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 congenital, 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

Fig. 202.-Macrodactyly: localized hypertrophy of a single finger (Ridlon).

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 acromegalia. 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.

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 attempt. 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 stigmata 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.

Cases appearing before the sixth day usually die; those appearing after the twelfth day are likely to recover. Death results from apnea and heart-strain. Favorable indications are: late onset, limited muscular spasm, absence of respiratory and medullary symptoms, infrequency of convulsions, normal temperature, and ability to receive and assimilate nourishment.

Treatment. If the wound of entry for the tetanus infection is in an unhealthy state, surgical measures of local disinfection are always in order, and usually consist of scraping, cauterization, and the employment of active germicides. Lambert 1 believes that hydrochloric and carbolic acid together furnish the best local application. It often happens that the infection atrium is completely healed, and even early cauterization seems to be of doubtful assistance in checking the disease. The general management is of prime importance. The patient should be secluded in a darkened room and every possible excitation be prevented. Alimentation should be carefully maintained by easily digested fluid foods, and, if necessary, by the use of the nasal tube or by rectal injection. Sedative drugs and antispasmodics are indicated, and various ones have cures credited to them. Chloroform and nitrite of amyl are useful to meet the convulsions. Chloral, bromids, morphin, calabar bean, and curare are advised, but must be used with a free hand or omitted entirely. Hot baths sometimes act most soothingly. Active artificial respiration is required in case of dyspnea and threatened asphyxia. Immunization of late years has been attempted by the use of the antitoxins introduced by Tizzoni and Catani. They have been found practical and reliable in animal experiments. There is much diversity of opinion regarding their value in human tetanus. Kneass, 2 from a tabulation of sixty-one cases treated by tetanus antitoxin, finds an insignificant advantage over the older medicinal methods, and Berger, Roux, Yandell, and others are of the same opinion. Lambert 3 states a mortality of thirty-seven per cent. under the antitoxin in acute cases developing within eight days of the infection. It is not unlikely that the antitoxins will be so much improved as to give better and more reliable results, and they can not well be omitted in the treatment of this disease. To be of much value they must be exhibited early. At present, medicinal preparations are imperatively demanded.

HYDROPHOBIA.

Hydrophobia is an acute, infectious disease of carnivorous animals, transmissible to man and to other animals by inoculation. It is also known as rabies and lyssa. The inoculating animals usually are dogs or wolves, but the cat, skunk, and even poultry may carry the disease. The exact nature of the poison is unknown. It undoubtedly is a living contagium. The disease is rare in this country, but seems to be growing more common in the Eastern States, and almost invariably, in man, is the

1 "Amer. Jour. Med. Sciences," Aug., 1897.

2 Jour. Am. Med. Association," July 18, 1896.

3 Loc. cit.

result of bites by rabid dogs. In North Germany, where the muzzling of dogs is rigidly enforced, the disease is almost unknown. It is, therefore, in civilized countries a preventable disease.

Morbid Anatomy.-The nervous system frequently shows lesions, but these may be completely lacking and to some extent, when present, are secondary to the disease, following the spasms, dyspnea, and cardiac failure. They consist essentially of vascular disturbances: dilatation, perivascular leukocytal infiltration, ante-mortem intravascular clots, and minute hemorrhages. Such changes are most frequently encountered in the cortex cerebri, the medulla, and cord. According to Gowers, they are most intense in the neighborhood of the pneumogastric and hypoglossal nuclei. The perivascular infiltration in this locality may be intense enough to suggest miliary abscesses. The salivary glands and kidneys frequently show a similar infiltration and the mucous membrane of the pharynx and larynx is commonly congested.

Symptoms. Incubation requires a variable period of from two weeks to six months, and there are reported cases occurring twelve and even eighteen months after inoculation, the virus having remained dormant. The ordinary incubation period is six weeks to two months. The length of incubation time, according to Horsley, is modified by a number of factors: (1) It is shorter in children than in adults. (2) Wounds of the face, neck, head, and hands, and the unclothed parts are especially dangerous, and the disease then develops promptly. (3) Punctures are the most dangerous; lacerations are serious in proportion to their extent. (4) The bites of rabid animals are serious in this order : Wolf, cat, dog, and other animals. About fifteen per cent. of the persons bitten by dogs known to be rabid develop hydrophobia.

In cases of

Rabies varies in intensity in both animals and man. great severity paralytic features develop early, there is little excitement, and death promptly supervenes. When the poisoning is less profound, the disease runs a longer course, and presents a period of great motor and cerebral excitement. In man the invasion of the disease is frequently marked by irritation about the wound, with pain or numbness. Usually there is headache, depression, loss of appetite, irritability, sleeplessness, and anxiety. The pulse and temperature may be slightly increased. Bright lights, noises, and slight excitement of any sort are shunned owing to the increased sensibility. Stiffness of the throatmuscles and difficulty in swallowing are noticed. A period of excitement then usually develops, when, in rare instances, the central apparatus may be overwhelmed and the paralytic form, with ascending paraplegia and heart-failure, terminates the case within a comparatively few hours. In the excited period there is great motor restlessness and hypersensibility : spasms affecting the throat are induced by any fictitious stimulus, and swallowing becomes impossible, so that fluids are shunned, and the sight of them may even become unbearable; hence the name, hydrophobia. Noises, lights, a breath of air, may provoke the spasm; and it may involve the larynx and thorax, producing dyspnea, cyanosis, and an alarming asphyxia that even tracheotomy may fail to relieve. The respiratory and deglutition spasms are often attended by hoarse sounds