MISCELLANEOUS SURGICAL ANOMALIES. 11 page

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

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