influence of,
in treatment, I. 1
Medicines. See Drugs.
Mechanical supports for varix of lower
extremities, I. 1313
vibration, III. 213-221
Meckel's diverticulum, II. 277
Mediastino-pericarditis, chronic and ad-
herent pericardium, I. 1186
Mediastinum, caseating tuberculous
glands in, I. 1176
inflammation of, surgical treatment of,
I. 1176
injuries of, I. 1031
new growth in, I. 1178
Mediterranean fever, III. 399
Melaena in newborn child, IV. 370
Melancholia, II. 1290-1298
acute stage of, II. 1291
electricity in, II. 1294
feeding in, II. 1292
opium in, 1297
psychotherapy in, II. 1295
hypnotism in case of, III. 171
with delusions, hypnotism in case of,
III. 173
Melanoderma, III. 1073
Melanuria, II. 741
Membrana flaccida shrapnelli, perforation
of, in epitympanic suppuration, III.
912
Membranes, perforation of, in accidental
haemorrhage during pregnancy, IV.
25
rupture of, in inducing abortion, IV.
436
in second stage of labour, IV. 112
Menier's disease of the labyrinth, III. 970
Meningeal artery, middle, haemorrhage
from, I. 1275
Meninges cerebral, direct drainage from,
in purulent meningitis, I. 252
74
A SYSTEM OF TREATMENT.
Meningitis, cerebro-spinal, I. 250
complicating pregnancy, IV. 49
chronic basilar, I. 253
complicating diseases of the ear, III.
937-939
influenza, I. 241
typhoid fever, I. 362
forms of infection in, I. 251
meningococcus, I. 250
palliative measures and general points
in treatment in, I. 253
pneumococcus, I. 250
purulent, drainage by limber puncture,
I. 251
specific treatment of the infective
process in, I, 249
spinal gummatous, II. 1068
streptococcus, I. 250
tuberculous, drainage in, I. 249
non-specific measures in, I. 248
specific measures in, I. 249
Meningocele concealed in lipoma, I.
107
cranial, II. 1194
in spina bifida, I. 914
of newborn child, IV. 357
Meningococcus infection, Flexner's anti-
meningitis serum in, III. 282
serum therapy of, III. 282-283
meningitis, I. 250
Meningo encephalitis. I. 885
Menopause, dyspepsia in, IV. 501
effect on metabolism. I. 389
flushes of heat in, IV. 502
insomnia in, IV. 502
leucorrhoea in, IV. 557
management of, IV. 501-503
menorrhagia in, IV. 503
mental irritability in, IV. 502
metorrhagia in, IV. 503
nervous depression in, IV. 502
neurasthenia in, IV. 503
overstrain in, IV. 503
polysarcia abdominalis in, IV. 501
tachycardia in, IV. 502
Menorrhagia, IV. 751-764
curettage in, IV. 758
douches in, IV. 756
drugs in, IV. 754
electrical treatment of, IV. 762
ergot in, IV. 754
general treatment, IV. 752
. hydrastis canadensis in, IV. 755
hysterectomy in, IV. 763
in the menopause, IV. 503
in puberty, IV. 501
intra-uterine applications in, IV. 758
obphorectomy in, IV. 763
plugging in, IV. 757
steaming the uterus in, IV. 760
Menorrhoea, crypto-, IV. 732
Menstruation, disorders of, IV. 725-764
establishment of, IV. 499
hidden, IV. 732
leucorrhoea replacing, IV. 557
Menstruation (contd.}
operations during, III. 24
scanty, IV. 725, 734
Mental aspects of epilepsy, II. 1310-1312
of hysteria, II. 1306-1308
cough in pulmonary tuberculosis, I.
1144
diseases, II. 1274-1283
certification in, II. 1278
general considerations of, II. 1274
in pregnant women, IV. 46-58
prophylaxis of, II. 1279
See also Insanity, &c.
irritability in the menopause, IV. 502
torticollis, II. 1052
Mercurial inunctions, I. 70
in disseminated sclerosis, II. 1072
in syphilis, I. 319
ointment in goitre, II. 63
poisoning, treatment of, I. 530
purgatives in constipation in adults, II t
450
stomatitis, II. 125
Mercury, biniodide of, in treatment of
actinomycosis, I. 177
effect of, on children, I. 68
in arterio-sclerosis, I. 1292
in cerebro-spinal syphilis, II. 1065
in syphilitic affections of the vulva,
520
ulcers of tongue, II. 135
in tabes dorsalis, II. 1086
in undefined tropical fevers, III.
410
percentage of in cyanide gauze, I. 76
perchloride of, as disinfectant, I. 339
in lotions, I. 73
strength of solution, I. 81
in typhoid fever, I. 353
in trypanosomiasis, III. 421
treatment of syphilis by, I. 317
Mesenteric arteries, embolism of, I. 1307
Mesentery, injuries to, II. 252
Mesmer's method of inducing hypnotism,
III. 163
Mesocolon, operation for shortening, in
volvulus of colon, II. 592
Mesometrium, cyst of, IV. 769
Mesosalpinx, cyst of, IV. 768
Mesotan liniment in rheumatism, I. 487
Metabolism, defective, exercises in diseases
associated with, III. 254
disorders of, in constitutional diseases,
I. 386-390
influence of climate on, I. 460
Metacarpal bones, fractures of, I. 604
bone, excision of head of, I. 810
Metacarpo-phalangeal joints, amputation
and disarticulation at, I. 807-811
Metal splints for fractures, I. 574
suspension splint for the ankle, I. 773
Metallic poisoning due to poisonous
metals in tinned foods, I. 510
Metals, poisonous, in tinned foods, poison-
ing due to, I. 510
75
A SYSTEM OF TREATMENT.
Metastasis of carcinoma, permeation
theory of, I. 124, 126
Metatarsalgia, Morton's neuralgia, I.
964
Metatarsus, amputation of. I. 830
disease of, I. 773
Lisfranc's disarticulation of, I. 837-839
MetchnikofFs curdled milk in achylia,
II. 295
sour milk in cancer of the stomach, II.
298
Methyl, bichlorinated chlorate as anaes-
thetic, III. 13
Methylene blue in bilharzia disease, III.
499
in chronic dysentery, III. 436
Metritis, sterility and, IV. 845
Metrorrhagia, IV. 751-764
curettage in, IV. 758
douches in, IV. 756
. drugs in, IV. 754
electrical treatment of, IV. 762
ergot in, IV. 754"
general treatment, IV. 752
hydrastis canadensis in, IV. 755
hysterectomy in, IV. 763
in the menopause, IV. 503
intra-uterine applications in, IV. 758
oophorectomy in, IV. 763
plugging in, IV. 757
steaming the uterus in, IV. 760
Micrococcns catarrhalis infections, vaccine
therapy of, III. 283
melitensis in goat's milk, III. 384
neoformans vaccine in cancer, 1. 152
vaccine therapy of, III. 299
Micro-organisms, virulent, conservative
factors of resistance to, I. 10, 11
Micturition, frequency of, in pendulous
belly during pregnancy, IV. 61
obstruction of, due to premature en-
largement of the prostate, II. 930
precipitate, in myelitis, II. 1218
Mid-tarsal joint, Chopart's disarticulation
at, I. 840
Middledorf s triangle, use of, in fractures,
1.591
Migraine, II. 1027-1035
drugs in, II. 1029
exciting causes of attack, II. 1027
fatigue in, II. 1027
functional troubles of the eyes in, III.
545
ophthalmoplegic, II. 1033
surgical procedures for, II. 1031
treatment of attacks of, II. 1031
between attacks, II. 1029
Miliary or generalised tuberculosis, I. 332
Milium, III. 1073
Milligan (William), cholesteatoma, III.
934
chronic suppurative inflammation of
the middle ear, III. 904-918
diseases of the mastoid process, III.
919-933
Milligan (William) (contd.*)
tuberculous disease of the middle ear
and its accessory cavities, III.
935-936
Milligan's flap in operation for diseases
of mastoid process, III. 924, 952
intra-tympanic syringe, III. 906
Milk, boiled, in the tropics, III. 384
carrier of typhoid, I. 337
citrated, in infant feeding, II. 225
composition of, in infant feeding, II.
221
condensed chemical composition of,
II. 194
in infant feeding, II. 227
cow's, in infant feeding, II. 219
diet, additions to in fevers, I. 158
for infants, I. 59
in arthritis deformans. I. 393
in chronic dysentery, III. 434
in gastric cancer, II. 297
neurasthenia, II. 355
ulcer, II. 210
in gout, I. 452
in pellagra, I. 522
in scurvy, I. 475
in sprue, III. 442
in typhoid fever, I. 340
diluted by adding fat in infant feeding,
II. 223
by adding sugar in infant feeding,
II. 223
in infant feeding, II. 222
disordered digestion, due to, I. 61
dried, II. 228
in infant feeding, II. 228
effects upon digestion of young children,
I. 60
foods in marasmus, I. 466
human, best for infants, II. 215-218
in food fever, II. 237
in hill diarrhosa, III. 438
in pneumonia, I. 258
Metchnikoff's sour, in cancer of the
stomach, II. 298
Pasteurisation of, II. 220
peptonised. preparation of, I. 42
predigested, in infant feeding, II. 226
soured, in achylia, II. 295
in sprue, III. 445
sterilisation of, in infant feeding, II.
220 ; IV. 345
various forms of, in infant feeding, II.
221
whole, in infant feeding, II. 221
Miller's disarticulation at the knee by a
circular incision, I. 861
Milne (Eobert), on inunction of eucalyptus
oil in scarlet fever, I. 288
Mimicry, nervous, of joint disease, I. 787-
788
Mind, effect on temperature by, I. 1141
Mineral acids, poisoning by, treatment of,
I. 526
springs, general characters of, III. 114
76
A SYSTEM OF TREATMENT.
Mineral (contd.~)
waters, classification of, in treatment of
gout, I. 460
in acute gastritis, II. 351
in arthritis deformans, I. 398
in atony of stomach, II. 289
in chronic rheumatism, I. 491
in gout, I. 457
in obesity, I. 470, 471
thermal, III. 116
tonicity of, III. 115
uses of, III. 116
Mineralisation of springs, III. 114
Miner's dermatitis, III. 1030
nystagmus, II. 1140
Missiles, lodged, I. 558
Modern life, effect upon the nervous
system, I. 8
Moebius's anti-thyroid serum in exophthal-
mic goitre, II. 56
Moffat spa, III. 153
Molar roots, upper, extraction of, III.
1183
Molars, lower, extraction of, III. 1185
third, extraction of, III. 1186
upper, first and second extraction of.
III. 1182
third, extraction of, III. 1183
Moles, III. 1077-1081
blood or carneous, IV. 59
carneous, complicating pregnancy, IV.
59
hydatidiform. IV. 59
pigmented, III. 1080
vesicular, IV. 59
Mollities ossiuin complicating pregnancy,
IV. 58
Molluscum contagiosum, III. 1073
fibrosum, III. 1074
severest forms of, I. 112
Monilithrix, III. 1075
Monsarrat (K. W.), injuries and diseases
of the head, I. 872-887
Monsummano spa, III. 153
Mont Dore spa, III. 153
Montecantini spa, III. 153
Moore on moist applications in small-
pox, I. 306
Mooren's ulcer of the cornea, III. 566
Morcellement in chronic injections of the
tonsil, III. 751
Morgagni on aortic aneurysm, I. 1 297
Morgan and Harvey on bacillus typhosus,
1.336
Morphia, hypodermic injection of, I. 134
before operation, I. 84
in accidental hemorrhage during
pregnancy, IV. 26
in constipation in adults, II. 446
in eclampsia, IV. 36
in malignant disease of the thyroid, I.
74
in peritonitis, II. 638
injection of, in morphinism, I. 519
poisoning by, coma in, II, 984
Morphia (contd.*)
prevention of shock by, I. 96
use of, in blackwater fever, III. 388
Morphine and scopolamine, injection of,
in labour, IV. 378
in asthma, I. 1038
poisoning by, I. 531
Morphinism, I. 516-520
hyoscine in, I. 517
psychotherapy in, I. 519
Morphoea, III. 1075
Mortality after operation for perforation
of the intestine, II. 556
from gastric cancer, II. 302
in abdominal injuries, II. 243
of nephrectomy, II. 827
of operations on jaws, II. 117
of scarlet fever, I. 287
of typhoid fever, I. 335
Morton's fluid. See lodo-glycerin.
neuralgia, I. 964
Motion, disorders of, II. 1257
Moullin (Mansell) on sprains, I. 738
Moure's operation on the nasal septum,
III. 681
Mouth -breathing in anaemia, II. 14
in children, prevention of, I. 49
care of, after abdominal operations, II.
264
in children, I. 49
diseases of, II. 120-129
dry, in inflammation of parotid glands,
II. 163
xerostomia, II. 130
epithelioma of tongue invading floor of,
II. 143
floor of, cysts of, II. 145
ranula cyst of, II. 145
hygiene of, III. 1170
in sprue, III. 445
in syphilis, I. 318
in typhoid fever, I. 356
operation on, and anaesthetics, III. 26
-prop, wooden, in anaesthetics, III. 1
sepsis of, II. 127
voice production and, III. 336
washes, II. 121, 135
antiseptic, I. 259
in scarlet fever, I. 285
in syphilis, I. 324'
Movements, heavy, in physical exercises,
III. 225
passive, in acute anterior polio-myelitis,
II. 1056
Moynihan (B. G. A.) on gastrectomy in
gastric cancer, I. 140
Mud baths, III. 136
in arthritis deformans, I. 398
Mules' operation for enucleation of the
eyeball, III. 660
Mummery (P. Lockhart), adhesions of the
colon, II. 559-561
cancer of the colon, II. 578-584
congenital abnormalities of the colon,
II. 585-587
77
A SYSTEM OF TREATMENT.
Mummery (P. Lockhart) (contd.}
multiple polypi of the colon, II. 588
operative treatment of chronic con-
stipation due to disease or abnor-
malities of the colon, II. 470
perforating ulcer of the colon, II. 589
shock and collapse, I. 93-105
treatment of colitis, II. 570
surgical treatment of enteroptosis, I.
431
tuberculosis of the colon, II. 590
volvulus of the colon, II. 591
Mumps, I. 256-257
simple and secondary, II. 157
Muriated baths, III. 130
Murphy's method of artificial pneumo-
thorax, I. 1170
Murray (George R.) chronic polycythaemia
with cyanosis and enlarged spleen,
11.84
Hodgkin's disease (lymphadenoma), 1.
1341-1343
leukaemia, II. 38-42
purpura, II. 43-45
splenomegaly, II. 82-83
Muscles, abdominal, rupture of, II. 252
weak electricity in, II. 465
affections of, II. 1321
atrophy of, II. 1252
and contractions of, in fractures, I.
577
in hemiplegia, II. 1187
peroneal, II. 1253
progressive, II. 1081-1082
calf, spasm of, II. 1160
in cerebral palsies of infancy, II.
1160
contraction of, in fractures, I. 570
static, physical exercises for, III. 229
contusions of, II. 1321
cysts of, II. 1325
dystrophy of, II. 1250-1251
development of contractures in, II.
1251
education of, in cerebral palsies of
infancy, II. 1161
facial, paralysis of, II. 995
fibromata of, II. 1325
flaps of, in amputations, I. 796
functions of, disorders of, II. 1254
inflammatory affections of, II. 1324-
1325
injuries of, II. 1321-1323
laryngeal, intrinsic, paralysis of, III.
841-844
lipomata of, II. 1325
malignant new growths of, II. 1325
massage of, III. 205
new growths of, II. 1325
innocent, II. 1325
ocular, cyclophoria of, III. 648
diseases of, III. 646-655
esophoria of, III. 646
exophoria of, III. 647
heterophoria of, III. 646
Muscles, ocular (contd.~)
hyperphoria of, III. 647
migrainous recurrent paralysis of,
III. 649
nystagmus and, III. 649
ophthalmoplegia of, III. 649
paralysis of, acute nuclear, III. 649
haemorrhagic, III. 648
paralytic diplopia of, III. 649
post-diphtheritic paralysis of, III.
649
primary nerve degenerations of, III.
649
ptosis of, III. 650
rheumatic paralysis of, III. 649
thrombotic paralysis of, III. 648
pectoral, removal of, in malignant
disease of breast, II. 971, 972
rupture of, II. 1322
sarcoma of, II. 1325
spasm of weight-extension in, I. 742
wasting of in sprains, I. 739
wounds of, II. 1321
Muscular atrophy in children, II. 1247
progressive, II. 1081
exercises, physiological effect of, III.
206
fibres, hernia of, II. 1323
reaction, I. 16
rheumatism, I. 492-494
Musculo-spiral nerve, injuries of, II. 1112
Mushroom poisoning causing diarrhoea, II.
480
Mustard bath for children, I. 38
leaves, I. 36
plasters, I. 36
poultice, I. 34
in catarrhal pneumonia, I. 69
Mutton, chemical composition of, II. 193
in dietary of children, 1. 69
Myasthenia gastrica, II. 286
gravis, II. 1254
Mycetoma or madura foot, III. 485
Mycosis fungoides, III. 1076
Routgen rays in, III. 1076
Mydriatics in acute iritis, III. 583
Myelitis, II. 1212-1218
acute stage of, II. 1213
atrophic flaccid palsy in, II. 1217
bedsores in, II. 1218
bronchitis in, II. 1216
chronic stage of, II. 1216
cystitis in, II. 1217
diet in, II. 1216
drugs in, II. 1215
local treatment of, II. 1216
pain in, II. 1215
precipitate micturition in, II. 1218
prophylaxis of, II. 1212
spasticity in, II. 1217
Myeloid sarcomata of the jaw, II. 110
Myeloma of the bones of the skull, I. 895
Myelomata, central, of the jaw, II. Ill
of bones, I. 710
Myiasis, III. 483
78
A SYSTEM OF TREATMENT.
Myocardial affections, I. 1240
Myocarditis in acute rheumatism, I. 272
Myoclonus spasm, II. 1049
Myomata of the skin, III. 1057
of the vagina, IV. 553
Myomectomy, abdominal, IV. 658
when fibroid is pedunculated, IV. 658
is sessile, IV. 658
in uterine fibroids, IV. 658
Myopia, III. 538
high, III. 541
discission in, III. 541
removal of lens in, III. 541
Myositis, acute simple, II. 1324
suppurative, II. 1324
ossifying, II. 1325
rheumatic, II. 1324
syphilitic, II. 1324
Myotonia atrophica, II. 1252
congenita, II. 1252
Myringitis of the tympanic membrane,
III. 891
Myxoedema and cretinism, II. 72
complicating pregnancy, IV. 58
Naemo-lymphangioma, radium therapy
in, III. 314
Neevi, III. 1077-1081
capillary, II. 133
small, III. 1078
carbon dioxide snow in, III. 1078
electrolysis in, III. 1079
excision of, III. 1080
radium in, III. 1079
vaccination in, III. 1080
cavernous, II. 133
in newborn child, IV. 3G3
lymphatic, II. 133
of the lips, II. 97
of the tongue, II. 133
spider, III. 1077
stellate, III. 1077
Nails, atrophy of, III. 1082
chronic affections of, X-rays in, III.
351
diseases of, III. 1082
eczema of, III. 1082
favus of, III. 1082
hypertrophy of, III. 1082
malformation of, III. 1082
position of, during X-rays applications,
III. 351
psoriasis of, III. 1121
ringworm of, III. 1012, 1131
Narcotics, poisoning by, I. 530-534
Nares, lupus of, III. 687
tuberculosis of, III. 687, 688
Nasal accessory chambers, diseases of,
headache from, II. 1033
bones, fractures of, III. 671
catarrh and Eustachian obstruction,
III. 945
mucopurulent. chronic and Eusta-
chian obstruction, III. 946
Nasal (contd.')
feeding, method of, I. 33
passages in children, care of, I. 49
secretion clearance of in children, I.
' 49
septum, dislocation of, III. !7'.l
fractures of, III. 679
Gleason's operation on, III. 681
injuries and malformations of, III.
678
malformation of, Kilian's method in,
III. 683
symptoms requiring treatment,
III. 678
Moure's operation on, III. 681
simple crest operation on, III. 680
submucous resection of, III. 682
splint for fracture of the nose, III. 671
Naso-pharyngeal catarrh, III. 739-741
chronic and Eustachian obstruction,
III. 946
Eustachian obstruction and, III. 945
cavity, diseases of, III. 732-743
wool-carriers, III. 740
Nasopharynx, adhesions of, and Eusta-
chian obstruction, III. 947
growths of, III. 699
in asthma, morbid conditions of, 1. 1037
lupus of, III. 742
malignant disease of, III. 700
syphilis of, III. 743
tuberculosis of, III. 742
tumours of, and Eustachian obstruction,
III. 947
voice production and, III. 336
Nastin treatment of leprosy, III. 452
Nature, influence of in treatment, I. 1
Nauheim spa, III. 153
Nausea in disordered digestion, II. 373
Neck, acute cellulitis of, dangerous for
anesthesia, III. 23
aerial fistula of, II. 166
blood cysts of, II. 167
branchial cysts of, II. 167
fistula; of, II. 166
bursal cyst of, II. 168
cellulitis of, complicating scarlet fever,
1.290
cystic hygroma of. II. 169
cysts of, II. 167-170
dermoid cyst of, II. 168
diffuse lipomata of, I. 107
diseases of, II. 164-170
enlarged glands in, in anaemia, II. 14
fistulas of, II. 166-167
gunshot wounds of, I. 564
hydatid cysts of, II. 169
hydroceles of, II. 169
injuries of, II. 164-170
lymphangioma of, II. 169
lymphatics of, in epithelioma of tongue,
II. 144
malignant cysts of, II. 169
massage of, III. 209
median cervical fistula of, II. 167
79
A SYSTEM OF TREATMENT.
Neck (contd.*)
preparation of for operation, I. 88
sebaceous cysts of, II. 170
septic cellulitis of, complicating cut
throat, II. 165
thyro-glossal cysts of, II. 170
fistula of, II. 167
thyro-hyoid cyst of, II. 168
thyroid cysts of, II. 170
fistula of, II. 167
tics of, II. 1052 '
varix of, I. 1321
Necrosis in acute abscess, I. 167, 171
in syphilis of ribs and sternum, I.
1032
of the jaw, II. 108
of the labyrinth, III. 965-966
Needle carrier for Gigli's saw in
pubiotomy, IV. 448, 449
Nenndorff spa, IIT. 153
Nepenthe for relief of pain, I. 134
Nephrectomy, dangers of, in renal
growths, II. 833
for primary tuberculosis of the kidney,
immediate mortality in, II. 827
for renal calculus, II. 765, 779
for tuberculous disease of the kidney,
II. 825
in pyonephrosis, II. 817
partial, in tuberculosis of the kidney,
II. 822
results of, for primary tuberculosis of
the kidney, II. 827
Nephritis, acute, II. 796-797, 798
chronic diffuse parenchymatous, II.
794-795
interstitial, II. 792-793
with haematuria, II. 799
results of operative treatment, II.
890
with pain, II. 799
complicating diabetes mellitus, I. 426
diphtheria, I. 202
influenza, I. 241
scarlet fever, I. 292
diet in, II. 204
non-suppurative, surgical treatment of,
II. 798-800
Nephro-cysto anastomosis, II. 777
Nephrolithotomy, dangers of, II. 761
for renal calculus, II. 759, 764
Nephropexy in intermittent hydrone-
phrosis, II. 774
Nephrostomy for hydronephrosis, II.
779
in pyonephrosis, II. 815
Nephrotomy for tuberculosis of the kidney,
II. 828
in urinary obstruction due to cancer, I.
143
Neris spa, III. 153
Nerve anastomosis in infantile paralysis,
II. 1059-1060
in nerve injuries, II. 1104
auditory, polyneuritis of, III. 977
Nerve (contd.~)
bridging in injuries of nerves, II. 1103
circumflex, injuries of, II. 1111
deafness due to disturbance of cochlea
division of the eighth nerve, III.
977
facial, injuries of, II. 1108
musculo-spiral, injuries of, II. 1112
ocular, primary degeneration of, III.
649
of Bell, injuries of, II. 1112
optic, diseases of, III. 645
posterior thoracic, injuries of, II. 1112
ulnar, injuries of, II. 1112
Nerves, concussion of, I. 560
derangement of, massage in, III.
210
diffuse neuroma of, II. 1142
diseases of, II. 1093
division of, for relief of pain, in inoper-
able cancer, I. 135
in amputations, I. 802
in Berger's operation, I. 831
posterior roots of, in neuritis, II.
1035
effect of massage on, III. 205
general considerations regarding opera-
tions upon, II. 1001
injection of alcohol into, I. 135
injuries of, II. 1098-1105
anastomosis in, II. 1006
complicating dislocations, II. 1102
general lines of treatment in, II.
1098
in fractures, II. 1101
in gunshot wounds, I. 560
in wounds, II. 1099
nerve anastomosis, II. 1104
nerve-bridging in, II. 1103
secondary suture in, II. 1102
subcutaneous, II. 1100
malignant tumours of, II. 1142
musculo-spiral injury to, in fractures,
1.592
neuro-fibromatosis of, II. 1142
neuromata of, circumscribed, II.
1142
operations on, II. 1099
paralysis of, deformities due to, I. 988-
990
posterior roots of, division of, in
neuritis, II. 1133
rest to affected portion of, in neuritis,
II. 1033
secondary suture of, II. 1102
special, injuries of, II. 1108-1113
subcutaneous injuries to, II. 1100
suture of, secondary, II. 1102
tumours of, II. 1142
circumscribed neuromata, II. 1142
malignant, II. 1142
Nervous depression in the menopause,
IV. 502
diseases, climate for, III. 99
complicating pregnancy, IV. 50
80
A SYSTEM OF TREATMENT.
Nervous
symptoms complicating pernicious
anaemia, II. 10
system, affections of, electro-thera-
peutics in, III. 108
central, diseases of, nystagmus in, II.
1140
nystagmus in disease of, II. 1042
derangement of, massage and, III.
210
diseases of, II. 1014
general, II. 1054
physical exercises in, III. 2."ii;
disorders of, mineral waters and baths
in, III. 146
effect of alcoholism upon, I. 496
electric shock on, I. 548
in typhoid fever, I. 362
influence of on process of repair, I.
12
progressive chronic, physical exercises
in, III. 256
strain of, causes of, I. 8
Neuenahr spa, III. 153
Neumann syringe, III. 913
Neuralgia, II. 1114-1126
brachial, II. 1121
complicating diabetes rnellitus, I. 426
dental, II. 1114
diathetic, affecting head, II. 1122
limbs, II. 1122
facial, hypnotism in case of, III. 170
surgical treatment of, II. 1127
following influenza, I. '2 IL>
headache accompanied by soreness of
scalp in, II. 1117
in foramen ovale, II. 1119
in foramen rotundum, II. 1118
in infra-orbital foramen, II. 1118
laryngeal, III. 845
maintenance of trophic condition of
parts supplied by affected nerve in,
II. 1132
mammary, II. 976
occipital, II. 1120
of the pharynx, III. 782
of supra-orbital notch, II. 1117
of the third division, II. 1119
painful heel in, II. 1123
post-herpetic, II. 11^-'
scapular, II. 1121
supra-orbital, II. 1115
periodic, II. 1115
surgical treatment of, II. 1117, 1127-
1129
torticollis in, II. 1050
toxic, affecting head, II. 1122
affecting limbs, II. 1122
trigeminal, II. 1116
alcohol injection in, II. 1117
drugs in, II. 1116
excision of gasserian ganglion for,
II. 1128
hot-air douche for, III. 66
ionic medication of, III. 184
81
Neuralgia, trigeminal (contd.)
visceral, II. 1122
Neurasthenia, II. 1038-1043
anorexia nervosa, II. 1042
gastric, II. 354
diet in, II. 355
electricity in, II. 354
medicinal treatment of, II. 356
in the menopause, IV. 503
phosphaturia and, II. 748
traumatic, II. 1042
Weir Mitchell method in, II. 1040
Neuritis, II. 1130-1132
alcoholic, II. 1134
contractures in, II. 1135
deformity in, II. 1 135
drugs in, II. 1135
application of vibration in, III. 221
arsenical, II. 1138
beri-beri and, II. 1139
chronic, of ulnar nerve at the elbow, II.
1112
complicating influenza, I. 241
compression, II. 1131
diabetic, II. 1131
division of posterior roots in, II.
1033
gouty, I. 444; II. 1130
lead,' II. 1137
local, II. 1130
removal of cause in, II. 1130
malarial, II. 1131
multiple, II. 1134-1139
arising from unknown cause, II.
1139
optic, III. 645
complicating typhoid fever, I. 363
in tumours of brain, II. 1201
post-diphtheritic, II. 1138
prevention of deformity in the paralysis
of, II. 1132
puerperal, II. 1139
rest to affected portion of nerve in, II.
1131
retro-bulbar, III. 645
rheumatic, II. 1130
sciatic, old -standing chronic, II. 1125
senile, II. 1139
syphilitic, II. 1130
traumatic, II. 1106-1107
Neuro-fibroma, plexiform, I. 112
varieties of, I. 112
Neuro-fibromatosis of nerves, II. 1142
Neuro-fibromatous tumours of the scalp
1.893
Neuroma, diffuse, of nerves, II. 1142
Neuromata, amputation, I. 112
circumscribed, of nerves, II. 1142
Neuropathic arthritis, I. 785
Neuroses following spinal injury, I. 899
motor, of the larynx, III. 840
nasal, III. 689
of occupation, II. 1264
of the heart, I. 1252
of the larynx, III. 840-845
6
A SYSTEM OF TREATMENT.
Neuroses (contd.~)
of the meatus, III. 884
of the pharynx, III. 782-783
of the skin, III. 998
rectal, II. 614
sensory, of the larynx, III. 844
vasomotor, II. 1242-1243
Nicoll's operation for inguinal hernia II.
511
Nicotine, poisoning by, I. 533
Night terrors, II. 1036-1037
in the young, prevention of, I. 55
Nipples, affections of, II. 977-978
areola abscess of, II. 977
care of, in pregnancy, IV. 8
cracks of, prevention of, II. 977
depressed, in the puerperium, IV.
332
fissures of. II. 977
management of, in pregnancy, IV.
330
Paget's disease of, II. 978
sore, in the puerperium, IV. 333
Nitrate, see Silver, nitrate of
Nitre, sweet spirits of, in diseases of the
heart, I, 1224
Nitrites in arterio-sclerosis, I. 1293
in chronic polycythemia, II. 85
in diseases of the heart, 1. 1223
Nitrobenzene, poisoning by, I. 533
Nitrogen apparatus in artificial pneumo-
thorax, I. 1166
Nitrogenons food, value of, I. 451
Nitro-glycerine in eclampsia, IV. 37
in gouty angina pectoris, I. 443
Nitrous oxide as anaesthetic, III. 2
preceded by ether as anaesthetic, III.
11
gas, apparatus for administration
of, III. 3
steps of the administration of,
III. 3
Nodal fever, I. 212-213
rhythm in diseases of the heart, I.
1231
Noise in sick room, avoidance of, I. 26
Noma, II. 124-125
and cancrum oris. gangrenous, I. 219
of the auricle, III. 882
of the vulva, IV. 508
Noorden's (Von) treatment of oedema, I.
422
Norwood treatment of alcoholism, I. 501
Nose, accessory sinuses of, diseases of, III.
716-731
benign growths of, III. 692
bridge of, depression, III. 673
care of, in children, I. 49
cough in pulmonary tuberculosis, I.
1145
deformity of, injection of paraffin wax
in, III. 674
destruction of parts of, III. 675
diseases of, III. 664-666
epistaxis from, III. 664-666
Nose (contd.)
examination of, in epilepsy, II. 991
external malformation of, III. 673
foreign bodies in, III. 667
hygiene of in typhoid fever, I. 356
immediate arrest of bleeding from, in
epistaxis, III. 666
injection of paraffin wax in, III. 674
intranasal malformation of, III. 672
irritation of, III. 691
lateral deflection of, III. 673
leprosy of, III. 780
maggots in, III. 669
malformations of. III. 671-677
malignant growths of, III. 694
curative treatment, III. 695
located anteriorly in, III. 695
small size, III. 695
neurosis of, III. 689
intranasal treatment, III. 691
new growths of, III. 692-698
obstruction of, III. 691
occlusion of the choana of, III. 672
operations on, and ansesthetics, III.
26
packing of, in chronic rhinitis, III. 708
permanent arrest of bleeding from, III.
666
polypi of, III. 691
powdered pollantin serum for, III. 287
rhinitis anterior sicca of, III. 665
rhinoleths of, III. 669
stenosis of the anterior nares of, III.
672
synechiae of, III. 672
syphilis of, III. 714-715
general treatment of, III. 714
local treatment of, III. 714
wounds of, III. 671-677
Nostril in harelip, II. 90
Novocaine, injection of, for spinal anal-
gesia, III. 37
Nuchal position of the arm, in breech
presentation of labour, IV. 132
Nuck, canal of, hydrocele of, IV. 512
Nuclein in boils, III. 1008
Nulliparse. chronic endo-cervical catarrh
in, IV. 566
Nursery, fittings and furniture for, I. 45
hygiene of the, I. 44
sanitary arrangements for, I. 45
Nurses, cookery to be undertaken by, I.
42
directions to, in gynaecological opera-
tions, IV. 485
duties of, rules for, I. 26
Nursing in acute disease, I. 19
in chorea, II. 1262
in plague, III. 403
in puerperal sepsis, IV. 313
of enteric fever, I. 40
of infectious cases. I. 41
Nussbaum's bracelet on writer's cramp, II,
1265
Nutrient enemata, I. 32
82
A SYSTEM OF TREATMENT.
Nutrition, disorders of, in children, causes
of, I. 63
food values and, I. 450
of infants and children, I. 46
Nuts, chemical composition of, II. 197
Nux vomica in constipation in adults, II.
446
Nystagmus, II, 1140-1141
and ocular muscles, III. 648
head-nodding ia, II. 1141
horizontal, II. 1140
in disease of central nervous system, II.
1140
in miners, II. 1140
Oak Orchard Springs, acid baths of, III. 137
Oatmeal cure of diabetes, I. 422
treatment of diabetes, I. 421
Oberst's solution for local analgesia, III.
39
Obesity, anasmic, I. 468, 472
climate for, III. 92
diet in, II. 212
diabetic treatment of, I. 470
drugs in, I. 470
exercises in, I. 469
glandular relations of, I. 473
mineral waters and baths in, III. 140
ordinary, I. 468
salt contra-indicated in, I. 470
secretory, I. 468, 472
toxic, I. 468, 472
vegetables, suitable in, I. 472
vegetarian, system in, I. 471
Wertheim's operation in, IV. 605
Obsessive ideas, II. 1313-1314
Obstetric operations, IV. 373-374
general considerations in, IV. 373
preparation of instruments in, IV. 374
of operator in, IV. 373
of patient in, IV. 373
Obstetrical bag in management of normal
labour, IV. 93
Obturators, treatment of cleft palate by,
II. 152
Occipital neuralgia, II. 1120
Occipito-posterior presentation in labour,
IV. 144-146
Occupation dermatitis, III. 1029
Occupations, diseases resulting from, I, 5
incidence of cancer and, I. 117
lead poisoning, I. 514
neuroses of, II. 1264
hammerman's cramp in, II. 1267
telegraphist's cramp in, II. 1266
writer's cramp in, II. 1264
Odontoma, III. 1194
Odontomes, epithelial, of the jaws, II. 112
radicular, II. 110
O'Dwyer's bronchial instrument, III. 804
Ody's truss for inguinal hernia, II. 527
OZdema, angioneurotic, II. 1228-1229 ;
III. 1154-1156
arterio-sclerosis, I. 1294
OZdema (contd.~)
cerebral, in injuries of the head, I. 884
in fractures, I. 578
of the larynx, III. 858-860
of legs in chlorosis, II. 31
of lungs, I. 1080
of prepuce complicating gonorrhoea, I.
225
of uvula, III. 745
theophyllin in, I. 422
(Esophageal bougie, black elastic, II. 172
conical-ended black. II. 172
silk web, II. 172, 173
feeding, method of, I. 33
(Esophagoscope, Bruning's, for foreign
bodies in the oesophagus, II. 187
CEsophagotomy, cervical, for foreign
bodies in the oesophagus, II. 186
Oesophagus, burns of, II. 188
cancer of, regurgitation, I. 138
relief of obstruction in, I. 139, 140
diseases of, II. 171-189
diverticular of, II. 189
forceps for removal of foreign bodies in,
II. 184-185
foreign bodies in, II. 184-189
Bruning's oesophagoscope for, II. 187
gastrotomy for, II. 186
injuries of, II. 171-189
malformations of, 189
malignant stricture of, II. 175
after treatment in, II. 183
Frank's operation for, II. 177
gastrostomy for, II. 176
methods in, II. 183
Senn's method for, II. 180
Witzel's method for, II. 182
simple stricture of, II. 171-183
stricture of, continuous dilatation in,
II. 174
dilatation of, II. 171
intermittent dilatation of, II. 171
medicinal treatment of, II. 171
operative treatment in, II. 174
spasmodic, II. 175
surgical treatment of, II. 171
treatment by tubes, II. 175
ulcers of complicating typhoid fever, I.
357
wounds of, II. 188
in cut throat, II. 165
Oeynhausen spa. III. 154
Ogle (Cyril), diseases of the pericardium,
I. 1179-1187
inflammatory conditions of medias-
tinum, I. 1176
new growth in the mediastinum, 1. 1178
Oil diet in duodenal ulcer, II. 211
dressings in burns and scalds, I. 541-548
inunction of, I. 70
See also Castor oil, Olive oil.
Ointments for acne vulgaris, III. 986
for eczema vulva?, IV. 530
in herpes zoster, II. 1096
inunction of, I. 70
83 62
A SYSTEM OF TREATMENT.
Olecranon, fracture of, I. 596-686
Oligo-hydramnios complicating pregnancy.
IV. 44
Olive oil enema, I. 32
injections of, in constipation in adults.
II. 456
Oliver (Thomas), arsenical poisoning, I.
503-504
auto-intoxication, I. 386-390
electrical injuries and burns, I. 547-549
lead poisoning, I. 512-515
phosphorus poisoning, I. 525
Oliver on arterio-sclerosis, I. 1294
Oliver's alcoholic instrument for test of
blood pressure, I. 1281
Omentum, wounds of, II. 253
Onanitic prostatitis, II. 927
Onions in dietary of children, I. 59
Onyalai, III. 469
Onychia. III. 1082
Onychitis, syphilitic, III. 1082
tuberculous, III. 1082
Oophorectomy in dysmenorrhoea, IV. 749
in mammary cancer, I. 150
in menorrhagia, IV. 763
in metrorrhagia, IV. 763
Open-air, exercise in, for children, I. 52
methods in inoperable cancer, I. 133
treatment in medical climatology, III..
76
Operating table, description of, I. 28
fittings and preparation of. I. 71
Operation, available, for varicocele, 1. 1325
outfit for, I. 28
preparation of patient for, I. 27
room, preparation of, I. 71
Operations, Ball's (Sir Charles), for pru-
ritus ani, II. 597
Beyea's, for gastroptosis, II. 324
Garden's, I. 862
Cheyne's, for malformation of the nose,
III. 674
Estlander's, I. 1107
Eve's, for gastroptosis, II. 323
Frank's, for malignant stricture of the
oesophagus, II. 177
Gaillard Thomas's, for fibro-adenomata
of the breast, II. 956
Gleason's, on the nasal septum, III. 681
Gritti's, I. 862
gynaecological, IV. 474-486
' after-treatment in, IV. 487-497
post operative complications, IV. 487-
497
Halsted's for inguinal hernia, II. 507
in pregnancy, IV. 58
in varicocele, I. 1324
Jordan's, I. 868
Krause's, for pruritus ani, II. 597
Loreta's, for hypertrophic stenosis of
the pylorus, II. 339, 342
Lotheissen's, for femoral hernia, II. 511
McEwen's, for inguinal hernia, II. 507
Mayo's, for umbilical hernia, II. 513
Miller's, I. 861
Operations (cnfd.')
Moure's, on the nasal septum, III.
681
Mules', for enucleation of the eyeball,
III. 660
Nicoll's, for inguinal hernia, II. 511
obstetric, IV. 373-374
Paul's, for cancer of the colon, II. 580
Schwartze's, for opening mastoid
antrum, III. 898
Smith's, for immature cataract. 111. (i21
Stephen Smith's, I. 859-861
surgical, antiseptic precautions during,
1.81
Operator, preparation of, in obstetric
operations, IV. 373
Ophthalmia, gonorrhoeal, I. 228
in the adult, III. 555
neonatorum, III. 553
in newborn child, IV. 366
Ophthalmitis, sympathetic, III. 598
curative treatment, III. 600
prophylaxis of, III. 598
Ophthalmoplegia and migraine, II. 1033
of ocular muscles, III. 648
Opium habit, combretum sundiacum in,
1.518
in constipation in adults, II. 446
in diabetes mellitus, I. 424
in diseases of the heart, I. 1 225
in epilepsy, II. 998
in epithelioma of the tongue, II. 144
in melancholia, II. 1297
in pericarditis, I. 1180
in peritonitis, II. 638
in pruritus, III. 1099
in smallpox, I. 308
poisoning by, I. 531
relief of pain by, I. 134
use of, in diseases of children, I. 66
Opsonic index, high, vaccine therapv and,
1.208
in acute tuberculosis, I. 334
Opsonins in serum therapy, III. 259
Optic atrophy, III. 645
nerve, diseases of, III. 645
neuritis, III. 645
Oral administration in vaccine therapy,
III. 265
antiseptics in pernicious anaemia, II. 6
sepsis, II. 127-129
prophylaxis of, II. 127
Orbit, arterio venous aneurysms of, III.
662
cellulitis of, III. 661
diseases of. III. 661-663
tenonitis of, III. 662
thrombosis of, III. 662
tumours of, III. 662
wounds of, III. 661
Orbital foramen, infra-neuralgia in, II.
1118
neuralgia, periodic supra, II. 1115
supra, II. 1115
notch, supra-neuralgia of, II. 1117
A SYSTEM OF TREATMENT.
Orchitis, acute, II. 906
complicating mumps, I. 257
filarial, III. 503
vaccine therapy of, III. 281
Organotherapy in cancer, I. 149
in epilepsy, II. 999
in sterility, IV. 854
of plague, III. 409
Oriental sore, III. 454-456
general treatment of, III. 454
Oro-pharynx, benign growths of, III. 784
malignant growths of, III. 785
new growths of, III. 784-785
Orsudan in syphilis, I. 321
Orthopaedic measures in arthritis defor-
mans, I. 397
in osteo-arthritis, I. 403
Orthopaedics, physical exercises in, III. 233
calcis, fracture of, I. 632
hypertrophy of, III. 405
tuberculosis of. I. 773
Os uteri, dilatation of, in normal labour,
IV. 103
Osier (Sir W.) on Banti's disease, II. 82
Ossiculectomy in chronic inflammation of
the middle ear, III. 913
Osteitis after amputations, I. 804
deformans, II. 1237
tuberculous, of the skull, I. 889
Osteo-arthritis, chronic rheumatism and,
1.483
complicating pregnancy, IV. 57
diet in, I. 400
local treatment of, I. 402
massage in, I. 402
medicinal treatment of, I. 401
of temporo-maxillary joint, II. 105
orthopaedic measures in, I. 403
Osteoarthropathy, pulmonary, hyper-
trophic, II. 1233
Osteogenesis imperfecta, II. 1237
Osteoma of the jaw, II. 109
of the scalp, I. 893
Osteomalacia complicating pregnancy,
I. 712 ; IV. 58
Osteomalacic pelvis complicating labour,
IV. 172
Osteomyelitis, acute, in infective lesions
of the skull, I. 889
of the spine, I. 916-917
after amputations, I. 804
of the thoracic wall, I. 1032
suppurative, I. 696, 698
traumatic in injected lesions of the
skull, I. 889
Osteo-periosteal method of amputation,
I. 801
Osteotomy in ankylosis, I. 764
in rachitic deformities, I. 972
Otalgia of the meatus, III. 884
Otitis externa circumscripta of the
meatus, III. 885
croupous, of the meatus, III. 884
diffusa of the meatus, III. 886
media, III. 894-903
Otitis (contd.)
catarrhal, chronic, and Eustachian
obstruction, III. 944
chronic, III. 904
complicating diphtheria, I. 202
meningitis, I. 252
scarlet fever, I. 289
purulent, III. 904
pyogenic, III. 904
Oto-fibrosis and Eustachian obstruction,
III. 944
Otomasseur, Delstanche's, III. 952
Otomycosis of the meatus, III. 886
Otorrhcea in measles, I. 246
in scarlet fever, I. 282, 289
Otosclerosis, III. 954-957
deafness in, III. 956
general treatment of, III. 954
local treatment of, III. 955
symptomatic treatment of, III. 995
Ovarian dermoids, I. 110.
Ovaries, abscess of, IV. 765
care of, in ovariotomy, IV. 779
cysts of, suppurating, IV. 797-798
tapping of, in ovariotomy, IV. 782
diseases of, IV. 765-798
mineral waters and baths in, III. 145
sterility in, IV. 846
hernia of, IV. 767
metabolic disorder and, I. 389
pain in, chronic, IV. 766
prolapse of, IV. 796
removal of, in dysmenorrhoea, IV. 746
in uterine fibroids, IV. 639
tumours of, Cassarean section in, IV.
384
during labour, IV. 773-774
during pregnancy, IV. Ill-Ill
during puerperium, IV. 774
malignant, IV. 770
Ovariotomy, IV. 775-795
adhesions in, IV. 780
after-treatment of, IV. 789
care of other ovary in, IV. 779
drainage in, IV. 785
dressing in, IV. 788
haemorrhage after, IV. 793
hiccough after, IV. 792
in pregnancy, IV. 771
injury to intestine in, IV. 78.".
instruments for, IV. 776
ligatures in, IV. 776
of pedicle in, IV. 783
operation of, IV. 777
peritonitis after, 1 V. 7'.M
preparation of patient, IV. 775
shock after, IV. 793
sutures in, IV. 776
of abdominal wall in, IV. 787
tapping the cyst in, IV. 782
thrombosis after, IV. 794
vaginal, IV. 795
vomiting after, IV. 791
Overstrain in the menopause, IV. 503
mineral waters and baths in, III. 146
85
SYSTEM OF TREATMENT.
Ovum forceps for retained placenta, IV. 226
Oxalic acid in foodstuffs, II. 744
poisoning by, treatment of, I. 528
Oxaluria, II. 742
Oxybutyne (B.), acid in the urine, I. 417
Oxygen in acute bronchitis, I. 1051
in asthma, I. 1040
in diseases of the heart, I. 1225
in eclampsia, IV. 37
in haemorrhage, I. 1267
in poisoning, I. 528, 531, 533, 535
inhalations in pernicious anaemia, II. 9
in pneumonia, I. 245, 2,61
Oxymel of squill in laryngitis, I. 245
Oxyuriasis, III. 495
prophylaxis of, III. 493
Pachydermia laryngis, III. 850
Pachy meningitis, I. 905
Packs, use of, I. 37, 38
Paget's disease, II. 1237
of the nipples, II. 978
recurrent fibroid, I. 114
Pain, abdominal, complicating typhoid
fever, I. 359
relief of, I. 513
after abdominal operations, II. 263
after cataract extraction, III. 632
as symptom of cancer of cervix, IV. 585
complicating gynaecological surgery,
IV. 490
tuberculous peritonitis, II. 646
ulcer of the stomach, II. 380
. in aortic aneurysm, I. 1299
in ascites, II. 627
in cancer, relief of, I. 133, 134
of cervix, IV. 617
of the stomach, II. 299
in chronic nephritis, II. 799
in disordered digestion in the stomach,
II. 373
in gunshot wounds, I. 558
in haemorrhoids, II. 617
in hemiplegia, II. 1188
in herpes zoster, III. 1043
in labour, IV. 103
in lead poisoning, I. 512
in myelitis, II. 1215
in non-operative appendicitis, II. 423
in normal puerperium, IV. 264
in secretory disorders of the stomach,
II. 363
in uterine fibroids, IV. 638
in varicose veins, IV. 89
opium in, I. 67
ovarium, chronic, IV. 766
pre-cordial, complicating acute endo-
carditis, I. 1193
rectal, II. 614
relief of, by injection of alcohol into
nerve trunks, I. 135
in pleurisy, I. 1094
severe, in chronic dilatation of the
stomach, II. 314
Paints for herpes zoster, II. 1096
Palate, cleft, II. 147-156
after-treatment in, operations for, II.
151
anaesthetic in operation for, II. 149,
III. 28
Brophy's operation in, II. 149
gag in operation for, II. 150
haemorrhage in operation for, II. 150
in newborn child, IV. 357]
operation for, II. 149
operative treatment of, II. 147
treatment of by obturators, II. 152
spasmodic affections of, and neuroses of
pharynx, III. 783
Palatine arteries, haemorrhage from, I.
1275
Palliative treatment, I. 18
of inoperable cancer, I. 131
Palmar arteries, wounds of, I. 1276
Palpation in normal labour, IV. 97, 98
Palpitation in angina pectoris, I. 1252
Palsy, atrophic flaccid, in myelitis, II.
1217
brachial, in newborn child, IV. 365
bulbar, II. 1061
cerebral, of infants, II. 1153-1156
surgical treatment of, II. 1157-1164
craft, II. 1267
facial, in newborn child, IV. 365
See also Paralysis.
Pancreas, abscess of, II. 720
calculi of, II. 724-725
pancreo-lithotomy in. II. 724
cancer of, II. 729
cysts of, II. 726-728
statistics, II. 727
diseases of, II. 716-729
enlargement of and cholelithiasis, II.
694
inflammation of, II. 717
parenchymatous inflammations of,
acute. 717
wounds of, II. 716-729
Pancreatitis, acute, II. 718-719
chronic, II. 723
subacute, II. 720-722
Pancreo-lithotomy in pancreatic calculi,
II. 724
Panhysterectomy of the uterus, IV. 401
Pause's flap in operation for diseases of
mastoid process, III. 924, 925
Pansini on influence of red and blue light,
III. 194
Fanticosa spa, III. 154
Papilloma, duct, of the breast, II. 954
of Fallopian tube, IV. 816
single, of the bladder, II. 870
Papillomata of lingual tonsil, III. 762
of the meatus, III. 883
of the penis, II. 878
multiple of bladder, II. 871
of the larynx in children, III. 851
Paracentesis of anterior chamber of ciliary-
body, III. 593
86
A SYSTEM OF TREATMENT.
Paracentesis (contd.~)
in ascites, II. 628
in inflammations of middle ear, III. 895,
904, 905
in pericarditis, I. 1182
method of, in hydrothorax, I. 1091
pericardii, I. 1188
technique of, in acute inflammation of
the middle ear, III. 895
Paracretinoid lipomatosis, I. 108
Parsesthesia of the pharynx, III. 782
Paraffin eczema, I. 117
in skin eruptions, I. 446
injections in chronic rhinitis, III. 709
liquid, in constipation in adults, II. 4~>1
wax, injection of, in nose, III. 674
Paraldehyde in insomnia, II. 1023
Paralysis, acute nuclear, of ocular muscles,
III. 649
associated with labour, IV. 280
with the puerperium, IV. 281
brachial birth, II. 1012, 1110
complete recurrent, of vocal cords, III.
844
complicating pregnancy, IV. 60
diphtheritic, forms of, I. 200
diplopic, of ocular muscles, III. 649
divers, 1. 1306
due to spinal injury, I. 899
facial, II. 1093-1095
electricity in, II. 1094
massage in, II. 1094
nerve anastomosis in, II. 1109
nerve crossing in, II. 1 1 09
family periodic. II. 1247
flaccid, in paraplegia, II. 1197
following anaesthesia, III. 35
functional, hypnotism in case of, III.
171
general, of the insane, II, 1077
anti-syphilitic treatment in, II. 1078
congestive attacks, II. 1079
constipation in, II. 1079
excitement in, II. 1079
irritability in, II. 1079
late stages of, II. 1086
refusal of food in, II. 1079
serum therapy of, II. 1079
surgery of, II. 1079
symptomatic treatment, II. 1079
hasmorrhagic, of ocular muscles, III.
648
in hemiplegia, II. 1184
in lead poisoning, I. 513
in neuritis, prevention of deformity
from, II. 1034
in spina bifida, I. 916
infantile, nerve anastomosis in, II. 1059-
1060
Laudry's, II. 1080
Little's, in infants, I. 886
migrainous recurrent, of ocular muscles,
III. 649
of muscles of the larynx, III. 842
of inter-arytenoideus muscle, III. * 1 1
Paralysis (contd.)
of pharynx, III. 782
of thyro-arytenoidei interni tensors of
. the vocal cords, III. 843
of ulnar nerve, II. 1267
post-diphtheritic, of ocular muscles, III.
649
prevention of bedsores in, I. 31
deformity in, in neuritis, II. 1132
rheumatic, of ocular muscles, III. 649
spastic, in paraplegia, II, 1197
spinal, deformities due to, I. 988-990
syphilitic, II. 1069
thrombotic, of ocular muscles, III. 648
Paralysis agitans, II. 1269-1270
drugs in, II. 1270
Paralytic deformities of the upper limb,
I. 990
distension complicating abdominal
operations, II. 271
torticollis, II. 1051
Parametritis, chronic, in pelvic cellulitis,
IV. 834
remote, in pelvic cellulitis, IV. 833
Paramyoclonus multiplex, II. 1255-1256
Paranoia, II. 1309
Paraphimosis of the penis, II. 879
Paraplegia, II. 1195-1199
bedsores in, II. 1199
electricity in, II. 1198
endogenous, II. 1196
exogenous, II. 1196
flaccid paralysis in, II. 1197
genito-urinary symptoms in, II. 1199
hereditary spastic, II. 1249
in severe injuries of the spine, I. 906
in tuberculous disease of the spine, I.
926-927
massage in, II. 1198
of cerebral causation, II. 1195
of cerebro-spinal origin, II. 1196
of spinal origin, II. 1196
rectum symptoms in, II. 1199
spastic paralysis in, II. 1197
Parapsoriasis. III. 1084
Parasites, certain diseases caused by, III.
487
intestinal and anaemia, II. 15
of the stomach, II. 359
Pardoe (John), diseases and affections of
the prostate gland, II. 918-929
diseases and affections of the tunica
vaginalis, II. 913-929
fibroma of the prostate, II. 950-951
tumours of the prostate, II. 930-949
Parenchymatous cells, embolism by, I.
1306
goitre, II. 63, 67
haemorrhage, I. 1272
Parker's tracheotomy tubes, use of, I.
196
Parotid gland, inflammation of, II, 157-
163
dry mouth and, II. 163
ptyalisra and, II. 161
87
A SYSTEM OF TREATMENT.
Parotid gland (contd.}
ranula cyst and, II. 158
salivary calculi and, II. 159
salivary fistula and, II. 160
salivation and, II. 161
xerostomia and, II. 163
tumours of, II. 161
innocent, operation for, II. 161
malignant, operation for, II. 162
wounds of, II. 162
Parotitis, I. 256-257
complicating gynaecological surgery,
IV. 495
typhoid fever, I. 357
secondary, II. 158
simple, II. 157
symptomatic, II. 131, 158
Partsch's metal band for fracture of the
jaws. II. 114
Parturition. See Labour and Puerperium.
Pasteur (W.) on active collapse of the
lung, I. 1065
Pasteurisation of milk, II. 220
Pasteur's inoculation method of treatment
of rabies, I. 264
Patella, dislocations of, I. 728
fractures of, I. 620-622, 679
Paterson (D. B.), actinomycosis of the
pharynx, III. 765
chronic hyperplasia of the mucous
membrane of the upper respiratory
tract, III. 774
glanders, III. 670
gout affections of the throat, III. 775
hypertrophy of the pharyngeal tonsil,
III. 732-738
keratosis of the pharynx, III. 779
naso-pharyngeal catarrh, III. 739-741
pharyngomycosis, III. 787
rheumatic affections of the throat,
III. 764
rhinoscleroma, III. 713
thrush, III. 792
Paterson (Marcus). The treatment of
pulmonary tuberculosis bv graduated
labour, I. 1159-1163
Paterson's electric-heated infusion ap-
paratus, I. 100
forceps, III. 849
Pathology, recuperative factors in, I. 10,
11
Patient, care of, in typhoid fever, I. 338
fhial directions to, after abdominal
operations, II. 268
general health of, in abdominal opera-
tions, II. 257
general management, I. 9
individuality of, I. 25
position of, in gynaecological surgery,
IV. 487
preparation of, for operation, I. 27, 83
in abdominal operations, II. 257 ;
IV. 485
in Csesarean section, IV. 385
in obstetric operations, IV. 373
Patient, preparation of (contd.)
in shock, I. 95
in vaginal operations, IV. 484
protection of. in X-ray treatment, III.
345
Patients after abdominal operation, treat-
ment of, II, 262
Paul's operation for cancer of the colon,
II. 580, 584
Pavy's method of estimation of sugar, I.
420
Pawlik's grip in palpation in normal
labour, IV. 100, 101
Pawlow on food values, I. 449
Pearson (S. V.) and Claude Willingston.
The treatment of pulmonary tubercu-
losis by the induction of an artificial
pneumothorax, I. 1164-1173
Peat baths, III. 135
in arthritis deformans, I. 398
Pedicle needle in laceration of the genital
tract, IV. 192
Pediculosis, III. 1086-1087
capitis, III. 1086
in anaemia, II. 14
corporis, III. 1086
pubis, III. 1087
Pellagra, I. 521-524
advanced cases of, I. 521
blood transfusion in, I. 523
diart-hoea in, I. 522
drugs in, I. 522
lunacy of, I. 523
Pelvi-rectal abscess of the anus, II. 604
Pelvic cellulitis, IV. 824-838
abscess cavities in, drainage of, IV.
848
anti-streptococcus serum in, IV. 833
in diseases of pelvic bones, IV. 836
inflammation virulent in, IV. 831
moderate acute infection in, IV. 827
parametritis, chronic in, IV. 834
remote in. IV. 833
summary of treatment, IV. 837
suppuration in, IV. 828
treatment of, IV. 826
vaccine treatment of, IV. 837
grip in palpation in normal labour, IV.
101, 102
lifting exercise in heart disease, III. 253
Pelvis, bones of. pelvic cellulitis in, IV.
836
bony, hydronephrosis due to obstruction
in, II. 772
cellular tissue of, drainage of in puer-
peral sepsis, IV. 306
contractions of, Caesarean operation in,
table of mortality, IV. 402
Cassarean section in, IV. 383
complicating labour, IV. 163-175
Caesarean section in, IV. 170
cleidotomy in, IV. 171
hebosteotomy in, IV. 171
pubiotomy in, IV. 171
symphysiotomy in, IV. 1171
A SYSTEM OF TREATMENT.
Pelvis, contractions of (contd.*)
decapitation in, IV. 415
diet in, in labour, IV. 174
induction of premature labour in. IV.
434
rare, complicating labour, IV. 172-
175
deformities of, symphysiotomy for, IV.
454
drainage of, by vaginal incision in
puerperal sepsis, IV. 302
examination of, in sterility, IV. 851
exostosis of, complicating labour, IV. 174
flat, complicating labour, IV. 168
flattened, podalic version in, IV. 466
floor of, rigidity of, forceps in, IV. 420
fracture of, I. 605
in abdominal injuries, II. 249
infective processes in, subinvolution of
uterus by, IV. 723
ky photic, complicating labour, IV. 173
malacosteon, complicating labour, IV.
172
maternal, disproportion between child
and, forceps in, IV. 417
position of blades of forceps to, IV.
431
oblique, complicating labour, IV. 173
organs of, in normal puerperium, IV.
257
osteomalacic, complicating labour, IV.
172
pseudo - osteomalacic, complicating
labour, IV. 172
Robert's, complicating labour, IV. 173
spondylolisthetic, complicating labour,
IV. '173
Pemphigus, III. 1088-1089
acute, III. 1088
chronic, III. 1088
contagiosus, III. 474
foliaceus, III. 1089
of the pharynx, III. 788
vegetans, III. 1089
Pendlebury (H. 8.), caseating tuberculous
glands in the mediastina, I. 1177
inflammation of the ribs and sternum,
I. 1032-1033
inflammatory conditions of medias-
tinum, surgical treatment of, I. 1176
injuries of the chest, I. 1031
new growths of the thoracic wall, I.
1034
surgical treatment of abscess of the
lung, I. 1060-1062
surgical treatment of growths of the
lung, I. 1175
surgical treatment of hydrocephalus.
II. 1193
surgical treatment of pericarditis, I.
1188-1189
surgical treatment of purulent pleural
effusion, I. 1101-1109
surgical treatment of pyopneumothorax,
I. 1114
Penis, bruises of, II. 876
cancer of, relief of obstruction in, I. 142
chordee and painful erections of, com-
. plicating gonorrhoea, I. 226
diseases of, II. 874
dressing of, in operation for elephan-
tiasis scrote, III. 513
flaps to, in operation for elephantiasis
scrote, III. 511
grafting of in operation for elephantiasis
scrote, III. 511
injuries of, II. 876
lacerations of, II. 876
malformations of, congenital, II. 875-
876
malignant disease of, II. 877
papillomata of, II. 878
paraphimosis of, II. 879
phimosis of, II. 879
rupture of fraenal artery of, II. 876
sloughing of, I. 316
Pepsin, effect on gastric function, II. 291
Peptonised beef-tea, preparation of, I. 42
milk, II. 226
preparation of, I. 42
Peptonuria, II. 733
Perambulators for young children, use of,
I. 52
Perchloride of mercury, in lotions, I. 73
solution, strength of, I. 81
Pericardial adhesions, I. 1189
Pericarditis, I. 1179
chronic, mediastinal, and adherent
pericardium, I. 1186
complications of, I. 1179
drugs in, I. 1180
in acute rheumatism, I. 272, 278
in rheumatism, I. 1179
in childhood, I. 278
pneumococcus, infection with, I. 1182
purulent, I. 1184
surgical treatment of, I. 1188-1189
tuberculous, I. 1184
with kidney disease, I. 1185
Pericardium, adherent, and chronic medi-
astino-pericarditis. I. 1186
diseases of, I. 1179-1187
operation and drainage in, I. 1183
drainage of, I. 1188
injuries of, I. 1030
Perichondritis of the auricle, III. 881
of the larynx, III. 861-862
Pericolitis. II. 574
general peritonitis in, II. 576
localised abscess in. II. 575
perforation in, II. 576
Perigastritis, complicating hour-glass
stomach, II. 336
Perineal dressing in operation for
elephantiasis scroti, III. 513
Perineorraphy, IV. 549
Perinephritic abscess, II. 801-802
results of operation for, II. 801
Perineum, blow on, injuries of the urethra
by, II. 882
A SYSTEM OF TREATMENT.
Perineum (contd.)
examination of, in labour, IV. 126
falls on, injuries of urethra by, II. 882
laceration of, complicating labour, IV.
204
pedunculated fibromata of, I. 112
rupture of, treatment, IV. 208
support of, in second stage of labour,
IV. 113
threatened rupture of, forceps in, IV.
420
Permeal muscular atrophy, II. 1253
Periodontal membrane, diseases of, III.
1174
Periodontitis suppurative, chronic, III.
1176
Periosteal flaps, I. 800
Periosteum, treatment of, in amputations,
I. 800
Periostitis, acute, I. 694
in infective lesions of the skull, I.
889
non-suppurative, I. 694, 703
of the spine, I. 916-917
Peritoneal infusion in shock, I. 101
toilet in perforation of the intestine, II.
554
Peritoneum, adhesions of, division of, in
constipation in adults, II. 467
contained in lipomata, I. 107
diseases of, II. 626-642
fistulas of, II. 280
Peritonitis, II. 632-642
abdominal distension in, II. 638
acute, table of cases of, at St. Thomas'
Hospital, II. 633
administration of fluids per rectum in,
II. 635
after ovariotomy, IV. 794
.artificial leucocytosis in, II. 637
colon bacillus, II. 641
complicating gynaecological surgery, IV.
492
typhoid fever, I. 359
diffuse, in appendicitis, II. 422
feeding in, II. 640
general, and appendicitis, II. 405
in appendicitis, II. 422
in pericolitis, II. 576
gonorrhceal, II. 642
hiccough in, II. 639
in abdominal injuries, II. 244
in gunshot wounds, I. 566
incision in operation for, II. 634
morphia in, II. 639
operation for, II. 633
opium in, II. 638
pneumococcal, II. 641
proctoclysis in, II. 635
purgatives in, II. 638
repeated sickness in, II. 638
rules before operation, II. 633
serum treatment of, II. 637
special forms of, II. 641-642
staphylococcic, II. 641
Peritonitis (contd.*)
stimulants in, II. 638
streptococcic, II. 641
tuberculous, II. 645-647
appendix and, II. 411
complications of, II. 645
general measures in, II. 645
medicinal measures in, II. 645
removal of ascetic fluid in, II. 647
tuberculin in, II. 646
vaccine treatment of, II. 637
Peri-urethral abscess, II. 895-896
complicating gonorrhoaa, I. 226
Perkins (J. J.), abscess of the lung, 1. 1059
gangrene of the lung, I. 1059
hasmothorax, I. 1090
hydrothorax, I. 1091-1092
pneumothorax, I. 1112-1113
pyopneumothorax, I. 1113
Perlsucht tuberculin, III. 294
Permanganate, potassium in gastric lavage,
I. 528, 531
Peroxide of hydrogenas a haemostatic, I.
138
of iron, hydrated in arsenical poisoning,
I. 504
Persuasion method in hysteria, II. 1012
Perversions, II. 1315
Pes arcuatus, I. 963
cavus, I. 963
Pessaries in prolapse of uterus, IV. 690-
692
mechanical treatment of retroflexion of
uterus, IV. 678, 680
Petrissage and massage, III. 204
Phagedaena in syphilis, I. 316
tropical, III. 472
Phagedsenic ulcers, I. 369
Phagocytosis, invigoration of, I. 7, 11
Phalanges, fracture of, I. 605
of the thumb, congenital lateral devia-
tion of, I. 938
Phalanx, middle, amputation through, I.
806
Pharyngeal fibromata, I. 113
tonsil diseases of, III. 732-738
Pharyngitis, acute catarrhal, III. 766-767
chronic catarrhal, III. 767-769
complicating influenza, I. 239
Pharyngo-keratosis of lingual tonsil, III.
762
Pharyngomycosis, III. 787
Pharynx, actinomycosis of. III. 765
acute septic inflammation of, III. 772
anaesthesia of, III. 782
and voice production, III. 335
cancer of, relief of obstruction in, I.
139
diseases of, III. 765-783
haemorrhage from, III. 776-777
herpes of, III, 778
hyperaasthesia of, III. 782
keratosis of, III. 779
leprosy of, III. 780
lupus of, III. 781
90
A SYSTEM OF TREATMENT.
Pharynx (contd.~)
malignant growths of, III. 786
mycosis of, III. 787
naso-diseases of, III. 732-743
neuralgia of, III. 782
neuroses of, III. 782-783
motion of, III. 782
sensation of, III. 782
new growths of, III. 699-700
parassthesia of, III. 782
paralyses of, III. 782
pemphigus of, III. 788
spasmodic affections of the palate, III.
783
syphilis of, III. 791-792
tuberculosis of, III. 793-794
ulceration of, III. 795-796
wounds of, in cut throat, II. 165
Phenacetin for relief of pain, I. 134
in influenza, I. 233
poisoning by, I. 533
Phenazone in diabetes insipidus, I. 429
in whooping cough, I. 382
Phenol, poisoning by, I. 527
Phimosis in the newborn child, IV. 360
of the penis, II. 879
Phlebitis and thrombosis, I. 1328-1338
gouty, I. 1330
in gout and gouty conditions, I. 444
in varicose veins, IV. 89
non-infective, I. 1328
septic cases of, I. 1329
simple, I. 1328
syphilitic, I. 1330
Phlebotomus fever, III. 400
Phlegmasia alba dolens in puerperal
sepsis, IV. 321
Phlegmonous gastritis, II. 353
Phlyctenular conjunctivitis, III. 552
ulceration of the cornea, III. 567
Phosphaturia, II. 746
Phosphoretted hydrogen, poisoning by, I.
535
Phosphorus, effect of, on the teeth, II.
108
in rickets, I. 480
poisoning, I. 525
acute, I. 528
Photophobia in measles, I. 242
Phthisis complicating pregnancy, IV.
49
pulmonary, I. 1117-1126
Physical exercises, III. 222-257
methods in hysteria, II. 1012
Physostegmine or eserine, poisoning by,
I. 533
Piedra, III. 476
Pieniazek on tracheoscopy, III. 805
Pigmentations, preceding melanotic
cancer, I. 120
Piles, operations for, II. 618
palliative treatment, II. 615
Pillows, arrangement of, I. 30
Pilocarpine in eclampsia, IV. 37
poisoning by, I. 533
Pinard's registering separator for sym-
pbysiotomy, IV. 457
Pinhble os, leucorrhoea in, IV. 567
Pinna, deviated, III. 877
Pinta or caraate, III. 477
Pirogoff 's amputation, I. 848
von Pirquet's skin reaction in diseases of
the pericardium, I. 1185
Pituitary body, influence on obesity, I.
473
extract in obesity, I. 473
in pneumonia, I. 261
infusion in shock, I. 103-5
Pituitous catarrh or bronchorrhoea serosa,
I. 1058
Pityriasis rosea, III. 1090-1091
general treatment of, III. 1090
local treatment of, III. 1090
rubra, III. 1093
pilaris, III. 1092
gravis of Hebra, III. 1151
versicolor, III. 1095
Placenta, adherent, complicating labour,
IV. 228, 234
removal of, IV. 234
examination of, in third stage of labour,
IV. 123
expression of, in third stage of labour,
IV. 120, 121
expulsion of, in third stage of labour,
IV. 119
prasvia, Cassarean section in, IV. 385
central insertion of de Ribes' bag in,
IV. 67, 68
complicating pregnancy, IV. 65.
epitome of treatment of, IV. 69
lateral insertion of de Ribes' bag in,
IV. 66, 68
marginal insertion of de Ribes' bag
in, IV. 66, 68
occurring before labour has begun,
IV. 65
post-partum haemorrhage in, IV. 68
syncope in, IV. 69
removal of, in Caesarean section, IV. 391
retention of, complicating labour, IV.
225-237
in hour-glass contraction of uterus,
IV. 230, 231
in missed abortion, IV. 225
in third stage of labour, IV. 229
in uterine atony, IV. 229
succenturiate, in third stage of labour,
IV. 124
Placental extract in cancer, 1. 150
Plague, III. 401409
antiseptic drugs in, III. 406
bubo in, III. 405
carbuncles in, III. 406
contacts in, III. 402
convalescence of, III. 406
diet in, III. 403
disinfection during illness from, III.
402
general management of, III. 401
91
A SYSTEM OF TREATMENT.
Plague (contd.')
initial precautions in, III. 401.
nursing in, III. 403
organo-therapy of, III. 409
pneumonic, III. 405
point of inoculation in, III. 405
preventive inoculation in, III. 284
results, III. 284
re-inoculation in, III. 284
serum-therapy of, III. 407
specific methods of treatment of, III.
406-409
stimulants in, III. 403
symptomatic treatment of, III. 404
ulcer in, III. 406
vaccine therapy of, III. 284
Plantar neuralgia, I. 964
Plaster of Paris splinting, I. 574
splints, I. 628
splint in tuberculous disease of hip-
joint, I. 760
Plasters, application of, I. 36
Plastic operations in ulceration, I. 375
Pleura, wounds of, I. 1027
Pleural cavity, injections into, in pleural
effusion, I. 1097
Pleurisy, after-treatment of, I. 1097
and pleural effusion (sero-fibrinous), I.
1093-1098
complicating artificial pneumothorax,
1.1170
pregnancy, IV. 50
pulmonary tuberculosis, I. 1158
delayed re-expansion of lung in, I.
1098
physical exercises in, III. 252
relieved by belladonna plaster, I.
1307
with effusion and tumours of the lung,
I. 1174
(purulent), I. 1099-1100
surgical treatment of, I. 1101
treatment by tapping or aspiration,
I. 1095
Plombieres spa, III. 154
Plumbism and anemia, II. 16
complicating pregnancy, IV. 56
industrial, prevention of, I. 514
"Pneumatic cabinet" in emphysema. I.
1086
treatment of asthma, I. 1042
Pneumatoceles of the skull, I. 896
Pneumaturia, II. 749
Pneumococcal arthritis, I. 783-784
Pneumococcic vaccine treatment in
diseases of the pericardium, I. 1184
Pneumococcus infections, serum therapy
of, III. 285
in pericarditis, I. 1182
meningitis, I. 250
peritonitis, II, 641
vaccine, dose of, III. 286
Pneumokoniosis. I. 1115
Pneumonia, I. 258-263
abscess of lung following, I. 1060
Pneumonia
bronchial, I. 1066-1073
horse serum in, III. 262
catarrhal, external applications in, I. 69
chronic interstitial, I. 1074-1075
prophylaxis of, I. 1074
complicating gynaecological surgery,
IV. 494
influenza, I. 240
typhoid fever, I. 361
delayed resolution after, III. 252
drugs in, I. 259-261
feeding in, I. 258
glandular extracts in, I. 261
in injuries of the spine, I. 909
ice-poultice in, I. 259
jacket, how to make, I. 34
lobar, complicating pregnancy, IV. 49
in pericarditis, I. 1182
in measles, I. 245
serum treatment of, I. 262
sleeplessness in, I. 259
stimulants in, I. 259
vaccine treatment of, I. 263
Pneumonic plague, III. 405
Pneumothorax, artificial, choice of patient,
I. 1171
completion and the maintenance of,
I. 1168
complications of, I. 1171
difficulties in the course of the opera-
tion, I. 1167
duration of treatment, I. 1169
dyspepsia complicating, I. 1170
Forlanini's method of, I. 1170
modifications of method, I. 1170
Murphy's method of, I. 1170
pleurisy complicating, I. 1170
technique of, I. 1165
treatment of pulmonary tuberculosis
by the induction of, I. 1164-1173
complicating pregnancy, IV. 50
in injuries of the thorax, I. 1029
Poisoning, artificial respiration in, I. 530,
532, 534
by acetanilide, I. 533
by aconite, I. 532
by aconitine, I. 532
by ammonia, I. 527
by aniline, I. 533
by antifebrin, I. 533
by antimony, I. 529
by antipyrin, I. 533
by arsenic, I. 529
by arseniuretted hydrogen, I. 535
by atropine, I. 532
by belladonna, I, 532
by benzene, I. 533
by calabar bean, I. 533
by cantharides, I. 532
by carbolic acid, I. 527
by carbon dioxide, I. 534
by carbon monoxide, I. 534
by carbonic acid, I. 534
by caustic alkalies, I. 527
92
A SYSTEM OF TREATMENT.
Poisoning (contd.)
by chloral hydrate, I. 530
by chloroform, I. 531
in fatty liver, II. 668
by cocaine, I. 532
by colchicine, I. 533
by colchicum, I. 533
by digitalis, I. 533
by ergot, I. 533
by eserine, I. 533
by gabarandi, I. 533
by hellebore, black, I. 533
green, I. 533
white, I. 533
by henbane, I. 532
by hydrocyanic acid, I. 530
by hyoscine, I. 5 32
by hyoscyamine, I. 532
by laburnum, I. 533
by mercury, I. 530
by mineral acids, I. 526
by morphia, I. 531
coma in, II. 984
by mushroom causing diarrhoea, II. 480
by nicotine, I. 533
by nitro-benzene, I. 533
by opium, I. 531
by oxalic acid, I. 528
by phenacetin, I. 533
by phenol, I. 527
by phosphoretted hydrogen, I. 535
by phosphorus, I. 525, 528
by physostigmine, I. 533
by pilocarpine, I. 533
by potassium chlorate, I. 532
by pyridine, I. 533
by salts of barium, I. 529
of copper, I. 529
of lead, I. 529
of tin, I. 529
of zinc, I. 529
by savin, I. 533
by scopolamine, I. 532
by stramoniun, I. 532
by sulphonal, I. 531
by sulphuretted hydrogen, I. 534
by tetronal, I. 531
by tobacco, I. 533, 534
by trional, I. 531
by turpentine, I. 532
by vegetable irritants, I. 533
by veratrme, I. 533
by veronal, I. 531
by yew, I. 533
oxygen in, I. 528, 531, 533, 535
potassium permanganate in, I. 528, 631
renal complications in, I. 530, 532
Poisons and antidotes, I. 526-535
corrosive, I. 526-528
gaseous, I. 534-535
irritant, I. 528-530
narcotic, I. 530-534
Polio-myelitis, acute, anterior, II. 1055-
1058
electricity in, II. 1056
Polio-myelitis, acute, anterior (contd.)
massage in, II. 1056
passive movements in, II. 1056
pyrexial stage, II. 1055
Politzer's method in patency of Eustachian
tube, III. 948
Pollantin, Uunbar antitoxic serum, III.
28(5-287
Polycythsemia, chronic, with cyanosis and
enlarged spleen, II. 84
Polydactylism, I. 943
Polyneuritis of auditory nerve caused by
general neurasthenic state of the system,
III. 977
Polypus, aural, III. 909-911
ribrinous, of placenta complicating
labour, IV. 228
fibroid, of the meatus, III. 882
uterine, IV. 658-661
mucous, of cervix, IV. 567, 662
of uterus, IV. 662
multiple, of the colon, II. 588
of the nose, III. 691
placental, complicating labour, IV. 228
Polysarcia abdominalis in the meno-
pause, IV. 501
Polyuria of diabetes insipidus, I. 428
Pomegranate root in intestinal tseniasis,
III. 518, 519
Ponos, III. 440-441
prophylaxis of, III. 440
treatment of, III. 440
Pontine hemorrhage, II. 1175
Pork, chemical composition of, II. 193
Poroplastic sheet cut for a moulded
shoulder cap, 1. 588
Port wine in gout, I. 457
stains, III. 1077
carbon dioxide in, III. 1078
Portal vein, thrombosis of, 1. 1331 ; II.
666-667
Posthitis, II. 874
Postures, faulty, in children, I. 56
Pbstyen spa, III. 154
Potam's bottle aspirator apparatus for
pleural effusion, I. 1095
Potash, bicarbonate of, in influenza, 1. 234
chlorate of, in ulcerative stomatitis, II.
121
Potassium, bromide of, in exophthalmic
goitre, II. 55
in insomnia. II. 991
in whooping cough, I. 380
chlorate, dosage of in children's diseases,
1.67
poisoning by, I. 532
impotence due to use of, I. 231
iodide of, in actinomycosis, I. 178
in aortic aneurysm, I. 1298
in diseases of the heart, I. 1224
in gouty joints, I. 436
in lead colic, I. 513
in new growth in the mediastinum,
I. 1178
in tabes dorsalis, II. 1087
93
A SYSTEM OF TREATMENT.
Potassium, iodide of (contd.~)
in typhoid fever, I. 355
in undefined tropical fevers, III. 410
permanganate in gastric lavage, I.
528-531
salts in sub-acute gout, I. 435
Potato diet in gout, I. 453
in dietary of children, I. 59
Potts' disease, line of incision in, I. 916
of the spine, I. 922-927
fracture, I. 629
Pouges spa, III. 154
Poultices in acute bronchitis, I. 1050
in broncho-pneumonia, I. 1067
in chronic rheumatism, I. 486
preparation and use of, I. 33
Poultry, chemical composition of, II. 193
Powders in herpes zoster, II. 1096
in pruritus, III. 1099
Powell (Llewelyn), anaesthetics in preg-
nancy and labour, IV. 373-381
Pozzuoli spa, III. 154
Practice, medical, general considerations,
1.22
Predisposition to diseases, causes of, I. 5, 6
Pregnancy, abnormalities of, IV. 14-90
abortion in, IV. 14
incomplete in, IV. 21
inevitable in, IV. 18
later than first twelve weeks, IV. 20
missed in, IV. 22
threatened in, IV. 117
accidental haemorrhage in, Bossi's
dilator for, IV. 26
Caesarean section for, IV. 25
cases before labour has begun, IV.
26-28
hysterectomy for, IV. 25
morphia in, IV. 26
perforation of membranes and, IV. 25
plugging the vagina in, IV. 24
rest in, IV. 24
sedatives in, IV. 24
shock from, IV. 26
use of a dilating bag for, IV. 25
vaginal hysterectomy for, IV. 26
Addison's disease in, IV. 50
affections of the breasts in, IV. 330-
336
albuminuria in, IV. 7, 30-33
anaesthetics in, III. 24 ; IV. 58, 375-376
anthrax in, IV. 49
appendicitis in, II. 406 ; IV. 54
ascites in, IV. 65
auto-intoxications in, I. 389
blood or carneous mole, IV. 59
cancer in, I. 128
care of nipples in, IV. 8
cerebro-spinal meningitis in, IV. 49
chorea gravidarum in, IV. 51
clothing during, IV. 8
complicating cancer of the breast, II.
965
pulmonary tuberculosis, I. 1155
complications of, IV. 14-90
Pregnancy (coittd.')
cystitis in, IV. 272
danger signals of, IV. 4
death of fretus during, IV. 14
diabetes insipidus in, IV. 55
meUitus and, I. 425 ; IV. 54
diet during, IV. 6
diphtheria in, IV. 49
diseases of, induction of abortion in, IV.
433
induction of premature labour in, IV.
434
eclampsia in, IV. 34-41
erysipelas in, IV. 49
exercise in, IV. 7
exophthalmic goitre in, IV. 57
extra-uterine, complicated with fibroids,
IV. 82
conditions simulating rupture of a
gravid tube in, IV. 84
risks of operation in, IV. 83
troubles with decidua in, IV. 83
unavailing labour at term, IV. 87
filariasis in IV. 57
general management of, IV. 1-13
treatment of, IV. 3
haemorrhage, accidental, during, IV.
23-29
occurring after labour, IV. 28
haemorrhoids in, IV. 42
heart disease in, IV. 52
herpes in, IV. 56
hydatidiform mole in, IV. 59
hydramnios in, IV. 43
chronic, IV. 43
in bicornate uterus, IV. 712
insanity, complicating, IV. 45
intra- abdominal tumours in, IV. 55
jaundice in, IV. 53
later months of, deformities of the foetus
obstructing labour in, IV. 178
leucorrhoea in, II. 557, 558
lobar pneumonia in, IV. 49
malaria in, IV. 48
management of the breasts in, IV.
330
of the nipples in, IV. 330
medicines during, IV. 9
mental diseases complicating, IV. 46-58
minor ailment in, IV. 11
mollities ossium in, IV. 58
myxcedema in, IV. 58
nervous diseases in, IV. 50
oligo-hydramnios in, IV. 44
operations in, IV. 58
osteo-arthritis in, IV. 57
osteo-malacia in, IV. 58
ovarian tumours complicating, IV. 771-
772
ovariotomy in, IV. 771
paralyses of, IV. 60
pendulous belly in, IV. 61
pernicious vomiting in, IV. 62-64
starvation in, IV. 62
phthisis in, IV. 49
94
A SYSTEM OF TREATMENT.
Pregnancy (cmtd.)
placenta praevia in, IV. 65
occurring before labour has begun
in, IV. 65
pleurisy in, IV. 50
plumbism in, IV. 56
pneumothorax in, IV. 50
prolapse of pregnant uterus in, IV. 70
of the vagina in, IV. 71
prolongation of, induction of premature
labour in, IV. 436
pruritus in, IV. 56
vulva in, IV. 72-73
psoriasis in, IV. 56
pyelitis in, II. 806
pyelonephritis of, II. 806
regulation of the bowels in, IV. 8
retroflexion of the uterus in, IV. 74-75
rheumatoid arthritis in, IV. 57
scarlet fever in, IV. 48
spleno-medullary leuchasmia in, IV. 55
syphilis in, IV. 76-77
foetal in, IV. 77
maternal, IV. 76
table of diseases complicating, IV. 46, 47
tetany in, IV. 51
therapeutics of the unborn infant
during, IV. 12
tubal, IV. 78-88
and uterine, concurrent, IV. 81
colpotomy in, IV. 87
conditions simulating rupture in,
IV. 84
of a gravid tube in, IV. 84
diagnostic doubts in, IV. 85
expectant treatment of, IV. 78
extra-uterine pregnancy complicated
with fibroids in, IV. 82
hysterectomy in, IV. 87
transfusion in haemorrhage in, IV.
85
treatment of non-gravid tube in, IV.
86
operative, IV. 79
tuberculosis in, IV. 50
typhoid fever in, IV. 48
urticaria in, IV. 56
vaginal examination in, IV. 5
vaginitis in, leucorrheal, IV. 564
varicose veins in, IV. 89-90
vesicular mole in, IV. 59
Premaxillary bones, harelip and. II. 91,
92
Premolars, lower, extraction of, III. 1184
upper, extraction of, III. 1181
Prepuce, oedema of, complicating gonor-
rhoea, I. 225
of the newborn child, IV. 339
Presbyopia, III. 533
Pressure bandage in ulcers, I. 370
local, in haemophilia, II. 33
Price (Frederick W.), bronchiectasis, I.
1043-1048
chronic interstitial pneumonia, I. 1074-
1075
Price (Frederick W.) (contd)
pneumokonissis, I. 1115
pulmonary aspergillosis, I. 1116
Prickly heat, III. 470
general management of, III. 470
local treatment of, III. 471
prognosis in, III. 470
Principles of treatment, I. 1-25
Probangs, II. 185
Probe, aural, III. 908
Proctitis, epidemic gangrenous, III. 437
infective ulcerative, II. 610
Proctoclysis, electrical apparatus for, II.
637
in peritonitis, II. 635
Prostate gland, abscess of, II. 922
after-treatment of operation for, II.
922
operation for, II. 922
adenoma of, II. 940-949
complications. II. 944-946
cystitis in, II. 945
epididymitis in, II. 945
haemorrhage in, II. 94. r >
operations for, conclusions, II. 948
operative treatment, II. 941
palliative treatment, II. 941
perineal prostatectomy in, II. 946-948
prognosis in, II. 946
supra-pubic prostatectomy in, II.
942
calculi of, II. 918
in bed of, complicating adenoma of
prostate, II. 945
carcinoma of, II. 933
operation for, conclusions, II. 940
permanent supra-pubic drainage in,
II. 939
diseases of, II. 918-929
endothelioma of, II. 932
enlargement of, permanent, obstruction
to micturition in, II. 930
X-rays in, III. 367
fibroma of, II. 950-951
perineal prostatectomy for, II. 950
malignant tumours of, II. 932-938
operation for, II. 933
sarcoma of, II. 932
syphilis of, II. 927
tumours of, II. 930-949
obstruction to micturition in, II. 930
wounds of, II. 919
Prostatectomy, perineal, advantages of,
II. 948
after-treatment of, II. 947
disadvantages of, II. 948
for fibroma of the prostate, II. 950
in adenoma of the prostate, II. 946
operation of, II. 946
supra-pubic, in adenoma of the pros-
tate, II. S42
Prostatic veins, thrombosis of, I. 1331
Prostatitis, acute, II. 920-923
recto-urethal fistula and, II. 923,
chronic, II. 924-926
95
A SYSTEM OF TREATMENT.
Prostatitis, chronic (contd.}
Janet's method of posterior irrigation
in, II. 925
complicating gonorrhoea, I. 226
gouty, II. 926
onanitic, II. 927
tuberculous, II. 928-929
Proteid food and over-nutrition, I. 451
Protein diet for diabetics, I. 419
effect of, on kidneys, II. 204
food in dietetics, II. 200
foods arranged in order of value in,
II. 197
Proteins, digestion of, II. 191
Protene Company diabetic food. I. 414, 418
flour, I. 423
Prurigo, III. 1096
Pruritus, alcohol in, III. 1098
carbolic acid in, III. 1098
chemical remedies in, III. 1098
complicating diabetes mellitus, I. 425
pregnancy, IV. 56
creams in, III. 1099
electrical methods in, III. 1101
external treatment of, III. 1098
general remarks on, III. 1097
gouty, I. 446
hydrotherapy in, III. 1100
ichthyol in, III. 1099
in jaundice, II. 670
internal treatment of, III. 1098
lead in. III. 1099
localised, III. 1100
lotions for, III. 1098 ; IV. 530
of the vulva, IV. 517-519
opium in, III. 1099
or itching, III. 1097-1101
physical methods in, III. 1100
powders in, III. 1099
tar in, III. 1099
X-rays in, III. 359
Pruritus ani, II. 593 ; III. 1102-1105
electrical methods in, III. 1104
local treatment of, III. 1103
vulvae, III. 1106-1108
complicating pregnancy, IV. 72-73
treatment of, local, III. 1107
Prussic acid, poisoning by, I. 530
Pseudo-angina pectoris in gout, 1. 444
dipsomania, I. 498
leukaemia, II. 42
osteomalacic pelvis complicating labour,
IV. 172
Psoas abscess, I. 916
evacuation of, in tuberculous disease
of the spine, I. 931
contraction in Potts 1 disease of the
spine, I. 927
Psoriasis, III. 1109-1123
after-treatment of, III. 1122
alkalies in, III. 1114
anthrarobin in, III. 1119
arsenic in, III. 1111
chrysarobin in, III. 1117
complicating pregnancy, IV. 56
96
Psoriasis (contd.~)
diet in, III. 1110
general management of, III. 1110
general remarks on, III. 1109
of the nails, III. 1121
of the scalp, III. 1121
pyrogallol in, III. 1121
salicin in, III. 1114
tar in, III. 1119
thyroid extract in, III. 1114
treatment of, internal, III. 1111
local, III. 1115
tuberculous, III. 1152
X-rays in, III. 351, 1122
Psychalgia, II. 1123
Psychasthenia, II. 1044-1046
agoraphobia in, II. 1044
claustrophobia in. II. 1044
echolalia in, II. 1045
treatment of, II. 1046
Psychical impotence, I. 231, II. 911
Psycho-analysis in hysteria, II. 1010
Psychoses associated with changes in
thyroid gland, II. 1301-1302
exhaustion, II. 1299-1300
toxic. II. 1303-1304
Psychotherapy in constipation in adults,
II. 441
in melancholia, II. 1295
in morphinism, I. 519
Pterygium of conjunctiva, III. 561
Ptomaine poisoning or bacterial food
poisoning, I. 507-510
Ptosis, adiposa, III. 650
congenital, III. 650
Fuchs' myopathic, III. 650
hysterical, III. 650
morning, III. 650
neurasthenic, III. 650
of ocular muscles, III. 650
of the eyelids, III. 579
reflex, III. 650
Ptyalism, II. 130
and inflammation of parotid gland, II.
161
Puberty, dysmenorrhoea in, IV. 501
management of, IV. 498-501
mastitis at, II. 960
menorrhagia in, IV. 501
precocious, IV. 500
Pubic dressing in operation for elephan-
tiasis scroti, III. 513
Pubiotomy, IV. 446-450
Gigli's saw in, IV. 447
in contracted pelvis complicating
labour, IV. 171
operation of, IV. 447
results of, IV. 448
Puddings, necessary in dietary of children,
I. 59
Pudenda, granuloma of, constitutional
treatment of, III. 457
local treatment of, III. 457
palliative measures in, III. 458
ulcerating granuloma of, III. 457-458
A SYSTEM OF TREATMENT.
Puerperal infection, IV. 282-323
bacteriology of, IV. 284
consecutive lesions in, IV. 283
metastatic lesions in, IV. 283
method of, IV. 285
nature of lesion in, IV. 282
primary lesion in, IV. 282
insanity, IV. 277-278
mania, hypnotism in case of, III. 173
neuritis, II. 1139
sepsis, abdominal drainage in, IV. 300
administration of saline solution in,
IV. 311
application of strong antiseptics to
the uterus in, IV. 310
curative treatment of, IV. 294-307
curettage of the uterus in, IV. 299
drainage of pelvic cellular tissue in,
IV. 306
drainage of the pelvis in, by vaginal
incision, IV. :;oi.'
drugs in, IV. 313
eclampsia and, IV. 34-41
empty uterus and, IV. 290
femoral thrombo-phlebitis in, IV. 321
fever, breast, in, IV. 315
continued in, IV. 317
early acute, in, IV. 317
early slight, in, IV. 314
reaction in, IV. 315
free vaginal drainage in, IV. 290
Livneral management of, IV. 313
hysterectomy in. IV. 302
identification of causative organism
in, IV. 3U7
intra-uterine douching in, IV. 310
isolation of causative organism in,
IV. 307
ligation of pelvic veins iu, IV. 304
notification of, IV. 322
nursing in, IV. 313
particular classes of, treatment, IV.
314-323
phlegmasia alba dolons in, IV. 321
prevention of. I V. 2S7-294
prevention of injury to the soft parts
in, JV. i".i!
removal of a pyosalpinx in, IV. 307
re-sterilisation of general tract after
probable infection in, IV. 290
salpingectomy in, IV. 300
serum treatment of. IV. 308
sterilisation of hands in, IV. 288
instruments in, IV. 288
lower genital tract in. 1 V. 289
treatment of, non-operative. IV. 307-
314
uterine exploration in, IV. 295
vaccine treatment of. IV. .'ln'.t
vaginal douching of. IV. 311
va.LMiiitis. I V. .".liij
Puerperium. affections of the breasts in,
IV. 33(i-33i!
complications of. IV. _ > 72-l'7t;
cystitis in. IV. 272
Puerperium (i'ontd.)
fever, late, in, IV. 320
galactocele in, IV. 330
'mastitis in, 1 V. 334-335
nipples, depressed in. I V. 332
sore in, IV. 333
normal, anatomy of, IV. 257
blood in, IV. 258
bowels in, IV. 266
breast-feeding in, IV. 266
breasts in, IV. 258
care of breasts in, IV. 266
cleanliness of vulva in, IV. 260
centra-indications to breast-feeding
in, IV. 268
diet in, IV. 269
involution of uterus in, IV. 261
lochia in, IV. 257, 262
management of, IV. 256-271
pain in, IV. 264
passage of urine in, IV. 265
pelvic organs in, IV. 257
physiology of, IV. 257
pulse in, IV. 261
removal of, discharges in, IV. 260
sleep in, IV. 264
temperature in, IV. 261
time of staying in bed in, IV. 270
urine in, IV. 258
uterus in, IV. 257
vagina in, IV. 257
painful engorgement of, oreasts in, IV.
331
paralysis associated with, IV. 281
pulmonary embolism in, IV. 324-325
tetanus in, IV. 326-327
tumours of ovary complicating, IV. 790
urethritis in, IV. 329
Pulley and weight for elbow exercises, I.
778
extension apparatus for fractures, 1. 576
Pulp, diseases of, III. 1173
Pulse, failure of, in cholera, III. 426
in gynaecological surgery, IV. 487
in normal puerperium, IV. 261
in typhoid fever, I. 364
Pulse-rate as a guide to treatment in
pulmonary tuberculosis, I. 1141
in non-operative appendicitis, II. 424
Pupils, condition of in cerebral com-
pression, I. 880
dilatation of, after mature cataract, III.
630
Purgation, in iutra-cerebral haemorrhage,
II. 1171
predisposes to shock. I. 95
Purgatives, anthracene, in constipation in
adults, II. 447
choice of, in constipation in adults, II.
445
dosage of, in constipation in adults, II.
I):,
in ascites, II. 627
in constipation in adults, II. 444
in non-operative appendicitis, II. 423
97
A SYSTEM OF TREATMENT.
Purgatives (contd.)
in peritonitis, II. 638
in taeniasis intestinal, III. 518
in typhoid fever, I. 355
mercurial, in constipation in adults, II.
450
saline, in constipation in adults, II. 449
sunthesised, in constipation in adults, II.
449
vegetable, in constipation in adults, II.
447, 454
Purin bodies, effect of in food, II. 207
Purin-free diet in gout, I. 452
Purpura, II. 43-45 ; III. 1124
general treatment of, II. 43
hajmorrhagica, II. 44
medicinal treatment, II. 44
Parslow (C. E.), air embolism in labour,
IV. 161-162
albuminuria during pregnancy, IV.
30-33
complications of the puerperium, IV.
272-276
eclampsia, IV. 34-41
insanity of lactation, IV. 279
insanity of pregnancy, IV. 45
paralyses associated with labour, IV. 280
paralyses of pregnancy, IV. 60
puerperal insanity, IV. 277-278
pulmonary embolism in the puerperium,
IV. 324-325
tetanus in the puerperium, IV. 326-327
tetany in the puerperium, IV. 328
urethritis in the puerperium, IV. 329
Pus, evacuation of in Bier's treatment,
III. 50
formation, Gauvain's method in, I. 757
in abcess of the liver, II. 649
in the liver, needle in search for, II.
650
in pelvic cellulitis, IV. 828
tuberculous, antibacterial properties of,
I. 174
Pustulation in herpes zoster, III. 1013
Pyaemia and septicremia, general and local
treatment of, I. 295-298
Pyelitis, II. 803-806
diagnosis of, II. 803
in childhood, II. 805
of infancy, II. 805
of pregnancy, II. 806
operative treatment of, II. 806
treatment of, II. 806
Pyelolithotomy for renal calculus, II. 763,
764
Pyelonephritis, ascending, II. 810
acute, II. 811
acute operative treatment of, II. 811
chronic, II. 812
prognosis in, II. 810
haematogenous, II. 807
infective, II. 807-813
drugs in, II. 808
medicinal treatment of, II. 808
operative treatment of, II. 809
Pyelonephritis, infective (contd.')
prognosis in, II. 807
vaccine treatment of, II. 808
of pregnancy, II. 806
primary, II. 807
secondary, II. 810
Pylephlebitis, suppurative, of the liver,
II. 666
Pylerodiosis for pyloric stenosis, II. 316
Loreta's operation, II. 317
Pylorectomy for hypertrophic pyloric
stenosis, II. 342
for pyloric stenosis. II. 316
in gastric cancer, II. 306
Pyloroplasty for liypertrophic stenosis of
the pylorus, II. 339, 342, 343
for pyloric stenosis, II. 316
in ulcer of the stomach, II. 385
three stages of operation of, II. 384
Pylorus, congenital atresia of, II. 344
hyperplasia of, II. 337
obstruction of, due to gastric cancer,
I. 140
stenosis of, II. 312-315
in gastric cancer, II. 298
surgical treatment, II. 316
hypertrophic, II. 337-341
after-treatment in. II. 340
infantile, II. 338
spasm in, II. 337
surgical measures, II. 339-342
treatment of, II. 342-344
Pyonephrosis, II. 814-818
drainage by ureteral catheter, II. 815
nephrectomy in, II. 817 .
nephrostomy in, II. 815
plastic operations in, II. 815
X-rays in, II. 814
Pyopneumothorax, I. 1113
cases of an entirely tuberculous nature,
1.1114.
surgical treatment of, 1114
Pyorrhoea alveolaris, III. 1176
vaccine therapy of, III. 287
Pysosalpinx, removal of, in puerperal
sepsis, IV. 307
Pyothorax in injuries of the thorax, I.
1029
Pyrexia, complicating operation for
goitre, II. 69
in fevers, relief of, I. 159
in typhoid fever, I. 348
of relapsing fevers, I. 2G6
Pyridine, poisoning by, I. 533
Pyrmont spa, III. l.vi
Pyrogallic acid in lupus, III. 1150
Pyrogallol in psoriasis, III. 1121
Pyuria, II. 749
Quackery, cancer cures and, I. 147, 148
Quarantine for small-pox, I. 310
Quinine in arthritis deformans, I. 395
in blackwater fever, III. 386
in chlorosis, II. 27
A SYSTEM OF TREATMENT.
Quinine (cuntd.)
in chronic dysentery, III. 434
in gonorrhoeal arthritis, I. ~s:!
in typhoid fever, I. 352
in undefined tropical fevers, III. 41U
in whooping cough, I. 382
ointment inunction of, I. 70
rectal administration of, III. 396
use of, in malaria, III. 392, 394
value of during convalescence. I. 65
Rabies, I. 264-265
incnhatnm period in, I. 2<>5
Pasteur's inoculation method of treat-
ment. I. .Ml I
treatment at sight of, I. 264
yeast in. III. 288
Racket incision in amputations, I. 796
Radiant heat, treatment by, III. 316-326
Radicularodontom.es, II. 110
Radio-active waters in rheumatism, I. 491
Radio-activity, induction of, III. 315
of mineral waters, I. 458
i if waters. III. 115
Radium, application of, to the mucous
cavities, III. 308
to the skin, III. 308
effect of on growth of cancer cells, I.
129
in cancer, I. 155
of cervix. IV. <!1.~>
in epithelioma of, II. 139, 144
in lupus, III. 1150
erythema) OH is. III. 1071
in rodent ulcer, I. 115
in small capillary n:rvi, III. 1079
therapy, III. 303-315
caustic method in, III. 308
combined with surgical operations,
ill. :u:<
composite-ray apparatus in, III.
306
method in, III. 305
induction of radio-activity in, III.
:i i :,
introduction of tubes into the tissues
in, III. :U1
method of implication by. III. 3i>3
methods of use, III. 3nX
topographical view of, III. 306
ultra-penetrant ray apparatus in, III.
306
method in. III. 305
tubes, introduction of, into the tissues,
III. 311
Radius, absence of. I. 936
Colles's fracture of, I. 578
congenital defects of, I. 936
dislocation of head of. I. 936
dislocations of, I. 721
epiphysis of, lower, separation of, in
fractures, I. 603
fracture of. I. 686
head of, fracture of, I. 598
Radius (contd.)
separation of the upper epiphysis of, in
fractures, I. 599
shaft of. fracture of, I. 599, 600, 601
Ragatz-Pfaefer's spa, III. 154
Ranula cyst and inflammation of the
parotid gland, II. 158
of floor of mouth, II. 145
of the tongue, II. 1 r>
Rashes following ether anaesthesia, III. 9
use of antitoxin, I. 193
Rational treatment, principles of, I. 2
Raw beef essence, preparation of, 1 . 1 1'
Raynaud's disease, I. 218-219; IT. 1238-
1241
gangrene in, II. 1240
general treatment of, I. 218
local treatment of, I. 218
of the auricle, III. ssn
Rays, infra-penetrant. III. 304
ultra-penetrant, III. 304, 310
Reach in physical exercises, III. 230
von Recklinhausen's disease, I. 112 ; III.
1074
Rectal feeding in scarlet fever, I. 284
in stricture of the oesophagus, II.
171
methods of, I. 29
infusion in shock, I. 99
inje 'lions for lowering temperature, I.
69
Rectocele of the vagina complicated by
ulceration, IV. 547
operative treatment, IV. 551
palliative treatment of, IV. 517
surgical treatment of, IV. 693
Recto-urethral fistula and acute pro-
statitis, II. 923
Recto-vaginal tistuhe, complications of,
II. 609
Rectum, administration of fluids by, in
peritonitis, II. 635
quinine by. in malaria, III. 396
cancer of, relief of obstruction in, 1. 141
diseases of, II. 593-625
in bilharzia, III. 500
enemata by, in constipation in adults,
II. 455
in Wcrtheim's operation, IV. 607
malignant growths of, II. 625
neurosis of, II. 614
operations up, anaesthetics in. III. 32
pain in. II. till
procidentia of. II. r,2l-<;23
prolapse of, 11.621-623
operations for, II. 622
simple tumours of, II. 624
symptoms in paraplegia, II. 1199
wound of, complicating perineal prosta-
tectomy in adenoma of prostate, II.
948
Rectus abdominalis, tetanic rupture of,
II. LM'.i
Red light, use of, III. 187
bath, III. 193
99 72
A SYSTEM OF TREATMENT.
Reflector bath in radiant heat therapy,
III. 321
Reflex epilepsy, II. 991
Refraction and cataract, III. 618
errors of, headache in, II. 1033
of the eye, errors of, III. 528-542
Regime lactee in chronic congestion of
the lungs, I. 1079
Reichenhall spa, III. 154
Reichmann on irrigation of the stomach,
II. 365
Relapse in rheumatism, acute, I. 273
in childhood, I. 279
Repair, factor of inflammation, I. 10
process of, influence of nervous system
on, I. 12
Resistance, natural, to pathological pro-
cesses, I. 3, 5
Resolvent baths, III. 126
Respiration, artificial, in electrical injuries
and burns, I. 547
in poisoning, I. 530, 532, 534
Schultze's method of, in asphyxia of
newborn child, IV. 352
children to be taught correct method
of, I. 49
effect of shock on, I. 94, 97
impaired in diphtheritic paralysis, I. 201
rate in gynecological surgery, IV. 487
See also Breathing.
Respiratory organs, cancer of, relief of
obstruction in, I. 142
system and typhoid fever, I. 360
anthrax of, I. 179
tract, upper, chronic hyperplasia of
mucous membrane of, III. 774
Rest and fixation in tuberculous disease
of the hip-joint, I. 755
of the knee-joint, I. 765
and pelvic support for applying a plaster
spica to the hip, I. 946
automatic provision of, I. 16
during accidental haemorrhage in preg-
nancy, IV. 24
arthritis deformans, I. 392
importance of in treatment, I. 12
in acute endocarditis, I. 1191
in acute rheumatism, 269, 274
in aortic anenrysm, I. 1299
in bed in gynaecological surgery, IV. 489
in chlorosis, II. 20
in chorea, II. 1260
in diphtheria, I. 187
in diseases of the heart, I. 1203
in exophthalmic goitre, 54
in guides to the control of auto-inocu-
lation, I. 1162
in hemorrhage, I. 1262
in pernicious anemia, II. 1
in pleurisy, I. 1093
in pulmouar}' tuberculosis, I. 1122
in rheumatism (chronic), I. 489
in treatment of ulcers, I. 368
in the tropics, III. 379
in tuberculous disease of joints, I. 752
Rest (contd.~)
in wounds, I. 554
influence of in dietetics, II. 199
question of, for young children, I. 56
stage in sanatorium treatment of tuber-
culosis, I. 1128
therapeutic value of, 1. 16
Restlessness complicating acute rheu-
matism, I. 272
Retina, arteria centralis of, embolism of,
III. 644
detachment of, III. 643
diseases of, III. 042-644
tumours of, III. 644
Retinal veins, thrombosis of, III. (544
Retinitis complicating diabetes mellitus,
1.426
pigmentosa, III. 644
Retro-peritoneal lipoma, I. 106
Retro-pharyngeal abscess, III. 789-790
in diseases of the spine, I. 916
Retro-rectal abscess of the anus, II.
604
Rheinerz spa, III. 155
Rheinfelden spa, III. 155
Rheumatic fibrositis, II. 1023, 1121
Rheumatism (acute), I. 268-275
calomel or hydrargyrum cum creta
in, I. 270
complications of, I, 272
convalescence from, I. 273
diet in, I. 270
general measures in, I. 269
in anemia, II. 15
local applications in, I. 269
medicinal measures in, I. 270
persistence of temperature in, I. 272
prophylaxis of, I. 275
salicylates in, I. 271
serum treatment of, I. 272
affections of the throat in, III. 764
(chronic), I. 483-491
allied conditions of, I. 483
clothing in, I. 485
diet in, I. 486
drugs in, I. 490
electricity in, I. 488
exercise in, I. 489
external applications in, I. 486-488
heat therapy in, I. 486
ianisation in, I. 488
liniments for. I. 487
massage in, I. 488
rest in, I. 489
spa treatment, I. 491
climate for, III. 94
gonorrhoea!, I. 228
hypnotism in case of, III. 171
(in childhood), I. 276-279
after-treatment of, I. 279
cardiac lesions in, I. 278
details of treatment calling'for special
comment, I. 277
drugs in, I. 278
prophylaxis of, I. 277
100
A SYSTEM OF TREATMENT.
Rheumatism (in childhood) (contd.)
treat mi-lit of. every rheumatic mani-
I'e-tation, I. 277
iritis in. III. ."iS7
mineral waters, and baths in, III. 142
(muscular), I. I'.HM'.M
chronic, massage in, III. 209
drugs in. I. 4!'3
heat therapy in, I. 493
massage in, I. 494
in\ iritis iii. 1 1. 1324
m-iiritis in, II. 1130
paralysis of ocular muscles in, III. 649
pericarditis in, I. 1179
scarlatinal, I. 290
MM- of the blister in, I. 69
Rheumatoid arthritis. See utulrr Arth-
ritis.
conditions, climate for, III. 94
Rhinitis, acute, III. 701-704
prophylaxis of. III. 702
simple, III. 701
atrophic, III. 706
local treatment of, III. 707
chronic, III. 7<C.-712
anti-toxins in, III. 709
friction in, III. 709
general treatment of, III. 708 '
local complications of. III. 708
packing the nose in, III. 708
paraffin injections in, III. 709
simple, III. 705
vaccine treatment of, III. 709
vibratory massage in, III. 709
fibrinous. ill. 703
hypertrophic, III. 710
chronic, and Eustachian obstruction,
111. ;>lt;
purulent, III. 703
sicca, III. 711
anterior of nose, III. 665
local treatment of, III. 711
traumatic. III. 7"!
vasomotor, III. 704
Rbinoliths. III. f.c.'.i
Rhinophyma, III. 1 135-1 136
Rhinorrhcea in scarlet fever, I. 282
paroxysmal, III. ('*'.'
vasomotor, III. 689
Rhinoscleroma. III. 713
deRibes' bag, IV. isr,
central insertion of in placenta
pncvia, IV. 67, 68
in forcible methods of delivery, IV.
442
in induction of premature labour, IV.
440
in placenta prajvia, IV. 66, 68
position of in uterus in induction of
premature labour, IV. 441
Ribs cartilage, of tuberculous disease of, I.
1032
cervical, brachial plexus injury and, II.
1012
injury of brachial plexus in, II. 1110
Ribs (contd.)
fracture of, in newborn child, IV. 352
inflammation of, I. 1032-1033
new growths of, I. 1034
re-section of, in generalised empyema,
I. 1104
syphilis of, I. 1032
tuberculous disease of, I. 1032
Richet (Charles), method of hypnotism,
III. 165
Rickets, climate for, III. 96
clothing in, I. 478
cod-liver oil in, I. 66
deformities of, I. 970-972
of bones in, I. 481
diet in, 1.479
digestive disorders in, I. 479
drugs in, I. 479
hydrotherapy in, I. 478
in anajmia, II. 14
in newborn child, IV. 371
open-air treatment, I. 478
special measures in, I. 480
Ricketts (T. F.), small-pox, I. 302-311
vaccination, I. 311-314
Ricord's paste in soft chancre, I. 315
Riedel's lobe of the liver, II. 659
Rigg's disease, vaccine therapy of , III. 287
Ring forceps, IV. 475, 476
Ringworm, III. 1125-1131
in the tropics, III. 473
of the beard, III. 1130
of the nails, III. 1082, 1131
pustular, III. 1129
X-rays in, III. 354, 1125
Rippoldsau spa, III. 155
Robert's pelvis complicating labour, IV.
173
Roberts (C. Hubert), pubiotomy, IV. 446-
450
symphysiotomy. IV. 452-460
Roberts (J. Reid), typhoid fever, I. 335-
364
Roberts (Sir Wm.), paraffin in skin
eruptions, I. 446
Robson (A. W. Mayo), acute post-opera-
tive dilatation of the stomach, 11.311
fistula; of the gall-bladder and bile
ducts, II. 698-6W
hour-glass stomach, II. 334-336
inflammatory affections of the gall
bladder and bile ducts, II. 700-709
injuries and diseases of the pancreas,
II. 716-729
injuries of the bile passages, II. 680-
681
injuries to the stomach, II. 282
perforation of ulcer of the duodenum,
II. 396-398
perforation of ulcer of the stomach,
II. 389-390
surgical treatment of cancer of the
stomach, II. 302-3U9
surgical treatment of cholelithrasis, II.
686-697
101
A SYSTEM OF TREATMENT.
Robson (A. W. Mayo) (w/rfrf.)
surgical treatment of gastroptosis, IT.
328-324
surgical treatment of haemorrhage, II.
881-333
surgical treatment of pertrophichy
pyloric stenosis, II. 342-344
surgical treatment of pyloric stenosis
and obstructive dilatation, II. 316-
317
surgical treatment of ulcer of duodenum,
II. 391-394
surgical treatment of ulcer of stomach,
II. 3X2-388
tetany of stomach, II. 399
tumours of bile ducts. II. 713-715
of gall bladder, II. 710-712
(simple) of stomach, II.
volvulus of the stomach, II. 400
Rodagen in exophthalmic goitre, II. 56
Rodent ulcer, III. 1132-1134
excision of, I. 114
free and wide, III. 1132
extension of, I. 123
Finsen light in, III. 1134
freezing in, I. 115
ionic medication of, III. 184
ionisation in, III. 1133
of the cornea, III. 566
of vulva, IV. 508
radium in, I. 115
Rontgen rays in, III. 1133
solid carbon dioxide in, I. 115
spread of, I. 125
X-rays in, I. 114
Rolleston (H. D.), acute yellow atrophy
of the liver, II. 657-658
anomalies in form and position of the
liver, II. 659
ascites, II. 626-631
cholelithiasis, II. 682-685
degenerations of the liver, II. 668
functional derangement of the liver,
1 1. 668
hydatid cysts of the liver, II. 669
hypertrophic biliary cirrhosis (Hanoi's
disease), II. 664
jaundice, II. 670-675
lavdaceous or amyloid liver, II. 675
portal or common cirrhosis of the liver,
II. 660-663
syphilitic cirrhosis of the liver, II. 665
thrombosis of the portal vein, II. 666-
667
tumours of the liver, II. 679
Romer (Frank), sprains, I. 737-740
Roncegno .spa. 1 1 1 . 1 .V>
Rontgen rays. See under X-rays.
Rood's apparat us for intravenous anaes-
thesia, III. 35
Rooms, aspect of, to be south or west, I.
44
preparation of, for operation, I. 26-31
Roots of teeth, lower, extraction of, III.
1186
Rosacea, III. 1135-1136
Rotch on modified milk in infant feeding,
II. 224
Roth-Drager apparatus for anaesthetics,
III. 14.
Rough ton's splint, I. 630
Roulte's Hushing curette in retained
placenta, IV. 227
Round ligaments, shortening of, in retro-
flexion of the uterus, IV. 681
Roux's curette, IV. 624
Rowntree (Cecil), general principles of
the treatment of cancer, I. 116-156
surgical treatment of tumours, I. 106-
156
Royat spa, III. 155
Rubber cord, application of, in elephan-
tiasis scroti, III. 505
gloves in gynaecological operations, IV.
483
goods, disinfection of, I. 161
tooth cleaner, II. 128
tourniquet in haemorrhage, I. 1258
Rubella, I. 280
Rudel on urea solution, I. 437
Rupture of muscles, II. 1322
subcutaneous, of tendons, II. 1328.
Russell (J. Risien), disseminated sclerosis,
II. 1070-1076
tabes dorsalis, II. 1085-1092
Rye bread, gangrene from use of. I. 219
Saccharin in obesity, I. 472
Saccharine foods in gout, I. 453
Sacculus of the female urethra, IV. S7<i
Sacro-iliac disease, I. 920
joint, tuberculous disease of, I. 780
Sacrum, fracture of, I. 608
Saint- Armand spa, III. 155
St. George's Hospital diet table, II. 202
statistics of appendicitis at. II. 402
Saint-Gervais spa, III. 155
Saint-Honore spa, III. 155
St. Moritz spa, III. 155
St. Nectaire spa, III. 155
St. Sauveur spa, III. 155
St. Thomas' Hospital, table of cases of
acute peritonitis at, II. 633
Sal alembroth gauze and wool, I. 78
Salads, danger of, in the tropics, III. 384
vegetables and, in obesity, I. 472
Salicine in influenza, I. 234
in psoriasis, III. 1114
Salicylate of soda in erythema nodosum,
I. 213
in rheumatism in childhood, I. 278
ionisation with, I. 488
Salicylates, action of, I. 388
in acute rheumatism, I. 271
in chronic rheumatism, I. 487
in typhoid fever, I. 352
Salicylic acid in lupus, III. 1150
gauze and wool, I. 78
Salies de Beam spa, III. 155
102
A SYSTEM OF TREATMENT.
Saline enema. I. 33
infusion in ha-morrliage. I. 1262
intravenous, in eclampsia, IV. 3.".
subcutaneous in eclamp-ia, IV. M.">
intra-peritoneal, administration of, in
haemorrhage, I. 1208
normal, infusion of, in shock, I. 98
purgatives in constipation in adults, II.
149
solution, administration of, in puer-
peral sepsis. IV. 311
injection of, in sciatica, II. Io27
intravenous injection of, in scarlet
fever, I. 288
Salines in alcoholic gastritis, II. 353
Salins spa. II I. l.'.i!
Salins-Moutiers spa. See Brides les
Bains.
Salisbury dietary in chronic rheumatism,
I. 486
treatment of obesity. I. 468. 471
Salit liniment in rheumatism, I. 487
Salivary calculi and inflammation of
parotid gland. II. l.~>9
fistula and inflammation of the parotid
gland, II. 160
glands, diseases of. II. 130-131, 157-163
injuries of, IT. 157-163
Salivation and inflammation of parotid
gland. II. 161
increased, II. I""
Salmon's truss for inguinal hernia, II.
527
Salol in typhoid fever, I. 354
Salpingectomy in puerperal sepsis, IV.
soo
Salpingitis. IV. so.vsi I
acute, of Fallopian tube. IV. 810
chronic . of Fallopian tube, IV. 813
gonoroccus in, IV. 831
ii-liu-al, in children, IV. 807
of Fallopian tubes, IV. 821-830
complicating cancer of the uterus, IV.
830
preventive treatment of, IV. 815
septic infection of tubes in, IV. 807
si reptococcus in, IV. 831
treatment of. preventive, IV. 831
tubercle bacillus in, IV. 831
tuberculous. IV. 833-835
Salpingostomy in inflammation of Fallo-
pian tubes. IV. M.I
Salsomaggiore spa, III. 156
Salt contra-indicated in obesity. I. 470
diminution of, in typhoid fever, I. 343
effect of. on kidneys, II. 206
muriatcd waters. III. 118, 129
restriction of, in chlorosis, II. 28
Salts in malaria, III. 393
irritant, poisoning by. I. .">28-530
Salvarsan ("606") in spinal syphilis, I.
917
in Frambresia tropica, III. 463
in syphilis. I. 14'.'. 3i'L'
in tabes dorsalis. II. 1088
Sanatorium treatment of pulmonary
tuberculosis, I. 1127-1158
Sand baths, III. 136
flea (dermatophiliasis), III. 481
" fly fever, III. 400
Sandefjord spa. III. 15ii
Sandwith (F. M.) pellagra, I. 521-524
Sanitasa useful douche, I. 137
Electrical C'o.'s vibrator, III. 214
Santonin in ascariasis, III. 494
Sarcoid of Boeck, multiple benign, 111.
1152
Sarcoma, amputation in, I. 791
Coley's fluid in, I. 153, 920; III.
299
cutis, III. 1037
extension of, I. 124
melanotic, true nature of, I. 125
of bones, I. 711
of muscle, II. 1325
of nerves, II. 1044-1142
of the breast, II. 975
of the female urethra, IV. 872
of tjie gall bladder, II. 712
of the jaws, II. 112
of the prostate, II. 932
of the scalp, I. 893
of the spleen, II. 81
of the tongue, II. 144
of the umbilicus, II. 281
of the uterus, IV. 718-719
leucorrhoea in. IV. r>71
of the vulva, IV. 516
operability of, I. 122
primary, of the vagina, IV. 553
radium therapy of, III. 312
secondary growths of, I. 1 2">
Sarcomata, myeloid, of the jaw, II. 110
of the bones of the skull, I. 895
Sarsaparilla in syphilis, I. 323
Saturnine cachexia in lead poisoning, I.
514
encephalopathy in lead poisoning, I.
514
Saugman's needle in artificial pneumo-
thorax. T. 1167
Saundby (Sir Eobert), enteritis (acute and
chronic) in adults, II. 479-482
Sausages, chemical composition of, II.
193
poisoning by, I. 510
Savin, poisoning by, I. 533
Sazin in obesity, I. 472
Sayres's strapping in fractures, I. 583-586
Scabies, III. 1137-1138
Scafati (Signer), and voice production, III.
338
Scalds of the trachea, III. 797
and burns, I. 540-544
general treatment of, I. 543
immediate treatment of, 540
local treatment of burnt areas in, I.
540
treatment of contractions following,
I. r.43
103
A SYSTEM OF TREATMENT.
Scale preparations in chlorosis, II. 24
Scalp, alopecia dependent on morbid con-
ditions of, III. 1000
avulsion of, I. 875
bald, after X-rays, "5-exposure method,"
III. 358
contusions of, I. 873
dermoid cysts of, I. 110
generalised infections of, I. 888
haemorrhage from, I. 1275
infective lesions of, I. 888
injuries of, I. 873-875
localised infections of, I. 888
psoriasis of, III. 1121
scales on, in psoriasis, III. 1116
seborrhoea of, III. 1141
soreness of, neuralgic headache in, II.
1116
surgical diseases of, I. 888
tumours of, I. 892-896
wounds of, I. 874
Scapula, acromion process of, fracture of,
I. 586
coracoid process of, fracture of, I. 586
detachment of, in Berger's operation, I.
834
fractures of, I. 585-586
neck of, fracture of, I. 585
neuralgia, II. 1121
Scarification in cheloid, III. 1018
in lupus, III. 1149
Scarlet fever, I. 281-294
acute inflammation of middle ear in,
III. 902
adenitis complicating, I. 290
arthritis complicating, I. 290
cardiac affections complicating, I. 293
cervical cellulitis complicating, I. 290
complicating pregnancy, IV . 48
complications of treatment of, I. 289
diet in, I. 283
general management of, I. 281
hyperpyrexia in, I. 289
infectivity of, I. 282
nephritis complicating, I. 292
otitis media complicating, I. 289
remedial treatment of, I. 284
" return cases " of, I. 282
septic, I. 283, 284, 287
serum therapy in, I. 286
toxic, I. 288
ulcerative stomatitis in, I. 293
vaccine therapy of, I. 288
Scars in burns and scalds, I. 543
seat of carcinoma, I. 1 17
Schatz's method in face presentation of
labour, IV. 141
Schinznach spa, III. 156
Schlangenbad spa, III. 156
Schlatter (Prof.), on results of operations
on jaws, II. 117
Schleich's solution for local analgesia,
III. 38
Schlbsser's method of division of nerves
I. 135
Schnee four-cell bath, I. 747
School children, sleeplessness in, causes
of, I. 55
work, pressure in, to be avoided, I.
8, 9
Schools, diphtheria in, prophylactic use of
antitoxin, I. 192
Schroeder's operation in endometritis, IV.
629, 630
Schrotter's hollow vulcanite bougie, III.
865
Schultze's artificial respiration in as-
phxyia of the newborn child, IV.
352
pessary in retroflexion of uterus, IV.
680
Schummelbusch's mask in anaesthetics,
III. 9, 10
Schwalbach spa, III. 156
Schwartze's operation for opening the
mastoid antrum. III. 898
technique of, III. 898
post-aural operation in diseases of mas-
toid process, HI. 922, 923
tenotomes, III. 914
Sciatic arteries, injuries to, I. 1276
neuritis, old-standing chronic, II. 1125
Sciatica, II. 1123
acute, II. 1123
chronic, II. 1125
complicating diabetes mellitus, I. 426
hypnotism in case of, III. 170, 171
in gout and gouty conditions, I. 444
massage in, III. 210
mineral waters and baths in, III. 142
surgical treatment of, II. 1129
Scirrhus. atrophic, of the breast, II. 964
Scissors, long, for enucleation of tonsil,
III. 753
Sclavo's anti-anthrax serum, I. 179
Sclerodermia, III. 1139
Sclerosis, amyolrophic lateral, II. 1054
disseminated, II. 1070-1076
fibrolysin in, II. 1074
general treatment, II. 1071
mercurial inunction in, II. 1072
prophylaxis of, II. 1071
special symptoms of, II. 1075
tonic medicines in, II. 1073
Sclerotomy, posterior, in glaucoma, III.
602
Scoliosis, active movements for the
muscles on the convex side in, III.
246
deformities of the shoulders, and tor-
ticollis, I. 972-988
four-footed exercises for, III. 248
movements giving equal work to back
muscles in, III. 243
to exercise muscles in, III. 248
to improve mobility in, III. 242
physical exercises for, III. 241
Zander treatment in, III. 372
Scopolamine and morphine, injection of.
in labour. IV. 378
104
A SYSTEM OF TREATMENT.
Scopolamine (rnntd )
(Jivoscvamine or hyoscine), poisoning
by, f. 532
Scrofuloderma, III. 1152
X-rays in. III. ii.">2
Scrotum. diseases of, II. !ou
elephantiasis of. III. :.u|-:,lC,
epithelioina of. 1 1. Hi MI
tihirial lymph. III. .litf
luematoma of. II. '.mil
wound* of. II. '.Mill
Scurvy ami infantile scurvy, curative
treatment of, I. 476
<liet in, I. J7.1
preventive I reatllieiit, I. 475
in newborn child, IV. 371
Sea-bathing in diseases of the heart, I.
1210
Sea-sickness, II. H'.c,
Seawater, purified, subcutaneous injec-
tions of. in marasmus. I. 407
Sebaceous adenomata. I. 109
cysts, J. MS; III. 114U
suppuration of, I. 109
of neck. 11. 17o
of the scalp, I. MI2
horns. I. lo'.i
Seborrhcea. III. 1141-1142
eapitis, III. 1141
X-rays in. III.S.IO
Seborrtioeic dermatitis, III. 1143
Secretions, abnormal, application of vibra-
tion in. III. 22<)
internal, disorders of, I. 388
and obesity. I. K'.s, 472
Sedative baths,' III. 125
Sedatives, dosage of, in diseases of chil-
dren. I. <J7
during accidental ha-m.-.rrhage in preg-
nancy. 21
in diseases of the heart, I. 1224
in relief of pain in inoperable cancer, I.
134
Seminal vesicles, tinal separation of, in
carcinoma of the prostate, II. 936
vesiculitis complicating gonorrhoea, I.
227
Semple on vaccine therapy in typhoid
fever. I. ;M.">
Senile alopecia, III. 998
decav. mineral waters and baths in, III.
1 IT.
endonietritis. leucorrlnea in, IV. 570
jaiiurene. I. 21">
neuritis, II. lull, HIV.i
v:v_ r initis. leueorrhrea in, IV. .">(!">
warts. III. 1159
Senn's method for malignant stricture of
the (esophagus, II. 180
Senna in constipation in adults, II.
IIS
Sepsis after amputations, I. 803
of the cord in newborn child, IV. 370
puerperal, prevention of, IV. 287-294
Septic cases, management of, I. 92
Septic (contd.)
infection complicating operation for
goitre, II. 68
states in anasmia, II. 16
wounds, I. 558
Septicaemia and pyremia, general and
local treatment of, I. 295-298
following compound fractures, I. 581
Sequelae and complications of disease, I.
22
Sera, administration of, III. 261
Sere-vaccines in infective endocarditis, I.
SKM
Serum, anti-plague, III. 285
anti-pneumococcus, III. 285
antirabic injection in rabies, I. 265
anti-streptococcus, III. 290
in pernicious anasmia, II. 8
in pelvic cellulitis, IV. 833
anti-tetanic, in tetanus in puerperium,
IV. 326
diphtheritic, dangers and ill-effects of,
III. 274
Dunbars antitoxic, III. 286-287
Flexner's anti-meningitis, III. 282
Moebius's antithyroid, in exophthalmic
goitre, II. 56
rabbit, effect on coaguability of blood,
I. 129
sickness in serum therapy, III. 261
staphylococcus, III. 288
therapy, administration of sera in, III.
261
doses, summary of, III. 301
general principles of, III. 258-270,
260
horse serum in, III. 261
in epilepsy, II. 999
in gonorrhosal arthritis, I. 783
in infective endocarditis, I. 205
in purulent meningitis, I. 250
in pyasmia and septicaemia, I. 297
in scarlet fever, I. 286
of acute dysentery, III. 430
of bacillus coli communis, III. 271
of cancer, I. 152
of cholera, III. 273
of diphtheria, III. 273
of dysentery, III. 279
of general paralysis of the insane,
II. 1079
of gonococcus infections, III. 280-
281
of intermittent claudication, II. 1235
of leprosy, III. 451
of meningococcus infection, III.
282-283
of micrococcus catarrhalis infections,
III. 283-284
of peritonitis, II. 637
of plague, III. 284-285, 407
of pneumococcus infections, III. 285-
286
of pneumonia, I. 262
of puerperal sepsis, IV. 308
105
A SYSTEM OF TREATMENT.
Serum therapy (contd.)
of pyorrhoea alveolaris, III. 287
of rheumatism, acute, I. 272
of streptococcus infections, III. 289
of tetanus, I. 329-330
of tuberculosis, III. 297
of typhoid fever, I. 345 ; III. 300
serum sickness in, III. 261 .
Sexual function, female disorders of, IV.
839-864
obesity and, I. 473
hypochondriasis in impotence, I. 232
neurasthenia, I. 231
Shattock (S. G.), on lipomatosis, 1. 108
Shaving, previous to operation, I. 84-93
Shaw-Mackenzie, on trypsin treatment of
cancer, I. 151
Sheep, anthrax amongst, I. 179
Sheets, arrangement of, before and after
operation, I. 30
Shellfish, chemical composition of, II. 194
poisoning, I. 506
Sherren (James), division of posterior
roots in neuritis, II. 1035-1133
infantile paralysis, nerve anastomosis
in, II. 1059-1060
injuries of nerves, II. 1100-1107
injuries of special nerves, II. 1108-
1113
surgical treatment of neuralgia, II.
1127-1129
traumatic neuritis, II. 1106-1107
tumours of nerves, II. 1142
Shock after amputations, I. 803
after cataract extraction, III. 632
after ovariotomy, IV. 793
after radical operation for cancer of the
breast, II. 967
anassthesia in relation to, I. 95
and anaesthetics, III. 24
and collapse, I. 93-105
bibliography of, I. 105
causes of, I. 93
complicating abdominal operations. II.
269
gynecological surgery, IV. 491
due to heat, I. 537
electric, I. 547
from accidental haemorrhage during
pregnancy, IV. 26
from burns and scalds, I. 540. 548
in abdominal injuries, II. 244
in emergency cases of abdominal opera-
tions, II. 260
in gunshot wounds, 558
in injuries of the stomach, II. 283
in post-partum haemorrhage, IV. 222
in severe contusions of the spine, I.
898
in Wertheim's operation, IV. 607
position during operation in, I. 95
preparation of the patient in, I. 95
prevention of, I. 95
by strychnia, I. 84
technique of operation in, I. 96
Shock (eontd.)
treatment of, 96-104
by drugs, I. 102
by feeding, I. 103
by infusion of normal saline, 1. 98
by intra-peritoneal infusion, I. 101
by intravenous infusion, I. 100
by rectal infusion, I. 99
by subcutaneous infusion, I. 99
by transfusion of human blood, I. 102
Shoulder, congenital elevation of, I. 9sr>
deformities of, scoliosis and torticollis,
I. 972-988
hot-air apparatus for. III. 322
operative treatment of tuberculous dis-
ease of, I. 770
tuberculous disease of, I. 775-777
Shoulder-joint, congenital dislocation of,
I. 935
disarticulation of by a racket inci-
sion, I. 827
through, the, I. 827-830
dislocation, complicating fracture, I.
587
reduction of, I. 715
Shoulders, round, I. 986
Shrnbsall (Frank C.), physical exercises,
III. 222-257
Sickness, repeated, in peritonitis, II. 638
Sick-room cookery, I. 42
and dietary for, I. 42
duties of the nurse in, I. 27
fittings and furniture in, I. 26
hygienic measures in, I. 26, 40
management of, I. 2(5-43
for typhoid fever, I. 338-340
preparations for operation in, I. 27
Siegel's speculum in massage of tympanic
membrane, III. 952
Sigmoid. overloaded condition of, in
constipation in children, II. 435
sinus, thrombosis of, complicating
diseases of the ear, III. 941-943
Sigmoidoscope in chronic mucous colitis.
II. 570
Silk ligatures, sterilisation of, I. 72
web cesophageal bougie, II. 172, 173
Silk's celluloid mask, III. 733
Silkworm gut sutures, I. 86
Silver, nitrate of, in diseases of the
conjunctiva, III. 548
in gonorrhoea, I. 223, 227, 229
in lupus, III. 1150
wire netting in operation for umbilical
hernia, II. 513
Sim's dilator, modification of, IV. 623
Simpson (W. J.), personal and general
hygiene in the tropics. III. 375-385
Singer's nodules of the larynx, III. 851
Singing,, voice production' and, III. 331-
340
Sinus, accessory of nose diseases of, III.
716-731
and fistula, general and local treatment
of, I. 299-301
106
A SYSTEM OF TREATMENT
Sinus (i-nntil.)
cthnioid.il, diseases of, III. 727
formation in tuberculous disease of hip-
joint, I. 7.V.
frontal, diseases of, III. 727-730
irregularity of the heart, I. 1228
maxillary, diseases of, III. 721-727
persistent, of the breast, II. 960
spenoidal. diseases of, III. 730
Sitting in physical exercises, III. 229
with Legs crossed, exercise for flat foot,
III. 2:r>
" Skewed " heel for weak foot, I. 968
Skey's modification of Lisfranc's amputa-
tion. I. 840
Skin, anthrax of, I. 179
application of radium to, III. 308
carcinoma of, secondary growths rare
in, I. I2.">
care of, in infants, I. 48
in scarlet fever, I. 288
cough, in pulmonary tuberculosis, I.
1144
diseases of, III. 982- In.". 7
ascribed to vaccination, I. 313
electro-therapeutics in, III. 110
gouty, I. -Hi;
mineral waters and baths in, III. 144
tropical, III. 470-486
X-ray treatment of, III. 341-359
elasticity of, restoration of, I. 69
epithelioma of, III. 1037-1038
Haps, in amputations, I. 796
functions of, modified by X-rays, III.
S69
grafting in burns and scalds, I. 543
in nlceration. I. :i7:{-H7.">
in wound contraction, I. 555
hygiene of. in arterio-sclerosis, I. 12!>1
inunction of. value of, I. 70
Kaposi's diM-iise of, III. 1057
localised inflammations of X-rays in,
111. 349
myomataof, III. 1057
preparation of, in abdominal operations,
II.S69
in emergency cases of abdominal
operations. II. 260
in ovariotomy, IV. 775
protection of, in small-pox, I. 305
sarcoma of, III. UU7
scarring of, in acne vulgaris, III. 986
-tcrilisation of, I. 27, 557
before operation, I. 84
treatment of, in burns and scalds, I. 541
in typhoid fever, I. 356
tuberculosis of, X-rays in. III. 353
tumours of, innocent, III. 1057
Skinner's mask in ana-sthetic-. III. 9, 10
Skull, actinomycosis of, I. 891
air-containing tumours of the. I. 896
bones, diseases of, headache from, II.
1088
bony tumours of, I. 895
fractures of, I. 875-878
Skull, fractures of (cantd.}-
base of, I. 877
Gushing 1 s method in, 1. 882
depressed, I. 876
in infants, I. 886
in newborn child, IV. 364
in separation of the upper jaws from,
II. 100
gunshot fractures of, I. 562
infective lesions of bones of, I. 889-891
injuries of, I. 875-878
surgical diseases of, I. 888
syphilis of, I. 890
tuberculous osteitis of, I. 889
tumours of, growing from the bony walls
of, I. 894
vault of, fractures of, I. 876
Sleep, amount required by infants and
children, I. 54
in acute bronchitis, I. 1050, 1052
in broncho-pneumonia, I. lui;9
in normal puerperium, IV. 264
in the tropics, III. 379
Sleeping in open-air for children, I. 52
sickness in the tropics. III. 383
See also Trypanosomiasis.
suits for children, I. 45
Sleeplessness. See Insomnia.
Smallpox, I. 302-311
complications of, I. 308-310
confluent, treatment of, I. 306
distribution of eruption in, I. 303
drugs in, I. 308
general management of, I. 307
ha-morrhagic, I. 310
moist applications in, I. 306
protection of the skin in, I. l?o."i
protective measures in, I. 302
quarantine for, I. 310
vaccination and, 311-314
varieties of, I. 310
Smith (A. Lionel), abortion, IV. 14-22
hydramnios, IV. 43-44
mole, blood or carneous in pregnancy,
IV. 59
mole, hydatidiform or vesicular in
pregnancy, IV. 59
Smith (Eustace), food fever, II. 233-241
hygiene and care of infants and children,
' I. 11-70
on treatment of whooping cough, I. 382
Smith (G. F. Darwall). contracted pelvis
and labour, IV. 163-175
precipitate labour, IV. 224
tonic contraction of the uterus, IV.
248-249
uterine exhaustion, IV. 250-251
uterine inertia. IV. 252-255
Smith (L. G. Bellingharm. diseases of the
female bladder, IV. s7.">-883
diseases of the urethra, IV. 868-874
Smith (Maynard), acute abscess, I. 166-172
burns and scalds, I. 540-544
cellulitis, I. 181-184
contusions and hsetnatoma, I. 545-546
107
A SYSTEM OF TREATMENT.
Smith (Maynard) (contd.)
erysipelas, I. 209-211
gangrene, I. 214-220
lardaceous disease (albuminoid or amy-
loid degeneration), I. 462
septicaemia and pyaemia, I. 295-298
sinus and fistula, I. 299-301
tuberculous abscess, I. 173-176
ulceration, I. 368-375
wounds, I. 550-556
Smith's gag in operation for cleft palate,
II. 150
operation for immature cataract, III.
621
(Stephen) operation, I. 859-861
Smoking, effect in affections of tongue,
II. 135
Snare, aural, III. 901
Snow, carbon dioxide, for naevi, III. 1078
in rodent ulcer, I. 115
blindness of the conjunctiva, III. 560
Soamin in cancer, I. 149
in syphilis, I. 321
in trypanosomiasis, III. 420, 421
in undefined tropical fevers, III. 411
Soap and water enema, I. 32
for acne vulgaris, III. 985
suitable for infants, I. 48
Socket (tooth), septic infection of, after
extraction, III. 1190
Soda, bicarbonate, in acute gastritis, II.
847
in diabetes, I. 423, 425
in rheumatism, I. 271, 278
to produce alkalinity of urine, I. 410,
418
chlorate, dosage of, in children's diseases,
1.67
chloride, ionisation with, I. 488
citrate of, added to milk in infant feed-
ing, II. 225
potassium in trypanosomiasis, III. 421
salicylate in diabetes mellitus, I. 424
in rheumatism, I. 271, 278
sulphate of, in constipation in adults.
11.449
Soden spa, III. 156
Soil, influence of, in rheumatism, I. 484
Solanum carolinense in epilepsy, II. 998
Soldiers, avoidance of sunstroke by, I. 536
Soloids, Burroughs and Wellcome's in-
fusion of, I. 98
Solutions for infusions, I. 98
Somatic heniasis, III. 521
Sound, reposition by, in retroflexion of
the uterus, IV. 677
sterilisation of, I. 92
Southey's tubes for dropsy, in diseases of
the heart, I. 1244
Spa, choice of, for gout, I. 459
treatment in arterio-sclerosis, I. 1291
in cholelithiasis, II. 683
in chorea, II. 1263
in diseases of the heart. I. 1210
of chronic rheumatism, I. 491
Spa treatment (contd.*)
of constipation in adults, II. 465
of uterine leucorrhoea, IV. 571
Spas, (Belgium) III. 156
for chlorosis, II. 26
index of, III. 147-158
Spasmodic diseases, infantile, warm baths
in, I. 70
Spasms. II. 1047-1049
facial, II. 1<>47
hysterical, II. 1049
laryngeal, in adults, III. 840
in children, III. 827-830
myoclonus, II. 1049
of calf muscles, II. 1062
in cerebral palsies of infancy, II. 1160
of hiccough. II. 1048
phonetic, of the larynx, III. 841
pyloric, II. 337
reflex, in disseminated sclerosis, II. In7.">
trismus, II. 1048
Spasticity in hemiplegia, II. 1186
in myelitis, II. 1217
Speaking, voice production and, III. 331-
340
Spectacles, cataract, III. 633
dark, in cataract, III. 618
for accommodation and refraction of the
eyes, III. 42
Speech, defects of, of cerebral origin, II.
1143
effect of cleft palate upon, II. 147
restoration of, by functional compensa-
tion, II. 1147
in aphasia, by functional compensa-
tion, II. 1147
Speuce's method of disarticulation through
shoulder-joint, I. 827-830
Spencer (Major C. J.), gunshot wounds, I.
557-567
Spencer's table, IV. 479
Spermatic cord, diseases of, II. 917
encysted hydrocele of, II. 917
h;ematoma of, II. 917
Sphenoidal sinuses, III. 730
Sphincter ani, spasmodic construction of
in constipation in children, II. 436
Spider nasvi, III. 1077
Spigelia anthelmintica in epidemic gan-
grenous proctitis, III. 437
Spinabifida, I. 912-<.tl6
age for operation in, I. 915
centra-indications to operation in, I. 915
excision in, I. 914
injection of iodo-glycerin solution in, I.
913
of the newborn child, IV. 361
palliative treatment of, I. 912
pressure in, I. 912
simple tapping in, I. 912
spontaneous cure in, I. 912
strangulation of the sac in, I. 912
Spinal anaesthesia. See under Anaesthesia,
analgesia, III. 36
canal, haemorrhage into, I. 904
108
A SYSTEM OF TREATMENT.
Spinal (contd.}
cord, affections of, II. 12o,s
degeneration of, sub-acute, combined,
II. 1083
diseases of, II. 1208
electro-therapeutics in, III. 108
disseminated sclerosis of, II. 1070-
1076
gummatous meningitis of, II. 1068
injuries of. I. 1)00-911
complications in. f. 908-911
tumours of, II. 1221-1225
medicinal treatment, II. 1222
operation in. 1 1. 1223
paralysis, deformities due to I. 9SX-990
paraplegia. 1 1. 1196
Spine, abscess in connection with tuber-
culous disease of, I. 92S. 932
actinomveosis of, I. 919
caries of', I. 922-927
concussion of I. *99
counter-irritation in rheumatoid
arthritis, I. |or,-|u7
curvature of, application of vibration
in, III. 220
lateral, I. 972
physical exercises for, III. 236
rotate-lateral, I. 972
deformities of, in children, I. 56
dislocations and fracture-dislocations
of, I. 902
gunshot wounds of. I. r>ii3. 902
hvdatid disease of, I. 918
injuries of, I. 898-911
concussion, I. 899
contusions, I. 898
dislocations, I. 902
fracture-dislocations, I. 903
non-operative treatment. I. 907-911
operative treatment of, I. 905, 907
severe, non-operative treatment of,
I. 907, 911
operative' treatment of, I. 905, 907
wounds ,,f, I. 9(U
new growth-, of. I. 919-920
Sprains of. I. 9oi>
syphilis of, I. 917-91 S
tuberculous disease of, ambulatory
treatment of, I. 921
paraplegia in, I. 92(5-927
summary, I. 925
treatment by recumbency, I. 923
tumours of, f. 919
Spirits, effect on the tongue, II. 135, 138
in gouty conditions. I. l.~,r>
Spitta (Harold), anthrax, I. 179, 180
bacillus coli communis, infections of,
III. 271-27:.
cholera, III. 27::
disinfection, I. 1(51 -1C,:,
dysentry, III. 279-280
glanders, I. 221-222
gonococcus infections. I [I. 280-281
pollantin (l)unbar antitoxic serum),
III. 286-287
Spitta (Harold) (contd.)
pyorrhoea alveolaris (Rigg's disease),
III. 287-288
rabies, I. 264-265
streptococcus infections, vaccine
therapy of, III. 289-291
tetanus, 1. 329-331
Spleen, abscess of, II. 81
. contusions of, II. 79
cysts of, II. 81
diseases of, II. 81-8-1
embolism of, I. 1307
enlarged, chronic polycythremia with
cyanosis and. II. 84
injuries of, II. 79-80, 251
laceration of, II. 79
malarial, II. 81
removal of in leukasmia, II. 41
sarcoma of, II. 81
surgical treatment of, II. 83
wandering, II. 81
X-rays in, II. 82
Spleno-medullary leukamiia, II. 38
complicating pregnancy, IV. 55
Splenomegaly, II. 82-83
general treatment of, II. 82
medicinal treatment of, II. 82
Splint sore, I. 572
Splints, abduction, and pad for the
shoulder, I. 776
adjustable, for the knee, I. 769
for the wrist, I. 779
back and side, I. 630
for fractures of tibia, I. 625, 627
Bavarian, I. 574
Bryant's, I. 617
Carr's, I. 603
complicated, in fractures of the jaws,
II. 102
Croft's, I. 574, 629
Dupuytren's, I. 630
for fractures of lower jaw, II. 101
for gunshot fractures, I. 5(51
for paralytic dropped wrist, I. 992
for prevention of claw hand, II. 1014
forms of, for fractures, I. 572
fraction, in tuberculous disease of the
hip-joint, I. 765
(iooch's, I. 573
hallus valgus or rigidus, I. 966
Hodgen's, I. 614
in fractures of jaws, II. 114
in rickets, I. 4S1
internal angular for the arm and fore-
arm in fractures, I. 593
leather, for the knee, I. 766
Listen's, I. 617
in hip-joint disease, I. 754, 7t!2
Maclntyre's, I. 618
measurements of, I. 575
metal, I. 574
suspension, for the ankle, I. 773
plaster of Paris, I. 628
posterior moulded, for the elbow, I. 600
Roughton's, I. 630
109
A SYSTEM OF TREATMENT.
Splints (coHtd.)
Thomas's caliper, I. 767
hip, I. 756, 765
Spondylitis deformans, I. 404
syphilitic, I. 917
Spondylolisthetic pelvis complicating
labour, IV. 173
Spondylotomy, dangers of, IV. 451
in labour, IV. 451
Sponging, cold, in typhoid fever, I. 350
for young children, I. 47
methods of, I. 37
Sporotrichosis, III. 1143
Sprains, I. 737-740
electro-therapeutics in, III. 109
massage in, I. 737, 740 ; III. 207
of the spine, I. 900
weight-extension in, I. 742
Spray chambers in emphysema, I. 1086
Spraying, disinfection by, I. 163
Sprays in asthma, I. 1040
Sprengel's deformity, I. 985
Spriggs (E. I.), diabetes insipidus, I.
428-429
diabetes mellitus, I. 408-427
infant feeding, II. 214-232
marasmus, I. 463
principles of dietetics, II. 190-213
Spring catarrh of the conjunctiva, III.
560
Springs, mineralisation of, III. 114
Sprue, III. 442-446
complications of, III. 445
convalescence in, III. 445
fruit in, III. 443
local treatment in, III. 445
meat diet in, III. 443
medicinal treatment of, III. 444
milk diet in, III. 442
soured milk in, III. 443
Squill, oxymel of, in laryngitis, I. 245
Squills in diseases of the heart, I. 1223
Stab-wound over stomach region, II. 282
Stacke's post-aural operation in diseases
of mastoid process, III. 922, 923, 926
Stammering, III. 327-330
Standing in physical exercise?, III. 229
Stapes, removal of, in chronic inflamma-
tion of middle ear, III. 916
Staphylococcus infections, vaccine therapy
of, I. 182 ; III. 288
peritonitis, II. 641
serum, III. 288
Starch diet, effect on young children, I.
58, 61
foods in gout, I. 453
without, in infant feeding, II. 229
-free flour, I. 421
in food, effect on diabetes, I. 411
poultice, I. 34
Starches, chemical composition of, II. 195
Starvation in perniciuus vomiting of
pregnancy, IV. 62
predisposes to shock, I. 95
treatment in acute gastritis, II. 346
Statical treatment, III. 106
Status epilepticus, II. 1004
lymphaticus and anesthetics, III. 25
Steam, disinfection by means of, I. 162
kettle and tent, I. 39
in broncho-pneumonia, I. 1067
pressure, disinfection by, I. 162
tents in diphtheria, I. 192, 194
Steel plate, use of, in operative treatment
of fractures, I. 644
Stegomyia calopus and yellow fever, III.
382
Stellate naevi, III. 1077
Stephens (G. A.), on lead colic, I. 513
Sterilisation in cesarean section, I V.
394, 396
in gynecological operations, IV. 483
of instruments, methods of, I. 72
of surgical dressings, I. 75-77
preparatory to operation, methods of,
I. 27-30
Sterilisers, preparation of, I. 28-30
Sterility, dilatation of cervix in, IV. 854
electricity in, IV. 857
epididymitis causing, I. 227
female, marriage and, IV. 843
pelvic examination in, IV. 851
voluntary, IV. 844
from discharge from vagina, IV. 852
in azoospermia, IV. 849
in caruncle of female urethra, IV. 852
in diseases of the ovary, IV. 846
in endometritis, IV. 845
in general diseases, IV. 847
in inflammation of Fallopian tubes, IV.
845
in man, IV. 848
treatment of, IV. 850
in nietritis, IV. 845
in spasmodic dysmenorrhoea, IV. 847
in the female, IV. 843-859
lacerated cervix in, IV. 857
organo-therapy in, IV. 854
removal of Fallopian tubes and, IV. 856
retroflexion of uterus in, IV. 856
vaginal discharge in, IV. 845
Sterno-mastoid, hematoma of, in new-
born child, IV. 365
Sternum, inflammation of, I. 1032-1033
syphilis of, I. 1032
tuberculous disease of, I. 1032
Stevens (Thos. G.), hemorrhoids in
pregnancy, IV. 42
pendulous belly in pregnancy, IV. 61
pernicious vomiting of pregnancy, IV.
62-64
prolapse of the pregnant uterus, IV. 70
prolapse of the vagina in pregnancy,
IV. 71
pruritus vulvas in pregnancy, IV. 72-73
retroflexion of the pregnant uterus in
pregnancy, IV. 74-75
syphilis in pregnancy, IV. 76-77
varicose veins in pregnancy, IV. 89-90
Stewart (Purves), alcoholism, I. 495-502
110
A SYSTEM OF TREATMENT.
Stewart (Purves) (coitttl.*)
lumbar puncture, II. 1025-1026
paralysis agitans, II. 1269-1270
Stewart (T. Grainger), cerebral embolism,
II. 11G7
cerebral hfemorrhage.il. 1168-1176
cerebral thrombosis, II. 1179-1180
coma, II. '.>S2-!IH.-)
medical treatment of tumours of the
brain, II. 1200-1203
multiple neuritis, II. 1134-1139
neuritis. II. 1130-11:52
Stiles (Harold J.), intussusception, II.
641-549
Still's organism in basilar meningitis, I.
2.-) 1
Stimson's method in dislocations, I. 725
Stimulants, contra-indicated in shock, I.
97
in acute bronchitis, I. 1051
in blackwater fever, III. 389
in chronic bronchitis. 1. 1055
in pericarditis, I. 1180
in peritonitis, II. 638
in plague. III. 403
in typhoid fever, 1.311
in typhus fever, I. 367
use of, in diphtheria, I. 193
in fevers, directions for, I. 158
Stitch sinuses complicating gynaecological
surgery. IV. l'.C>
Stitches, removal of, after abdominal
operations, II. 267
Stockings for young children, necessity
of, I. 51
Stokes's supracoudyloid amputation, I.
863
Stomach, achylia of, II. 368
acidity in disordered digestion in, II. 370
atonic dyspepsia of, II. 2S6
atony of, II. 286-292
baths in. II. !'*'.
climate in. II. 289
diet in. 11. 28'.i
electricity in, II. 288
general treatment in, II. 287
lavage in. II. 288
medicinal treatment, in, II. 290
prophvlaxis of. 1 1. 286
atrophy of 0-ylia). " 2!i3-2!J."
from chronic gastritis, II. 21)4
from ingestion of corrosives, II. 291
general treatment in. II. 293
with pernicious anajmia, II. 293
cancer of, II. 296-3OI
acidity in, II. 3(in
anorexia and, II. i".i8
constipation in, II. 3ou
diet in. II. 297
general treatment of, II. 296
ha'tnatemesis in, II. 3iiu
jejunostomy for, II. 305
lavage in. II. 296
medicinal treatment of, II. 298
mortality from, II. 3i>2
Stomach, cancer of (cuntd.*)
pain in, II. 299
partial gastrectomy for, II. 308
.radical operation for, II. 308
relief of obstruction in, I. 139, 140
surgical treatment of, II. 302-309
symptomatic treatment of, II. 298
vomiting and, II. 299
cardiospasin of, II. 357
catarrh of, diet in, II. 209
colic fistulas of, II. 490
concretions of, II. 35'.)
contraction of, II, 334-336
partial gastrectomy for, II. 336
perigastritis complicating, II. 336
cough in pulmonary tuberculosis, I.
1146
crisis of, in tabes dorsulis, II. 1090
descent of total, II. 319
dilatation of, II. 310-311
acute post-operative, II. 311
chronic, diet in, II. 313
general treatment of, II. 312
lavage in, II. 312
medicinal treatment of, II. 314
pyloric stenosis, II. 312
in pulmonary tuberculosis, I. 1150
obstructive, II. 316
diseases of, diet in, II. 209
displacements of, II. 318-322
upward, II. 318
vertical, II. 318
distension of, complicating abdominal
operations, II. 270
electrical treatment of, II. 355
examination of, in epilepsy, II. 992
external injuries associated with wound
of, II. 282
flatulence in disordered digestion in,
II. 371
foreign bodies in, II. 285
gastrotomy for, II. 285
gunshot injuries of, II. 283
habitual rcgurgitation of, II. 357
haemorrhage from, II. 325-330
acute gastric ulcer and, II. 325
in cancer, II. 329
in hepatic cirrhosis, II. 329
hour-glass, II. 334
hyperacidity of, II. 360
hypersecretion of, II. 364-365
medicinal treatment of, II. 367
inflammations of. iSee Gastritis,
injuries of, II. 282-285
caused by blow, II. 283
by kick, II. 283
due to swallowing caustic fluids, II.
284
puncture from within in, II. 284
rupture from within in, II. 284
without external wound, II. 283
lavage of, in acute alcoholism, I. 495
in acute catarrh, I. 506
in poisoning, I. 528
motor insufficiency of, II. 209
111
A SYSTEM OF TREATMENT.
Stomach (contd.)
nausea in disordered digestion in, II.
373
nervous diseases of, II. 354-358
eructation of, II. 357
neurasthenia of, II. 354
operations upon, food before, II. 259
pain in disordered digestion in, II. 373
parasitis of, II. 359
region, stab-wound over, II. 282
rupture of, within, II. 284
secretory disorders of, II. 360-369
diet in, II. 361
lavage in, II. 361
medicinal treatment of, II. 363
symptoms of disordered digestion in, II.
370-374
tetany of, II. 399
tumours of, simple, II. 400
ulcer of, II. 375-381
acute, II. 325, 382
chronic, II. 382
simple, II. 327
complications of, II. 380
constipation in, II. 381
diet in, II. 210, 376
gastro-enterostomy in, II. 386
general treatment, II. 375
medicinal treatment of, II. 378
pain in, II. 381
perforated, II. 389
preceding cancer, I. 119
prophylaxis of, II. 375
pyloroplasty in, II. 385
surgical treatment, II. 382-388
symptoms of, II. 381
tetany in, II. 381
vomiting in, II. 380
volvulus of, II. 400
vomiting in disordered digestion in, II.
373
water-rash in disordered digestion in,
II. 374
Stomatitis, II. 120-125
aphthous, II. 120-121
food administration in, II. 121
general treatment of, II. 121
local treatment of, II. 120
prophylaxis of, II. 120
catarrhal, II. 120
follicular, III. 1192
gangrenous, II. 124-125
in measles, I. 246
mercurial, II. 125
prophylaxis of, II. 125
treatment of, II. 125
parasitic, prophylaxis of, II. 122
(thrush), II. 122-124
treatment of, II. 123
recurrent, II. 122
ulcerative, II. 121-122 ; III. 1192
chronic, III. 1192
complicating scarlet fever, I. 293
diet in, II. 122
general hygiene in, II. 122
Stomatitis, ulcerative (cantd.)
local treatment of, II. 121
prophylaxis of, II. 121
Stools, characteristics of, infant feeding
and, II. 231
disinfection of, I. 40, 164
examination of, I. 510
Stoppany's plate for fracture of the jaws,
II. 114
Stovaine, injection of, for spinal analgesia,
III. 37
Strabismus, III. 651
convergent, III. 651
divergent, III. 654
operative treatment, III. 653
vertical, III. 655
Strain caused by excessive exercise, I. 8
Stramonium, poisoning by, I. 532
Strapping in fractures of clavicle, I. 584
Strathpeffer spa, III. 156
Strawberries, idiosyncrasy to, I. 454
Streptococcus angina, III. 771
directions for isolating, III. 289
in infective endocarditis, I. 203
in salpingitis, IV. 815
infectious, vaccine therapy of, I. 182 ;
III. 289-291
meningitis, I. 250
peritonitis, II. 641
Streptothrix infection, I. 177
leproides in leprosy, III. 452
Stretch in physical exercises, III. 280
Stretching movements for scoliosis, III. i' 1 1
Strophauthus, in diseases of the heart, I.
1222
Strophulus, in newborn child, IV. 371
Strychnine, contra-indicated in shock, I.
97
in alcoholism, I. 501
in beri-beri, III. 415
in chronic congestion of the lungs, I.
1079
in constipation in adults, II. 446
in diseases of the heart, I. 1227
in epilepsy, II. 998
in heart failure, I. 193, 200
in infantile debility, I. 66
in pellagra, I. 522
in pneumonia, I. 260
in poisoning, I. 527, 531, 533
injection of, in dangers arising during
anaesthesia, III. 33
prevention of shock by, I. 84
Stapes and fomentations, I. 35
Styptics in haemophilia, II. 32
in haemorrhage, I. 1261
Sub-thermal baths, III. 125
Subastragaloid disarticulation, Fara-
boeuf's, I. 843
Subclavian aneurysm, I. 1304
artery, haemorrhage from, I. 1275
Subcutaneous infusion in shock, I. 99
Sublingual abscess and affections of the
tongue, II. 133
glands, inflammation of, II. 158
112
A SYSTEM OF TREATMENT.
Submaxiliary irlands. inflammation of, II.
158
tumours of, II. 162
Subphrenic abscess, II. 643-644
Suction-apparatus for hyperremic treat-
ment, III. 56-60
Sugar in diet for trout, I. 453
in urine in diabetes, quantities of. I. 410
milk diluted with, II. 223
Suggestion in hysteria, II. 1009
in nocturnal enuresis, II. 76
treatment by, III. 159-1 7!>
Sulphated purgative waters, III. 121
Sulphonal in diseases of the heart, I. 1225
in insomnia. I \. !!>!. 1023
IM iisiinin<_' by, I. 531
Sulphur baths, III. 133
in boils, III. K07
in chlorosis, II, 27
in osteo-arthritis, I. 401
waters, 111. 117
Sulphuretted hydrogen poisoning, I. 534
Sulphurous acid in typhoid fever, I. 355
Sulphurous acid -as, use of, for fumiga-
tion, I. 162
Sun in troiiics, precautions when exposed
to, III. 377
Sunderland (Septimus), leucorrhcea, IV.
566-574
Sunshine in chlorosis, II. 20
Sunstroke, preventive treatment of, I.
536-537
sequelae of, I. 538-539
Suppositories, glycerine, in constipation
in adults. II. 453
in constipation in adults, II. 452
Suppuration, acute, in disease of the hip-
joint, I. 763
complicating wound after abdominal
operation, II. 273
following compound fractures, I. 582
in pelvic cellulitis, IV. 828
in tuberculous disease of the knee-joint.
I. 768
pelvic. I. 917
prolonged, disease of the hip-joint, I.
7C.5
Supracondyloid amputation through
thigh. I. Sii2
Supramalleolar amputation (Guvon), I.
860
Supra-orbital neuralgia, II. 1115
notch, alcohol injection into, for
neuralgia, II. 1117
Suprapubic drainage in carcinoma of the
prostate, II. 939
fistula, failure of closure of, com-
plicating adenoma of the prostate,
11.946
prostatectomy in adenoma of the
pi -state. II. 942
Suprarenal extract in hirmatemesis, II.
300
Suture of arteries for injury to I. 1279
Surgeon, antiseptic precautions for, I. 80
Surgery, antiseptic methods of, I. 84-92
gynaecological, after-treatment of, IV.
487-489
operative, technique of, I. 71-92
radium therapy, combined with, III,
313
technique, operation room, I. 71-71
preparation of instruments, I. 30
of patient, I. 27, 83-87
of room, I. 28, 71
of special regions, I. 87-91
septic cases, I. 92
surgeon and assistants, I. 80-83
surgical dressings, I. 74-80
Sutherland (G. A.), colic in children, II.
428-431
constipation in children, II. 432-438
diarrhoeal diseases in children, II. 471-
478
scurvy and infantile scurvy, I. 475-477
Sutures in ovariotomy, IV. 776
methods of, in wounds, I. 553
sterilisation of, I. 72
Swabs in gynaecological operations, IV.
483
Swayne (Walter Charles), pelvic cellulitis,
IV. 824-838
Sweat glands, adenoma of, III. 1044
hydradenomata of, III. 1044
Sweating, coloured, or chromidrosis, III.
1021
excessive, III. 1044-1045
in pulmonary tuberculosis, I. 1143
Swedish gymnastics in constipation in
adults, II. 459, 460
Sweep's eczema, I. 117
Switzerland, Fb'hn wind of, III. 75
Sycosis, III. 1144-1145
X-rays in, III. 350
Sydenham on small-pox, I. 302
Symblepharon of the conjunctiva, III.
548
Syme's disarticulation at the ankle-joint,
I. 845
operation, comments on, I. 848
incisions in, I. 845
Syraonds' short resophageal tube, II. 175
with terminal opening, II. 176
short tube, special form of, introducer
for, II. 176
Symphysiotomy, IV. 452-460
anatomy of. IV. 454
child alive and at term in, IV. 453
dangers to patient in, IV. 459
in contracted pelvis, complicating
labour, IV. 171
injuries to soft parts in, IV. 460
limits of operation in, IV. 453
mortality of, IV. l.V.i
open method of, IV. 457
operation of, IV. 456
pelvis greatly deformed and. IV. 151
Pinard's register for, IV. 457
prognosis in, \\' . 45'J
repeated, IV. 460
113
A SYSTEM OF TREATMENT.
Symphysiotomy (contd.)
results of, IV. 459
division of symphysis in, IV. 452
separation of bones in, IV. 453
subcutaneous, IV. 458
Symphysiotomy knife, Galbiati's, IV. 457
Symphysis, division of, results of, IV.
452
Symptomatic treatment, I. 18
Syncope in placenta praevia, IV. 69
Syndactyly or webbed fingers, I. 943
Synechia of the nose, III. 672
Synovial disease, primary, of the ankle
and tarsus, I. 772
effusion in tuberculous disease of the
knee-joint, I. 767
Synovitis, I. 483
acute, I. 741-742
deformity of, I. 742
or sub-acute in gonorrhoeal arthritis,
I. 781
chronic. I. 745-748
ionic medication of, III. 185
electro-therapeutics in, I. 746
fibi-olysin in, I. 748
hydro-therapeutics in, I. 745
local applications in, I. 748
scarlatinal, I. 290
teno-acute, suppurative, I. 170
tuberculous, I. 752
Syphilis. I. 316-324
and anaemia, II. 17
and aphasia, II. 1144
arsenic in, I. 321
aryl-arsonate groups in, I. 321
bursitis in, II. 1335
calomel in, I. 318
cerebral, headache from, II. 1034
thrombosis in, II. 1069
cerebro-spinal, II. 1063-1069
anti-syphilitic therapy, II. 1065
arsenic in, II. 1067
intracranial gumma in, II. 1067
iodides in, II. 1065
mercury in, II. 1065
prophylaxis of, II. 1063
cirrhosis of the liver in, II. 665
clinical pathology of, in relation to
treatment, I. 325-328
complicating pregnancy, IV. 76-77
pulmonary tuberculosis, I. 1156
congenital, in newborn child, IV. 369
jaundice and, II. 672
constitutional treatment of, I. 316
cranial, I. 890
drugs in, I. 317, 319, 324
foatal, complicating pregnancy, IV. 77
grey oil injections in, I. 319
hectine in, I. 323
hygiene of the month in, I. 318
intramuscular injections in, I. 318
intravenous injections in, I. 320, 322
inunctions in, I. 319
iodine in, I. 321
iritis in, III. 588
Syphilis (coiitil.)
mercury in treatment of, I. 317
mineral waters and baths, in, III. 143
myositis in, II. 1324
neuritis in, II. 1130
of bones, I. 703
of joints, I. 784
of the internal ear, III. 978
of the larynx, III. 868-869
of the meatus, III. 883
of the naso-pharynx, III. 743
of the nose, III. '714-715
of the pharynx, III. 791-792
of the prostate, II. 927
of the ribs and sternum. I. 1032
of the spine, I. 917-918
of the testis, II. 907
of the tongue, II. 134-137
of the tonsil, III. 756
of the vulva, IV. 520-521
paralysis in, II. 1069
salvarsan (" 606") in, I. 322 ; II. 1144
sarsaparilla in, I. 323
tenosynovitis in, II. 1330
Wassermann reaction in, I. 325
Syphilitic onychitis, III. 1082
phlebitis, I. 1330
vascular disease, cerebral thrombosis due
to, II. 1177
Syringe, Blake's tympanic, III. 912
Neumann's, III. 913
Syringomyelia, II. 1219-1220
arthritis in, I. 786
Kb'ntgen rays in, II. 1219
Tabes dorsalis, II. 1085-1092
electricity in, II. 1091
fibrolysin, II. 1086
Fraenkel's exercises in, II. 1091
gastric crises in, II. 1090
hydropathy in, II. 1092
iodide of potassium in, II. 1087
massage in, II. 1091
medicinal remedies in, II. 1088
mercury in, II. 1086
salvarsan in, II. 1088
sphincter of bladder troublesome in,
II. 1090
Tachycardia, I. 1235
and anaesthetics, III, 23
in the menopause, IV. 502
paroxysmal, I. 1236
Tseniasis, intestinal, III. 517-520
anthelmintic treatment of, III. 518
preparatory treatment in, III. 518
prophylaxis of, III. 517
purgative treatment of, III. 518
somatic, III. 521
visceral, III. 521
Takadiastase in gouty dyspepsia, I. 442
Talipes equino-varus, I. 952, 953
in newborn child, IV. 362
physical exercises for, III. 233
114
A SYSTEM OF TREATMENT.
Tampons in puerperal vaginitis, IV. 5 1 1 3
wool, in retroversion of the uterus, IV.
674
Tannin in haemorrhage, I. li't',1
Tapotement and massage, III. L'o4
Tapping, in pletiral effusion, I. 1095-1097
in spina-bifida, I. 902
Tar, Harbados, in water itch, III. 486
in pruritus. III. lo'.i'.i
in psoriasis, III. 1119
workers' dermatitis. III. Io3n
Tarasp-Schuls spa. III. 156
Tarsal bones, fractures of, I. 632-633
Tarsus, disease of. I. 773
operations on, in congenital club-foot,
[. 957
tuberculous disease of, I. 772-775
Tartar emetic in trypanosomiasis, III.
421
Taylor (Ames), psychasthenia, II. H'll-
1046
Taylor (E. H.). amputations, I. 789-872
Taylor (Gordon), ha-morrhage and injuries
of arterirs. I. 12.W1277
sui'L'ieal diseases of arterio-sclerosis, I.
1296
wounds of arteries, I. 1278-1280
Taylor (James), neurasthenia, II. 1038-
1043
Tea in typhoid fever, I. 343
Teale's amputation, I. s.">l
Teeth, abnormalities of position of. III.
1165
artificial, cleansing of, II. 128
care of, II. 127
in children, I. 49
in cleft palate operation, II. 152
in scarlet fever, I. 294
in sprue. III. 44."i
in syphilis, I. 318
caries of. III. 1 1 72
cleaner, rubber, II. 128
crowns of. artificial, III. 1178
dislocation of, III. 1177
displacement of in fracture of the jaw,
II. 99
examination of in epilepsy, II. 992
extraction of. III. 117'.
anaesthetics for, III. 29
casualties in. III. 1188
complications. III. 11^--
luemorrhage following. 1 1 1. 1 IS'.i
local anaesthetics and. III. 1190
methods applicable to individual
teeth, III. 1181-1188
septic infection of socket following,
III. 1190
under anesthetics. III. 1190
fracture of, III. 1177
nrcroMs of jaw and. II. Ins
pulp of. diseases of, 111. 1 1 7:>
temporary, extraction of. III. 1188
ulcer in tuberculous disease of the
tongue. 11.1 33
Telegraphist's cramp. II. 12i'.;
Telephone ear. III. 880
Telling (W. H. Maxwell), actinomycosis,
- 1.177
erythema nodosum, I. 212-213
Glenard's disease (enteroptosis), I. 430
rheumatism in childhood, I. 276-279
Temperance, general, a principle of treat-
ment, I. 9
Temperature (body) in blackwater fever,
III. 388
in infectious diseases, I. 159, 160
in non-operative appendicitis, II. 424
in sanatorium treatment of tuber-
culosis, I. 1132
in tuberculin therapy, I. 1141
in typhoid fever, I. 348
methods of reduction of, I. 36
persistent, complicating acute rhcu-
mati-m, I. 271'
reduction of, by baths, I. 69
effect of the mind on, I. 1141
gastro-intestinal in pulmonary tuber-
culosis, 1. 1 139
in gynaecological surgery, IV. 487
in normal puerperium, IV. 261
in sanatorium treatment of pulmonary
tuberculosis, I. 1131, 1135
increase of in pulmonary tuberculosis,
I. 1140
post-hiemorrhagic rise of, I. 1141
changes of, children require pro-
tection from, I. 50
of baths and packs, I. 36, 38
of nurseries, regulation of, I. 44
Temporo-maxillary joint, inflammatory
diseases of, II. 105
injuries of. II. 104
sphenoidal abscess complicating diseases
of the ear, III. 939
Tendo Achillis, rupture of, II. 1328
Tendon sheaths, affections of, II. 1330-
1333
ganglion of, II. 1332
excision in, II. 1332
puncture in, II. 1332
infection of, I. 169
tumours in connection with, II. 1331
Tendons, diseases of, II. 1326-1333
dislocation of, II. 1326
division of, II. 132<>
injuries of, dropped finger in, II. 1329
rupture of, subcutaneous. II. 1328
stitf and painful action of in fractures,
1.578
wounds of, II. 1326-1329
Tenonitis of the orbit, III. 662
Tenosynovitis. acute septic, II. 1330
simple. II. 1330
chronic simple, II. 1330
massage in. III. 209
suppmative. I. 169
syphilitic. II. 1330
tuberculous, II. 1331
cassation in, II. 1331
early stages of, II. 1331
lit
A SYSTEM OF TREATMENT.
Tenotomes, Schwartz's, III. 914
Tenotomy of the plantar fascia in con-
genital club-foot, I. 954
Tent and steam kettle, I. 39
Teplitz spa, III. 156
Terminations of disease, aspects of, I. 21
Testis, diseases of, II. 901
ectopia of, II. 904
enucleation of, in operation for elephan-
tiasis scroti, III. 507
hernia of, II. 901
imperfect descent of, II. 902-905
inflammation of, II. 906
non-descent of, in newborn child, IV.
360
syphilitic disease of, II. 907
torsion of, II. 907
tuberculous disease of, II. 908-909
tumours of, II. 910
wounds of, II. 907
penetrating, II. 907
Tetanic rupture of rectus abdominalis, II.
248
Tetanus, I. 329-331
complicating the puerperium, IV. 326-
327
incubation period of, I. 329
local treatment of wound in, I. 329
means of infection in, I. 329
medicinal treatment of, I. 330
methods of examination in, I. 329
prophylactic treatment with anti-teta-
nic serum, I. 330
serum therapy of, I. 329
Tetany, II. 1271
complicating pregnancy, IV. 51
the puerperium, IV. 328
ulcer of the stomach, II. 381
gastric, I. 388
in children, II. 1272-1273
of the stomach, II. 399
Tetronal, poisoning by, I. 531
Thecal whitlow, I. 169
Theocin in oadema, I. 422
Theocin-sodium acetate in chlorosis, II.
27
Theophyllin in oedema, I. 422
Therapeutic procedure, diagnosis to pre-
cede, I. 23
Therapeutics, principles of, I. 1-25
Thermal baths, III. 124, 126
mineral waters, III. 116
or hot douche bath, III. 127
Thermo-cautery, use of, in operable cancer,
I. 137
Thermometers, use of, in baths and packs,
I. 36, 38
Thiersch grafts in cheloid, I. 113
in tropical phagedena, III. 473
value of, I. 118
method of skin grafting, I. 543
skin grafts, I. 374
Thigh, amputations through, I. 862-866
by a long anterior flap, I. 864
Thiosinamin in cheloid, III. 1018
Thirst after abdominal operations, II. 263
in cholera, III. 426
in diabetes, I. 417
Thomas" abduction frame, II. 1061, 1159
caliper splint, I. 767
(Guillard) operation for fibro-adeuomata
of the breast, II. 956
hip splint, I. 756, 765
in tuberculous disease of hip-joint,
I. 765
wrench in congenital club-foot, 1. 955
Thomson (H. Campbell), hysteria, II, 1008-
1013
Thomson (J. C.), plague, III. 401-409
Thomson's (St. Clair) post-nasal forceps,
III. 734
Thoracic aorta, surgery of, in aneurysm,
I. 1303
nerve, posterior, injuries of, II. 1112
wall, new growths of, I. 1034
osteomyelitis of, I. 1032
Thoracopagus, podalic version in, IV.
468
Thoracoplasty in empyema, I. 1107
Thorax. See Chest.
Thorburn (William), injuries and diseases
of the spine, I. 898-911
Throat, care of, in scarlet fever, I. 284
coughs in pulmonary tuberculosis, I.
1145
cut, II. 164
after-treatment of, II. 165
complications of, II. 165
sequelae of, ii. 166
gouty affections of, III. 77o
rheumatic affections of, III. 764
sore, complicating influenza, I. 239
swabbing of, in diphtheria, I. 194
ThromMc obstruction in injuries of
arteries, I. 1278
Thrombosis after ovariotomy, IV. 794
and phlebitis, I. 1328-1338
arterial, I. 1337
cerebral, II. 1177-1180
due to abnormal blood states, II.
1179
circulatory enfeeblement, II. 1178
obstruction by pressure from without,
II. 1179
senile arterial changes, II. 1178
syphilitic, II. 1069
vascular disease and, II. 1177
associated with renal disease, II.
1178
treatment of, 11.1179
chlorotic, I. 1331
complicating abdominal operations, II.
274
femoral, complicating gynaecological
surgery, IV. 4!)4
in puerperal sepsis, IV. 321
gangrene due to sudden obliteration of
arteries by, I. 215
of corpus cavernosum, I. 1331
of the orbit, III. 662
116
A SYSTEM OF TREATMENT.
Thrombosis
of portal vein, I. 1331 ; II. 6G<i-ir,7
of prostatic veins, I. i:!31
of retinal veins, III. (> 14
of sigmoid sinus, complicating
of the ear, III. 941-943
of the veins of broad ligaments, IV.
822-828
prophylaxis of, after abdominal opera-
tions, II. 271
treatment of, after abdominal opera-
tions, II. 274
venous, complicating typhoid fever,
I. 360
Thrombus in varicose veins, I. 1331 ; IV.
89
Thrush, II. 122-124 ; III. 7!2
Thumb, amputation of, I. Sll
congenital lateral deviation of the
phalanges of, I. 938
Thymol in typhoid fever, I. 355
treatment of ankylostomiasis. III. 490
Thymus extract in cancel 1 , I. l.~>0
Thyro-glossal cysts of neck, II. 170
fistula, II. 167-170
Thyro-hyoid cyst of neck, II. K',s
space, injury to in cut throat, II. 1<>4
Thyroid arteries, ligature, in exophthalmic
goitre. II. .V.i "'
i-ysts of neck, II. 1 7o
extract, administration of, II. 49-50
in cancer, I. 150
in eclampsia. IV. :>7
in goitre, II. 62
in lipomatosis, I. 108
in nocturnal enuivsis, II. 76
in obesity, I. 473
in ostco-arthritis, I. 402
in psoriasis, III. 1114
fistuhe of neck, II. 167
inland, changes in, psychoses associated
with, II. 1801-1302
congestion of, II. 51
diseases of, II. 49-74
cnucleation of, in goitre, II. 64
extirpation of, in goitre, II. 63
hypertrophy of, 1 1. "> I
inflammation of, II. 51
influence on obesity, I. 473
growths of, respiratory obstruction due
to, I. 142
inadequacy, II. 78
inflammation of, acute, II. .VJ
chronic, II. 53
surgical treatment of, II. 5.'>
malignant disease of, IF. 73-71
palliative treatment of, II. 73
radical treatment of, II. 73
Thyroidectomy for exophthalmic goitre,
1 1. oil
Thyroidism, in exophthalmic goitre, II. 59
complicating operation for goitre, II.
89
Thyrotomy in malignant growths of the
larynx. III. 854
Tibia, congenital defects of, I. 950
epiphysis. lower separation of in
fracture, I. 632
upper separation of in fracture, I.
624
extremity, upper, fracture of, I. 623
fractures of, I. (>22-632
involving the ankle-joint, I. C>2S
internal malleolus of, fracture of, I. (!28
operations on, in congenital club-foot,
1.958
shaft of, fracture of, I. 624, 625, (J26
spine of, fracture of, I. 624
torsion or spiral fracture of, I. l>.~>7
tuberosities of, fracture of, I. 623
Tic douloureux, II. 1116
Tics, II. 1047-1049
convulsive, II. 1047
of neck, II. 1052
Tilley's tonsil catch forceps, III. 7.", I
Tin, salts of, acute poisoning by, treat-
ment of, I. 529
Tinea cruris, III. 478
imbricate, III. 480
Tinned foods, poisoning by, I. 510
Tinnitus of the labyrinth, III. 971-973
Tobacco and arterio-sclerosis, I. 12H2
intoxication by, in epilepsy. II. 993
poisoning by, I. 533
chronic, I. 534
Tod (Hunter;, acute inflammation of the
middle ear, III. 894-!io3
Tod's (lap in operation for diseases of
mastoid process, III. 925 1
Toes, amputations of, I. 834 % -836
deformed by boots, I. 57
Faraboeuf's method of amputation of, I.
88B
general considerations concerning am-
putations of, I. 834
Tolu, syrup of, in bronchitis, I. 245
Tongue, acute parenchymatous glossitis
in, II. 133
affections of, II. 132-140
as an indication of disease, I. 65
cancer of, I. 124
ligature of, arteries in, I. 136
chancre of, II. 134
drugs in, II. 134
cysts of, II. lir>
epithelioma of, II. 138-144
after-treatment of operations for, II.
142
choice of operation for, II. 139
invading floor of mouth, II. 143
operation for, II. 141
X-rays in, II. 139, 144
forceps in amesthetics, III. 2
geographical (annulus migrans), II.
126-12H
leucomata of, II. 137
leukoplakia of, II. 137
na'vi of, II. 133
operations on, and anaesthetics, III. 27
lanula cyst of, II. 145
117
A SYSTEM OF TREATMENT.
Tongue (contd.~)
sarcoma *of, II. 144
secondary syphilitic lesions of, II. 135
sublingual abscess in, II. 133
syphilitic affections of, II. 134-138
inveterate chronic glossitis in, II. 136
tie, II. 132
in newborn child, IV. 358
tuberculous disease of, II. 133
wounds of, II. 132
Tonics in influenza, I. 236
premature use of. I. *>4
Tonsil, acute tuberculous ulceration of,
III. 757
care of in acute rheumatism, I. 271, 276
in scarlet fever, I. 284
chronic infections of, III. 750-759
clinical types, III. 750
galvano-cautery in, III. 751
general treatment, III. 751
morcellemeiit and, III. 751
operative treatment, III. 751
removal by guillotine, III. 751
tubercular ulcer of, III. 757
diseases of, III. 747-763
embedded in relation to the fauces, III.
750
enlarged, in anaemia, II. 14
enucleation of, III. 752
lingual, benign tumours of, III. 762
chronic abscess of. III. 762
diseases of, III. 760-763
lupus of, III. 757
operations of, after-treatment, III. 754
pharyngeal, hypertrophy of, III. 732-
738
anaesthetic in, III. 734
instruments in operation for, III.
735
operation for, III. 735
removal of, and anaesthetics, III. 28
retained secretion within, III. 755
syphilis of, III. 756
tonsilloliths of, III. 755
tuberculosis of, III. 757
tumours of, III. 758-759
benign, III. 758
malignant, III. 758
Tonsillitis, acute, III. 747-749
general treatment of, III. 748
lacunar, III. 747
lingual, III. 760
local treatment, III. 748
parenchymatous, III. 747
prophylaxis of, III. 748
chronic lingual, III. 761
joint affections complicating, I. 391
ulcerative, III. 747
Tonsilloliths, III. 755
Tonsillotome, lingual, III. 761
Tooth, adjacent, extraction of, III. 1188
brush, daily use of, II. 127
fracture of, in extraction, III. 1188
haemorrhage from socket of, I. l-_'7.".
Tophi of the auricle, III. 880
Torrens (James), coeliac disease, II. 426-
427
embolism (excluding cerebral embolism),
I. 1306-1308
medical treatment of aortic aneurysm,
I. 1297-1300
myasthenia gravis. II. 1254
pseudo-leukaemia, II. 42
treatment of fistulous tracks in
empyema by the injection of bismuth
and vaseline. I. 1110-1111
Torsion-clamp, method in operation for
elephantiasis scroti, III. 509
Torticollis, II. 1050-1053
mental, II. 1052,
neuralgic, II. 1050
paralytic, II. 1051
professional, II. 1050
rhythmic, II. 1052
scoliosis and deformities of the shoul-
ders, I. 972-988
spasmodic, true, II. 1051
wryneck or, I. 987
Tourniquet, control of haemorrhage, I.
798
use of, in haemorrhage, I. 559
Towels, arrangement of before operation,
I. 85
sterilisation of, I. 73
Toxaemias, subinvolution of uterus in,
IV. 720
Toxic psychoses, II. 1303-1304
Trachea, cancer of, relief of obstruction
in, I. 142
compression of from without, III. 801
diseases of, III. 797
fistula of, III. 799
gummata of, III. 801
inflammation of, in influenza, III. 798
injuries of, III. 797
in cut throat, II. 165
obstruction of, III. 800-802
rupture of. III. 797
scalds of, III. 797
structure of, III. 801
Tracheo-laryngostomy in stenosis of the
larynx, III. 866
Tracheotomy, high and low, merits of,
I. 197
in aortic aneurysm, I. 1299
in cancer of larynx, I. 142
in diphtheria, I. 195
in foreign bodies, III. 820
in malignant disease of the thyroid,
11.74
Trachoma, III. 557
Transcondyloid amputation through thigh,
I. 862
Transfusion in pernicious anaemia, II. 9
in tubal pregnancy, IV. 85
of human blood in shock, I. 102
Traumatic cases, amputation in, I. 789
cataract, III. 638
cyclitis, III. 595
gangrene, I. 582
118
A SYSTEM OF TREATMENT.
Traumatic
neuritis. II. 1106
of the uvula, III. 7 IT.
osteomyelitis. L 889
periostitis. I. 7<>3
pvopneumothorax, I. 1114
rhinitis, III. 704
Traumatism. mineral waters and baths in,
III. 145
shock caused by, I. 96
Treatment, based on aetiology, I. 3-9
clinical indications for, I. 2<>-22
symptomatic, I. 15-20
conservative factors in, I. 11
empirical, I. 1
indications for, I. 2
methods of natural resistance indicating,
I. 4
of acute disease, I. 20
of chronic disease. I. 20
of complications and sequela?, I. 22
of specific causes of disease, I. 4-8
palliative, I. 18
pathological indications for, I. 10-15
practice and management of, I. 22-25
principles of, I. 1-25
rational, I. 1
symptomatic, I. 18
Trendelenburg position, value of, I. 95
Trephining in infective lesions of skull,
I. 889
preparation of head for, I. 87
Trichiasis of the eyelids, 1 1 \. 580
Trichinelliasis, III. 524
prophylaxis of. III. 524
Trichini'asis, IIL 524
prophylaxis of, IIL ~>'l I
Trichinosis. III. 524
prophylaxis of, III. ."ii'l
Trichlormethane as anaesthetic, III. 13
Trichocephaliasis, III. 493, 496
Trichorrhexis nodosa, III. 1145
Trigeminal neuralgia, II. 1116
Trigger linger, I. '.Ml'
Trigone, exposure and division of, II. 935
Trillat autoclave, fumigation by, I. 163
Trinitin in high blood pressure, I. 1283
Trional, poisoning by, I. 531
Trismus spasm, II. 1048
Trophic diseases, II. 122i',
Tropical anemia, II. 15
diseases, HI. :i7r,-.->n;
fevers, undefined, III. 410
liver. II. 676-678
phagedeiia, II I. 172
general treatment of, III. 472
local treatment of, HI. 473
prophylaxis of, III. 472
regions, physiological effect of, on
Europeans, III. 37.".
skin diseases, lit. 47i>-|xr,
ulcer, III. I7i>
Tropics, adaptation of habits to climate
in, III. 376
diet in. III. 378
Tropics (contd.)
diseases disseminated by insects in, III.
379
'dress in, III. 377
drink in, III. 378
excretal diseases and their dissemina-
tion in the tropics, III. 383
food in, III. 378
general hygiene in, III. 375
housing in, III. 379
insecticides in, III. 383
malaria in, III. 380
milk, boiled in, III. 384
personal hygiene in, III. 375
precautions against insanitary condi-
tions in, IIL 383
when exposed to sun in, III. :<77
protection from insect-borne diseases
in, III. 379
rest in, III. 379
ringworm in, III. 478
sleep in, III. 379
sleeping sickness in, III. 383
water boiled in, III. 384
yellow fever in. III. 382
Tropococaine, injection of, for spinal
analgesia, III. 37
Trunk exercises in gymnastics, III. 226
-raising exercises for spinal curvatures,
III. 238
-rolling exercise in pulmonary disease,
III. 252
for scoliosis, III. 242
-rotation exercise in defective meta-
bolism, III. 255
for lardosis, III. 240
varix affecting, I. 1320
Truss, child's double, for inguinal hernia,
II. 527
for femoral hernia, II. 526
for inguinal hernia, II. 527
for irreducible hernia, II. 527
for movable kidney, II. 787
in palliative treatment of hernia, II.
498
umbilical, II. 527
Trypanosomiasis, III. 417-422
arsacetin in, III. 421
arsenious acid in, III. 42 JL
arscnophenylglycin in, III. 419
combined therapy of, III. 421
general principles of chemotherapy,
III. 419
general treatment of, III. 122
tartar emetic in, III. 421
Trypsin in cancer, I. 151
in treatment of cancer of alimentary
system, I. 140
Tubercle bacillus in salpingitis, IV. 815
fistula of anus due to, II. (509
Tubercula dolorosa, I. 112
Tuberculide, papulo-squamous, III. 11 .".2
Tuberculides, III. 1146-1152
Tuberculin, bacillary emulsion sensi-
tized, III. 294
119
A SYSTEM OF TREATMENT.
Tuberculin (contd.~)
Beraneck's, III. 293
Denys' bouillon filtre", III. 293
exercise after the administration of,
I. 1139
in pulmonary tuberculosis, I. 1119
in tuberculous lymphatic glands, I.
1346
meningitis, I. 249
peritonitis, II. 646
Koch's new, 111. 293
Koch's old, III. 293
Perlsucht, III. 293
therapy, dosage in, III. 295
in tuberculosis, I. 323 ; III. 291-298
method of administration, III. 294
of tuberculosis of the kidney, II. 820
secondary infections in, III. 297
temperature in, I. 1141
Tuberculosis, acute, I. 332-334
without localising symptoms, I. 332
climate for, III. 100
complicating pregnancy, IV. 50
diet in, II. 203
hyperplastic of the colon, II. 590
miliary or generalised, I. 332
mineral waters and baths in, III. 143
of bladder, II. 820
of breast, II. 981
of colon, II. 590
of conjunctiva, III. 560
of kidney, II. 819-829
of larynx, III. 870-875
of nares, III. 687, 688
of naso-pharynx, III. 742
of pharynx, III. 793-794
of tonsil, III. 757
of uvula, III. 745
of vulva, IV. 508
prophylaxis of, I. 1126
pulmonary, I. 1117-1126
after-treatment of. I. 1125
anaemia caused by, II. 13
amemia in, I. 1149
auto-inoculation, regulation of, in, I.
1121
climate and, IV. 1118
complications of, I. 1155-1158
by albuminuria, I. 1157
by cystitis, I. 1156
by diabetes, I. 1158
by empyema, I. 1158
by epididymitis, I. 1157
by ischio-rectal abscess, I. 1156
by pleurisy, I. 1158
by pregnancy, 1. 1155
by syphilis, I. 1156
coughs in, various, I. 1144
creosote vapour bath in, I. 1149
diet in, I. 1119
dust and, I. 1118
dyspnoea in, I. 1138
exercise in, I. 1123
fresh air in, I. 1118
graduated labour in, T. 1159-1163
Tuberculosis, pulmonary (matd.')
guide to control of auto-inoculation
in, I. 1162
haemoptysis in, I. 1150
mild, I. 1150
moderate, I. 1151
severe, I. 1154
increase of patient's resistance to, I.
1118
induction of an artificial pncumo-
thorax in treatment of, 1. 1164-1173
inhalers, dry, in, I. 1148
injections, intra-tracheal in, I. 1149
injections, secondary in, I. 1126
insomnia in, I. 1149
Kuhn's mask in, I. 1148
light treatment in, III. 201
massage in, I. 1139
pneumothorax, artificial in, I. 1164-
1173
completion and maintenance of, I.
1168
complications of, I. 1171
difficulties of, I. 1167
duration of, I. 1169
dyspepsia complicating, I. 1170
Forlanini's method, I. 1170
modifications of method, I. 1 1 70
Murphy's method, I. 1170
nitrogen apparatus for, I. 1166
pleurisy complicating, I. 1170
Saugman's needle for, I. 1107
pulse rate in, I. 1141
rest as guide to control of auto-inocu-
lation in, I. 1162
rest in, I. 1122
sanatorium treatment of, I. 1127-1158
daily notes in, I. 1132-1142
exercise stage in, I. 1129, 113.")
exhaustion in, I. 1138
lassitude in, I. 1138
rest stage in, I. 1128
temperature (body), in, I. 1131,
1135
secondary infections in, I. 1126
specific measures for, reputed, I.
1126
stomach dilatation in, I. 1150
sweating in, I. 1143
temperature, effect of the mind on,
in, I. 1141
Castro-intestinal in, I. 1139
increase in, I. 1140
post-haemorrhagic in, I. 1141
tuberculin treatment of, 1. 1119 ; III.
285-295
exercise in, I. 1139
temperature in, I. 1141
weight, loss of, in, I. 1155
wind and, I. 1118
Tuberculous abscess, methods of treat-
ment of, I. 173-176
adenitis, III. 757
bursitis, II. 1335
cystitis, II. 861-863
A SYSTEM OF TREATMENT.
Tuberculous cystitis (contd.}
complicating pulmonary tuberculosis,
I. 1156
disease of the ankle and tarsus, I. 772-
776
of bones, I. 7n4
of elbow, I. 777-779
of Fallopian tubes, IV. 817-819
of hip-joint, I. 752-705
of jaws, II. ln.)
of joints, I. 750-752
of knee- joint, I. 765-772
of lymphatic glands, I. 1344-1347
of middle ear and its accessory
cavities, III. 935-9:56
of ribs, rib cartilages, and sternum,
I. 1032
of sacro-iliac joint, I. 780
of shoulder, I. 775-777
of testis, II. 908-909
of tongue, II. 133
of wrist, I. 779
spinal, Pott's disease, I. 922-927
empyema, I. 1108
cpididymitis complicating pulmonary
tuberculosis, I. 1157
glands, cheating, in the mediastinum,
I. 1177
suiirical treatment of, I. 1348
X-rays in, III. 367
iritis. III. 589
keratitis of the cornea, III. 569
meningitis. I. 2 is, 249
onvchitis, III. 10*2
osteitis of the skull, I. 889
pericardit is. I. 1 184
peritonitis. 1 1. t;i5-r,l7
prostatitis, II. 928-929
psoriasis, III. 1152
pyopneumothorax, I. 1114
salpiiiL'itis, IV. 817-819
sinuses, chronic, I. 176
synovitis, I. 752
tenosynovitis, II. 1331
ulcer, chronic, of tonsil, III. 757
ulceration, acute, of tonsil. III. 7". 7
Tufnell's treatment of aortic aneurysm, I.
1297
Tumour cells, embolism by, I. 1306
Tumours, air containing, of the skull, I.
896
cerebral, in children, II. 1166
- ;-ic. simple, II. 400
growing from the bony walls of the
cranium, I. S'.i 1
in connection with tendon sheaths, II.
1331
innocent, of the lips. II. ( .i7
of the vulva. IV. nil -.ML'
intra-abdominal, complicating preg-
nacy. IV. 5 5
intra-eranial, coma and, II. 983
headache from, II. KCIt
localised, IT. 12<2. 12n:;
intra-liganic nt;u y. IV. 7(18-770
Tumours (i-ontd.}
malignant, Coley's fluid, III. 298-299
degeneration of, I. 119
of the lips, II. 97
of the prostate, II. 932-938
naso-pharyngeal, and Eustachian ob-
struction, III. 947
of bones, I. 708
of brain, medical treatment of, II.
120(1-1203
surgical treatment of, II. 1204-1207
of breast, doubtful, operative diagnosis
in, II. 979-980
operative diagnosis of. II. 979
of ovary, complicating labour, IV. 77:!-
774
complicating puerperium, IV. 774
during pregnancy, IV. 771-772
malignant, IV. 786
of bile ducta, II. 713-715
of bladder, II. 870-873
of broad ligaments, IV. 823
of gall bladder, II. 71O-712
of liver, II. 679
of nerves, II. 1142
of nose, III. 692
of orbit, III. 662
of prostate, II. 930-949
of scalp, I. 892-896
of skin, III. 1057
of spinal cord, II. 1221-1225
of testis, II. 910
of uterus, inversion due to, IV. 699
of vagina, IV. 553-554
of umbilicus due to vitelline remains,
II. 278
pulmonary, I. 1175
simple fibrous, of the vulva. IV. 511
solid, of the scalp, I. 892
surgical treatment of, I. 106-156
vascular, of the scalp, I. 893
See also under Organs and Regions.
Tunbridge Wells spa, III. 156
Tunica vaginal is, diseases and affections
of, II. 913-929
Turkish, baths in subacute gout contra-
indicated, I. 441
Turner (<J. K.), hernia, II. 498-527
Turner (Philip), fractures, I. 568-633
Turner (William Aldren), epilepsy, II.
990-1007
Tumour (Meadows), on return cases of
diphtheria, I. 188
Turpentine, Chian, in cancer, I. 148
enema, I. 32
in constipation in adults, II. 454
in phosphorus poisoning, I. 525
in typhoid fever, I. 354
liniment in whooping cough, I. 379
oil of, in haemophilia, II. 34
poisoning by, I. 532
stupe, I. 35
Tweedy (E. Hastings), management of
labour in special presentations, IV.
128-156
121
A SYSTEM OF TREATMENT.
Tweedy (E. Hastings) (eontd.*)
management of normal labour, IV. 91-
127
Twins, locked, forceps in, IV. 422
poclalic version in, IV. 467
presentation of, in labour, IV. 1 55
Tylosis, III. 1153
Tympanic cavity, mucous membrane of,
III. 951
membrane, adhesions of, III. 892
calcareous deposits in, III. 892
congenital absence of, III. 891
perforations of, III. 891
diseases of, III. 891-893
ecchymoses of, III. 891
herpes of. III. 891
inflammation of, III. 891
injuries of, III. 893
malformations of, III. 891
massage of, III. 952
myringitis of, III. 891-892
perforations of, III. 892
in acute inflammation of middle
ear, III. 896
rupture of, III. 893
ossicles, massage of, III. 952
Tympanitis complicating typhoid fever, I.
358
Typhoid arthralgia, I. 784
fever, I. 335-364
albumin-water in, I. 342
anti-pyretic treatment of, I. 348
antiseptic treatment of, I. 352
appendicitis and, II. 411
arthritic'and bone complications in,
I. 363, 784
bacteriology of, I. 345
calomel in, I. 353
cardiac complications in, I. 364
complicating pregnancy, IV. 48
complications and sequelae of, I. 356-
364
cutaneous complications of, I. 356
delirium in, I. 362
diarrhoea in, I. 358
diet in, I. 340 ; II. 202
drugs in, I. 351
epidermiology of, I. 335-337
epistaxis in, I. 357
gastric complications of, I. 357
general remarks on, I. 344
genito-urinary complications in, I.
361
haemorrhage in, I. 359
hepatic complications in, I. 360
hygiene and management of the
patient and household in, I. 338
of mouth and nose in, I. 356
intestinal antiseptics in, I. 353-356
complications in, I. 359
lumbar puncture in, I. 362
meat broths, etc., in, I. 342
middle ear, disease in, III. 902
milk diet in, I. 341
nervous complications in, I. 362
Typhoid fever (eont<l.~)
nursing of, I. 40
origin of outbreaks, I. 336
perchloride of mercury in, I. 353
peritonitis in, 1. 359
preventive inoculation of, III. 299
prophylactic inoculation in, I. 348
purgatives in, I. :>.">.">
respiratory complications in, I. 361
serum therapy of, I. 347 ; III. 300
thrombosis in, I. 1331
vaccine therapy of, I. 345 ; III. 293,
SCO
vascular complications in, I. 360
whey in, I. 341
with perforation, II. 550
Woodbridge treatment of, I. 355
Typhus fever, diet in, I. 366
general management of, I. 365
remedial treatment of, I. 366
Tyrnauer's electrical hot-air appliances,
III. 320
Ulcers, anaemic, I. 372
callous, I. 370
chronic, I. 369
amputation in, I. 790
dental, in tuberculous disease of the
tongue, II. 133
diabetic, I. 373
duodenal, II. 391-394
diet in, II. 211
gastric. II. 375-381
perforation of, II. 389
surgical treatment of, II. 382-388
healing, I. 374
horse serum in. III. 262
in plague, III. 406
inflamed, I. 368
irritable, I. 372
of leg, antiseptic treatment of, I. 83
of the cornea, III. 563
phagedenic, I. 369
perforating, I. 373
complicating diabetes mellitus, I. 426
rodent, III. 1132-1134
ionic medication of, III. 184
of the auricle, III. 879
of the lips, II. 97
of vulva, IV. 508
X-rays in, III. 347
skin grafting in, I. 373-375
sub-lingual in whooping cough, I. 385
syphilitic, mercurial treatment of, II.
135
tropical, III. 472
varicose, I. 372
Ulceration, I. 368-375
complicating cystocele of the vairina,
IV. 547
rectocele of the vagina, IV. 547
control of in inoperable cancer, I. 136
of the pharynx, III. 7!>.~>
treatment of, I. 137
A SYSTEM OF TREATMENT.
Ulna, congenital defects ,,f. I. <.i:;r,
dislocations of, 1. 721
shaft of, I'racliiiv of, I. :,'.>>.). Ctii). i'.ol
stvloid process of, 1'ract.un: of, I. G03
Ulnar nerve, dislocation of. II. UK?
injuries of, II. 1112
neuritis of, at elbow-joint, IT. 1112
paral vsis of. 1 1. 12f>7
Umbilical belt, child's. II. :,27
cord. e.\|)ressioii of, in podalic version,
iv. 4<;<;
expression of. forceps in, IV. 421
failure of. to pull up with uterus in
third stage of labour. IV. 12o
lengthening of, in third stage of
labour, IV. 11!)
liirature of, in third stage of labour
IV. 117
pfolap>e of, forceps in, IV. 421
lalxnir in, I V. 117
podalic version in. IV. Itii'i
rupture of, in newborn child, IV.
366
secondary h;eniorrhage of in new-
born child, IV. 370
sepsis of, in newborn child, IV. 37o
shortness of, and accidental haemor-
rhage. IV. 2!)
grip in palpation in labour, IV. w
Umbilicus, acquired affections of, II. 279-
28]
inflammatory conditions of umbilicus
as, II. 27li
urachal cysts as, II. 27'.)
acquired fistula of. II. 2so
affections of, II. 27H-2S1
angioina of. in newborn child, IV. 37(1
antiseptic treatment of, I. !1
congenital malformations of, II. 227
and urinary fistula in infants, If. 278
persistence of urachal remains and,
II. 278
vitelline remains in, II. 277
vitello-intestinal fistula and, II. 278
inflammation of, II. 27!)
primary epithelioma of, II. 281
sarcoma 'of, II. 281
'iidary cancer of, II. 281
tumours of, II. 280
due to vitelline remains, II. 278
urinary fistula at. in adults, II. 279
in infants. 1 1. 27s
Uncinariasis, III. Is:
Undulant fever. III. 39!)
Unna's treatment of ulcers, I. 371
Urachus. cysts of, in acquired affections
of the umbilicus, II. 27!>
persistence of remains of, in congenital
malformations of the umbilicus, II.
878
Uraemia. II. s;i7-839
headache from, II. 1034.
Uraemic coma, II.!S2
Urea, solution of. I. l:!7
Ureter, diseases of, II. 730, 840-851
Ureter (nmtd.)
fistula of, II. 842-SI5
results of uretero-cysto-ncostomy in,
II. 844
treatment, II. 843
implantation of in vesical cancer, 1. 143
malformations of, acquired, II. 774
obstruction of, in cancer, relief of, I.
143
operations for congenital malformations
of, II. 77-1
stone in, II. 846-851
instrumental treatment of, II. 847
medicinal treatment of, II. 847
operative treatment, II. 848
results of operative treatment, II.
860
wounds of, II. 840
results of operative treatment, II. 841
Ureteral catheter in pyonephrosis, II. 815
Uretero-cysto-neostomy in fistula of the
ureter, II. 844
Uretero-pyelo-neostomy, II. 776
Uretero- vaginal fistulas, IV. 534
Urethra, after transverse section of, II.
934
caruncle of, dyspareunia in, IV. 841
diseases and affections of, II. 882-899
female, abscess of, IV. 870
carcinoma of, IV. 872
caruncle of, IV. 872
dilatation of, IV. 869
diseases of, IV. 868-874
displacements of, IV. 868
fibroma of, IV. 872
haemorrhoids of, IV. 872
mucous membrane of, prolapse of,
IV. 869
sacculus of, IV. 870
sarcoma of, IV. 872
stricture of, IV. 871
tender red patches in, IV. 873
fistuhe of, II. 894
foreign bodies in, II. 884
operation for, II. 885
hydronephrosis due to obstruction in,
II. 772
imperforate, of foetus, complicating
labour, IV. 180
injuries of. II. 882-885
by blow on the perineum, II. 882
obstruction due to cancer, relief of,
I. 142
piostatic, gonorrhoeal infection of, I.
227
stricture of, II. 886-892
acute retention of urine in. If. 890
internal urethrotomy in, II. 889
uncomplicated, II. 886
Urethritis, chronic (gleet), II. 877-87!)
complicating the puerperium, IV. 32!)
gonorrhoeal, complicating the puer-
perium, I V. :<:.".)
Urethro-cystitis complicating gonorrhoea,
I. 22S
123
A SYSTEM OF TREATMENT.
Urethrotomy, external, in acute retention
of urine complicating stricture, II.
891
internal, in stricture, II. 889
TJriage spa, III. 157
Uric acid, diet and, II. 207
in gout and gouty conditions, I. 436
solvents of, I. 436
so called, I. 436
Urinary fistula?, IV. 535
organs, cancer of, relief of obstruction
in, I. 141, 142
diseases of, II. 730
Urine, acute retention of, complicating
stricture of urethra, II. 890
alkaline, bicarbonate of soda, produc-
ing, I. 423
production of, I. 410, 418
Bence Jones protein in, II. 749
diacetic acid in, in diabetes mellitus, I.
409, 417
diversion of, in ectopia vesicae, II. 866
effect of food on, II. 205
examination of, in infants, I. 53
in poisoning, I. 526, 529
extravasation of, II. 893-894
in normal puerperium, IV. 258
incontinence of, I. 53
care of the skin in, I. 31
complicating gynaecological surgery,
IV. 497
nocturnal, II. 75-77
passage of, in normal puerperium, IV.
265
reflex incontinence of, injuries of the
spine, I. 909
retention of, after operation, manage-
ment of, I. 29
complicating abdominal operations,
II. 272
gynaecological surgery, IV. 496
in acute prostatitis, II. 921
in injuries of the spine, I. 909
scanty in scarlet fever, I. 292
sugar in, in diabetes mellitus, I. 410
suppression of, in mercurial poisoning,
1.530
in yellow fever, III. 413
typhoid bacillus in, I. 346
Urticaria, III. 1154-1156
complicating pregnancy, IV. 56
pigmentosa, III. 1154-1156
Uterine forceps with pledget of wool, IV.
625
souffle in normal labour, IV. 104
Uterus, absence of, IV. 711
adenomyoma of, IV. 663
anteflexiou of, IV. 670-672
acquired, IV. 671
acute, subinvolution in, IV. 722
congenital, IV. t;70
juvenile, IV. ''.7"
anteversion of, IV. r.ii'.t
application of strong antiseptics to, in
puerperal sepsis, IV. 310
Uterus (contd.)
atony of, after removal of child, in
Ctesaiean hysterectomy, IV. 399
retention of placenta in, IV. 229
bicornal, pregnancy in, IV. 712
bi-manual compression of post-partum
haemorrhage, IV. 220
body of, leucorrhoea from, IV. 568
broad ligaments of, diseases of* IV.
820-823
cancer of, IV. 575-581
abdominal total hysterectomv in, IV.
579
Caesarean hysterectomy in, IV. 398
curative treatment, IV. 576
diagnosis of, IV. 576
hystero-vaginectomy in, IV. 580
limits of operations in, IV. 581
operative treatment, IV. 578
preventive treatment, IV. 575
results of operations for, IV. 581
salpingitis complicating, IV. 814
vaccine treatment of, I. 133
vaginal hysterectomy in, IV. 578
cervical canal of, malposition of, com-
plicating labour, IV. 157
cervical tear of, secondary closure of,
IV. 190
cervix. See Cervix uteri.
chorio-carcinoma of, IV. 618-619
chorion epithelioma of, IV. 618-U19
cicatrix of, danger of giving way in
Caesarean section, IV. 396
condition of in forceps, IV. 424
contraction of, tonic, complicating
labour, IV. 248-249
control of. in third stage of labour, IV.
118
curettage of, in puerperal sepsis, IV. 299
decidua of, and extra-uterine preg-
nancy, IV. 83
deciduoma malignum of, IV. 618-619
degeneration of, Caesarean hysterectomy
in, IV. 398
development of, imperfect, IV. 711
diseases of, IV. 575
dyspareunia in, IV. 841
mineral waters and baths in, III. 145
displacements of, IV. 669-699
double, IV. 543
douching of, in puerperal sepsis, IV.
310
empty, and puerperal sepsis. IV. 290
enlargement of, in acute hydramnios,
IV. 44
evacuation of in puerperal sepsis, IV.
297
exhaustion of, complicating labour, IV.
250-251
exploration of. in puerperal sepsis, IV.
295
fibro-myoma of, Cresarean hysterectomy
in, IV. 398
tibro-myoinata of , Caesarean section in,
IV. 384
124
A SYSTEM OF TREATMENT.
Uterus
fibroids of, IV. 634-663
complicating extra-uterine pregnancy,
IV. 82
polypus of. IV. 659
fistula? of, IV. 664-668
due to injury, IV. 665
from malignant growths, IV. 668
flexions of, IV. 66<J-t;!>:t
t'undus of, complete transverse rupture
of, complicating labour, IV. 243
compression of in post-partum
hsemorrlia.Lri', I V. 219
rising uf. in third stage of labour, IV.
120
haemorrhage of, accidental, Csesarean
hysterectomy in, IV. 398
hour-glass contraction of, retained
placenta in, IV. 230, 231
in normal puerperium. IV. 257
incision of, in Cajsarean section, IV.
888
inert ia of, complicating labour, IV. 252-
2:,:,
drugs in. IV. 253
primary, forceps to assist delivery in,
iv. -ii-.i
infantile, IV. 711
infective processes of, fistulas from, IV.
668
inflammation of, chronic, Cassarean
hysterectomy in. IV. 398
injuries of, IV. 575, 707-710
by operative procedure, criminal, IV.
708
legitimate, IV. 708
incidental, IV. 709
inversion of, chronic, IV. 697-699
elastic pressure in. IV. 698
puerperal, IV. <>'.'7
surgical treatment of, IV. 698
complete, complicating labour, IV. 184
complicating labour, IV. 182-187
due to tumours, IV. 699
involution of, in normal puerperium,
IV. 261
leucorrhcea of, IV. 565
malformations of, IV. 711-717
maseulinus in hermaphroditism, IV.
86fi
mobility of, in third stage of lalxmr, IV.
120
mucous polypus of, IV. 662
muscular wall of, overstretching of,
subinvolution in, IV. 722
myoma of. X-rays in, III. 366
obliquity of, abnormal, forceps in, IV.
120
panliysteivctomv of, IV. 401
plugging of , in meiioiThagia, I V. 7 57
in mi'trorrhagia. I V. 7.~>7
pregnant, prolapse of, I V. 70
prolapse of, IV. 688
amputation of cervix in, IV. t'.'.i:.
anterior colporrhaphy in. IV. 694
Uterus, prolapse of (contd.*)
posterior colpo-perineorrhaphy in,
IV. 694
preventive treatment, IV. 688
reduction in, IV. 689
results of operation, IV. 697
retention by pessaries, IV. 690
surgical treatment, IV. 692
vaginal hysterectomy in, IV. 693
vesico-vaginal interposition in, IV.
696
retroflexion of, IV. 674-688
abdominal fixation in, IV. 686
operation, IV. 687-688
Alexander's operation in, IV. 681,
683
difficulties, IV. 683
bimanual manipulation in, IV. 676
complicating pregnancy, IV. 74-75
difficulties in reposition of, IV. 677
mechanical treatment by pessaries,
IV. 678
pessaries in, mode of action of, IV.
680
reposition in, IV. 676
by the sound, IV. 677
sterility in, IV. 856
subinvolution in, IV. 722
surgical treatment, IV. 681
vaginal fixation in, IV. 684
retroversion of, IV. 672-674
douches in, IV. 673
massage in, IV. 673
reposition by the volsella, IV, 677
wool tampons in, IV. 674
rudimentary, IV. 711
rupture of, Caesarean hysterectomy in,
IV. 399
complicating labour, IV. 238-247
curative treatment, IV. 244
in puerperal sepsis, IV. 303
incomplete, involving perineal coat
only, complicating labour, IV. 242
limited to lower segment, complicat-
ing labour, IV. 240
lower wall, complicating labour, IV.
241
prophylaxis of, IV. 241
sarcoma of, IV. 718-719
septic, Caesarein hysterectomy in, IV.
399
shape of, in third stage of labour, IV.
120
steaming of, in menorrhagia, IV. 760
in metrorrhagia, IV. 760
subinvolution of, IV. 720-724
by acute fevers, IV. 720
by deficiency of lime salts in the
blood, IV. 721
by infective processes in pelvis, IV.
' 7i'::
by retention of products of concep-
tion, IV. 721
by toxaemias, IV. 720
due to general causes, IV. 720
125
A SYSTEM OF TREATMENT.
Uterus, subinvolution of
local causes, IV. 721
in Caesarean section. IV. 391
tumours of, inversion in, IV. 699
wall of. growths in, subinvolution by,
IV. 722
Uvula, acute inflammation of, III. 74.">
benign growths of, III. 746
deformities of, III. 744
diseases of, III. 744-746
elongation of, III. 744
infections of, III. 745
malignant diseases of, III. 746
oedema of, III. 945
traumatism of. III. 745
tuberculosis of, III. 745
Vaccination, I. 311-314
anti-choleraic, III. 423
diseases ascribed to. I. 313
in small capillary naevi, III. 1080
methods of, I. 312
protective effect of, I. 311
Vaccine in cholera, III. 424
therapy, control of subsequent tloses,
III. 267
doses, summary of, III. 301
general principles of, III. 258-270.
263
in acute dysentery. III. 430
in acute tuberculosis, I. 332
in cervical endometritis, IV. 630
in cystitis, II. 860
in infective endocarditis, I. 206
in inoperable cancer, I. 133
in prophylaxis, III. 262
in purulent meningitis, I. 251
in staphylococcus infections, III. 282-
283
initial dose in. III. 265
length of, IIL 264
method of administration of, III. 265
of acne vulgaris, III. 989
of acute arthritis, I. 744
bronchitis, I. 1052
gonorrhoea, III. 274
of asthma, I. 1041
of bacillus coli communis. III. 271
of boils, III. 1008
of cancer, I. 152
of carbuncles, III. 1013
of cellulitis, I. 182
of cholera, III. 273
of chronic bronchitis, I. 1056
gonorrhoea, III. 275
rhinitis, III. 7i".i
of corporeal endometritis, IV. 630
of dysentery, III. 280
of gonorrhoea, I. 225 ; III. 274
of gonorrho?al arthritis. I. 7*2 : III
275
vulvitis. IV. :,-27
of infective pyelonephritis, II. 808
of influenza, I. 235, 238
Vaccine therapy (cvntd.')
of leucorrluea. IV. "'72
of lupus. III. IK."
of micrococcus catarrhalis infections,
III. i>77
of neonoformans. III. 293
of pelvic cellulitis. IV. 837
of peritonitis, II. 637
of pernicious anemia, II. 7
of plague, III. 277
of pneumonia, I. 263
of puerperal sepsis, IV. 309
of pyorrhoea alveolaris, III. 287
of Rigg's disease, III. 287
of scarlet fever, I. 288
of streptococcus infections, III. 289-
291
of tuberculous abscess, I. 176
of typhoid fever, I. 345 ; III. 300
of ulcerative colitis, II. 568
of whooping cough, I. 383
pneumococcic. in diseases of the
pericardium. I. 1184
results of. III. 269
Vaccines, sensitized, in serum therapy,
III. 260
use of, I. 206. L'"7
Vacuum, partial for hypenemic treatment,
III. 56
Vagina, absence of lower portion of, IV.
543
atresia of. IV. 541
cancer of. primary. IV. 553
congenital malformations of, IV. 541
cvstocele of, complicated by ulcera-
tion, IV. 547
operative treatment, IV. 549
palliative treatment, IV. 547
cysts of, IV. 531-532
discharge from, in sterility, IV. 845,
852
diseases and injuries of, IV. 531-.~7 1
distension of, with lotions in leucor-
rhoea, IV. 562. 563
double, IV. c43
douching of, I. 39
drainage of, free, in puerperal sepsis,
IV. 290
fistula? of, IV. 533-53>
fixation of, retroflexion of uterus by,
IV. 684
foreign bodies in, IV. 537
haemorrhage from, in newborn child,
IV. 371 -
hysterectomy by, in fibroids, IV. 655-
658
in normal puerperium, IV. 257
incision of, for drainage of pelvis in
puerperal sepsis. IV. :^i~2
infections of, IV. 538-539
inflammations of, gonorrbceal, IV. .V,i
in pregnancy. I V. .".; j
puerperal, IV. 562
senile leucorrhcea in. IV. 5t'..i
iniuries of, IV. 540
126
A SYSTEM OF TREATMENT.
Vagina
inversion of. complicating labour, IV.
182
laceration of, complicating labour, IV.
201
leucorrhtjL'a of. I V. Mil
lithotomy by, IV. S77
lower third, laceration of, complicating
labour. IV. 2o I
malformations of , IV. .M 1-544
IK' [Ililcd. I V. .". 1 1
niyomata of. I V. .V)3
operations on, preparation of patient
in, IV. is |
ovariotomy by, IV. ~'.5
pluming of. in accidental haemorrhage
daring pregnancy. I V. -' I
in inenorrhagia. IV. 757
in metrorrhagia. I\'. 7~>7
prolapse of, IV. :>ir>-552, 688
eoniplieating pregnancy. IV. 71
preventive treatment, IV. 688
rectocele of, complicated by ulceration,
IV. :,I7
operative treatment. I V. .Vil
palliative treatment. IV. 547
>areomaof, primary. IN'. .">.">:
tumours of, l\". ."> .">-."> I
leueorrlnea in, IV. .V<7
Vaginal douches, directions as to, I. :;;i
examination, in normal labour, l\'. lul
in pregnancy. I V. .">
injections in vulvitis, IV. 529
Vaginismus, IV. 860-864
glass dilators in, IV. 863
operative treatment of, IV. 863
palliative treatment of. IV. 862
Valerian in diabetes insipidus. I. (:.",
Valsspa, III. 157
Valsalva on aortic aneurysm, I. 1297
Valsalva's experiment in patency of
Kustachian tube. III. '.MS
Van Horn's catgut, sterilisation of, I. 72
Vapour, anaesthetic, inhalation of, in
labour. IV. 376
baths, I. 38 ; III. 129
Vapours in asthma, I. 1039
medicated, in patency of Eustachian
tube, III. 951
Varicocele. I. 1323-1327
diminution in size of. I. 1327
operation available for, I. 1 :>!>.">
operative treatment of, I. 1324
spontaneous disappearance of, I. 1327
Varicose Ivmphatic glands, III. 516
ulcers, f. :?7i'
veins. I. i:;o!>-1322
complicating pregnancy. IV. 89-90
ha-matoma in, complicating preg-
nancy. I V. '.in
haemorrhage from. I. lL'7i
of lower extremities, I. 1311-1319
hygienic treatment in, I. 1311
massage in. I. i:<li>.
mechanical supports for, I. 1313
Varicose veins of lower extremities
((until. )
non-operative, I. 1311
operative treatment of, I. 1315
of upper extremities, I. 1320
of vulva, IV. 522
pain in, complicating pregnancy, IV.
89
phlebitis in. complicating pregnancy,
IV. 89
recurrence in cases of, after onera-
tion, I. 1322
rupture of, complicating pregnancy,
I V. 89
shrinking of, I. 1321
spontaneous disappearance of, 1. 1321
thrombosis in, complicating preg-
nancy, IV. 89
thrombus in, I. 1331
Varix affecting the trunk, I. 1320
congenital, I. 1310
Varus at the elbow joint, I. 938
Vasa, division of, in carcinoma of the
prostate, II. 936
Vascular degeneration, cerebral throm-
bosis due to, II. 1177
disease associated with renal disease,
cerebral thrombosis due to, II.
1178
cerebral thrombosis due to, II. 1 177
syphilitic, cerebral thrombosis due to,
11.1177
Vaseline, injection of, in fistulous tracks
in empyema, I. 1110
Vaso-constriction, local, in haemophilia,
II. 33
Vasomotor centres, shock caused by ex-
haustion of, I. 93
diseases, II. 1226
neuroses, II. 1242-1243
drugs in, II. 1242
Veal, chemical composition of, II. 193
Vegetable food, II. 195
in gout, I. 452
poisoning, I. 506
irritants, poisoning by. I. 533
preparations for cancer, I. 148
purgatives, in constipation in adults,
II. 447, 454
Vegetables and salads in obesity, I. 472
chemical composition of, II. 195
in children's dietary, directions for, I. 59
Vegetarian treatment of oljesity, I. 471
Veins, diseases of, I. 1309-1338
hepatic, obstruction of, II. 667
methods of infusion into, I. 100
of the broad ligaments, thrombosis of,
IV. 822-823
pelvic, ligature of in puerperal sepsis,
IV. 304
portal, thrombosis of, II. 666-667
retinal, thrombosis of, III. 644
sub-inflammatory conditions of, mineral
baths in, III. 138
varicose, I. 1309-1322
127
A SYSTEM OF TREATMENT.
Veldt sore, III. 475
Venesection in aortic aneurysm, I. 1299
in chronic congestion of the lungs, I.
1078
in diseases of the heart, I. 1211
in eclampsia, IV. 36
in high blood pressure, I. 1283
in intra-cerebral haemorrhage, II. 1172
Venous haemorrhage, I. 1271
infusion in post-partum hemorrhage,
IV. 222
Ventilation in typhus fever, I. 365
of nurseries, methods of, I. 45
of sick room, I. 157
Ver du Cayor in myiasis, III. 483
Ver macaque in myiasis, III. 483
Veratrine, poisoning by, I. 533
Veratrum viride in eclampsia, IV. 37
Vernet-les-Bains spa, III. 157
Vernon-Harcourt inhaler for anaesthetics,
III. 14
Veronal in diseases of the heart, I. 1225
in insomnia, II. 990, 1022
poisoning by, I. 531
Verrucae, warts, III. 1157-1159
Verruga Peruviana, III. 459-460
prognosis in, III. 459
Version, anaesthetic in, IV. 463
cephalic, bi-polar, IV. 464, 467, 468
difficulties in, IV. 465, 469
position of mother in, IV. 465
steps of operation in, IV. 465
time for operating in, IV. 465
when head is presenting. IV. 469
when shoulder is presenting, IV.
469
difficulties of,'IV. 464
external, IV. 463
indications for, IV. 463
position of patient in, IV. 463
steps of operation for, IV. 463
centra-indications in, IV. 462
dangers of, IV. 461
difficulties of, IV. 461
in craniotomy, IV. 411
in labour, IV. 461-473
indications for, IV. 4G1
methods of, IV. 461
. podalic, IV. 465
accouchement force in, IV. 466
expression of cord in, IV. 466
in ante-partum haemorrhage, IV. 466
in cancer of cervix, IV. 468
in double monsters, IV. 467
in flattened pelvis, IV. 466
in locked twins, IV. 467
in prolapse of cord, IV. 466
indications in, IV. 465
internal, IV. 470
asphyxia neonatorum in, IV. 473
dangers of, IV. 473
difficulties of, IV. 472
position of mother in, IV. 470
position of operator in, IV. 470
steps of operation, IV. 470
Version, podalic, internal (contd.~)
time for operating in, IV. 470
when shoulder is presenting, IV.
472
mal-presentations of child in, IV. 1C5
position of child in, IV. 462
preliminary treatment for all methods
in, IV. 462
relative advantages of, IV. 432
varieties of, IV. 461
Vertebrae, cervical, unilateral luxations
of, I. 903
fractures of the lamina? of, I. 904
of spinous processes of, I. 904
Vertebral hook in craniotomy, IV. 411
Vertex, occipito-posterior positions of
forceps in, IV. 430
Vertigo, aural, indications for operation
in, III. 974
in disseminated sclerosis, II. 1075
laryngeal, III. 841
of labyrinth, paroxysmal, and middle
ear suppuration, III. 960-961
of vasomotor origin, III. 958-961 .
with destruction of one labyrinth,
III. 961
Vesico-cervical fistula, IV. 880
Vesico-urethral anastomosis, diagram
showing plan of, II. 937
Vesico-vaginal fistulae, IV. 533, 878-881
interposition in prolapse of uterus, IV.
696
Vesicular mole, IV. 59
Vestibulotomy, double, in labyrinthitis.
III. 962
inferior operation of, in labyrinthitis,
III. 962-963
Vibration massage, III. 204
mechanical, III. 213-221
application of, III. 215
in abnormal secretion, III. 220
in aphonia, III. 219
in asthma, III. 216
in enlarged glands, III. 218
in goitre, III. 216
in insomnia, III. 221
in neuritis. III. 221
in spinal curvature, III. 22n
to abdominal organs, III. 220
to ear, III. 215
to eye, III. 215
to face, III. 220
to the extremities, III. 220
to vocal cords, III. 218
Vibrator, Sanitas Electrical Co.'s, III. 214
Vibratory massage in constipation in
adults, II. 463
Vicarious action, I. 16
Vichy spa, III. 157
Vienna paste in lupus, III. 1150
Vinadis spa, III. 157
Vincent's angina, III. 771
Violet leaves in cancer, I. 149
Viscera, actinomycosis of, I. 177
displacement of, I. 430, 431
128
A SYSTEM OF TREATMENT.
Viscera (rowfr/.)
neuralgias of, II. 1122
perversion of functions of in epilepsy,
II. 1018
prolapse of, in wounds of abdominal
wall, II. 245
taeniasis of, III. 521
Vitality of children lowered by " harden-
in^'' system, I. 4<i. 5o
Vitelline remains in congenital malforma-
tions of the umbilicus, II. 277
Vitiligo, III. ll.V.t
Vitreous opacities in inflammation of
ciliarv bo.ly, 111. .V.)3
Vittel spa, III. 157
Vocal cords, application of vibration to,
III. 218
ataxia of, III. 841
internal tensors of, paralysis of, III.
843
paralysis of, complete recurrent, III. 844
Voeux (H. A. des), chicken pox, 1. 18.")
influenza, I. 233-242
mumps, I. 256-257
Voice production. III. 331-340
Voisin's method of hypnotism, III. 165
Volkmann's contraction. I. ."73
or ischiemic paralysis, 1. 940
perforating tuberculosis, I. 889
Volsellum. Fenton's, IV. 476
for lacerations of cervix. IV. 190
reposition by, in retroflexion of the
uterus, IV. 677
Volvulus of the colon. II. 591
of the stomach. II. 400
Vomit, examination of, in poisoning, I.
526-586
Vomiting, after ovariotomy, IV. 791
and modifications of diet in simple
diLre>tive d Borders, II. 230
anesthetic, after abdominal operations.
II. L'<;:<
complicating acute endocarditis, I.
1193
gynecological surgery, IV. 489
ulcer of the stomach, II. 380
drugs in. I. 507, 509, :>12
following amesthesia, III. 35
in acute gastritis, II. 347
in cancer of the stomach, II. 299
in disordered digestion in the stomach,
II. 373
in food fever, II. 234
in heart failure, complicating diphtheria,
I. 200
in pyloric spasm, II. 337
in relapsing fevers, I. 267
in \vhooping cough, I. 383
irritative, complicating gynecological
Miv-ery, IV. 489
mixture for, I. 507, 509
neurotic, complicating gynecological
Miruery, IV. 489
pernicious, complicating, pregnancy,
IV. 62-64
S.T.
Vomiting (cuiitil. )
persistent, complicating abdominal
operations, II. 26i>
post-aiiffisthetic, prevention of, I. 84
treatment of, in abdominal case, I. 29
Vulva, acuminate, condylomata of, IV.
511
atresia, superficial of, IV. 513
cancer of, relief of obstruction in, 1.14?
cleansing of, in normal puerperium, IV.
260
clitoris, hypertrophied, and, IV. 514
cysts of, IV. 511
dermatitis of, IV. 523
diphtheria of, IV. 523
diseases, affections and injuries of, IV.
505-530
eczema of, ointments for, IV. 530
effect of irritative discharges to, IV.
506
elephantiasis of, III. 515
arabum of, IV. 511
epithelioma of, IV. 515
erysipelas of, IV. 524
esthiomene of, IV. 508
hasmatoma of, IV. 522
hydrocele of the canal of nuck of, IV.
512
inflammation of, IV. 523-529
appendix of formulae for, IV. 529
dusting powders for, IV. 529
gonorrnceal, IV. 524
chronic, IV. 561
in children, IV. 560
in women, IV. 560
lotions for, IV. 530
mild in women, IV. 560
non-venereal, IV. 523
vaginal injections in, IV. 529
injuries of, IV. 509-510
kraurosis of, IV. 508
laceration of, complicating labour, IV.
204
leucoplakia of, preceding cancer, I. 119
leucorrhoea of, IV. 559
lipomata of, IV. 511
lupus of, IV. 508
malformations of, IV. 513-514
malignant disease of, IV. 515-516
noma of, IV. 508
pad in third stage of labour, IV. 125
pruritus of, III. 1106-1108 ; IV. 517-519
complicating pregnancy, IV. 72-73
drugs in, IV. 517
local treatment. IV. 518
rodent ulcer of, IV. 508
sarcoma of, IV. 516
syphilitic affections of, IV. 520-521
Ehrlich's "606" in, IV. .VJI
mercury in, IV. 520
tuberculosis of, IV. 508
tumours of, innocent, IV. 511-512
simple fibrous, IV. 511
varix of, IV. 522
Vulvo-vaginitis in children, IV. 528, 560
129 9
A SYSTEM OF TREATMENT.
Waggett (E. B.), injuries and malforma-
tions of the nasal septum, III. 678-686
Walcher's position for forceps, IV. 424
Walker (J. W. Thomson), affections of
the ureter, II. 840-851
aneurysm of the renal artery, II. 752
calculus, II. 753-766
hydronephrosis, II. 770-779
injury to the kidney without external
injury, II. 780-782
movable kidney, II. 785-791
perinephritic abscess, II. 801-802
pyelitis, II. 803-806
pyelonephritis infective, II. 807-813
pyonephrosis, II. 814-818
renal and peri-renal fistulas, II. 767-769 |
surgical treatment of non-suppurative
nephritis, II. 798-800
tuberculosis of the kidney, II. 819-829
tumours of the kidney in adults, II. 830-
835
tumours of the kidney in children, II.
836
Walker's balance for anaesthetics, III. 14
pliable ureteral scoop, II. 849
stone forceps for calculus, II. 760
Walking of infants, risks of too early, I. 51
on the dorsum exercise for flat foot, III.
235
Wall (Walker), on purin-free food, I. 452
Wallis (Sir F. C.), diseases of the ano-
rectal area, II. 593-612
haemorrhoids, II. 615-620
malformations of the anus, II. 613
malignant growths of the rectum, II.
625
prolapse and procidenta of the rectum,
II. 621-623
rectal neuroses and obscure rectal pain,
II. 614
simple tumours of the rectum, II. 624
Walls of nursery, covering of, I. 44
Walther (Otto) on pulmonary tuberculosis,
I. 1121
Warburg's tincture in malaria, III. 398
Warm climates, diseases of, III. 375-516
Warming for nursery, methods of, I. 44
Warmth necessary during operations I
96, 97
in shock, I. 97
Warts, anatomical, III. 1152
common, X-rays in, III. 347
excision of, importance of, I. 118
gonorrhaeal, 1. 226
ionic medication of, III. 184
of the scalp, I. 892
post-mortem, III. 1152
senile, III. 1159
solid carbon dioxide in, III. 1157
verrucas, III. 1157-1159
Washing, disinfection by means of, I. 163
of infants and children, I. 47
Wassermann reaction in syphilis, I. 325
Water, allowance of in nephritis, II. 206
as cause of goitre, II. 62
Water (c"#fr7.)
boiled, in the tropics, III. 384
borne typhoid, I. 337
cold, drinking, in fevers, necessity of,
I. 158
enemas of in typhoid fever, I. 355
drinking, for young children, reasons
for, I. 53
in gout, I. 434
in typhoid fever, I. 343
itch, III. 486
medicinal use of, III. Ill
nomenclature of, III. Ill
pillows, use of, I. 3 1
point of thermal indifference for, III.
113
sterile, for use at operations, I. 28
Waterbrash in disordered digestion in the
stomach, II. 374
Waterhouse (Herbert F.), Bier's treatment
by means of induced hyperremia, III.
40-68
Waters, alkaline, III. 119
in chronic gastritis, II. 351
arsenical, III. 122
in pernicious anaemia, II. 5
calcareous, III. 120
chalybeate, III. 1'2'2
diuretic, III. 120
hypertonic salt, III. 119
natural aperient, in constipation in
adults, II. 466
radio-activity of, III. 115
salt muriated, III. 118, 129
sulphated purgative, III. 121
sulphur, III. 117
Watson (C. Gordon), surgical diseases of
joints, I. 741-788
Watson- Williams (P.), anaemia and
hyperaemia of the larynx, III. 822
haemorrhage from the larynx, III. 824
laryngitis, III.. 831-837
neuroses of the larynx, III. 840-845
oedema of the larynx, III. 858-860
Weaning of infants, II. 218
Wearing apparel, disinfection of, I. 162
Weather, suitable for young children, I. 52
Webbed fingers or syndactyly, I. 943
Wedge, wooden, for separating clenched
teeth, III. 1
Weichselbaum's meningococcus, I. 254
Weight and pulley for elbow exercises, I.
778
(body) influence in osteo-arthritis, I. 400
extension in sprains, I. 739
in tuberculous disease of the knee-
joint, I. 767
in tuberculous joints, I. 764
synovitis, I. 752
loss of, in cancer of alimentary system,
1.139
in pulmonary tuberculosis, I. 1155
Weilbach spa, III. 157
Weir-Mitchell treatment in coccyerodynia,
I. 921
130
A SYSTEM OF TREATMENT,
Weir-Mitchell (V//V/.>-
in hysterical joint disease, I. 788
of neurasthenia. II. 1()4<>
Weisbaden spa, III. 157
Welch and Schamberg on treatment of
small-pox eruption, I. 306
Wells (A. Primrose), mechanical vibration,
III. 213-221
treatment by various forms of light,
III. 186-302
Wells (Russell) on cocaine in whooping
cough. I. 381
Wertheim's operation, complications of,
IV. (505
dangers of, IV. 605
difficulties of, IV. <;i>5
dividing para-vaginal tissue in, IV. 606
vagina in, IV. 607
hasmorrhage in, IV. 607
identifying the ureter in, IV. 603
immediate results of, IV. 608
in cancer of cervix. I V. ('.01
isolating the ureter in, IV. 605, 606
ligature of uterine artery in, IV. 604
limits of, IV. 610
percentage of, IV. 609
removing iliac glands in, IV. 608
shock in, IV. 607
standpoint of pathology of, IV. (501
technique of operation, IV. 602
ultimate results of, IV. 609
West (C. Ernest), acute diseases and sup-
puration of the labyrinth, III. 958-966
West Africa, rqalaria and, III. 381
Westmacott (F. H.), diseases and affec-
tions of the accessory sinuses of the
nose. III. 716-731
Wet-nursing. JI. 219
Wet-pack. u>e of. in typhoid fever, I. 350
Wethered (Frank J.), atelectasis and
collapse of the lungs, I. 1063-1065
emphysema and its varieties, I. 1082-
1089
Wetterstrand's method of hypnotism, III.
164
Whey in infant feeding, II. 227
in marasmus, I. 465
in typhoid fever, I. 341
Whistler's laryngeal forceps, III. 848
White (W. Hale), colitis, II. .V.2-569
empya-ma. I. 1099-1100
exophthalmic goitre, II. 54-57
pneumonia. I. 25S-263
Whitehead (A. L.), intra-cranial and intra-
venous complications of ear disease, III.
937-948
White-leg in puerperal sepsis, IV. 321
Whitlow (Sir W.), on food and diet, 1.341
Whitlow, cause and treatment of, I. 168-
170
sub-cutaneous, I. 169
sub-cuticular, I. 1 <'>'.'
sub-periosteal, I. 169
thecal, I. Ki'.i
Whooping-cough, I. 37(5-385
Whooping-cough (rontd.)
associated with measles, I. 243
diet in, I. 379
. external applications to chest in, I. 379
general treatment of, I. 377
incubation period of, I. :'.77
local applications in, I. 379
medicinal treatment of, I. 380
prevention of, I. 876
treatment during convalescence, I. 384
of paroxysm, 1. 379
vaccine therapy of, I. 383
Widal's test in typhoid, I. 337, 347
Wildbad spa, III. 157
Wilde's incision in acute inflammation of
middle ear, III. 897
Wildungen spa, III. 157
Wilkinson (G.), foreign bodies, maggots,
and rhinoliths, III. 667-669
influenzal tracheitis, III. 798
injuries of the trachea, III. 797
tracheal fistuhe, III. 799
obstruct ion, III. 800-802
Willcox (W. H.), asthma, I. 1035-1042
food poisoning, I. 506-511
poisons and antidotes, I. 526-535
Williams (Leonard), administration of
thyroid extract, II. 49-50
blood pressure, I. 1281-1286
congestion and inflammation of the
thyroid gland, II. 51-52
infantilism, II. 71
myxeedema and cretinism, II. 72
nocturnal enuresis, II. 75-77
obesity, I. 468-474
thyroid inadequacy, II. 78
Williams (Whitridge), on pubiotomy, IV.
449
Wilson (S. A. Kinnier), amyotrophic
lateral sclerosis, II. 1054
bulbar palsy, II. 1061
facial hemiatrophy, II. 1232
herpes zoster, II. 1096-1097
hydrocephalus, II. 1191-1192
intermittent claudication, II. 1234-1236
Landry's paralysis, II. 1080
paramyoelonus multiplex, II. 1255-1256
paraplegia, II. 1195-1199
progressive muscular atrophy. II. 1081-
1082
torticollis, II. 1050-1053
vasomotor neuroses, II. 1242-1243
Wilson (Thomas), flexions and displace-
ments of the uterus, IV. 669-699
Wind and pulmonary tuberculosis, I. 1118
cold, protection of young children from,
I. 52
Windows, arrangement of, in nurseries,
I. 45
Wine, avoidance of in gout, I. 448
egg, preparation of, I. 43
in gouty conditions, I. t.~>7
iron, in chlorosis, II. 25.
Witch hazel in haemorrhage, I. 1261
Withering on digitalis, I. 1218
131
A SYSTEM OF TREATMENT.
Witzel's method for malignant stricture
of the oesophagus, II. 182
Woillez. maladie de, I. 1076
Wolffs law in deformities, I. 934
Woodbridge treatment of typhoid fever,
T. 355
Woodhall spa, III. 157
Woods (John F.), hypnotism and treat-
ment by suggestion, III. 159-179
Woods' method of hypnotism, III. 166
Wool for surgical dressings, I. 74-78
Woollen clothing for rheumatism, I. 485
underclothing for children, I. 50
Wool-sorters' disease, I. 179
Word-deafness, restoration in by func-
tional compensation, II. 1146-1149
Workmen's Compensation Act and electric
shock, I. 548
Worth's amblyoscope in strabismus, III. j
652
Wounds. I. 550-556
antiseptic treatment of. I. 85
bursting of, complicating gynaecolo-
. gical surgery, IV. 496
cellulitis following, I. 181
cleansing of, I. 550
closure of, I. 551
complication of, I. 555
concentrated arc light in, III. 200
drainage of, I. 551
dressings in, I. 554
examination of, I. 550
gangrene from, I. 214
general, I. 540-544
treatment of, I. 555
granulation in, I. 554
gunshot, I. 557-567
abdominal injuries in, I. 565
amputation in, I. 562
cardiac injuries in, I. 565
cranial fractures in, I. 562
facial injuries in, I. 563
fractures in, I. 561
haemorrhage in, I. 559
injuries of nerves in, I. 560
joint injuries in, I. 562
lodged missiles in, I. 558
neck injuries in, I. 564
of liver, II. 251
of the abdomen, II. 248
of the eyeball, III. 657
of the skull, I. 877
of the spine, I. 902
of the stomach, II. 283
penetrating of chest, I. 564
prevention of infection in, I. 557
septic, I. 558
shock in, I. 558
spinal injuries in, I. 563
traumatic aneurysms in, I. 560
implantation cysts, due to, I. Ill
in tetanus, local treatment of, I. 329
incised, of abdominal wall, II. 249
injuries of, with external wound, II.
783-784
Wounds (contd.}
local treatment of. I. 55n
nerve injury in, II. 1099
non-penetrating, of abdominal wall, II.
246
Of brachial plexus, II. 1110
of diaphragm, II. 253
of facial nerve, II. 1108
of irie, III. 591
of lips, II. 96
of muscles, II. 1321
of nerves, II. 1098-1105
of special blood-vessels, I. 1274
of special nerves, II. 1108-1113
of tongue, II. 132
of uterus, IV. 575
subcutaneous, to nerves, II. 1100
sutures in, I. 553
in amputations, I. 802
vicious contraction in. I. 555
Wright (Sir Almroth)^ on pulmonary
tuberculosis, I. 1121
on vaccine treatment of cancer, I. 152
Wright's extension in tuberculous disease
of the hip-joint, I. 754
salt and citron lotion, I. 168, 176
Wringer for fomentations, I. 35
Wrist, congenital contraction of, I. 937
dislocation of, I. 723, 937
dropped, in paralytic deformities of the
upper limb, I. 990
paralytic, prognosis in, I. 992
paralysis of, in lead poisoning, I. 513
spontaneous subluxation of, I. 939
tuberculous disease of, I. 779-780
operative treatment, I. 780
Wrist-joint, disarticulation at, I. 813-816
by circular incision, I. 815
by elliptical incision, I. 813
fracture in the neighbourhood of, I.
602-603
Writer's cramp, II. 1264
hypnotism in case of, III. 174, 175
Xussbaum's bracelet in, II. 1265
Wryneck or torticollis, I. 987
physical exercise for, III. 233
spasmodic, physical exercises in, III.
257.
Wyatt (James), abnormalities of the
maternal soft parts affecting labour,
IV. 157-160
deformities and diseases of the foetus
causing obstruction to labour, IV.
176-181
Xanthelasma of the eyelids, III. 582
Xanthoma, III. 1160
diabeticorum, III. 1160
Xeroderma, III. 1053
pigmentosum, III. 1057
Xerosis of the conjunctiva, III. 561
Xerostomia (dry mouth), II. 130
in inflammation of parotid glands, II.
163
A SYSTEM OF TREATMENT.
X-rays, application of, for ringworm,
head in position during, III. 356
in leukaemia, II. 39
position of nails, during, III. 351
box shield, with lead-glass localiser, III.
342
dermatitis, preceding cancer, I. 117 ;
III. 1030
examination in calculus of the bladder,
II. 853
for comedones, III. 1023
in acne rosacea, III. 350
in acne vulgaris. III. 349, 987
in cancer, I. 154
in chronic affections of the nails, III.
351
eczema, III. 351
lichen planus, III. 351
localised inflammations, III. 349
in common warts, III. 347
in disease, cardinal points in, III. 362
in disseminated sclerosis, II. 1074
in elephantiasis. III. 353
in epithelioma of tongue, II. 139, 144,
III. 348
in Hodgkin's disease, I. 1342
in hyperidrosis, III. 359
in hypertrichosis, III. 1046
inkerion,III. 1129
in lichenification, III. 1060
in lupus, crusted and ulcerated. III. 353
verrucosus, III. 352
vulgaris. 11J. 352, 353, 1148
in malignant disease, III. 362
in mycosis fungoides, III. 1076
in pruritus, III. 359
in psoriasis, III. 351, 1122
in pyonephrosis, II. 814
in ringworm, III. 354, 1125
in rodent ulcer, I. 115 : III. 347, 1133
in scrofuloderma, III. 352
in seborrhcea, III. 359
in skin diseases, earlier methods of, III.
341
present methods, III. 342
protection of patient in, III. 345
in spleno-medullary leukaemia, III. 363
in sycosis, III. 350
in syringomyelia, II. 1219
in treatment of cancer, I. 129
of skin diseases, III. 340-359
X-rays (contd.')
in tuberculosis of the skin, III. 353
in tuberculous disease of lymphatic
glands, I. 1344
' modification of skin functions by, III.
353
treatment of diseases other than skin
diseases, III. 360-368
use of, protection of the operator during,
III. 343
Yaws (Framboesia tropica), III. 461
Yeast in acne vulgaris, III. 988
in boils, III. 1008
in leucorrhcea, IV. 572
in rabies. III. 288
powder in leucorrhoea, IV. 572
Yellow fever in the tropics, III. 382
prophylaxis of, III. 412
symptomatic treatment of, III. 412
Yew, poisoning by, I. 533
Young (E. A.), congestion and oedema of
the lungs, I. 1076-1081
Yverdon spa, III. 158
Zambelleti's subcutaneous injections of
iron and arsenic, II. 294
Zander Institutes, use of, in obesity, I. 470
Zander treatment, III. 369-374
in disorders of the circulation, III. 371
in disorders of the digestive system,
III. 372
in functional derangements of joint",
III. 373
in scoliosis, III. 372
of fractures, III. 374
Zeroni's hook, III. 915
Ziegler's sickle knife, III. 637
Zinc astringent solutions in gonorrhoea, I.
224
dressings in burns and scalds, I. 541
percentage of in cyanide gauze, I. 76
salts of, acute poisoning by, I. 529
in epilepsy, II. 998
Zittmann treatment of syphilis, I. 323
Zyzygium jambulanuin in diabetes melli-
tus, I. 424
S.T.
BKADBURY, AGSEW, & CO. LD., PRINTERS, LON'DOS ASD TOXBRIDGE.
133
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A system of treatment
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A system of treatment
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IRVINE, CALIFORNIA 92664