CHAPTER XV.

ANOMALOUS TYPES AND INSTANCES OF DISEASE.

Tumors.--In discussing tumors and similar growths no attempt will be

made to describe in detail the various types. Only the anomalous

instances or examples, curious for their size and extent of

involvement, will be mentioned. It would be a difficult matter to

decide which was the largest tumor ever reported. In reviewing

literature so many enormous growths are recorded that but few can be

given here. Some of the large cystic formations have already been

mentioned; these are among the largest tumors. Scrotal tumors are

recorded that weighed over 200 pounds; and a limb affected with

elephantiasis may attain an astonishing size. Delamater is accredited

with a report of a tumor that weighed 275 pounds, the patient only

weighing 100 pounds at death. Benign tumors will be considered first.

Pure adenoma of the breast is a rare growth. Gross was able to collect

but 18 examples; but closely allied to this condition is what is known

as diffuse hypertrophy of the breast. In some parts of the world,

particularly in India and Africa, long, dependent breasts are signs of

beauty. On the other hand we learn from Juvenal and Martial that, like

ourselves, the Greeks detested pendant and bulky breasts, the signs of

beauty being elevation, smallness, and regularity of contour. In the

Grecian images of Venus the breasts are never pictured as engorged or

enlarged. The celebrated traveler Chardin says that the Circassian and

Georgian women have the most beautiful breasts in the world; in fact

the Georgians are so jealous of the regular contour and wide interval

of separation of their breasts that they refuse to nourish their

children in the natural manner.

The amount of hypertrophy which is sometimes seen in the mammae is

extraordinary. Borellus remarks that he knew of a woman of ordinary

size, each of whose mammae weighed about 30 pounds, and she supported

them in bags hung about her neck. Durston reports a case of sudden

onset of hypertrophy of the breast causing death. At the postmortem it

was found that the left breast weighed 64 pounds and the right 40

pounds. Boyer successfully removed two breasts at an interval of

twenty-six days between the two operations. The mass excised was

one-third of the total body-weight.

Schaeffer speaks of hypertrophied mammae in a girl of fourteen, the

right breast weighing 3900 grams (136 1/2 oz.) and the right 3500 grams

(122 1/2 oz.). Hamilton reports a case of hypertrophied glands in a

woman of thirty-two, which, within the short space of a year, reached

the combined weight of 52 pounds. They were successfully excised.

Velpeau, Billroth, and Labarracque have reported instances of the

removal of enormously hypertrophied mammae. In 1886 Speth of Munich

described a hypertrophy of the right breast which increased after every

pregnancy. At the age of twenty-six the woman had been five times

pregnant in the space of a little over five years, and at this time the

right breast hung down to the anterior superior spine of the ilium. It

weighed 20 pounds, and its greatest circumference was 25 inches. There

was no milk in this breast, although the left was in perfect lactation.

This case was one of pure hypertrophy and not an example of

fibro-adenoma, as illustrated by Billroth. Warren figures a case of

diffused hypertrophy of the breast which was operated on by Porter. The

right breast in its largest circumference measured 38 inches and from

the chest-wall to the nipple was 17 inches long, the circumference at

the base being 23 inches; the largest circumference of the left breast

was 28 inches; its length from the chest-wall to the nipple was 14

inches, and its circumference at the base 23 inches. The skin was

edematous and thickened. Throughout both breasts were to be felt

hardened movable masses, the size of oranges. Microscopic examination

showed the growth to be a diffused intracanalicular fibroma. A peculiar

case was presented before the Faculty at Montpellier. The patient was a

young girl of fifteen and a half years. After a cold bath, just as the

menses were appearing, it was found that the breasts were rapidly

increasing in size; she was subsequently obliged to leave service on

account of their increased size, and finally the deformity was so great

as to compel her to keep from the public view. The circumference of the

right breast was 94 cm. and of the left 105 cm.; the pedicle of the

former measured 67 cm. and of the latter 69 cm.; only the slightest

vestige of a nipple remained. Removal was advocated, as applications of

iodin had failed; but she would not consent to operation. For eight

years the hypertrophy remained constant, but, despite this fact, she

found a husband. After marriage the breasts diminished, but she was

unable to suckle either of her three children, the breasts becoming

turgid but never lactescent. The hypertrophy diminished to such a

degree that, at the age of thirty-two, when again pregnant, the

circumference of the right breast was only 27 cm. and of the left 33

cm. Even thus reduced the breasts descended almost to the navel. When

the woman was not pregnant they were still less voluminous and seemed

to consist of an immense mass of wrinkled, flaccid skin, traversed by

enormous dilated and varicose blood-vessels, the mammary glands

themselves being almost entirely absent.

Diffuse hypertrophy of the breast is occasionally seen in the male

subject. In one case reported from the Westminster Hospital in London,

a man of sixty, after a violent fall on the chest, suffered enormous

enlargement of the mammae, and afterward atrophy of the testicle and

loss of sexual desire.

The names goiter, struma, and bronchocele are applied indiscriminately

to all tumors of the thyroid gland; there are, however, several

distinct varieties among them that are true adenoma, which, therefore,

deserves a place here. According to Warren, Wolfler gives the following

classification of thyroid tumors: 1. Hypertrophy of the thyroid gland,

which is a comparatively rare disease; 2. Fetal adenoma, which is a

formation of gland tissue from the remains of fetal structures in the

gland; 3. Gelatinous or interacinous adenoma, which consists in an

enlargement of the acini by an accumulation of colloid material, and an

increase in the interacinous tissue by a growth of round cells. It is

this latter form in which cysts are frequently found. The accompanying

illustration pictures an extreme ease of cystic goiter shown by Warren.

A strange feature of tumors of the thyroid is that pressure-atrophy and

flattening of the trachea do not take place in proportion to the size

of the tumor. A small tumor of the middle lobe of the gland, not larger

that a hen's egg, will do more damage to the trachea than will a large

tumor, such as that shown by Senn, after Bruns. When a tumor has

attained this size, pressure-symptoms are often relieved by the weight

of the tumor making traction away from the trachea. Goiter is endemic

in some countries, particularly in Switzerland and Austria, and appears

particularly at the age of childhood or of puberty. Some communities in

this country using water containing an excess of calcium salt show

distinct evidences of endemic goiter. Extirpation of the thyroid gland

has in recent years been successfully practiced. Warren has extirpated

one lobe of the thyroid after preliminary ligation of the common

carotid on the same side. Green practiced rapid removal of the tumor

and ligated the bleeding vessels later. Rose tied each vessel before

cutting, proceeding slowly. Senn remarks that in 1878 he witnessed one

of Rose's operations which lasted for four hours. Although the operatic

technic of removal of the thyroid gland for tumor has been greatly

perfected by Billroth, Lucke, Julliard, Reverdin, Socin, Kocher, and

others, the current opinion at the present day seems to be that

complete extirpation of the thyroid gland, except for malignant

disease, is unjustifiable. Partial extirpation of the thyroid gland is

still practiced; and Wolfler has revived the operation of ligating the

thyroid arteries in the treatment of tumors of the thyroid gland.

Fibromata.--One of the commonest seats of fibroma is the skin.

Multiple fibromata of the skin sometimes occur in enormous numbers and

cover the whole surface of the body; they are often accompanied by

pendulous tumors of enormous size. Virchow called such tumors fibroma

molluscum. Figure 237 represents a case of multiple fibromata of the

skin shown by Octerlony. Pode mentions a somewhat similar case in a man

of fifty-six, under the care of Thom. The man was pale and emaciated,

with anxious expression, complaining of a tumor which he described as a

"wishing-mark." On examination he was found to be covered with a number

of small tumors, ranging in size from that of a small orange to that of

a pin's head; from the thoracic wall over the lower true ribs of the

right side was situated a large pendulous tumor, which hung down as far

as the upper third of the thigh. He said that it had always been as

long as this, but had lately become thicker, and two months previously

the skin over the lower part of the tumor had ulcerated. This large

tumor was successfully removed; it consisted of fibrous tissue, with

large veins running in its substance. The excised mass weighed 51

pounds. The patient made an early recovery.

Keloids are fibromata of the true skin, which may develop spontaneously

or in a scar. Although the distinction of true and false keloid has

been made, it is generally discarded. According to Hebra a true typical

keloid is found once in every 2000 cases of skin-disease. It is,

however, particularly the false keloid, or keloid arising from

cicatrices, with which we have mostly to deal. This tumor may arise

from a scar in any portion of the body, and at any age. There seems to

be a disposition in certain families and individuals to

keloid-formations, and among negroes keloids are quite common, and

often of remarkable size and conformation. The form of injury causing

the cicatrix is no factor in the production of keloid, the sting of an

insect, the prick of a needle, and even the wearing of ear-rings having

been frequent causes of keloid-formations among the negro race.

Collins describes a negress of ninety, born of African parents, who

exhibited multiple keloids produced by diverse injuries. At fourteen

she was burned over her breasts by running against a shovelful of hot

coals, and several months later small tumors appeared, which never

suppurated. When a young girl a tumor was removed from the front of her

neck by operation, and cicatricial tumors then spread like a band

encircling one-half her neck. There were keloids over her scapulae,

which followed the application of blisters. On her back, over, and

following the direction of the ribs, were growths attributed to the

wounds caused by a flogging. This case was quite remarkable for the

predisposition shown to keloid at an early age, and the variety of

factors in causation.

About 1867 Duhring had under his observation at the Philadelphia

Hospital a negro whose neck was encircled by enormous keloids, which,

although black, otherwise resembled tomatoes. A photograph of this

remarkable case was published in Philadelphia in 1870.

A lipoma is a tumor consisting of adipose tissue. When there is much

fibrous tissue in the tumor it is much firmer, and is known as a

fibro-lipoma. Brander describes a young native of Manchuria, North

China, from whom he removed a fibro-lipoma weighing 50 pounds. The

growth had progressively enlarged for eleven years, and at the time of

extirpation hung as an enormous mass from beneath the left scapula. In

operating the tumor had to be swung on a beam. The hemorrhage was

slight and the patient was discharged in five days.

The true lipoma must be distinguished from diffuse accumulations of fat

in different parts of the body in the same way that fibroma is

distinguished from elephantiasis. Circumscribed lipoma appears as a

lobulated soft tumor, more or less movable, lying beneath the skin. It

sometimes reaches enormous size and assumes the shape of a pendulous

tumor.

Diffuse lipoma, occurring in the neck, often gives the patient a

grotesque and peculiar appearance. It is generally found in men

addicted to the use of alcohol, and occurs between thirty-five and

forty-five years of age; in no case has general obesity been described.

In one of Madelung's cases a large lobe extended downward over the

clavicle. The growth has been found between the larynx and the pharynx.

Black reports a remarkable case of fatty tumor in a child one year and

five months old which filled the whole abdominal cavity, weighing nine

pounds and two ounces. Chipault mentions a case of lipoma of the

parietal region, observed by Rotter. This monstrous growth was three

feet three inches long, descending to the knees. It had its origin in

the left parietal region, and was covered by the skin of the whole left

side of the face and forehead. The left ear was plainly visible in the

upper third of the growth.

Chondroma, or enchondroma, is a cartilaginous tumor occurring

principally where cartilage is normally found, but sometimes in regions

containing no cartilage. Enchondroma may be composed of osteoid tissue,

such as is found in the ossifying callous between the bone and the

periosteum, and, according to Virchow, then takes the name of

osteochondroma. Virchow has divided chondromata into two forms--those

which he calls ecchondromata, which grow from cartilage, and those that

grow independently from cartilage, or the enchondromata, which latter

are in the great majority. Enchondroma is often found on the long

bones, and very frequently upon the bones of the hands or on the

metatarsal bones.

Figure 244 represents an enchondroma of the thumb. Multiple

enchondromata are most peculiar, and may attain enormous sizes.

Whittaker describes a farmer of forty who exhibited peculiar tumors of

the fingers, which he calls multiple osteoecchondromata. His family

history was negative. He stated that at an early age he received a

stroke of lightning, which rendered him unconscious for some time. He

knows of nothing else that could be in possible relation with his

present condition. Nine months after this accident there was noticed

an enlargement of the middle joint of the little finger, and about the

same time an enlargement on the middle finger. Gradually all the joints

of the right hand became involved. The enlargement increased so that at

the age of twelve they were of the size of walnuts, and at this time

the patient began to notice the same process developing in the left

hand. The growths continued to develop, new nodules appearing, until

the fingers presented the appearance of nodulated potatoes.

One of the most frequent of the fibro-cartilaginous tumors is the

"mixed cartilaginous" tumor of Paget, which grows in the interstitial

tissues of the parotid gland, and sometimes attains enormous size.

Matas presented the photograph of a negress having an enormous fibroma

growing from the left parotid region; and there is a photograph of a

similar case in the Mutter Museum of the College of Physicians,

Philadelphia.

The hyaline enchondroma is of slow growth, but may at times assume

immense proportions, as is shown in the accompanying illustration,

given by Warren, of a patient in whom the growth was in the scapula.

In 1824 there is quoted the description of a peculiar growth which,

though not definitely described, may be spoken of here. It was an

enormous encysted tumor, springing from the clavicle of a Veronese

nobleman. Contrary to general expectations it was successfully removed

by Portalupi, a surgeon of Venice. It weighed 57 pounds, being 20 1/2

inches long and 30 inches in circumference. It is said this tumor

followed the reception of a wound.

Among the benign bone tumors are exostoses--homologous outgrowths

differing from hypertrophies, as they only involve a limited part of

the circumference. When developmental, originating in childhood, the

outgrowths may be found on any part of the skeleton, and upon many and

generally symmetric parts at the same time, as is shown in Figure 248.

Barwell had a case of a girl with 38 exostoses. Erichsen mentions a

young man of twenty-one with 15 groups of symmetric exostoses in

various portions of the body; they were spongy or cancellous in nature.

Hartmann shows two cases of multiple exostoses, both in males, and

universally distributed over the body.

Macland of the French navy describes an affection of the bones of the

face known as anakhre or goundron (gros-nez). It is so common that

about one per cent of the natives of certain villages on the Ivory

Coast, West Africa, are subject to it. As a rule the earliest symptoms

in childhood are: more or less persistent headache, particularly

frontal, sanguineous and purulent discharge from the nostrils, and the

formation of symmetric swellings the size of an almond in the region of

the nasal processes of the superior maxilla. The cartilage does not

seem to be involved, and, although it is not so stated, the nasal duct

appears to remain intact.

The headache and discharge continue for a year, and the swelling

continually increases through life, although the symptoms gradually

disappear, the skin not becoming involved, and no pain being present.

It has been noticed in young chimpanzees. The illustration represents a

man of forty who suffered from the disease since puberty. Pressure on

the eyeball had started and the native said he expected that in two

years he would lose his sight. Figure 251 shows an analogous condition,

called by Hutchinson symmetric osteomata of the nasal processes of the

maxilla. His patient was a native of Great Britain.

Among neuromata, multiple neurofibroma is of considerable interest,

chiefly for the extent of general involvement. According to Senn,

Heusinger records the case of a sailor of twenty-three in whom all the

nerves were affected by numerous nodular enlargements. Not a nerve in

the entire body was found normal. The enlargement was caused by

increase in the connective tissue, the axis-cylinders being normal. In

this case there was neither pain nor tenderness.

Prudden reports the case of a girl of twenty-five who, during

convalescence from variola, became paraplegic, and during this time

multiple neuromata appeared. At the postmortem more than a thousand

tumors were found affecting not only the peripheral branches and the

sympathetic, but also the cranial nerves and the pneumogastric. Under

the microscope these tumors showed an increase in the interfascicular

as well as perivascular fibers, but the nerve-fibers were not increased

in size or number. Virchow collected 30 cases of multiple

neurofibromata. In one case he found 500, in another from 800 to 1000

tumors.

Plexiform neuroma is always congenital, and is found most frequently in

the temporal region, the neck, and the sides of the face, but almost

any part of the body may be affected. Christot reports two cases in

which the tumors were located upon the cheek and the neck. Czerny

observed a case in which the tumor involved the lumbar plexus. Quoted

by Senn, Campbell de Morgan met with a plexiform neuroma of the

musculo-spiral nerve and its branches. The patient was a young lady,

and the tumor, which was not painful, had undergone myxomatous

degeneration.

Neuroma of the vulva is a pathologic curiosity. Simpson reports a case

in which the tumor was a painful nodule situated near the urinary

meatus. Kennedy mentions an instance in which the tumor appeared as

extremely tender tubercles.

Tietze describes a woman of twenty-seven who exhibited a marked type of

plexiform neurofibroma. The growth was simply excised and recovery was

promptly effected.

Carcinomatous growths, if left to themselves, make formidable

devastations of the parts which they affect. Warren pictures a case of

noli-me-tangere, a destructive type of epithelial carcinoma. The

patient suffered no enlargement of the lymphatic glands. The same

absence of glandular involvement was observed in another individual, in

whom there was extensive ulceration. The disease had in this case

originated in the scar of a gunshot wound received during the Civil

War, and had destroyed the side of the nose, the eye, the ear, the

cheek, including the corresponding half of the upper and lower lips.

Harlan reports a most extraordinary epithelioma of the orbit in a boy

of about five years. It followed enucleation, and attained the size

depicted in a few months.

Sarcomata, if allowed full progress, may attain great size. Plate 10

shows an enormous sarcoma of the buttocks in an adult negro. Fascial

sarcomata are often seen of immense size. Senn shows a tumor of this

variety which was situated between the scapulae.

Schwimmer records a curious case of universal small sarcomata over the

whole body of a teacher of the age of twenty-one, in the Hungarian

lowlands. The author called the disease sarcomata pigmentosum diffusum

multiplex.

The bones are a common seat of sarcomatous growths, the tumor in this

instance being called osteosarcoma. It may affect any bone, but rarely

involves an articulation; at times it skips the joint and goes to the

neighboring bone.

A case of nasal sarcoma is shown by Moore. The tumor was located in the

nasal septum, and caused a frightful deformity. In this case pain was

absent, the sense of smell was lost, and the sight of the right eye

impaired. Moore attempted to remove the tumor, but in consequence of

some interference of respiration the patient died on the table.

Tiffany reports several interesting instances of sarcoma, one in a

white female of nineteen following a contusion of tibia. The growth had

all the clinical history of an osteosarcoma of the tibia, and was

amputated and photographed after removal. In another case, in a white

male of thirty, the same author successfully performed a hip-amputation

for a large sarcoma of the left femur. The removed member was sent

entire to the Army Medical Museum at Washington.

The fatality and incurability of malignant growths has done much to

stimulate daring and marvelous operations in surgery. The utter

hopelessness of the case justifies almost any means of relief, and many

of the visceral operations, resections of functional organs, and

extraordinary amputations that were never dreamed of in the early

history of medicine are to-day not only feasible and justifiable, but

even peremptorily demanded.

Varicose veins sometimes become so enlarged and distorted as to

simulate the appearance of one varicose tumor. Adams describes a

curious case of congenital dilatation of the arteries and veins in the

right lower limb, accompanied by an anastomosis with the interior of

the os calcis. The affected thigh exceeded the other in size by

one-third, all the veins being immensely swelled and distorted. The

arteries were also distorted and could be felt pulsating all over the

limb. The patient died at thirty from rupture of the aneurysm.

Abbe shows a peculiar aneurysmal varix of the finger in a boy of nine.

When a babe the patient had, on the dorsum of the little finger, a

small nevus, which was quiescent for many years. He received a deep cut

at the base of the thumb, and immediately after this accident the nevus

began to enlarge rapidly. But for the local aneurysmal thrill at the

point of the scar the condition would have been diagnosed as angioma,

but as a bruit could be heard over the entire mass it was called an

aneurysmal varix, because it was believed there was a connection

between a rather large artery and a vein close to the mass. There is a

curious case reported of cirsoid tumor of the ear of a boy of thirteen.

Figure 259 shows the appearance before and after operation.

Jessop records a remarkable case of multiple aneurysm. This case was

particularly interesting as it was accompanied by a postmortem

examination. Pye-Smith reports an extremely interesting case in which

death occurred from traumatic aneurysm of an aberrant subclavian

artery. The patient fell from a height of 28 feet, lost consciousness

for a few minutes, but soon recovered it. There was no evidence of any

fracture, but the man suffered greatly from dyspnea, pain between the

shoulders, and collapse. The breath-sounds on auscultation and the

difficulty in swallowing led to the belief that one of the bronchi was

blocked by the pressure of a hematoma. Dyspnea continued to increase,

and eighteen days after admission the man was in great distress, very

little air entering the chest. He had no pulse at the right wrist, and

Pye-Smith was unable to feel either the temporal or carotid beats on

the right side, although these vessels were felt pulsating on the left

side. Laryngotomy was done with the hope of removing a foreign body,

but the man died on the tenth day. A postmortem examination disclosed

the existence of an aberrant right subclavian artery in the posterior

mediastinum, and this was the seat of a traumatic aneurysm that had

ruptured into the esophagus.

Relative to the size of an aneurysm, Warren reported a case of the

abdominal aorta which commenced at the origin of the celiac axis and

passed on to the surfaces of the psoas and iliac muscles, descending to

the middle of the thigh The total length of the aneurysm was 19 inches,

and it measured 18 inches in circumference.

A peculiar sequence of an aortic aneurysm is perforation of the sternum

or rib. Webb mentions an Irish woman who died of aneurysm of the aorta,

which had perforated the sternum, the orifice being plugged by a large

clot. He quotes 17 similar cases which he has collected as occurring

from 1749 to 1874, and notes that one of the patients lived seven weeks

after the rupture of the aneurysmal sac.

Large Uterine Tumors.--Before the meeting of the American Medical

Association held in Washington, D.C., 1891, McIntyre a reported a case

of great interest. The patient, a woman of thirty-eight, five feet 5

1/2 inches in height, coarse, with masculine features, having hair on

her upper lip and chin, and weighing 199 1/2 pounds, was found in a

poor-house in Trenton, Missouri, on November 26, 1890, suffering from a

colossal growth of the abdomen. The accompanying illustration is from a

photograph which was taken at the time of the first interview. The

measurements made at the time were as follows: circumference at the

largest part, just below the umbilicus, 50 inches; circumference just

below the mammae, 35 inches; from the xiphoid cartilage to the

symphysis pubis, 32 inches, not including the appendum, which is shown

in the picture. Percussion suggested a fluid within a sac. The uterus

was drawn up to the extent of from 12 to 14 inches. The woman walked

with great difficulty and with a waddling gait, bending far backward

the better to keep "the center of gravity within the base," and to

enable her to sustain the enormous weight of the abdomen. She was

compelled to pass her urine while standing. Attempts had been made six

and two years before to tap this woman, but only a few drops of blood

followed several thrusts of a large trocar. A diagnosis was made of

multilocular ovarian cyst or edematous myoma of the uterus, and on the

morning of December 7, 1890, an operation was performed. An incision 14

inches in length was first made in the linea alba, below the umbilicus,

and afterward extended up to the xiphoid cartilage. The hemorrhage

from the abdominal wall was very free, and the enormously distended

vessels required the application of a large number of pressure-forceps.

Adhesions were found almost everywhere the most difficult to manage

being those of the liver and diaphragm. The broad ligaments and

Fallopian tubes were ligated on either side, the tumor turned out, the

thick, heavy pedicle transfixed and ligated, and the enormous growth

cut away. After operation the woman was immediately placed on platform

scales, and it was found that she had lost 93 1/2 pounds.

Unfortunately the patient developed symptoms of septicemia and died on

the fifth day. In looking over the literature on this subject McIntyre

found no mention of any solid tumor of this size having been removed.

On April 18, 1881, Keith, late of Edinburgh, now of London,

successfully removed an edematous myoma, together with the uterus,

which was 42 pounds in weight. In a recent work Tait remarks that the

largest uterine myoma which he ever removed weighed 68 pounds, and adds

that it grew after the menopause. McIntyre believes that his tumor,

weighing 93 1/2 pounds, is the largest yet reported. Eastman reports

the removal of a fibroid tumor of the uterus weighing 60 pounds. The

patient recovered from the operation.

It is quite possible for a fibrocyst of the uterus to attain an

enormous size, equaling the ovarian cysts. Stockard describes an

instance of this nature in a negress of fifty, the mother of several

children. About twelve years before a cyst in the right iliac region

was tapped. The woman presented the following appearance: The navel

hung below her knees, and the skin near the umbilicus resembled that of

an elephant. The abdomen in its largest circumference measured 68

inches, and 27 inches from the ensiform cartilage to the umbilicus. The

umbilicus was five inches in diameter and three inches in length. Eight

gallons and seven pints of fluid were removed by tapping, much

remaining. The whole tumor weighed 135 pounds. Death from exhaustion

followed on the sixth day after the tapping.

Ovarian cysts, of which by far the greater number are of the glandular

variety, form extremely large tumors; ovarian dropsies of enormous

dimensions are recorded repeatedly throughout medical literature. Among

the older writers Ford mentions an instance of ovarian dropsy from

which, by repeated operations, 2786 pints of water were drawn.

Martineau describes a remarkable case of twenty-five years' duration,

in which 80 paracenteses were performed and 6630 pints of fluid were

withdrawn. In one year alone 495 pints were withdrawn. Tozzetti

mentions an ovarian tumor weighing 150 pounds. Morand speaks of an

ovarian cyst from which, in ten months, 427 pounds of fluid were

withdrawn. There are old records of tubal cysts weighing over 100

pounds. Normand speaks of an ovary degenerating into a scirrhous mass

weighing 55 pounds. Among recent operations Briddon describes the

removal of an ovarian cyst which weighed 152 pounds, death resulting.

Helmuth mentions an ovarian cyst from which, in 12 tappings, 559 pounds

of fluid were withdrawn. Delivery was effected by instrumental aid. The

tumor of 70 pounds was removed and death followed. McGillicuddy

mentions a case of ovarian cyst containing 132 pounds of fluid. The

patient was a woman of twenty-eight whose abdomen at the umbilicus

measured 69 inches in circumference and 47 inches from the sternum to

the pubes. Before the operation the great tumor hung down as far as the

knees, the abdominal wall chafing the thighs. Figure 263 shows the

appearance of a large ovarian cyst weighing 149 pounds. The emaciation

of the subject is particularly noticeable. Reifsnyder describes a

native Chinese woman affected with an ovarian tumor seen at the

Margaret Williamson Hospital at Shanghai. She was four feet eight

inches in height, and twenty-five years of age. The tumor had been

growing for six years until the circumference at the umbilicus measured

five feet 7 3/4 inches; 88 quarts of fluid were drawn off and the woman

recovered. In the College of Physicians, Philadelphia, there are

photographs of this case, with an inscription saying that the patient

was a young Chinese woman who measured but four feet eight inches in

height, while her girth was increased by an ovarian cyst to five feet 9

1/8 inches. The tumor was removed and weighed 182 1/2 pounds; it

contained 22 gallons of fluid. Figure 265 shows the appearance of the

woman two months after the operation, when the girth was reduced to

normal. Stone performed ovariotomy on a girl of fifteen, removing a

tumor weighing 81 1/2 pounds. Ranney speaks of the successful removal

of a unilocular tumor weighing 95 pounds; and Wall tells of a death

after removal of an ovarian tumor of the same weight. Rodenstein

portrays the appearance of a patient of forty-five after death from an

enormous glandular ovarian cystoma. The tumor was three feet high,

covered the breasts, extended to the knees, and weighed 146 pounds.

Kelly speaks of a cyst weighing 116 pounds; Keith one of 89 1/2 pounds;

Gregory, 80 pounds; Boerstler, 65 pounds; Bixby, 70 pounds; and Alston

a tumor of 70 pounds removed in the second operation of ovariotomy.

Dayot reports the removal of an enormous ovarian cyst from a girl of

seventeen. The tumor had been present three years, but the patient and

her family refused an operation until the size of the tumor alarmed

them. Its largest circumference was five feet 11 inches. The distance

from the xiphoid to the symphysis pubis was three feet. The tumor was

covered with veins the size of the little finger. The apex of the heart

was pushed to the 3d interspace and the umbilicus had disappeared.

There were 65 quarts of a thick, brown fluid in the tumor. The patient

recovered in twenty-five days.

Cullingworth of St. Thomas Hospital, London, successfully removed from

a girl of sixteen an ovarian cyst weighing over 80 pounds. The patient

was admitted to the hospital April 30, 1895. She gave a history of a

single menstruation, which took place in March or April, 1893, and said

that in the latter month she noticed that she was growing large. She

was tapped at Christmas, 1893, when a large quantity of fluid was

removed, and again in February, 1894, and a third time in May, 1894,

but without useful results. For the previous six months she had been

almost entirely bedridden because of the great size of the tumor. There

were no symptoms referring to the bladder and rectum. At the time she

entered the hospital she was much emaciated, the eyes were sunken, and

her cheeks had a livid hue. The chest was thin and the lower ribs were

everted; dulness began at the lower border of the 3d cartilage, and the

apex-beat was best felt in the third space. Liver-dulness began at the

4th rib cartilage in the nipple line. The abdomen was enormously

distended, and covered by large veins running from below upward to the

thorax. About 3 1/2 inches above the umbilicus there was a sulcus with

its convexity downward. There was dulness over the whole abdomen,

except at the sides parallel with the lumbar spines, and a resonant

band over the stomach. The greatest girth was 54 1/2 inches. By vaginal

examination the cervix was found to be pulled up and obliterated; the

anterior vaginal wall was bulged downward by the tumor. On May 3d

abdominal section was performed. An incision eight inches long was made

in the mid-line of the abdomen. A cystic tumor, formed of small cysts

in its upper part and of somewhat larger ones in the lower part, was

revealed. It was adherent to the abdominal wall, liver, spleen, and

omentum. The adhesions were separated and the cyst tapped with a large

trocar, and then the septa between the cysts were broken down with the

fingers. The pedicle was rather small and was tied in the usual way,

and the tumor was removed. Its seat of origin was the left ovary. The

right ovary and the uterus were healthy, but poorly developed. The

tumor weighed between 80 and 90 pounds,--the patient having weighed 170

pounds on the night before the operation and 79 1/2 pounds a week after

the operation. Alarming symptoms of collapse were present during the

night after the operation, but the patient responded to stimulation by

hypodermic injections of 1/20 grain of strychnin and of brandy, and

after the first twenty-four hours the recovery was uninterrupted.

Cullingworth thinks that the most interesting points in the case are:

the age of the patient, the enormous size of the tumor, and the advice

given by the surgeon who first attended the patient (insisting that no

operation should be performed). This case shows anew the uselessness of

tapping ovarian cysts.

In the records of enormous dropsies much material of interest is to be

found, and a few of the most interesting cases on record will be cited.

In the older times, when the knowledge of the etiology and pathology of

dropsies was obscure, we find the records of the most extraordinary

cases. Before the Royal Society, in 1746, Glass of Oxford read the

report of a case of preternatural size of the abdomen, and stated that

the dropsy was due to the absence of one kidney. The circumference of

the abdomen was six feet four inches, and the distance from the xiphoid

to the os pubis measured four feet 1/2 inch. In this remarkable case 30

gallons of fluid were drawn off from the abdomen after death.

Bartholinus mentions a dropsy of 120 pounds; and Gockelius one of 180

pounds; there is recorded an instance of a dropsy of 149 pounds. There

is an old record of a woman of fifty who had suffered from ascites for

thirty years. She had been punctured 154 times, and each time about 20

pints were drawn off. During each of two pregnancies she was punctured

three or four times; one of her children was still living. It has been

said that there was a case in Paris of a person who was punctured 300

times for ascites. Scott reports a case of ascites in which 928 pints

of water were drawn off in 24 successive tappings, from February, 1777,

to May, 1778. Quoted by Hufeland, Van Wy mentions 1256 pounds of fluid

being drawn from the abdomen of a woman in five years. Kaltschmid

describes a case of ascites in which, in 12 paracenteses, 500 pounds of

fluid were removed. In 1721 Morand reported two cases of ascites in one

of which, by the means of 57 paracenteses, 970 pounds of fluid were

drawn off in twenty-two months. In the other case 1708 pounds of fluid

issued in ten months. There is a record of 484 pounds of "pus" being

discharged during a dropsy.

The Philosophical Transactions contain the account of a case of

hydronephrosis in which there were 240 pounds of water in the sac.

There are several cases on record in which ovarian dropsies have

weighed over 100 pounds; and Blanchard mentions a uterine dropsy of 80

pounds.

The Ephemerides contains an account of a case of hydrocephalus in which

there were 24 pounds of fluid, and similar cases have been noted.

Elliotson reports what he calls the largest quantity of pus from the

liver on record. His patient was a man of thirty-eight, a victim of

hydatid disease of the liver, from whom he withdrew one gallon of

offensive material.

Lieutaud cites a case, reported by Blanchard, in which, in a case of

hydatid disease, the stomach contained 90 pounds of fluid.

Ankylosis of the articulations, a rare and curious anomaly, has been

seen in the human fetus by Richaud, Joulin, Bird, and Becourt.

Ankylosis of all the joints, with muscular atrophy, gives rise to a

condition that has been popularly termed "ossified man." A case of this

nature is described, the patient being a raftsman, aged seventeen, who

suffered with inflammatory symptoms of the right great toe, which were

followed in the next ten years by progressive involvement of all the

joints of the extremities, and of the vertebrae and temporo-maxillary

articulations, with accompanying signs of acute articular rheumatism.

At the age of thirty-one the pains had subsided, leaving him completely

disabled. All the joints except the fingers and toes had become

ankylosed, and from nonusage the muscles had atrophied. There were no

dislocations, anesthesia, or bedsores, and the viscera were normal;

there were apparently no gouty deposits, as an examination of the urine

was negative.

J. R. Bass, the well-known "ossified man" of the dime museums, has been

examined by many physicians, and was quite intelligent and cheerful in

spite of his complete ankylosis. Figure 269 represents his appearance

in 1887.

Percy speaks of a man named Simoore, born in 1752, who at the age of

fifteen was afflicted with ankylosis of all the joints, and at

different angles He was unable to move even his jaw, and his teeth had

to be extracted in order to supply him with nourishment. Even his ribs

were ankylosed; his chest puffed up, and the breathing was entirely

abdominal. In spite of his infirmities, after his pains had ceased he

lived a comparatively comfortable life. His digestion was good, and his

excretory functions were sufficient. The urine always showed

phosphates, and never the slightest sign of free phosphoric acid. He

still retained his sexual feeling, and occasionally had erections. This

man died in 1802 at the age of fifty, asphyxia being the precursor of

death. His skeleton was deposited in the Museum of the ecole de

Medecine de Paris. In the same Museum there was another similar

skeleton, but in this subject there was motion of the head upon the

first vertebra, the lower jaw was intact, and the clavicle, arms, and

some of the digits of the right hand were movable.

An ossified man has been recently found and exhibited to the Paris

Academy of Medicine. He is a Roumanian Jew of thirty who began to

ossify twelve years ago, first up the right side of his back, then down

the left side. He has hardened now to the nape of the neck, his head is

turned to the left, and the jaws are ankylosed. He can still move his

arms and legs a little with great difficulty.

Akin to the foregoing condition is what is known as petrifaction or

ossification of portions of the living human body other than the

articulations. Of the older writers Hellwigius, Horstius, and Schurig

speak of petrifaction of the arm. In the Philosophical Transactions

there was a case recorded in which the muscles and ligaments were so

extensively converted into bone that all the joints were fixed, even

including the vertebrae, head, and lower jaw. In a short time this man

was, as it were, one single bone from his head to his knees, the only

joints movable being the right wrist and knee. For over a century there

has been in the Trinity College at Dublin the skeleton of a man who

died about 20 miles from the city of Cork. The muscles about the

scapula, and the dorsum of the ilium (the glutei) were converted into

great masses of bone, equal to the original muscles in thickness and

bulk. Half of the muscles of the hips and thighs were converted into

bone, and for a long time this specimen was the leading curiosity of

the Dublin Museum. In the Isle of Man, some years ago, there was a case

of ossification which continued progressively for many years. Before

death this man was reduced to almost a solid mass of bony substance.

With the exception of one or two toes his entire frame was solidified.

He was buried in Kirk Andreas Churchyard, and his grave was strictly

guarded against medical men by his friends, but the body was finally

secured and taken to Dublin by Dr. McCartney.

Calculi.--In reviewing the statistics of vesical calculi, the strangest

anomalies in their size and weight have been noticed. Among the older

writers the largest weights have been found. Le Cat speaks of a

calculus weighing over three pounds, and Morand is accredited with

having seen a calculus which weighed six pounds. In his statistics in

1883 Cross collected reports on 704 stones, and remarked that only nine

of these weighed above four ounces, and only two above six, and that

with the last two the patient succumbed. Of those removed successfully

Harmer of Norwich reports one of 15 ounces; Kline, one of 13 ounces 30

grains; Mayo of Winchester, 14 ounces two drams; Cheselden, 12 ounces;

and Pare in 1570 removed a calculus weighing nine ounces. Sir Astley

Cooper remarks that the largest stone he ever saw weighed four ounces,

and that the patient died within four hours after its removal. Before

the Royal Society of London in 1684 Birch reported an account of a

calculus weighing five ounces. Fabricius Hildanus mentions calculi

weighing 20 and 21 ounces; Camper, 13 ounces; Foschini, 19 ounces six

drams; Garmannus, 25 ounces; Greenfield, 19 ounces; Heberden, 32

ounces; Wrisberg, 20 ounces; Launai, 51 ounces; Lemery, 27 ounces;

Paget, in Kuhn's Journal, 27 ounces (from a woman); Pauli, 19 ounces;

Rudolphi, 28 ounces; Tozzetti, 39 ounces; Threpland, 35 ounces; and

there is a record of a calculus weighing over six pounds. There is

preserved in Trinity College, Cambridge, a stone weighing 34 ounces

taken from the bladder of the wife of Thomas Raisin, by Gutteridge, a

surgeon of Norwich. This stone was afterward sent to King Charles II

for inspection. In his "Journey to Paris" Dr. Lister said that he saw a

stone which weighed 51 ounces; it had been taken from one of the

religious brothers in June, 1690, and placed in the Hopital de la

Charite. It was said that the monk died after the operation. There is a

record of a calculus taken from the bladder of an individual living in

Aberdeen. This stone weighed two pounds, three ounces, and six drams.

In the Hunterian Museum in London there is a stone weighing 44 ounces,

and measuring 16 inches in circumference. By suprapubic operation

Duguise removed a stone weighing 31 ounces from a patient who survived

six days. A Belgian surgeon by the name of Uytterhoeven, by the

suprapubic method extracted a concretion weighing two pounds and

measuring 6 1/2 inches long and four wide. Frere Come performed a high

operation on a patient who died the next day after the removal of a

24-ounce calculus. Verduc mentions a calculus weighing three pounds

three ounces. It was said that a vesical calculus was seen in a dead

boy at St. Edmund's which was as large as the head of a new-born child.

It has been remarked that Thomas Adams, Lord Mayor of London, who died

at the age of eighty-two, had in his bladder at the time of his death a

stone which filled the whole cavity, and which was grooved from the

ureters to the urethral opening, thus allowing the passage of urine.

Recent records of large calculi are offered: by Holmes, 25 ounces;

Hunter, 25 ounces; Cayley, 29 ounces; Humphrys, 33 ounces; Eve, 44

ounces; and Janeway, 51 ounces. Kirby has collected reports ol a number

of large vesical calculi.

Barton speaks of stone in the bladder in very young children. There is

a record of a stone at one month, and another at three years. Todd

describes a stone in the bladder of a child of sixteen months. May

removed an enormous stone from a young girl, which had its nucleus in a

brass penholder over three inches long.

Multiple Vesical Calculi.--Usually the bladder contains a single

calculus, but in a few instances a large number of stones have been

found to coexist. According to Ashhurst, the most remarkable case on

record is that of the aged Chief Justice Marshal, from whose bladder

Dr. Physick of Philadelphia is said to have successfully removed by

lateral lithotomy more than 1000 calculi. Macgregor mentions a case in

which 520 small calculi coexisted with a large one weighing 51 ounces.

There is an old record of 32 stones having been removed from a man of

eighty-one, a native of Dantzic, 16 of which were as large as a

pigeon's egg. Kelly speaks of 228 calculi in the bladder of a man of

seventy-three, 12 being removed before death. The largest weighed 111

grains. Goodrich took 96 small stones from the bladder of a lad. Among

the older records of numerous calculi Burnett mentions 70; Desault,

over 200; the Ephemerides, 120; Weickman, over 100; Fabricius Hildanus,

2000 in two years; and there is a remarkable case of 10,000 in all

issuing from a young girl. Greenhow mentions 60 stones removed from the

bladder. An older issue of The Lancet contains an account of lithotrity

performed on the same patient 48 times.

Occasionally the calculi are discharged spontaneously. Trioen mentions

the issue of a calculus through a perineal aperture, and there are many

similar cases on record. There is an old record of a stone weighing

five ounces being passed by the penis. Schenck mentions a calculus

perforating the bladder and lodging in the groin. Simmons reports a

case in which a calculus passed through a fistulous sore in the loins

without any concomitant passage of urine through the same passage.

Vosberg mentions a calculus in a patent urachus; and calculi have

occasionally been known to pass from the umbilicus. Gourges mentions

the spontaneous excretion of a five-ounce calculus; and Thompson speaks

of the discharge of two calculi of enormous size.

Of the extravesical calculi some are true calculi, while others are

simply the result of calcareous or osseous degeneration. Renal and

biliary calculi are too common to need mention here. There are some

extraordinary calculi taken from a patient at St. Bartholomew's

Hospital and deposited in the museum of that institution. The patient

was a man of thirty-eight. In the right kidney were found a calculus

weighing 36 1/2 ounces, about 1000 small calculi, and a quantity of

calcareous dust. In the left kidney there was a calculus weighing 9 3/4

ounces, besides a quantity of calcareous dust. The calculi in this case

consisted chiefly of phosphate of magnesium and ammonium. Cordier of

Kansas City, Mo., successfully removed a renal calculus weighing over

three ounces from a woman of forty-two. The accompanying illustration

shows the actual size of the calculus.

At the University College Hospital, London, there are exhibited 485

gall-stones that were found postmortem in a gall-bladder. Vanzetti

reports the removal of a preputial calculus weighing 224 grams.

Phillipe mentions the removal of a calculus weighing 50 grams from the

prepuce of an Arab boy of seven. Croft gives an account of some

preputial calculi removed from two natives of the Solomon Islands by an

emigrant medical officer in Fiji. In one case 22 small stones were

removed, and in the other a single calculus weighing one ounce 110

grains. Congenital phimosis is said to be very common among the natives

of Solomon Islands.

In September, 1695, Bernard removed two stones from the meatus

urinarius of a man, after a lodgment of twenty years. Block mentions a

similar case, in which the lodgment had lasted twenty-eight years.

Walton speaks of a urethral calculus gradually increasing in size for

fifty years. Ashburn shows what he considers the largest calculus ever

removed from the urethra. It was 2 1/8 inches long, and 1 1/4 inches

in diameter; it was white on the outside, very hard, and was shaped and

looked much like a potato. Its dry weight was 660 grains. At one end

was a polished surface that corresponded with a similar surface on a

smaller stone that lay against it; the latter calculus was shaped like

a lima bean, and weighed 60 grains. Hunt speaks of eight calculi

removed from the urethra of a boy of five. Herman and the Ephemerides

mention cases of calculi in the seminal vesicles.

Calcareous degeneration is seen in the ovary, and Peterman speaks of a

stone in the ovary. Uterine calculi are described by Cuevas and Harlow;

the latter mentions that the calculus he saw was egg-shaped. There is

an old chronicle of a stone taken from the womb of a woman near Trent,

Somersetshire, at Easter, 1666, that weighed four ounces. The

Ephemerides speaks of a calculus coming away with the menstrual fluid.

Stones in the heart are mentioned by medical writers, and it is said

that two stones as large as almonds were found in the heart of the Earl

of Balcarres.

Morand speaks of a calculus ejected from the mouth by a woman.

An old record says that stones in the brain sometimes are the cause of

convulsions. D'Hericourt reports the case of a girl who died after six

months' suffering, whose pineal gland was found petrified, and the

incredible size of a chicken's egg. Blasius, Diemerbroeck, and the

Ephemerides, speak of stones in the location of the pineal gland.

Salivary calculi are well known; they may lodge in any of the buccal

ducts. There is a record of the case of a man of thirty-seven who

suffered great pain and profuse salivation. It was found that he had a

stone as large as a pigeon's egg under his tongue.

Umbilical calculi are sometimes seen, and Deani reports such a case.

There is a French record of a case of exstrophy of the umbilicus,

attended with abnormal concretions.

Aetius, Marcellus Donatus, Scaliger, and Schenck mention calculi of the

eyelids.

There are some extraordinary cases of retention and suppression of

urine on record. Actual retention of urine, that is, urinary secretion

passed into the bladder, but retention in the latter viscus by

inanition, stricture, or other obstruction, naturally cannot continue

any great length of time without mechanically rupturing the vesical

walls; but suppression of urine or absolute anuria may last an

astonishingly extended period. Of the cases of retention of urine,

Fereol mentions that of a man of forty-nine who suffered absolute

retention of urine for eight days, caused by the obstruction of a uric

acid calculus. Cunyghame reports a ease of mechanic obstruction of the

flow of urine for eleven days. Trapenard speaks of retention of urine

for seven days. Among the older writers Bartholinus mentions ischuria

lasting fourteen days; Cornarius, fourteen days; Rhoclius, fifteen

days; the Ephemerides, ten, eleven, and twelve days. Croom notes a case

of retention of urine from laceration of the vagina during first

coitus. Foucard reports a case of retention of urine in a young girl of

nineteen, due to accumulation of the menstrual fluid behind an

imperforate hymen.

The accumulation of urine in cases of ischuria is sometimes quite

excessive. De Vilde speaks of 16 pints being drawn off. Mazoni cites a

case in which 15 pounds of urine were retained; and Wilson mentions 16

pounds of urine being drawn off. Frank reports instances in which both

12 and 30 pounds of urine were evacuated. There is a record at the

beginning of this century in which it is stated that 31 pounds of urine

were evacuated in a case of ischuria.

Following some toxic or thermic disturbance, or in diseased kidneys,

suppression of urine is quite frequently noticed. The older writers

report some remarkable instances: Haller mentions a case lasting

twenty-two weeks; Domonceau, six months; and Marcellus Donatus, six

months.

Whitelaw describes a boy of eight who, after an attack of scarlet

fever, did not pass a single drop of urine from December 7th to

December 20th when two ounces issued, after vesication over the

kidneys. On January 2d two ounces more were evacuated, and no more was

passed until the bowel acted regularly. On January 5th a whole pint of

urine passed; after that the kidneys acted normally and the boy

recovered. It would be no exaggeration to state that this case lasted

from December 5th to January 5th, for the evacuations during this

period were so slight as to be hardly worthy of mention.

Lemery reports observation of a monk who during eight years vomited

periodically instead of urinating in a natural way. Five hours before

vomiting he experienced a strong pain in the kidneys. The vomitus was

of dark-red color, and had the odor of urine. He ate little, but drank

wine copiously, and stated that the vomiting was salutary to him, as he

suffered more when he missed it.

Bryce records a case of anuria of seventeen days' standing. Butler

speaks of an individual with a single kidney who suffered suppression

of urine for thirteen days, caused by occlusion of the ureter by an

inspissated thrombus. Dubuc observed a case of anuria which continued

for seventeen days before the fatal issue. Fontaine reports a case of

suppression of urine for twenty-five days. Nunneley showed the kidneys

of a woman who did not secrete any urine for a period of twelve days,

and during this time she had not exhibited any of the usual symptoms of

uremia. Peebles mentions a case of suspension of the functions of the

kidneys more than once for five weeks, the patient exhibiting neither

coma, stupor, nor vomiting. Oke speaks of total suppression of urine

during seven days, with complete recovery; and Paxon mentions a case in

a child that recovered after five days' suppression. Russell reports a

case of complete obstructive suppression for twenty days followed by

complete recovery. Scott and Shroff mention recovery after nine days'

suppression.

The most persistent constipation may exist for weeks, or even months,

with fair health. The fact seemed to be a subject of much interest to

the older writers. De Cabalis mentions constipation lasting

thirty-seven days; Caldani, sixty-five days; Lecheverel, thirty-four

days; and Pomma, eight months; Sylvaticus, thirty months; Baillie,

fifteen weeks; Blanchard, six weeks; Smetius, five mouths; Trioen,

three months; Devilliers, two years; and Gignony, seven years. Riverius

mentions death following constipation of one month, and says that the

intestines were completely filled. Moosman mentions death from the same

cause in sixty days. Frank speaks of constipation from intestinal

obstructions lasting for three weeks, and Manget mentions a similar

case lasting three months.

Early in the century Revolat reported in Marseilles an observation of

an eminently nervous subject addicted to frequent abuse as regards

diet, who had not had the slightest evacuation from the bowel for six

months. A cure was effected in this case by tonics, temperance,

regulation of the diet, etc. In Tome xv of the Commentaries of Leipzig

there is an account of a man who always had his stercoral evacuations

on Wednesdays, and who suffered no evil consequences from this

abnormality. This state of affairs had existed from childhood, and, as

the evacuations were abundant and connected, no morbific change or

malformation seemed present. The other excretions were slightly in

excess of the ordinary amount. There are many cases of constipation on

record lasting longer than this, but none with the same periodicity and

without change in the excrement. Tommassini records the history of a

man of thirty, living an ordinary life, who became each year more

constipated. Between the ages of twenty and twenty-four the evacuations

were gradually reduced to one in eight or ten days, and at the age of

twenty-six, to one every twenty-two days. His leanness increased in

proportion to his constipation, and at thirty his appetite was so good

that he ate as much as two men. His thirst was intense, but he secreted

urine natural in quantity and quality. Nothing seemed to benefit him,

and purgatives only augmented his trouble. His feces came in small,

hard balls. His tongue was always in good condition, the abdomen not

enlarged, the pulse and temperature normal.

Emily Plumley was born on June 11,1850, with an imperforate anus, and

lived one hundred and two days without an evacuation. During the whole

period there was little nausea and occasional regurgitation of the

mother's milk, due to over-feeding. Cripps mentions a man of forty-two

with stricture of the rectum, who suffered complete intestinal

obstruction for two months, during which time he vomited only once or

twice. His appetite was good, but he avoided solid food. He recovered

after the performance of proctotomy.

Fleck reports the case of a Dutchman who, during the last two years, by

some peculiar innervation of the intestine, had only five or six bowel

movements a year. In the intervals the patient passed small quantities

of hard feces once in eight or ten days, but the amount was so small

that they constituted no more than the feces of one meal. Two or three

days before the principal evacuation began the patient became ill and

felt uncomfortable in the back; after sharp attacks of colic he would

pass hard and large quantities of offensive feces. He would then feel

better for two or three hours, when there would be a repetition of the

symptoms, and so on until he had four or five motions that day. The

following day he would have a slight diarrhea and then the bowels would

return to the former condition. The principal fecal accumulations were

in the ascending and transverse colon and not only could be felt but

seen through the abdominal wall. The patient was well nourished and had

tried every remedy without success. Finally he went to Marienbad where

he drank freely of the waters and took the baths until the bowel

movements occurred once in two or three days.

There is a record of a man who stated that for two years he had not

passed his stool by the anus, but that at six o'clock each evening he

voided feces by the mouth. His statement was corroborated by

observation. At times the evacuation took place without effort, but was

occasionally attended with slight pain in the esophagus and slight

convulsions. Several hours before the evacuation the abdomen was hard

and distended, which appearance vanished in the evening. In this case

there was a history of an injury in the upper iliac region.

The first accurate ideas in reference to elephantiasis arabum are given

by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account

that the disease received the name elephantiasis arabum. The disease

was afterward noticed by Forestus, Mercurialis, Kaempfer, Ludoff, and

others. In 1719 Prosper Alpinus wrote of it in Egypt, and the medical

officers of the French army that invaded Egypt became familiar with it;

since then the disease has been well known.

Alard relates as a case of elephantiasis that of a lady of Berlin,

mentioned in the Ephemerides of 1694, who had an abdominal tumor the

lower part of which reached to the knees. In this case the tumor was

situated in the skin and no vestige of disease was found in the

abdominal cavity and no sensible alteration had taken place in the

veins. Delpech quotes a similar case of elephantiasis in the walls of

the abdomen in a young woman of twenty-four, born at Toulouse.

Lymphedema, or elephantiasis arabum, is a condition in which, in the

substance of a limb or a part, there is diffused dilatation of the

lymphatics, with lymphostasis. Such a condition results when there is

obstruction of so large a number of the ducts converging to the root of

the extremity or part that but little relief through collateral trunks

is possible. The affected part becomes swollen and hardened, and

sometimes attains an enormous size. It is neither reducible by position

nor pressure. There is a corresponding dilatation and multiplication of

the blood-vessels with the connective-tissue hypertrophy. The muscles

waste, the skin becomes coarse and hypertrophied. The swollen limb

presents immense lobulated masses, heaped up at different parts,

separated from one another by deep sulci, which are especially marked

at the flexures of the joints. Although elephantiasis is met with in

all climates, it is more common in the tropics, and its occurrence has

been repeatedly demonstrated in these localities to be dependent on the

presence in the lymphatics of the filaria sanguinis hominis. The

accompanying illustration shows the condition of the limb of a girl of

twenty-one, the subject of lymphedema, five years after the inception

of the disease. The changes in the limb were as yet moderate. The

photograph from which the cut was made was taken in 1875 At the present

time (seventeen years later) the case presents the typical condition of

the worst form of elephantiasis. Repeated attacks of lymphangitis have

occurred during this period, each producing an aggravation of the

previous condition. The leg below the knee has become enormously

deformed by the production of the elephantoid masses; the outer side of

the thigh remains healthy, but the skin of the inner side has developed

so as to form a very large and pendant lobulated mass. A similar

condition has begun to develop in the other leg, which is row about in

the condition of the first, as shown in the figure. Figure 273

represents this disease in its most aggravated form, a condition rarely

observed in this country. As an example of the change in the weight of

a person after the inception of this disease, we cite a case reported

by Griffiths. The patient was a woman of fifty-two who, five years

previous, weighed 148 pounds. The elephantoid change was below the

waist, yet at the time of report the woman weighed 387 pounds. There

was little thickening of the skin. The circumference of the calf was 28

inches; of the thigh, 38 inches; and of the abdomen, 80 inches; while

that of the arm was only 15 inches.

The condition commonly known as "Barbadoes leg" is a form of

elephantiasis deriving its name from its relative frequency in

Barbadoes.

Figure 275 represents a well-known exhibitionist who, from all

appearances, is suffering from an elephantoid hypertrophy of the lower

extremities, due to a lymphedema. Quite a number of similar

exhibitionists have been shown in recent years, the most celebrated of

whom was Falmy Mills, one of whose feet alone was extensively involved,

and was perhaps the largest foot ever seen.

Elephantiasis seldom attacks the upper extremities. Of the older cases

Rayer reports four collected by Alard. In one case the hard and

permanent swelling of the arm occurred after the application of a

blister; in another the arm increased so that it weighed more than 200

Genoese pounds, 40 of which consisted of serum. The swellings of the

arm and forearm resembled a distended bladder. The arteries, veins,

and nerves had not undergone any alteration, but the lymphatics were

very much dilated and loaded with lymph.

The third case was from Fabricius Hildanus, and the fourth from Hendy.

Figure 276 represents a remarkable elephantoid change in the hand of an

elderly German woman. Unfortunately there is no medical description of

the case on record, but the photograph is deemed worthy of reproduction.

Terry describes a French mulatto girl of eleven whose left hand was

enormously increased in weight and consistency, the chief enlargement

being in the middle finger, which was 6 1/2 inches long, and 5 1/2

inches about the nail, and 8 1/2 around the base of the finger. The

index finger was two inches thick and four inches long, twisted and

drawn, while the other fingers were dwarfed. The elephantiasis in this

case slowly and gradually increased in size until the hand weighed 3

1/2 pounds. The skin of the affected finger, contrary to the general

appearance of a part affected with elephantiasis, was of normal color,

smooth, shiny, showed no sensibility, and the muscles had undergone

fatty degeneration. It was successfully amputated in August, 1894. The

accompanying illustration shows a dorsal view of the affected hand.

Magalhaes of Rio Janeiro reports a very interesting case of

elephantiasis of the scalp, representing dermatolysis, in which the

fold of hypertrophied skin fell over the face like the hide of an

elephant, somewhat similar in appearance to the "elephant-man." Figure

279 represents a somewhat similar hypertrophic condition of the scalp

and face reported in the Photographic Review of Medicine and Surgery,

1870.

Elephantiasis of the face sometimes only attacks it on one side. Such

a case was reported by Alard, in which the elephantiasis seems to have

been complicated with eczema of the ear. Willier, also quoted by Alard,

describes a remarkable case of elephantiasis of the face. After a

debauch this patient experienced violent pain in the left cheek below

the zygomatic arch; this soon extended under the chin, and the

submaxillary glands enlarged and became painful; the face swelled and

became erythematous, and the patient experienced nausea and slight

chills. At the end of six months there was another attack, after which

the patient perceived that the face continued puffed. This attack was

followed by several others, the face growing larger and larger. In

similar cases tumefaction assumes enormous proportions, and Schenck

speaks of a man whose head exceeded that of an ox in size, the lower

part of the face being entirely covered with the nose, which had to be

raised to enable its unhappy owner to breathe.

Rayer cites two instances in which elephantiasis of the breast enlarged

these organs to such a degree that they hung to the knees. Salmuth

speaks of a woman whose breasts increased to such a size that they hung

down to her knees. At the same time she had in both axillae glandular

tumors as large as the head of a fetus. Borellus also quotes the case

of a woman whose breasts became so large that it was necessary to

support them by straps, which passed over the shoulders and neck.

Elephantiasis is occasionally seen in the genital regions of the

female, but more often in the scrotum of the male, in which location it

produces enormous tumors, which sometimes reach to the ground and

become so heavy as to prevent locomotion. This condition is curious in

the fact that these immense tumors have been successfully removed, the

testicles and penis, which had long since ceased to be distinguished,

saved, and their function restored. Alibert mentions a patient who was

operated upon by Clot-Bey, whose scrotum when removed weighed 110

pounds; the man had two children after the disease had continued for

thirteen years, but before it had obtained its monstrous development--a

proof that the functions of the testicles had not been affected by the

disease.

There are several old accounts of scrotal tumors which have evidently

been elephantoid in conformation. In the Ephemerides in 1692 there was

mentioned a tumor of the scrotum weighing 200 pounds. In the West

Indies it was reported that rats have been known to feed on these

enormous tumors, while the deserted subjects lay in a most helpless

condition. Larrey mentioned a case of elephantiasis of the scrotum in

which the tumor weighed over 200 pounds. Sir Astley Cooper removed a

tumor of 56 pounds weight from a Chinese laborer. It extended from

beneath the umbilicus to the anterior border of the anus; it had begun

in the prepuce ten years previously. Clot-Bey removed an elephantoid

tumor of the scrotum weighing 80 pounds, performing castration at the

same time. Alleyne reports a case of elephantiasis, in which he

successfully removed a tumor of the integuments of the scrotum and

penis weighing 134 pounds.

Bicet mentions a curious instance of elephantiasis of the penis and

scrotum which had existed for five years. The subject was in great

mental misery and alarm at his unsightly condition. The parts of

generation were completely buried in the huge mass. An operation was

performed in which all of the diseased structures that had totally

unmanned him were removed, the true organs of generation escaping

inviolate. Thebaud mentions a tumor of the scrotum, the result of

elephantiasis, which weighed 63 1/2 pounds. The weight was ascertained

by placing the tumor on the scales, and directing the patient to squat

over them without resting any weight of the body on the scales. This

man could readily feel his penis, although his surgeons could not do

so. The bladder was under perfect control, the urine flowing over a

channel on the exterior of the scrotum, extending 18 inches from the

meatus. Despite his infirmity this patient had perfect sexual desire,

and occasional erections and emissions. A very interesting operation

was performed with a good recovery.

Partridge reports an enormous scrotal tumor which was removed from a

Hindoo of fifty-five, with subsequent recovery of the subject. The

tumor weighed 111 1/2 pounds. The ingenious technic of this operation

is well worth perusal by those interested. Goodman successfully

removed an elephantiasis of the scrotum from a native Fiji of

forty-five. The tumor weighed 42 pounds, without taking into

consideration the weight of the fluid which escaped in abundance during

the operation and also after the operation, but before it was weighed.

Van Buren and Keyes mention a tumor of the scrotum of this nature

weighing 165 pounds. Quoted by Russell, Hendy describes the case of a

negro who had successive attacks of glandular swelling of the scrotum,

until finally the scrotum was two feet long and six feet in

circumference. It is mentioned that mortification of the part caused

this patient's ultimate death.

Figure 281 is taken from a photograph loaned to the authors by Dr.

James Thorington. The patient was a native of Fiji, and was

successfully operated on, with preservation of the testes. The tumor,

on removal, weighed 120 pounds.

W. R. Browne, Surgeon-General, reports from the Madras General Hospital

an operation on a patient of thirty-five with elephantoid scrotum of

six years' duration. The proportions of the scrotum were as follows:

Horizontally the circumference was six feet 6 1/2 inches, and

vertically the circumference was six feet ten inches. The penis was

wholly hidden, and the urine passed from an opening two feet 5 1/2

inches from the pubis. The man had complete control of his bladder, but

was unable to walk. The operation for removal occupied one hour and

twenty minutes, and the tumor removed weighed 124 3/4 pounds. Little

blood was lost on account of an elastic cord tied about the neck of the

tumor, and secured by successful removal of a scrotal tumor weighing 56

pounds.

Fenger describes a case of the foregoing nature in a German of

twenty-three, a resident of Chicago. The growth had commenced eight

years previously, and had progressively increased. There was no pain or

active inflammation, and although the patient had to have especially

constructed trousers he never ceased his occupation as a driver. The

scrotum was represented by a hairless tumor weighing 22 pounds, and

hanging one inch below the knees. No testicles or penis could be made

out. Fenger removed the tumor, and the man was greatly improved in

health. There was still swelling of the inguinal glands on both sides,

but otherwise the operation was very successful. The man's mental

condition also greatly improved. Fenger also calls especial attention

to the importance of preserving the penis and testes in the operation,

as although these parts may apparently be obliterated their functions

are undisturbed.

The statistics of this major operation show a surprisingly small

mortality. Fayrer operated on 28 patients with 22 recoveries and six

deaths, one from shock and five from pyemia The same surgeon collected

193 cases, and found the general mortality to be 18 per cent. According

to Ashhurst, Turner, who practiced as a medical missionary in the

Samoan Islands, claims to have operated 136 times with only two deaths.

McLeod, Fayrer's successor in India, reported 129 cases with 23 deaths.

Early in this century Rayer described a case of elephantiasis in a boy

of seventeen who, after several attacks of erysipelas, showed marked

diminution of the elephantoid change; the fact shows the antagonism of

the streptococcus erysipelatis to hypertrophic and malignant processes.

Acromegaly is a term introduced by Marie, and signifies large

extremities. It is characterized by an abnormally large development of

the extremities and of the features of the face,--the bony as well as

the soft parts. In a well-marked case the hands and feet are greatly

enlarged, but not otherwise deformed, and the normal functions are not

disturbed. The hypertrophy involves all the tissues, giving a curious

spade-like appearance to the hands. The feet are similarly enlarged,

although the big toe may be relatively much larger. The nails also

become broad and large. The face increases in volume and becomes

elongated, in consequence of the hypertrophy of the superior and

inferior maxillary bones. The latter often projects beyond the upper

teeth. The teeth become separated, and the soft parts increase in size.

The nose is large and broad, and the skin of the eyelids and ears is

enormously hypertrophied. The tongue is greatly hypertrophied. The

disease is of long duration, and late in the history the bones of the

spine and thorax may acquire great deformity. As we know little of the

influences and sources governing nutrition, the pathology and etiology

of acromegaly are obscure. Marie regards the disease as a systemic

dystrophy analogous to myxedema, due to a morbid condition of the

pituitary body, just as myxedema is due to disease of the thyroid. In

several of the cases reported the squint and optic atrophy and the

amblyopia have pointed to the pituitary body as the seat of a new

growth of hypertrophy. Pershing shows a case of this nature. The

enlargement of the face and extremities was characteristic, and the

cerebral and ocular symptoms pointed to the pituitary body as the seat

of the lesion. Unverricht, Thomas, and Ransom report cases in which the

ocular lesions, indicative of pituitary trouble, were quite prominent.

Of 22 cases collected by Tamburini 19 showed some change in the

pituitary body, and in the remaining three cases either the diagnosis

was uncertain or the disease was of very short duration. Linsmayer

reported a case in which there was a softened adenoma in the pituitary

body, and the thymus was absent.

Hersman reports an interesting case of progressive enlargement of the

hands in a clergyman of fifty. Since youth he had suffered with pains

in the joints. About three years before the time of report he noticed

enlargement of the phalangeal joint of the third finger of the right

hand. A short time later the whole hand became gradually involved and

the skin assumed a darker hue. Sensation and temperature remained

normal in both hands; acromegaly was excluded on account of the absence

of similar changes elsewhere. Hersman remarks that the change was

probably due to increase in growth of the fibrous elements of the

subcutaneous lesions about the tendons, caused by rheumatic poison.

Figure 283 shows the palmer and dorsal surfaces of both hands.

Chiromegaly is a term that has been applied by Charcot and Brissaud to

the pseudoacromegaly that sometimes occurs in syringomyelia. Most of

the cases that have been reported as a combination of these two

diseases are now thought to be only a syringomyelia. A recent case is

reported by Marie. In this connection it is interesting to notice a

case of what might be called acute symptomatic transitory

pseudoacromegaly, reported by Potovski: In an insane woman, and without

ascertainable cause, there appeared an enlargement of the ankles,

wrists, and shoulders, and later of the muscles, with superficial

trophic disturbances that gradually disappeared. The author excludes

syphilis, tuberculosis, rheumatism, gout, hemophilia, etc., and

considers it to have been a trophic affection of cerebral origin.

Cases of pneumonia osteoarthropathy simulating acromegaly have been

reported by Korn and Murray.

Megalocephaly, or as it was called by Virchow, leontiasis ossea, is due

to a hypertrophic process in the bones of the cranium. The cases

studied by Virchow were diffuse hyperostoses of the cranium. Starr

describes what he supposes to be a case of this disease, and proposes

the title megalocephaly as preferable to Virchow's term, because the

soft parts are also included in the hypertrophic process. A woman of

fifty-two, married but having no children, and of negative family

history, six years before the time of report showed the first symptoms

of the affection, which began with formication in the finger-tips. This

gradually extended to the shoulders, and was attended with some

uncertainty of tactile sense and clumsiness of movement, but actual

anesthesia had never been demonstrated. This numbness had not invaded

the trunk or lower extremities, although there was slight uncertainty

in the gait. There had been a slowly progressing enlargement of the

head, face, and neck, affecting the bone, skin, and subcutaneous

tissues, the first to the greatest degree. The circumference of the

neck was 16 inches; the horizontal circumference of the head was 24

inches; from ear to ear, over the vertex, 16 inches; and from the root

of the nose to the occipital protuberance, 16 inches. The cervical

vertebrae were involved, and the woman had lost five inches in height.

It may be mentioned here that Brissaud and Meige noticed the same loss

in height, only more pronounced, in a case of gigantism, the loss being

more than 15 inches. In Starr's case the tongue was normal and there

was no swelling of the thyroid.

Cretinism is an endemic disease among mountainous people who drink

largely of lime water, and is characterized by a condition of physical,

physiologic, and mental degeneracy and nondevelopment, and possibly

goiter. The subjects of this disease seldom reach five feet in height,

and usually not more than four. The word cretin is derived from the

Latin creatura. They are found all over the world. In Switzerland it is

estimated that in some cantons there is one cretin to every 25

inhabitants. In Styria, the Tyrol, and along the Rhine cretins are

quite common, and not long since cases existed in Derbyshire. These

creatures have been allowed to marry and generate, and thus extend

their species. In "Le Medicin de Campagne," Balzac has given a vivid

picture of the awe and respect in which they were held and the way in

which they were allowed to propagate. Speaking of the endemic cretins,

Beaupre says: "I see a head of unusual form and size, a squat and

bloated figure, a stupid look, bleared, hollow, and heavy eyes, thick,

projecting eyelids, and a flat nose. His face is of a leaden hue, his

skin dirty, flabby, covered with tetters, and his thick tongue hangs

down over his moist, livid lips; his mouth, always open and full of

saliva, shows teeth going to decay. His chest is narrow, his back

curved, his breath asthmatic, his limbs short, misshapen, without

power. The knees are thick and inclined inward, the feet flat. The

large head droops listlessly on the breast; the abdomen is like a bag."

The cretin is generally deaf and dumb, or only able to give a hoarse

cry. He is indifferent to heat and cold, and even to the most revolting

odors. The general opinion has always been that the sexual desire and

genital organs are fully developed.

A quotation under our observation credits Colonel Sykes with the

following statistics of cretinism, which show how in some locations it

may be a decided factor of population. In December, 1845, in a

population of 2,558,349 souls (the locality not mentioned), there were

18,462 people with simple goiter. Of the cretins without goiter there

were 2089. Of cretins with goiter there were 3909; and cretins in which

goiter was not stated 962, making a total of 6960. Of these 2185 had

mere animal instincts; 3531 possessed very small intellectual

faculties; 196 were almost without any; 1048 not classified. Of this

number 2483 were born of healthy and sane fathers; 2285 from healthy

mothers; 961 from goitrous fathers; 1267 from goitrous mothers; 49 from

cretin fathers; 41 from cretin mothers; 106 from cretin fathers with

goiter; 66 from cretin mothers with goiter; 438 fathers and 405 mothers

were not specified.

Sporadic cretinism, or congenital myzedema, is characterized by a

congenital absence of the thyroid, diminutiveness of size, thickness of

neck, shortness of arms and legs, prominence of the abdomen, large size

of the face, thickness of the lips, large and protruding tongue, and

imbecility or idiocy. It is popularly believed that coitus during

intoxication is the cause of this condition. Osler was able to collect

11 or 12 cases in this country. The diagnosis is all-important, as the

treatment by the thyroid extract produces the most noteworthy results.

There are several remarkable recoveries on record, but possibly the

most wonderful is the case of J. P. West of Bellaire, Ohio, the

portraits of which are reproduced in Plate 11. At seventeen months the

child presented the typical appearance of a sporadic cretin. The

astonishing results of six months' treatment with thyroid extract are

shown in the second figure. After a year's treatment the child presents

the appearance of a healthy and well-nourished little girl.

Myxedema proper is a constitutional condition due to the loss of the

function of the thyroid gland. The disease was first described by Sir

William Gull as a cretinoid change, and later by William Ord of London,

who suggested the name. It is characterized clinically by a

myxedematous condition of the subcutaneous tissues and mental failure,

and anatomically by atrophy of the thyroid gland. The symptoms of

myxedema, as given by Ord, are marked increase in the general bulk of

the body, a firm, inelastic swelling of the skin, which does not pit on

pressure; dryness and roughness which tend, with swelling, to

obliterate the lines of expression in the face; imperfect nutrition of

the hair; local tumefaction of the skin and subcutaneous tissues,

particularly in the supraclavicular region. The physiognomy is

remarkably altered; the features are coarse and broad, the lips thick,

the nostrils broad and thick, and the mouth enlarged. There is a

striking slowness of thought and of movement; the memory fails, and

conditions leading to incipient dementia intervene. The functions of

the thoracic and abdominal organs seem to be normal, and death is

generally due to some intercurrent disease, possibly tuberculosis. A

condition akin to myxedema occurs after operative removal of the

thyroid gland.

In a most interesting lecture Brissaud shows the intimate relation

between myxedema, endemic cretinism, sporadic cretinism, or

myxedematous idiocy, and infantilism. He considers that they are all

dependent upon an inherited or acquired deficiency or disease of the

thyroid gland, and he presents cases illustrating each affection.

Figure 285 shows a case of myxedema, one of myxedema in a case of

arrested development--a transition case between myxedema of the adult

and sporadic cretinism--and a typical case of sporadic cretinism.

Cagots are an outcast race or clan of dwarfs in the region of the

Pyrenees, and formerly in Brittany, whose existence has been a

scientific problem since the sixteenth century, at which period they

were known as Cagots, Gahets, Gafets, Agotacs, in France; Agotes or

Gafos, in Spain; and Cacous, in Lower Brittany. Cagot meant the dog of

a Goth; they were of supposed Gothic origin by some, and of Tartar

origin by others. These people were formerly supposed to have been the

descendants of lepers, or to have been the victims of leprosy

themselves. From the descriptions there is a decided difference between

the Cagots and the cretins. In a recent issue of Cosmos a writer

describes Cagots as follows:--

"They inhabit the valley of the Ribas in the northwestern part of the

Spanish province now called Gerona. They never exceed 51 1/2 inches in

height, and have short, ill-formed legs, great bellies, small eyes,

flat noses, and pale, unwholesome complexions. They are usually stupid,

often to the verge of idiocy, and much subject to goiter and scrofulous

affections. The chief town of the Ribas Valley is Ribas, a place of

1500 inhabitants, about 800 feet above sea-level. The mountains rise

about the town to a height of from 6000 to 8000 feet, and command an

amazingly beautiful panorama of mountain, plain, and river, with

Spanish cities visible upon the one side and French upon the other. The

region is rich, both agriculturally and minerally, and is famous for

its medicinal springs. In this paradise dwell the dwarfs, perhaps as

degraded a race of men and women as may be found in any civilized

community. They are almost without education, and inhabit wretched huts

when they have any shelter. The most intelligent are employed as

shepherds, and in summer they live for months at an elevation of more

than 6000 feet without shelter. Here they see no human creature save

some of their own kind, often idiots, who are sent up every fifteen or

twenty days with a supply of food.

"It is said that formal marriage is almost unknown among them. The

women in some instances are employed in the village of Ribas as nurses

for children, and as such are found tender and faithful. Before

communication throughout the region was as easy as it is now, it was

thought lucky to have one of these dwarfs in a family, and the dwarfs

were hired out and even sold to be used in beggary in neighboring

cities. There are somewhat similar dwarfs in other valleys of the

Pyrenees, but the number is decreasing, and those of the Ribas Valley

are reduced to a few individuals."

Hiccough is a symptom due to intermittent, sudden contraction of the

diaphragm. Obstinate cases are most peculiar, and sometimes exhaust the

physician's skill. Symes divides these cases into four groups:--

(1) Inflammatory, seen particularly in inflammatory diseases of the

viscera or abdominal membranes, and in severe cases of typhoid fever.

(2) Irritative, as in direct stimulus of the diaphragm in swallowing

some very hot substance; local disease of the esophagus near the

diaphragm, and in many conditions of gastric and intestinal disorder,

more particularly those associated with flatus.

(3) Specific or idiopathic, in which there are no evident causes

present; it is sometimes seen in cases of nephritis and diabetes.

(4) Neurotic, in which the primary cause is in the nervous

system,--hysteria, epilepsy, shock, or cerebral tumors.

The obstinacy of continued hiccough has long been discussed. Osler

calls to mind that in Plato's "Symposium" the physician, Eryximachus,

recommended to Aristophanes, who had hiccough from eating too much,

either to hold his breath or to gargle with a little water; but if it

still continued, "tickle your nose with something and sneeze, and if

you sneeze once or twice even the most violent hiccough is sure to go."

The attack must have been a severe one, as it is stated subsequently

that the hiccough did not disappear until Aristophanes had excited the

sneezing.

Among the older medical writers Weber speaks of singultus lasting for

five days; Tulpius, for twelve days; Eller and Schenck, for three

months; Taranget, for eight months; and Bartholinus, for four years.

At the present day it is not uncommon to read in the newspapers

accounts of prolonged hiccoughing. These cases are not mythical, and

are paralleled by a number of instances in reliable medical literature.

The cause is not always discernible, and cases sometimes resist all

treatment.

Holston reports a case of chronic singultus of seven years' standing.

It had followed an attack of whooping-cough, and was finally cured

apparently by the administration of strychnin. Cowan speaks of a

shoemaker of twenty-two who experienced an attack of constant singultus

for a week, and then intermittent attacks for six years. Cowan also

mentions instances of prolonged hiccough related by Heberden, Good,

Hoffman, and Wartmouth. Barrett is accredited with reporting a case of

persistent hiccough in a man of thirty-five. Rowland speaks of a man of

thirty-five who hiccoughed for twelve years. The paroxysms were almost

constant, and occurred once or twice a minute during the hours when the

man was not sleeping. There was no noise with the cough. There is

another case related in the same journal of a man who died on the

fourth day of an attack of singultus, probably due to abscess of the

diaphragm, which no remedy would relieve. Moore records a case of a

child, injured when young, who hiccoughed until about twenty years of

age (the age at the time of report). Foot mentions a lad of fifteen

who, except when asleep, hiccoughed incessantly for twenty-two weeks,

and who suffered two similar, but less severe, attacks in the summer of

1879, and again in 1880. The disease was supposed to be due to the

habit of pressing the chest against the desk when at school. Dexter

reports a case of long-continued singultus in an Irish girl of

eighteen, ascribed to habitual masturbation. There was no intermission

in the paroxysm, which increased in force until general convulsions

ensued. The patient said that the paroxysm could be stopped by firm

pressure on the upper part of the external genital organs. Dexter

applied firm pressure on her clitoris, and the convulsions subsided,

and the patient fell asleep. They could be excited by firm pressure on

the lower vertebrae. Corson speaks of a man of fifty-seven who, after

exposure to cold, suffered exhausting hiccough for nine days; and also

records the case of an Irish servant who suffered hiccough for four

months; the cause was ascribed to fright. Stevenson cites a fatal

instance of hiccough in a stone-mason of forty-four who suffered

continuously from May 14th to May 28th. The only remedy that seemed to

have any effect in this case was castor-oil in strong purgative doses.

Willard speaks of a man of thirty-four who began to hiccough after an

attack of pneumonia, and continued for eighty-six hours. The treatment

consisted of the application of belladonna and cantharides plasters,

bismuth, and lime-water, camphor, and salts of white hellebore inhaled

through the nose in finest powder. Two other cases are mentioned by the

same author. Gapper describes the case of a young man who was seized

with loud and distressing hiccough that never ceased for a minute

during eighty hours. Two ounces of laudanum were administered in the

three days without any decided effect, producing only slight languor.

Ranney reports the case of an unmarried woman of forty-four who

suffered from paroxysms of hiccough that persisted for four years. A

peculiarity of this attack was that it invariably followed movements of

the upper extremities. Tenderness and hyperesthesia over the spinous

processes of the 4th, 5th, and 6th cervical vertebrae led to the

application of the thermocautery, which, in conjunction with the

administration of ergot and bromide, was attended with marked benefit,

though not by complete cure. Barlow mentions a man with a rheumatic

affection of the shoulder who hiccoughed when he moved his joints.

Barlow also recites a case of hiccough which was caused by pressure on

the cicatrix of a wound in the left hand.

Beilby reports a peculiar case in a girl of seventeen who suffered an

anomalous affection of the respiratory muscle, producing a sound like a

cough, but shriller, almost resembling a howl. It was repeated every

five or six seconds during the whole of the waking moments, and

subsided during sleep. Under rest and free purgation the patient

recovered, but the paroxysms continued during prolonged intervals, and

in the last six years they only lasted from twenty-four to forty-eight

hours.

Parker reports four rebellious cases of singultus successfully treated

by dry cups applied to the abdomen. In each case it was necessary to

repeat the operation after two hours, but recovery was then rapid.

Tatevosoff reports a brilliant cure in a patient with chronic chest

trouble, by the use of common snuff, enough being given several times

to induce lively sneezing. Griswold records a successful treatment of

one case in a man of fifty, occurring after a debauch, by the

administration of glonoin, 1/150 of a grain every three hours.

Heidenhain records a very severe and prolonged case caused, as shown

later at the operation and postmortem examination, by carcinoma of the

pancreas. The spasms were greatly relieved by cocain administered by

the mouth, as much as 15 grains being given in twelve hours. Laborde

and Lepine report the case of a young girl who was relieved of an

obstinate case of hiccough lasting four days by traction on her tongue.

After the tongue had been held out of the mouth for a few minutes the

hiccoughs ceased. Laborde referred to two cases of a similar character

reported by Viand.

Anomalous Sneezing.--In the olden times sneezing was considered a good

omen, and was regarded as a sacred sign by nearly all of the ancient

peoples. This feeling of reverence was already ancient in the days of

Homer. Aristotle inquired into the nature and origin of the

superstition, somewhat profanely wondering why sneezing had been

deified rather than coughing. The Greeks traced the origin of the

sacred regard for sneezing to the days of Prometheus, who blessed his

man of clay when he sneezed. According to Seguin the rabbinical

account says that only through Jacob's struggle with the angel did

sneezing cease to be an act fatal to man. Not only in Greece and Rome

was sneezing revered, but also by races in Asia and Africa, and even by

the Mexicans of remote times. Xenophon speaks of the reverence as to

sneezing, in the court of the King of Persia. In Mesopotamia and some

of the African towns the populace rejoiced when the monarch sneezed. In

the present day we frequently hear "God bless you" addressed to persons

who have just sneezed, a perpetuation of a custom quite universal in

the time of Gregory the Great, in whose time, at a certain season, the

air was filled with an unwholesome vapor or malaria which so affected

the people that those who sneezed were at once stricken with

death-agonies. In this strait the pontiff is said to have devised a

form of prayer to be uttered when the paroxysm was seen to be coming

on, and which, it was hoped, would avert the stroke of the death-angel.

There are some curious cases of anomalous sneezing on record, some of

which are possibly due to affections akin to our present "hay fever,"

while others are due to causes beyond our comprehension. The

Ephemerides records a paroxysm of continual sneezing lasting thirty

days. Bonet, Lancisi, Fabricius Hildanus, and other older observers

speak of sneezing to death. Morgagni mentions death from congestion of

the vasa cerebri caused by sneezing. The Ephemerides records an

instance of prolonged sneezing which was distinctly hereditary.

Ellison makes an inquiry for treatment of a case of sneezing in a white

child of ten. The sneezing started without apparent cause and would

continue 20 or 30 times, or until the child was exhausted, and then

stop for a half or one minute, only to relapse again. Beilby speaks of

a boy of thirteen who suffered constant sneezing (from one to six times

a minute) for one month. Only during sleep was there any relief. The

patient recovered under treatment consisting of active leeching,

purgation, and blisters applied behind the ear, together with the

application of olive oil to the nostrils.

Lee reports a remarkable case of yawning followed by sneezing in a girl

of fifteen who, just before, had a tooth removed without difficulty.

Half an hour afterward yawning began and continued for five weeks

continuously. There was no pain, no illness, and she seemed amused at

her condition. There was no derangement of the sexual or other organs

and no account of an hysteric spasm. Potassium bromid and belladonna

were administered for a few days with negative results, when the

attacks of yawning suddenly turned to sneezing. One paroxysm followed

another with scarcely an interval for speech. She was chloroformed once

and the sneezing ceased, but was more violent on recovery therefrom.

Ammonium bromid in half-drachm doses, with rest in bed for psychologic

reasons, checked the sneezing. Woakes presented a paper on what he

designated "ear-sneezing," due to the caking of cerumen in one ear.

Irritation of the auricular branch of the vagus was produced, whence an

impression was propagated to the lungs through the pulmonary branches

of the vagus. Yawning was caused through implication of the third

division of the 5th nerve, sneezing following from reflex implication

of the spinal nerves of respiration, the lungs being full of air at the

time of yawning. Woakes also speaks of "ear-giddiness" and offers a new

associate symptom--superficial congestion of the hands and forearm.

A case of anomalous sneezing immediately prior to sexual intercourse is

mentioned on page 511.

Hemophilia is an hereditary, constitutional fault, characterized by a

tendency to uncontrollable bleeding, either spontaneous or from slight

wounds. It is sometimes associated with a form of arthritis (Ogler).

This hemorrhagic diathesis has been known for many years; and the fact

that there were some persons who showed a peculiar tendency to bleed

after wounds of a trifling nature is recorded in some of the earliest

medical literature. Only recently, however, through the writings of

Buel, Otto, Hay, Coates, and others, has the hereditary nature of the

malady and its curious mode of transmission through the female line

been known. As a rule the mother of a hemophile is not a "bleeder"

herself, but is the daughter of one. The daughters of a hemophile,

though healthy and free from any tendency themselves, are almost

certain to transmit the disposition to the male offspring. The

condition generally appears after some slight injury in the first two

years of life; but must be distinguished from the hemorrhagic

affections of the new-born, which will be discussed later. The social

condition of the family does not alter the predisposition; the old Duke

of Albany was a "bleeder"; and bleeder families are numerous, healthy

looking, and have fine, soft skins.

The duration of this tendency, and its perpetuation in a family, is

remarkable. The Appleton-Swain family of Reading, Mass., has shown

examples for two centuries. Osler has been advised of instances already

occurring in the seventh generation. Kolster has investigated

hemophilia in women, and reports a case of bleeding in the daughter of

a hemophilic woman. He also analyzes 50 genealogic trees of hemophilic

families, and remarks that Nasse's law of transmission does not hold

true. In 14 cases the transmission was direct from the father to the

child, and in 11 cases it was direct from the mother to the infant.

The hemorrhagic symptoms of bleeders may be divided into external

bleedings, either spontaneous or traumatic; interstitial bleedings,

petechiae, and ecchymoses; and the joint-affections. The external

bleedings are seldom spontaneous, and generally follow cuts, bruises,

scratches, and often result seriously. A minor operation on a hemophile

may end in death; so slight an operation as drawing a tooth has been

followed by the most disastrous consequences.

Armstrong, Blagden, and Roberts, have seen fatal hemorrhage after the

extraction of teeth. MacCormac observed five bleeders at St. Thomas

Hospital, London, and remarks that one of these persons bled twelve

days after a tooth-extraction. Buchanan and Clay cite similar

instances. Cousins mentions an individual of hemorrhagic diathesis who

succumbed to extensive extravasation of blood at the base of the brain,

following a slight fall during an epileptic convulsion. Dunlape reports

a case of hemorrhagic diathesis, following suppression of the

catamenia, attended by vicarious hemorrhage from the gums, which

terminated fatally. Erichsenf cites an instance of extravasation of

blood into the calf of the leg of an individual of hemophilic

tendencies. A cavity was opened, which extended from above the knee to

the heel; the clots were removed, and cautery applied to check the

bleeding. There was extension of the blood-cavity to the thigh, with

edema and incipient gangrene, necessitating amputation of the thigh,

with a fatal termination.

Mackenzie reports an instance of hemophilic purpura of the retina,

followed by death. Harkin gives an account of vicarious bleeding from

the under lip in a woman of thirty-eight. The hemorrhage occurred at

every meal and lasted ten minutes. There is no evidence that the woman

was of hemophilic descent.

Of 334 cases of bleeding in hemophilia collected by Grandidier, 169

were from the nose, 43 from the mouth, 15 from the stomach, 36 from the

bowels, 16 from the urethra, 17 from the lungs, and a few from the skin

of the head, eyelids, scrotum, navel, tongue, finger-tips, vulva, and

external ear. Osler remarks that Professor Agnew knew of a case of a

bleeder who had always bled from cuts and bruises above the neck, never

from those below. The joint-affections closely resemble acute

rheumatism. Bleeders do not necessarily die of their early bleedings,

some living to old age. Oliver Appleton, the first reported American

bleeder, died at an advanced age, owing to hemorrhage from a bed-sore

and from the urethra. Fortunately the functions of menstruation and

parturition are not seriously interfered with in hemophilia.

Menstruation is never so excessive as to be fatal. Grandidier states

that of 152 boy subjects 81 died before the termination of the seventh

year. Hemophilia is rarely fatal in the first year.

Of the hemorrhagic diseases of the new-born three are worthy of note.

In syphilis haemorrhagica neonatorum the child may be born healthy, or

just after birth there may appear extensive cutaneous extravasations

with bleeding from the mucous surfaces and from the navel; the child

may become deeply jaundiced. Postmortem examination shows extensive

extravasations into the internal viscera, and also organic syphilitic

lesions.

Winckel's disease, or epidemic hemoglobinuria, is a very fatal

affection, sometimes epidemic in lying-in institutions; it develops

about the fourth day after birth. The principal symptom is hematogenous

icterus with cyanosis,--the urine contains blood and blood-coloring

matter. Some cases have shown in a marked degree acute fatty

degeneration of the internal organs--Buhl's disease.

Apart from the common visceral hemorrhages, the results of injuries at

birth, bleeding from one or more of the surfaces is a not uncommon

event in the new-born, particularly in hospital-practice. According to

Osler Townsend reports 45 cases in 6700 deliveries, the hemorrhage

being both general and from the navel alone. Bleeding also occurs from

the bowels, stomach, and mouth, generally beginning in the first week,

but in rare instances it is delayed to the second or third. Out of 50

cases collected by Townsend 31 died and 19 recovered. The nature of the

disease is unknown, and postmortem examination reveals no pathologic

changes, although the general and not local nature of the affection,

its self-limited character, the presence of fever, and the greater

prevalence of the disease in hospitals, suggest an infectious origin

(Townsend). Kent a speaks of a new-born infant dying of spontaneous

hemorrhage from about the hips.

Infantile scurvy, or Barlow's disease, has lately attracted marked

attention, and is interesting for the numerous extravasations and

spontaneous hemorrhages which are associated with it. A most

interesting collection of specimens taken from the victims of Barlow's

disease were shown in London in 1895.

In an article on the successful preventive treatment of tetanus

neonatorum, or the "scourge of St. Kilda," of the new-born, Turner says

the first mention of trismus nascentium or tetanus neonatorum was made

by Rev. Kenneth Macaulay in 1764, after a visit to the island of St.

Kilda in 1758. This gentleman states that the infants of this island

give up nursing on the fourth or fifth day after birth; on the seventh

day their gums are so clinched together that it is impossible to get

anything down their throats; soon after this they are seized with

convulsive fits and die on the eighth day. So general was this trouble

on the island of St. Kilda that the mothers never thought of making any

preparation for the coming baby, and it was wrapped in a dirty piece of

blanket till the ninth or tenth day, when, if the child survived, the

affection of the mother asserted itself. This lax method of caring for

the infant, the neglect to dress the cord, and the unsanitary condition

of the dwellings, make it extremely probable that the infection was

through the umbilical cord. All cases in which treatment was properly

carried out by competent nurses have survived. This treatment consisted

in dressing the cord with iodoform powder and antiseptic wool, the

breast-feeding of the baby from the first, and the administration of

one-grain doses of potassium bromid at short intervals. The infant

death-rate on the island of St. Kilda has, consequently, been much

reduced. The author suggests the use of a new iodin-preparation called

loretin for dressing the cord. The powder is free from odor and is

nonpoisonous.

Human Parasites.--Worms in the human body are of interest on account of

the immense length some species attain, the anomalous symptoms which

they cause, or because of their anomalous location and issue. According

to modern writers the famous Viennese collection of helminths contains

chains of tenia saginata 24 feet long. The older reports, according to

which the taenia solium (i.e., generally the taenia saginata) grew to

such lengths as 40, 50, 60, and even as much as 800 yards, are

generally regarded as erroneous. The observers have apparently taken

the total of all the fragments of the worm or worms evacuated at any

time and added them, thus obtaining results so colossal that it would

be impossible for such an immense mass to be contained in any human

intestine.

The name solium has no relation to the Latin solus, or solium. It is

quite possible for a number of tapeworms to exist simultaneously in the

human body. Palm mentions the fact of four tapeworms existing in one

person; and Mongeal has made observations of a number of cases in which

several teniae existed simultaneously in the stomach. David speaks of

the expulsion of five teniae by the ingestion of a quantity of sweet

wine. Cobbold reports the case of four simultaneous tapeworms; and

Aguiel describes the case of a man of twenty-four who expelled a mass

weighing a kilogram, 34.5 meters long, consisting of several different

worms. Garfinkel mentions a case which has been extensively quoted, of

a peasant who voided 238 feet of tapeworms, 12 heads being found.

Laveran reports a case in which 23 teniae were expelled in the same

day. Greenhow mentions the occurrence of two teniae mediocanellata.

The size of a tapeworm in a small child is sometimes quite surprising.

Even the new-born have exhibited signs of teniae, and Haussmann has

discussed this subject. Armor speaks of a fully-matured tapeworm being

expelled from a child five days old. Kennedy reports cases in which

tapeworms have been expelled from infants five, and five and one-half

months old. Heisberg gives an account of a tapeworm eight feet in

length which came from a child of two. Twiggs describes a case in which

a tapeworm 36 feet long was expelled from a child of four; and Fabre

mentions the expulsion of eight teniae from a child. Occasionally the

tapeworm is expelled from the mouth. Such cases are mentioned by Hitch

and Martel. White speaks of a tapeworm which was discharged from the

stomach after the use of an emetic. Lile mentions the removal of a

tapeworm which had been in the bowel twenty-four years.

The peculiar effects of a tapeworm are exaggerated appetite and thirst,

nausea, headaches, vertigo, ocular symptoms, cardiac palpitation, and

Mursinna has even observed a case of trismus, or lockjaw, due to taenia

solium. Fereol speaks of a case of vertigo, accompanied with epileptic

convulsions, which was caused by teniae. On the administration of

kousso three heads were expelled simultaneously. There is a record of

an instance of cardiac pulsation rising to 240 per minute, which ceased

upon the expulsion of a large tapeworm. It is quite possible for the

presence of a tapeworm to indirectly produce death. Garroway describes

a case in which death was apparently imminent from the presence of a

tapeworm. Kisel has recorded a fatal case of anemia, in a child of six,

dependent on teniae.

The number of ascarides or round-worms in one subject is sometimes

enormous. Victor speaks of 129 round-worms being discharged from a

child in the short space of five days. Pole mentions the expulsion of

441 lumbricoid worms in thirty-four days, and Fauconneau-Dufresne has

reported a most remarkable case in which 5000 ascarides were discharged

in less than three years, mostly by vomiting. The patient made an

ultimate recovery.

There are many instances in which the lumbricoid worms have pierced the

intestinal tract and made their way to other viscera, sometimes leading

to an anomalous exit. There are several cases on record in which the

lumbricoid worms have been found in the bladder. Pare speaks of a case

of this kind during a long illness; and there is mention of a man who

voided a worm half a yard long from his bladder after suppression of

urine. The Ephemerides contains a curious case in which a stone was

formed in the bladder, having for its nucleus a worm. Fontanelle

presented to the Royal Academy of Medicine of Paris several yards of

tapeworm passed from the urethra of a man of fifty-three. The following

is a quotation from the British Medical Journal: "I have at present a

patient passing in his urine a worm-like body, not unlike a tapeworm as

far as the segments and general appearance are concerned, the length of

each segment being about 1/4 inch, the breadth rather less; sometimes 1

1/2 segments are joined together. The worm is serrated on the one side,

each segment having 1 1/2 cusps. The urine pale, faintly acid at first,

within the last week became almost neutral. There was considerable

vesical irritation for the first week, with abundant mucus in the

urine, specific gravity was 1010; there were no albumin nor tube-casts

nor uric acid in the urinary sediments. Later there were pus-cells and

abundant pus. Tenderness existed behind the prostate and along the

course of left ureter. Temperature of patient oscillated from 97.5

degrees to 103.2 degrees F. There was no history at any time of

recto-vesical fistula. Can anyone suggest the name, etc., of this

helminth?"

Other cases of worms in the bladder are mentioned in Chapter XIII

Mitra speaks of the passage of round-worms through the umbilicus of an

adult; and there is a case mentioned in which round-worms about seven

inches long were voided from the navel of a young child. Borgeois

speaks of a lumbricoid worm found in the biliary passages, and another

in the air passages.

Turnbull has recorded two cases of perforation of the tympanic membrane

from lumbricoides. Dagan speaks of the issue of a lumbricoid from the

external auditory meatus. Laughton reports an instance of lumbricoid in

the nose. Rake speaks of asphyxia from a round-worm. Morland mentions

the ejection of numerous lumbricoid worms from the mouth.

Worms have been found in the heart; and it is quite possible that in

cases of trichinosis, specimens of the trichinae may be discovered

anywhere in the line of cardiac or lymphatic circulation. Quoted by

Fournier, Lapeyronnie has seen worms in the pericardial sac, and also

in the ventricle. There is an old record of a person dying of

intestinal worms, one of which was found in the left ventricle. Castro

and Vidal speak of worms in the aorta. Rake reports a case of sudden

death from round-worm; and Brown has noted a similar instance.

The echinococcus is a tiny cestode which is the factor in the

production of the well-known hydatid cysts which may be found in any

part of the body. Delafield and Prudden report the only instance of

multilocular echinococcus seen in this country. Their patient was a

German who had been in this country five years. There are only about

100 of these cases on record, most of them being in Bavaria and

Switzerland.

The filaria sanguinis hominis is a small worm of the nematode species,

the adult form of which lives in the lymphatics, and either the adult

or the prematurely discharged ova (Manson) block the lymph-channels,

producing the conditions of hematochyluria, elephantiasis, and

lymph-scrotum. The Dracunculus medinensis or Guinea-worm is a

widely-spread parasite in parts of Africa and the West Indies.

According to Osler several cases have occurred in the United States.

Jarvis reports a case in a post-chaplain who had lived at Fortress

Monroe, Va., for thirty years. Van Harlingen's patient, a man of

forty-seven, had never lived out of Philadelphia, so that the worm must

be included among the parasites infesting this country.

In February, 1896, Henry of Philadelphia showed microscopic slides

containing blood which was infested with numbers of living and active

filaria embryos. The blood was taken from a colored woman at the

Woman's Hospital, who developed hematochyluria after labor. Henry

believed that the woman had contracted the disease during her residence

in the Southern States.

Curran gives quite an exhaustive article on the disease called in olden

times "eaten of worms,"--a most loathsome malady. Herod the Great, the

Emperor Galerius, and Philip II of Spain perished from it. In speaking

of the Emperor Galerius, Dean Milman, in his "History of Latin

Christianity," says, "a deep and fetid ulcer preyed on the lower parts

of his body and ate them away into a mass of living corruption."

Gibbon, in his "Decline and Fall," also says that "his (Galerius's)

death was caused by a very painful and lingering disorder. His body,

swelled by an intemperate course of life to an unwieldy corpulence, was

covered with ulcers and devoured by immense swarms of those insects who

have given their names to this most loathsome disease." It is also said

that the African Vandal King, the Arian Huneric, died of the disease.

Antiochus, surnamed the "Madman," was also afflicted with it; and

Josephus makes mention of it as afflicting the body of Herod the Great.

The so-called "King Pym" died of this "morbus pedicularis," but as

prejudice and passion militated against him during his life and after

his death, this fact is probably more rumor than verity. A case is

spoken of by Curran, which was seen by an army-surgeon in a very aged

woman in the remote parts of Ireland, and another in a female in a

dissecting-room in Dublin. The tissues were permeated with lice which

emerged through rents and fissures in the body.

Instances of the larvae of the estrus or the bot-fly in the skin are

not uncommon. In this country Allen removed such larvae from the skin

of the neck, head, and arm of a boy of twelve. Bethune, Delavigne,

Howship, Jacobs, Jannuzzi and others, report similar cases. These

flesh-flies are called creophilae, and the condition they produce is

called myiosis. According to Osler, in parts of Central America, the

eggs of a bot-fly, called the dermatobia, are not infrequently

deposited in the skin, and produce a swelling very like the ordinary

boil. Matas has described a case in which the estrus larvae were found

in the gluteal region. Finlayson of Glasgow has recently reported an

interesting case in a physician who, after protracted constipation and

pain in the back and sides, passed large numbers of the larvae of the

flower-fly, anthomyia canicularis, and there are other instances of

myiosis interna from swallowing the larvae of the common house-fly.

There are forms of nasal disorder caused by larvae, which some native

surgeons in India regard as a chronic and malignant ulceration of the

mucous membranes of the nose and adjacent sinuses in the debilitated

and the scrofulous. Worms lodging in the cribriform plate of the

ethmoid feed on the soft tissues of that region. Eventually their

ravages destroy the olfactory nerves, with subsequent loss of the sense

of smell, and they finally eat away the bridge of the nose. The head of

the victim droops, and he complains of crawling of worms in the

interior of the nose. The eyelids swell so that the patient cannot see,

and a deformity arises which exceeds that produced by syphilis. Lyons

says that it is one of the most loathsome diseases that comes under the

observation of medical men. He describes the disease as "essentially a

scrofulous inflammation of the Schneiderian membrane, ... which finally

attacks the bones." Flies deposit their ova in the nasal discharges,

and from their infection maggots eventually arise. In Sanskrit peenash

signifies disease of the nose, and is the Indian term for the disease

caused by the deposition of larvae in the nose. It is supposed to be

more common in South America than in India.