ous, robust people, engaged in heavy and protracted physical labor. The proportion, however, between female and male subjects suffering from hysteria, varies according to different authorities; so that, while Briquet calculates the proportion as twenty to one, Pitres (1891) gives that of two to one. I believe that this great difference in figures depends on the fact that, at the time when Briquet made his observations, male hysteria had been little studied. and was diagnosed only in those cases in which it showed itself by quite evident symptoms. In a year that I have spent in the clinic of Prof. Bianchi, out of many hundreds of patients, I have seen only two hysterical men, but many hysterical women, but I am inclined to think that Pitres' ratio is less than it should be. And the reason thereof we must look for, not in the sexual difference of the two organisms, but in the different resisting power of the system in general and of the nervous system in particular. What is, however, more important is the identity of the circumstances under which the hysterical diathesis, as the French call it, reveals iself in the two sexes, and the identity of the manifestations. As in the woman, so also in the man, hysteria appears most frequently at puberty, although there have been described cases of this neurosis in children (Goldspiegel) and in old people (de Fleury). Yet, according to some authorities, male hysteria would present some characteristic feature. The influence of heredity, for example, would be more manifest in hysterical men than in women; of thirtyone patients, observed by Batault, twenty-six belonged indisputably by their antecedents to the neuropathic family, and Bitot (1890) writes that, out of twenty-two cases examined by him, heredity was quite clear in eighteen, who came from ancestors that had suffered from the most different nervous diseases. In the manifestations of hysteria in man, moreover, there would be seen a certain fixity, which may last a long time and thus give rise to some doubt as to the diagnosis and prognosis (Charcot). Very often in the cases of male hysteria there would occur the association of this neurosis with neurasthenia: Budenstein indeed has observed in four years one thousand two hundred and twenty-four cases of hysteria, of which one hundred and twenty-two were in men of different professions and trades, and in them he noted both hysterical and purely neurasthenic symptoms. If I have thought the following case worthy of notice, it is not because of the appearance of the hysterical manifestations in a male; but because they present particular groupings from which considerations of a general character arise. Two At a At Errichiello G., of Antimo, unmarried, unable to read or write. His mother was very nervous, and for some time has been subject to convulsions, which depend especially on anger or fear. brothers died of convulsions, a younger sister of measles. tender age he often got a decoction of poppy to procure sleep. the age of thirteen years he had typhoid, lasting for more than two months. At this time began the symptoms which the patient refers to his nerves and head. Sleep was often disturbed by bad dreams; often awoke with a start. fuse headache, in the exacerbations of which he experienced a horrible sensation as of pins entering his brain. As a result of these sufferings there ensued a change in his disposition, so that, being apprenticed to a shoemaker to learn that trade, he was dismissed for his inattention and neglect. At home he showed himself capricious, often disobeyed his mother, and every now and then gave himself up to incomprehensible soliloquies. Profiting by the little he had learned, he began to mend old shoes, working along the public road in the neighborhood of Naples. In this wandering life he began to use wine to excess, and practised onanism. Three years ago, during the night, while tormented by a troublesome cough, without other cause, he had a convulsive attack, preceded by a feeling of nausea, pain in the stomach, constriction of the throat, and not followed by a loss of consciousness. After that there followed a period of relative calm up to last September, when one evening the patient, without apparent cause, had a convulsive attack similar to the first. From that time the convulsions were repeated more frequently, at longer or shorter intervals; the last attack, in December, being the most violent. In this attack Errichiello bit his father who was trying to restrain him. After some days' rest he wished to again start out on one of his trips. His father accom After some time there was added a dif panied him, fearing some accident. Indeed, while he was working one day the poor fellow tried to cut his throat with one of his tools, but was prevented and brought to the asylum the 9th January, 1897 Present condition.-Normal development, good state of nutrition. Ears unequal and placed at different levels. Normal development of the genital organs; these are deeply pigmented. The interdigital space between the fourth and fifth fingers of the hands is much greater than normal. He cannot stand on one foot with his eyes closed. His gait is awkward; the flexion of the knee is greater than normal, His speech is slow, whimpering; every now and then he stutters, which is not at all congenital, according to the father. In the field of the special senses we note a considerable bilateral concentric narrowing of the field of vision. The perception of colors is disturbed. The tendon-reflexes are normal. Psychical examination.-He knows he is in the asylum and thinks that his father accompanied him here to cure him of a disease of the nerves from which he has suffered since childhood and which has caused displeasure to his parents. Asked about the attempted suicide, he replies: "You must know it is not I, it is my head. That beast, the devil, entered my brain and ordered me to kill myself." He has some difficulty in collecting his thoughts at times. (Then follows a detailed account of his condition at various times up to October 18th.) It is not my intention to discuss this case diagnostically; such a discussion would have a purely scholastic interest. I shall observe in the first place how far the hereditary influence is apparent in our patient. Direct heredity is frequent in hysteria, and, according to Briquet, half the hysterical mothers give birth to hysterical children. Liability to convulsions is one of the nervous manifestations most frequently transmitted to offspring (Féré), and the Errichiello family is a classical example of this, as, of three sons, two died at a tender age of convulsions, and the third is hysterical. In him the neurosis, latent up to the age of 13 years, reveals itself after an infection. The part which infections play in the production of the neuroses is certainly important, but I believe that their effects are subordinate, at least in the greater number of cases, to the individual predisposition. Grasset (1896) and Marie uphold the theory that general diseases, especially the infectious, determine, in and of themselves, the affections of the nervous system, including hysteria. If it were so, ought not every febrile delirium to assume a special form for every infectious disease; and in the organic diseases of the nervous centres would we not meet a constant relation between the agents of infection and the established anatomical lesions? Now clinical observation teaches us that febrile psychoses, the deliriums of convalesence, have a very great uniformity, whatever be the causal infection, and that hysteria, consecutive to the most varied infectious diseases and to the most varied poisonings, has no specific feature peculiar to the causative agent. Therefore it is more logical to admit that all these causes act by weakening the nervous system, so as to disturb that merely apparent equilibrium which depends on the neuropathic predisposition.-Translated from Giornale Internazionale delle Scienze Mediche for the CANADIAN PRACTITIONER by DR. HARLEY SMITH. (To be Continued.) Clinical Notes. CLINICAL NOTES ON ABDOMINAL SURGERY APPENDICECTOMY. BY JAMES F. W. Ross, M.D. TOR., Professor of Gynecology, University of Toronto; Professor of Gynecology and Abdominal FOLLO 'OLLOWING up some clinical notes published in the May number of THE PRACTITIONER, it may be of interest to some of your readers to continue the report of some of my recent experiences with disease of the vermiform appendix. The most recent experience strongly emphasizes the view I have already expressed, that if I myself were taken with sudden severe pain in the abdomen, vomiting, tenderness on pressure in the right iliac region, and rigidity of the right rectus muscle, I should ask a surgeon to open my abdomen. H.F., æt. 26. Was taken with pain in the abdomen on a Monday morning. He took a seidlitz powder, and went to business. All day he felt uncomfortable, and was half doubled with colic. On Monday evening the pain grew worse, and vomiting set in. He sent for his physician, who is a recent graduate, and is imbued with ideas coinciding with my own. Morphia was given to ease the pain. The temperature became elevated to about 100, and the pulse re mained about 70. On Tuesday morning he was again seen. Tenderness on pressure was made out in the right iliac region, and there was board-like rigidity of the right rectus muscle. On Wednesday morning I was called to see him in consultation. He had a pinched expression of countenance that was noticed by his wife and by the physician in charge and by myself. He laughed and chatted as if there was not much the matter with him. He said he scarcely considered the consultation necessary. His pulse was 70, temperature 99. There was no distension. The four cardinal symptoms, on which I have so frequently relied, were present, and I told him that I was satisfied he was safer with his abdomen open than with it closed. He decided to have operation performed at once. Two nurses were immediately sent to the house, preparations made, and in four hours his abdomen was opened. A large, fluidfilled, inflamed and partially gangrenous appendix was drawn up and removed without difficulty. One patch of lymph, being pushed aside, disclosed beneath a black, gangrenous area, about the size of a five-cent piece, ripe and ready to give way. The convalesence was uneventful. By such early operation all but a small percentage of doubt as to future progress of the case was eliminated. The probability of death was very much diminished, and a prolonged convalescence and abscess formation were set aside. In contra-distinction to this, another case, that of Miss C., may be mentioned. Patient took ill on May 10th with sudden pain in the abdomen. Managed to reach home; suffered a good deal of pain on the way. Had severe vomiting. Her physician was called, and found her complaining of tenderness across the abdomen, above the navel. Gradually great tenderness developed in the right loin. Temperature slightly elevated; pulse became gradually increased until, when I saw her, it had reached 120 per minute. The abdomen was considerably distended. I advised immediate operation, although I feared that already the peritoneal cavity had become generally infected. From the point of the greatest pain I concluded the appendix was high up, and back in the loin. Dullness on percussion was made out in the right loin. Abdomen was opened to the right of the right rectus muscle. The general cavity was packed off carefully with gauze. Gangrenous, thickened appendix was found with the tip adherent to the under surface of the liver. Appendix was enormously swollen and lay behind in the loin. An abscess cavity was found that contained about a wine-glass and a half of horrible smelling pus. After a great deal of difficulty the appendix was peeled off from its bed and removed. Operation consumed considerable time owing to the friable condition of the gangrenous parts. Gauze was packed into the cavity from which the appendix had been removed. Rubber drainage tube placed. Had not the appendix The patient was slightly jaundiced at the time of operation and became intensely jaundiced shortly after. The pulse became slow, coma set in, and she died from cholemia. been adherent to the under surface of the liver this acute hepatitis might have been avoided. |