same way. In certain cases the reaction of degeneration and a wasting of the thenar muscles have been seen. Dercum has finally demonstrated an interstitial neuritis. This has been confirmed by Burr,2 and both found suggestive changes in the thyroid gland. A neuropathic tendency can frequently be traced. The condition has been mistaken for myxedema in instances marked by diffuse lipomatosis, but the hands, feet, and face are spared. It is of interest to remember that in two cases a diseased condition of the thyroid has been found post mortem. The ill-defined fatty masses are commonly spread out at their borders into the surrounding tissue. They may, however, be globular or pyriform and pendent. Their common location is subdermal. In slighter cases discontinuance of the use of alcohol or antiluetic treatment has caused the tumors to recede. In aggravated cases medical treatment has apparently accomplished little or nothing, but recourse to thyroid feeding promises more, in view of its effect on obesity and the, at least occasional, presence of disease of the thyroid in these cases. Surgical removal is sometimes indicated. Unsymmetrical Hypertrophies.—In rare instances, usually con Fig. 215.-Macrodactyly: localized hypertrophy of a single finger (Ridlon). genital, and frequently of neurotic ancestry, one side of the body or one extremity, or a portion of an extremity, as a hand or one or more digits, may be disproportionately large. The asymmetry usually increases with the child's growth. In still rarer cases it makes its appearance after birth, and may occur at any time up to maturity. The hypertrophy usually involves the affected portions en masse, so that the increase in length is proportionate to the breadth and thickness. The principal increase is usually in the adipocellular tissue, but the muscles may be hypertrophic and may show correspondingly increased strength. Usually, however, the muscles are defective. The bones are simply enlarged. Sometimes the hypertrophied parts are warmer than their normal fellows and may show increased perspiration and evidences of hyperemia. Occasionally there are pigmentary markings. Hemihypertrophy of the face may be encountered, and Friedreich reports a case presenting hypertrophied left face and arm and right leg. In rare instances such localized hypertrophies are seen in gigantism and acro 1 "Jour. Nerv. and Ment. Dis.," Aug., 1900. 2 Ibid., Oct., 1900. megalia. Of their nature we know practically nothing. In some instances it has been attempted to check the overgrowth by compressing the arterial supply and by the injection of astringents, but no good seems to have resulted. Enlarged digits may be amputated. Chronic Hereditary Tropho-edema.-Henry Meige 1 describes a family in which edema affected eight members, both men and women, distributed through four generations. Four of these cases were observed, and present the same singular affection: namely, a chronic white, firm, and painless edema, appearing at the age of puberty, and affecting especially the feet and legs and sometimes the entire lower members, generally on both sides. He also refers to a remarkable family reported by Milroy, in which in six generations there were twenty-two cases. The condition in all known instances has caused but little inconvenience, has been attended by no suffering, has not shortened life, and has resisted all forms of treatment. 1 "Nouv. Icon. de la Salpêt.," Dec., 1899. 2" New York Medical Rec.," 1893. CHAPTER II. INFECTION NEUROSES. THE diseases now temporarily grouped among the neuroses because the essential histological lesions of the nervous apparatus still escape us, but due to the action of infections, are tetanus and hydrophobia, tetany and chorea. In the two former the infection is capable of experimental propagation; in the latter two the nature of the poison is as yet an inferential matter. All four present a preponderance of motor symptoms. Tetanus and hydrophobia are properly surgical conditions, and will be very briefly outlined. TETANUS. Tetanus is an acute infectious disease marked by tonic spasms of the voluntary muscles, usually commencing in those of the jaws; hence the names trismus and lockjaw. Etiology. The disease is comparatively more common in hot climates and in the colored races than among Caucasians in temperate and cold regions. This may have relation to the better protection by footwear and clothing in the latter conditions. It spares neither age nor sex, and is a common disease among horses. It may occur endemically. It is probably always introduced traumatically, and can usually be traced to inoculation by objects contaminated by the ground-soil, in which the bacillus of tetanus readily lives. Naturally, the hands and feet are the most common locations of such contaminated abrasions or more extensive lesions. The bacillus first discovered by Nicolaer, and cultivated by Kitasato, is an anaërobic, drumstick-shaped, motile microbe. Culture filtrates contain tetanizing poisons which are active when inoculated, but not when ingested. Experimental evidence indicates that, like strychnin, their action is mainly upon the spinal cord.1 Morbid Anatomy.-The condition of the wound presents nothing characteristic, and in the brain and spinal cord the congestion, perivascular exudation, small hemorrhages, and pigmentation of cells sometimes encountered are neither constant nor distinctive. They may even be looked upon as the results of the spasmodic conditions that mark the clinical course of the infection. The same is true of the serous ecchymoses, pulmonary congestions, and muscular ruptures. Symptoms. From two to twenty days or more after inoculation. the first symptoms appear. The intensity of the disease and its fatality are usually in direct proportion to its early onset. Stiffness of the neckand jaw-muscles first appears, limiting mastication, the movement of the tongue, and of the head. Malaise, chilly sensations, or rigors may antedate the muscular stiffness, but usually do not attract much attention. 1 Wasserman and Takaki, "Berlin. klin. Wochens.," June 3, 1898. The muscular spasm increases in intensity and invades the face and trunk. From the tonic action of the zygomatic group the angles of the mouth are retracted in the characteristic sardonic grin that uncovers the teeth, and the jaws can be only slightly separated or may be quite immovable. The head is then retracted, and the entire back may be affected, causing rigidity, or, in greater degree, opisthotonos. In some cases the trunk is bent laterally or forward. The lower extremities are usually more affected than the upper, and the forearm and hands are last and least involved. The muscular spasm is chiefly tonic, but if the condition becomes well marked there are sharp, short, convulsive exacerbations that may reach a most frightful intensity. They are then provoked by the slightest irritation, such as a sudden noise, a bright light, a touch, the jarring of the bed, or any motor effort. They may occur a few times a day or, in extreme cases, with great rapidity, at scarcely noticeable intervals. When these develop they are attended by pain proportional to their intensity and duration. They may impede the thoracic respiratory excursions or induce laryngeal spasm and dyspnea or asphyxia. Often the thoracic or laryngeal spasm induces a hoarse noise, which, taken with the distorted face, rigid limbs, retracted head, and opisthotonic position, presents a frightful picture. Profuse perspiration may be occasioned. The temperature may be normal, slightly increased, or hyperpyrexia may appear and ordinarily precedes a fatal termination. Through it all the mind remains unclouded. Varieties. Head tetanus or cephalic tetanus follows wounds upon the head, face, or neck; is usually of prompt appearance after the inoculation; is ordinarily marked by trismus, dysphagia, facial palsy, and respiratory difficulty, a rapid course, and a fatal termination. The modification of tetanus in this form appears to be due to early poisoning of the medulla. The facial palsy that frequently and the oculomotor palsies that sometimes occur indicate nuclear disturbance. The difficulty in swallowing gives a rough resemblance to rabies and has led to the term tetanus hydrophobicus. Tetanus neonatorum is usually due to infection of the umbilical stump, and is unknown to aseptic midwifery. Puerperal tetanus occurs in parturients. The invasion route is usually through the uterus. Diagnosis. Given a locus of inoculation, the disease can scarcely be mistaken. When a history of trauma is wanting hydrophobia may be suspected, but lacks the jaw-spasm and persistent muscular rigidity. Strychnin poisoning is a closer imitator, but has a more rapid onset, more violent and extensive convulsions, trismus is absent, and relaxation occurs between the spasms. Tetany affects the hands and feet mainly and primarily and shows a number of special reactions, such as increased electrical excitability and Trousseau's sign. Hysteria may imitate tetanus, but ordinarily gives a hysterical history and presents the stig mata of the neurosis. It also usually appears suddenly after a hysterical convulsion, suddenly disappears and recurs, and lacks the nuchal rigidity and mental clearness of tetanus. Bacteriological examination of pus from wounds may make or confirm the diagnosis. Prognosis is always grave and the mortality is over eighty per cent. |