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upon for appendicitis, hepatic colic, renal colic, etc. On the other hand repeated vascular disturbances in an organ may eventuate in such chronic affections, for example, as interstitial nephritis, gastric ulcer, general arteriosclerosis, angina pectoris. In some cases apoplexy has been the terminal event. Thus mistake is possible in either direction. Rheumatism, arthritis deformans, gout, tuberculosis, cancer, diabetes, and various nervous disorders are found in the family history; less commonly in the patient. Glycosuria, glycuronuria, polyuria, albuminuria, hematuria of various degrees, and swelling about the joints, are, however, among the transient, and not infrequent, phenomena recurring in
As a rule, the paroxysmal (critical) character of the vasomotor disorders, and the absence of distinctive signs of infectious malady or organic affection, will establish the probability of the diagnosis, either positively or by exclusion. It becomes more certain if
the patient's family history and previous personal history show the occurrence of similar or related "špells," and certain physical characteristics and significant reactions to environment are found to be present. In the papers referred to, these have been discussed at length. They are not all present at the same time, nor does every case show all of them at any time, while but few of them are present continuously. Nevertheless, every case will show, at one time or another, a sufficient number of them to be significant. They indicate persistent disturbance not only in the vasomotor nerves and centers, but in the autonomic system as a whole. Some of them are the exact opposites of others. They may be thus summarized:
PHYSICAL CHARACTERISTICS Skin. Marbling or mottling; dilatation of superficial vessels; petechiæ; angiomata; telangiectases; pigmented spots; papillary excrescences; tatooed appearances, coming on especially on exposure of the naked body to cold; massive congestion of dependent parts, especially hands, which may be pink, red, leaden, blue, purple, or variously mottled. Finger-tips often enlarged. Nails often curved, usually bi-colored or tri-colored, darker at base and exhibiting a deep red line near the finger tip; skin about nail base often thickened and brick red. Moist hot, or moist cold, hands; excessive sweating or less commonly, scantiness of perspiration even in summer bromidrosis.
Eyes. 10 Staring; widened commissure; retraction of upper or lower lid, or both, constant or intermittent, or developed on excitement or at command. Tremulousness of lids on light. closure. Interrupted (jerky) descent of upper lid (hitch); v. Graefe's and v. Stellwag's signs; paroxysmal winking; pigmentation in and around lids. Rarely, drooping lids or narrowed. (squinting) commissure. Dilatation of pupil; inequality; intermittent dilatation; hippus; nystagmus. Distention and tortuosity of retinal vessels; spastic contraction of retinal vessels.
Rarely Thyroid gland. Moderately or slightly enlarged; soft. Enlargement intermittent. Rarely atrophic.
Heart and Vessels. Easily disturbed. Palpitation. Palpitation. Blood pressure often very low (circa 100 S, 80 D); may be high in spastic paroxysms, functional murmurs frequent; organic affections may be present incidentally or essentially.
Tremors and involuntary muscular
10 See Hansell: Trans. Amer. Opthal. Soc'y. loc. cit.
movements not uncommon; leg-cramp occasional; muscular throbbings common. Sudden jerking of limbs on awakening; sometimes elipte form seiz
Blood. Moderate anemia not uncommon. A marked tendency, at tendency, at times, to autohemolysis. Hemoglobin and red cells not infrequently found in the urine, on microscopic, chemical or spectroscopic study, when blood or blood-pigment is not obvious to the naked eye. In some cases a remarkable and persistent eosinophilia; at times, a critical eosinophile rise.
Dermographism, either ischemic, hyperemic, or mixed. Factitious urticaria. Local or general pilomotor reflex. Blushing easily excited. Silver, less frequently gold, copper, silver, nickel, leaves a bluish-black or brown mark when drawn over the skin of face or breast. (Black mark due to (Black mark due to talc or zinc oxide face powder must be excluded.) Hot water intensifies redness of extremities. Ice-cold water may change blueness (cyanosis) to redness (hyperemia) in immersed member, the parallel non-immersed member being made deeply cyanotic. Sometimes ice-cold water produces blackness of nails. In dilative cases a cyanotic member (e. g., hand) if stroked or elevated, becomes pallid, and when the stroking is stopped or it is again depressed, changes from white to pink, to red, to purple, to blue as blood returns first to capillaries, then to venules, then to veins. In In spastic cases the stroking or gravity
has little effect.
TREATMENT is difficult, and must be persistent. It is preventive, pallia
tive and remedial.
The management of each case is individual. Rest and exercise are to
be prescribed specifically to suit the needs of the particular case. When possible, the patient is to be removed. from, or guarded against, the emotional (sometimes sexual) excitants of paroxysms. The secretions and excretions must be kept free. Calomel should be given occasionally. Lavage of stomach and bowel is often useful. Diet is to be regulated, fermentable foods and proteids being restricted, as a rule. Intestinal antiseptics, as lactic-bacilli, hexamethylenamin, phenyl salicylate, betanaphthol, guaiacol carbonate, should be administered fairly continuously for awhile. Eyestrain must be relieved by corrective lenses. lenses. Anatomical maladjustments, visceral ptoses, relaxation of ligaments, etc., if The present, should be corrected. vascular reactions are to be re-educated by hydrotherapeutic procedures, involving alternate applications of hot and cold water, and by friction. A convenient and usually effective measure is hot sponging or spraying for a minute or two, followed by cold sponging or shower, or by rubbing with handfuls of cold water, for an
other minute or two; winding up with a thorough friction-drying with a rough towel. It should be carried out every morning on rising. More elaborate applications of hot and cold water may be prescribed when necessary. Electric applications of various kinds are useful the special procedure depending on the special symptoms. Among those I have found effective in various cases are: faradization of the stomach; galvanization of the cervical sympathetic; iodic ionization of affected joints; the static breeze; the wave-current; high-frequency discharges from a Oudin resonator, to the spine, the neck, the thyroid gland;
general or local d'Arsonvalization, etc. Massage, general and local, and intermittent pressure upon the muscles around the spinal column, can also be employed with good results in certain cases. When there is cardiac palpitation or tachycardia - especially in Graves's syndrome-the patient should rest, and a pre-cordial coil, first with hot and then with cold water, or hot compresses followed by an ice-bag, be applied over the precordium for such time as may be indicated by the severity of the symptoms and the effect of the remedy. In Raynaud's syndrome, erythromelalgia and minor degrees of ischemic phenomena, the application of heat externally is often indicated. Medication likewise depends on the special symptoms. In migraine, asthma, and the like, it will depend on the nature of the attack constrictive or dilative whether vasodilators (e.g., — nitroglycerin, thyroid, iodides), or vasoconstrictors (e.g., cocain, atropin, pituitary, suprarenal) are to be used. In gastro-enteric disturbances, either acids or alkalis, ferments, sedatives or stimulants may be called for as palliatives. When there is excessive sweating, atropin is sometimes useful; sometimes minute doses of pilocarpin, gradually increased on the Mithridatic principle, act better. In cardiac disorders, cactus, digitalis, strophanthus, cocain, strychnin, camphor, atropin, ergot, calcium chlorid, barium chlorid, given singly or variously associated, are the principal agents to choose from when pressure is low, vigor reduced, peripheral vessels dilated, or a tendency to arrhythmia present — more especially when there is actual myocardial or valvular lesion. When blood-pressure is high, but cardiac vigor reduced, the pulse small and its rate irregular, spartein and cac
are useful. When pressure is high and vigor high or excessive, aconite may be employed - especially when the pulse is small and poorly filled. The nitrit group, especially erythrol tetranitrate, the iodides and thyroid preparations also do good. service temporarily or persistently in cases of constriction and hypertension, chiefly in cases exhibiting lowered cardiac force. Concerning other preparations of ductless glands, it may be said that thymus, adrenal and posterior pituitary preparations are all worth extended trial in dilative cases. Among plant principles, pictrotoxin and quinin occupy a peculiar place, being useful as regulators of vasomotor tone in nearly all varieties of cases. On the other hand, many patients exhibit quinin idiosyncrasies, and must be habituated to the drug Mithridatically. Quinin hydrobromid and ergotin may usefully be associated, or strontium br sodium bromid may be given concurrently with any quinin salt. Very many drug-idiosyncrasies are to be observed in the subjects of vasomotor ataxia. One case appears to be unique. The woman developed facial edema or general anasarca whenever nux vomica or strychnin was given. The use of morphin promptly by hypodermic injection is sometimes imperative in a crisis — especially in recurrent pulmonary edema. Tracheotomy may be necessary should local applications of pituitary, adrenal, or cocain preparations fail to give prompt relief in a case of laryngeal edema. Medication must be varied from time to
time, often intermitted for prolonged periods, sometimes prescribed only for emergencies. In no condition are the skill and the resources of the artist in therapeutics more severely taxed.
The Treatment of Surgical Tuberculosis in Children.
By LE GRAND KERR, M.D.
Visiting Pediatrist to the Methodist Episcopal (Seney), the Williamsburgh, the Bushwick and the Swedish Hospitals in Brooklyn, N. Y.; Consulting Pediatrist to the Rockaway Beach Hospital and the Industrial Home for Children.
While the tissue results are practically the same in tuberculosis as it affects the adult or the child when infection has once taken place, still there are some marked differences in the mode of invasion that need to be borne in mind. In dealing with the disease in adults, the mind naturally turns to pulmonary involvement. But to the pediatrist or the pediatric surgeon, tuberculosis means first some glandular, meningeal, miliary, bone, joint, peritoneal or diffused lesion while pulmonary involvement is the least prominent fea
Thus we find that the general principles of surgical treatment are directly influenced by the marked tendency of the disease to become generalized in childhood, no matter what or where the primary focus may be. The result is twofold; considerably more care and thought must be given to the question of operative interference and, when once the operation is determined upon, the most radical procedures seem to promise the greatest protection to the child.
All this requires an unusual nicety of judgment and thoroughness of examination seldom demanded in other conditions.
The treatment of surgical tuberculosis in children involves at the outset the protection of others, so that it becomes the immediate duty of the surgeon to destroy any infected material or discharge or at least to render it incapable of causing infection. While there are numerous ways in which this may be accomplished, fire offers the most certain and satisfactory results.
Unless the disease involves the respiratory tract, climate is of practically no importance, so that, generally speaking, surgical tuberculosis does not demand or need climatotherapy.
But, upon the other hand, the influence of sunshine and fresh air is nothing short of remarkable. It can be readily placed in the very front rank, as regards importance, in the surgical treatment of tuberculosis, constituting considerably more than one-half of the beneficial influence exerted upon the lesions. It is therefore imperative that the child spend most of its time in the open air and, when conditions permit, as many hours as possible should be spent in the sunshine. Outside of its general effect, direct sunshine influences the local lesion and therefore, when practical, the portion of the body affected by the disease should be exposed to the direct rays occasionally during the day. The local influence is manifested by an inhibitation of the growth of the bacilli and a stimulation of the local nutritive processes.
Rest is another important factor in treatment. This will often try the resources of the surgeon because its enforcement may seem at first to involve undesirable and probably harmful confinement in bed.
Circumstances may have to rule but compulsory restraint should always be coupled with the securing, for the child so confined, the benefits of a continuous supply of fresh air and all possible sunshine.
Now while the necessary rest which is entailed helps to bring about a condition which is characterized more or
less by the temporary retention of waste products and by atony of the musculature, these may be overcome to a large extent by passive motions. Gentle massage administered at stated intervals and passive motion of all unaffected parts will usually suffice.
The eliminative forces of the skin, the kidneys and the bowels must be aided and their unrestricted action encouraged. It is so easy and so comcom to give the bowel function adequate attention and to neglect the other factors. Elimination is not a one organ function; there are several factors directly involved and there must be coordination and co-operation of all of these, and the intricate yet correlated functions of each organ must be carried on freely and without strain.
Generally speaking, the diet should be that which represents the full digestive capacity of the individual. This requires the most careful attention to the digestion and at no time should the desire to increase the nutrition jeopardize the continuance of normal digestion. There has not been devised yet a plan of dieting which will suit all cases, but a mixed diet is best suited to the indications.
Most of the digestive disturbances are directly traceable to one large meal, and, knowing this, an effort should be made to control it.
Smaller meals at lessened intervals are more readily taken. It is unnecessary to consider in detail the various articles of food, whether they be milk, eggs, cod liver oil or other things; all this is necessary is to reiterate that the bulk of the treatment lies in the proper administration of rest, fresh air and sunshine and a dietary beyond that needed for the mere repair of waste but restricted carefully to fit the digestive capacity.
Drug administration is restricted in its value to the control of undesirable symptoms and to the influencing of the nutritive and reparative processes and occasionally as adjuvants to the eliminative forces.
Local treatment creates a demand for rest and this may necessitate the application of some restraining apparatus. During the acute and pain-· ful stage the best restraining apparatus is undoubtedly carefully applied plaster which besides being efficient cannot be disturbed by the child. But as quickly as the circumstances will allow, substitution may be made to leather or a less harsh restraining apparatus than the cast. There is also another element in the rest treatment that we must always consider and that is that the limb is not alone placed at absolute rest but must also be in a good position. This position must always approximate as closely as possible the position of the limb in repose and therefore there is a different position for each joint.
But, irrespective of rest and position, there are several drugs that possess antituberculous properties and these may occasionally be used with advantage in the local treatment of the lesion.
Iodoform is the best of these if used in a part where air is excluded. Guaiacol has been used as an application over an affected part, but is of doubtful utility. Zinc chloride, balsam of Peru, oil of cinnamon, ichthyol and mercury have all won advocates but their use is always limited even if it may be of some service.
The Finsen light and the X-ray have a place in the local treatment where there exist localized areas, especially in lupus, in which their influence for good is often marked. Lupus, however, is