, , First, occasional very rapid development; 2d. vomiting after the onset of pain; 3d, aggravation of pain in the tumor for a few days prior to the menstrual epoch; 4th, unreliability of Kuster's sign-position of the tumor anterior to uterus; 5th, irregularity of outline; 6th, abdominal free fluid, the diagnosis of ovarian dermoids can never be positive-at the most it is inferential. to be entirely contributory as Baumgarten and Rizor have shown that blood, contained between two ligatures in a vessel where the walls were not lacerated and where no bacteria were present, would remain fluid for weeks. The studies of Flexner, Pearce, Winne and others tend to show that thrombi due only to agglutination exist. To this class especially belong hyalin thrombi. It is also known that any roughened surface UNUSUAL CASES OF VENOUS THROM- along the course of a blood-vessel or a rough BOSIS.* By HENRY WARNER JOHNSON, A.M., M.D. Hudson, N. Y. SYNOPSIS. Report of four cases of venous thrombosis, of which three complicated typhoid fever. Two of these suppurated and two developed infarction of the lung. The fourth case complicated rheumatism, the thrombus advancing from left saphenous vein. through iliacs to right side then ascending through vena cava. ETIOLOGY OF THROMBOSIS. In 1823 Dr. Davis of London University first discovered that Phlegmasia Dolens was an affection of the venous structure. It was found at this time that changes had taken place in the walls of the blood vessels and that the cavity was occluded by an organized coagulum. The name Thrombosis means simply the formation of a thrombus, as ascites means the collecting of fluid, but neither of these terms has a single pathological analogy. The theory of the etiology of coagulation now most widely held is that in the presence of lime salts thrombogen of the blood is acted upon by a fibrin ferment, thrombokinase. Thrombokinase is found to exist constantly in the walls of the blood-vessels below the tunica intima, in muscle tissue and in certain glands. Krehl's Clinical Pathology claims that this ferment is necessary to the formation of thrombus and speaks of the lack of this ferment as probably the principal etiological factor in hemophilia; Sahli has also brought forth much evidence to establish this contention. As to the introduction of thrombokinase into the circuation, much can be said. Of course the simplest explanation is the tearing or denuding of the tunica intima thus exposing the deeper tissues where thrombokinase is known to exist. It is known that bacteria may influence the formation of thrombus. It is equally fair to suppose they carry the ferment, or wound the blood-vessel, thus liberating the same, as that their action upon the blood is primary. Slowing of the blood current is known to be a factor in the etiology. I, however, believe it *Read before Third District Branch of the New York State Medical Society, October 27, 1908. object introduced into the blood current will act as a nucleus for the formation of a clot. Clinically, thrombi have three important features, first the amount of mechanical interference with the circulating current which is in direct proportion to the size of the clot with the caliber of the vessel occluded; second, the amount of inflammation associated with the thrombus and its effect upon surrounding tissues; and third, the firmness of the thrombus and its parts to the vessel wall, since the freeing of the entire clot, or a part of the same, into the blood current may produce serious consequences in other parts of the body. All of these conditions are shown in cases I have chosen to report herewith. THROMBOSIS COMPLICATING TYPHOID FEVER. CASE 1.-W. N., male, aged seventeen years, a student in high school, I first saw during the tenth week of his illness. He then had a small superficial thrombus over the shin of the left leg which the nurse in charge was religiously rubbing three times per day. This procedure was stopped, and after a few days an abscess pointed at this location which was opened and evacuated. Drainage continued but a short time. After two weeks, during which time I did not see the case, I was again called, found pulse and temperature normal and patient anxious to be out of bed. On palpating the abdomen I found a tumor midway between tumbilicus and pelvis. Within a few days tumor had increased to the size of an orange and was found to contain a large quantity of pus. The incision was a deep one and drainage was continued for some weeks. From the location and depth of the tumor I concluded a second thrombus had formed in the epigastric vein and had broken down as had the one in the leg. From the finding of this tumor to the discharge of patient there was no rise in temperature. CASE 2.-G. C., female, aged thirty-two years, developed femoral thrombosis in the left leg at the end of the third week of typhoid fever. On July 10, 1906, during the second week of the thrombosis the nurse in charge informed me by telephone that the patient was suffering a chill, that an eruption had started on the feet and was progressing over the legs. Upon my arrival at the hospital I found the Showing chart during period of infarction of lung. patient not cold but experiencing a severe rigor, temperature 105°, pulse of very low volume 108, respiration 36, with great anxiety and other neurotic symptoms. During my visit the eruption, an urticaria, advanced over the thighs, abdomen, chest and face like a marching flame. It disappeared in a few days. After a short remission another rigor presented, temperature 106°, pulse 120, respiration 40. An area of dullness could be made out in the middle lobe of the right lung and some fine râls indicating infarction. During the two succeeding days other rigors were experienced but of mild degree, and with no increase in the physical signs which gradually faded. However, temperature continued with remission each day of some two or three degrees and an evening rise. The thrombus advanced to the iliac veins descending the femoral on the opposite side. During the first week in September a tumor appeared in Scarpa's triangle left side, which fluctuated, and on September 10th I incised the same, obtaining a large amount of pus. Soon another abscess appeared in the popliteal space in the same leg, then another under the gastrocnemius muscle and finally a fourth in Scarpa's triangle of the right leg. For months the patient was unable to walk but recently has made an apparently complete recovery and weighs 180 pounds. CASE 3.-P. L., male, aged twenty-five years, farmer, I first saw September 9, 1908, when his rose eruption was already developed and at which time the diagnosis was made. From the appearance of the eruption and other facts gathered, I concluded his thrombus developed about the end of the third week. Pain began in lower left side of abdomen, then in left leg. Tenderness was most marked in region of left iliac vein where I believe the process started. At midnight of the fourteenth day after the thrombus developed, the nurse in charge in Mr. P.L. Oct. DATE. TIME. formed me the patient was suffering a rigor of such severity that the whole body and even bed were in motion: temperature by mouth 105.2°, pulse rapid and scarcely perceptible, respiration 34. Patient was perfectly conscious, alert, anxious and exceedingly neurotic. During my examination he pointed to the lower part of the left lung as the probable cause of his distress. Over the left lower lobe and to the right of the mammillary line I found an area of distinct dullness and by auscultation many fine râls. Little or no pain was experienced. During the succeeding twenty-four hours the temperature was very erratic, dropping two degrees or more and rising to about 105° within HUDSON CITY HOSPITAL Dr. Johnson. 17 4|8|24|8|24|8|24|8|24|8|24|8|24|8|24|8|24|8|24|8|24|0|24|8|24|8|24|8|24|8 18/24 V2 18 |24|8|24|8|12|| 0107 an hour, then in a very short time, the following day, dropping to 98°. A profuse perspiration lasted for forty-eight hours during which time the temperature remained about normal, then rising to 102.6° when a general urticaria appeared. Again the temperature receded to 99.6°. At midnight, on the fifth day following the first rigor, the temperature again shot from normal to 105.2° by mouth, much the same train of symptoms was again noted, and at four A. M. of the same day the chart showed a precipitant fall to 98.6°. A slight increase in the area of dullness over the same lobe of the left lung was the only physical sign apparent the next day. Since that time the temperature has been practically normal and the patient advancing rapidly toward recovery. In these two latter cases I believe the eruption is of no great moment as its appearance in the second case bore no true relation to the time of infarction. Thayer, in his 1,458 case of typhoid fever, reports 2.5 per cent. as developing thrombosis and one-half of these as occurring in the femoral vein. In most of the reference works to which I have had access infarctions of the lung are spoken of as fatal, though some of the later ones describe the condition with recovery. THROMBOSIS COMPLICATING RHEUMATISM. CASE 4.-Mrs. J. G., aged fifty-nine years, in the history of whose case is a hemiplegia about one year before present illness which started as acute rheumatism. These symptoms had abated before I saw her, February 23, 1908, when there remained an endocarditis with evidence of extreme depletion, anemia and a decided secondary leucocytosis. On February 28th she began to complain of pain in left leg with marked swelling and shiny hue to the skin. The engorgement seemed most intense along the saphenous vein but extended to the femoral, the entire leg becoming so engorged that the toes stood apart. Dr. Gordinier saw patient with me March 7th. On March 17th, after some moderation of above symptoms, signs of extension of the thrombus through iliacs to vessels of right leg appeared: the legs remained greatly swollen. Within a short time a long tense tumor appeared under abdominal wall extending along left side from the pelvis following the line of large intestine to right side of abdomen. With this was associated a complete obstipation which was not relieved by washing with colon tube. It seemed that the inferior mesenteric vein had become occluded before the superior, as it was some three or four days before the hardness had extended to the entire abdomen when no visceral signs remained. JOURNAL OF MEDICINE This disease is supposed to occur most frequently in illy-nourished children and young adults, and sometimes in middle life, in patients with auto-toxemia often following the exanthems with diphtheria, and in those who live in illy-ventilated houses; it is aggravated by filth, dust, dirt, and traumatism. While I believe the fact is that the chief causes are the excess lymphoid growths in the naso-pharynx, enlarged faucial tonsils, which causes the rheumatic diathesis, and deflected septa, causing the naso Read before the Sixth District Branch of the Medical Society of the State of New York, October 6, 1908. pharyngeal catarrh, with sinusitis, auto-toxemia, and infection. PATHOLOGY. TREATMENT. The treatment should be first surgical and then constitutional, local, and hygenic. To remove The first change in the conjunctiva is a collecthe cause surgically, clean the nose of the breedtion of round lymphoid cells under the epithe- ing ground for bacteria by removing the adelium, which is lifted up, this causes a phlycte-noids and faucial tonsils and straighten the deflected septum, if necessary, ridding the patient of sinusitis thoroughly, if possible, also polyps and enlarged turbinates. Daily hot baths should be taken, followed with thorough rubbing. Calomel and salts must be administered daily, followed with phosphate of soda. Sleeping in a large, airy, well-ventilated room, with clean pillow case every night is recommended; handkerchiefs for both nose and eyes. should be provided; lots of out-of-door exercise should be taken. The eyes must be protected by smoked glasses, and auti-strumatic medication not forgotten. Treatment of the eyes: Keep the eyes cleansed with bichlorid (one to ten thousand), or ten per cent. boracic acid wash, and instil argentic vitellin every hour, and keep the pupils dilated with atropin and frequent washing with cold water; all of which is secondary to the surgical and constitutional treatment. Give internally Syr. Iod. of iron and cod liver oil; prescribe glasses, if needed. nule and is usually at the external or internal portion near the limbus; if at the internal canthus it comes direct from the lachrymal apparatus, if external it is often due to the discharge from the nose getting on the pillow, which the child wallows in, as it were. The efflorescence is in reality never a vesicle, but a solid, the soft projection of which is formed chiefly by these lymphoid cells. The softening and liquefaction of this cellular mass does not begin in the interior of the projection, but at the apex, so that there is no formation of a cavity, vesicle or pustule, but a loss of substance (ulcer) lying upon the free surface at the apex. The old terms "herpes febrile" and "herpes zooster," are misnomers, since it has not a neuritis as a cause. It is usually due to a mixed infection, but there is a herpes of the cornea, which is not infective, due to a neuritis unlike the subject in question. SYMPTOMS. The secretion is first watery, and by running over the edges of the lids may excoriate the surrounding skin, which will show infection of its superficial veins and in some cases the lids are slightly edematous. The secretion sometimes becomes mucous or muco-purulent, according to the grade of the inflammation, and sometimes gathers a slightly frothy material only at the commissural angles, or is very freely secreted, and when it dries agglutinates the lids and cilia so that they may become adherent, damming up. the secretions, thereby macerating the already irritated conjunctiva and cornea, and acting as a culture medium, like a poultice of alum curd, wet tea leaves, scraped apple, raw beef, all of which should be avoided. Lachrymation and extreme photophobia are atypical symptoms. The photophobia is much worse if the ulcers are situated on the corneal margin or cornea. When pres ent in children they are constantly protecting their eyes by burying them in the pillow or mother's dress, to keep them from the bright light; adults continually wear smoked glasses and always avoid exposure to bright light. There is always a more or less acrid discharge from the nose, which often excoriates the upper lip especially in children, and I have seen thick crusts, calcarious in nature, covering its entire surface. If left to themselves, or poorly treated, these ulcers become deep-seated, and if on the cornea leave cicatrices or leukomas, which permanently destroy the clearness of the cornea; and if central, the vision is very much impaired. I have seen a general uveitis caused in neglected cases resulting in post synechia, and in one case almost complete loss of vision in one eye. Before the last session of the American Medical Association, Ophthalmology Section, a distinguished author and ophthalmologist contributes an exhaustive and classic article on auto-toxemia as the cause of this condition, but does not allude to that which I believe to be the most frequent. primary cause. I could cite many cases but will content myself with two: Miss A. W., ten years of age, called to see me, sent by a nurse who had found her in the street with the eye covered, being led by her little sister. Upon being interrogated she said that she was blind and had been so for six weeks. Upon examination I found both eves congested with both conjunctival and corneal phlyctenules in great numbers with irides inactive and contracted, great photophobia and lachrymation and some muco-pus flecks. Examination of throat showed that she had enlarged faucial tonsils and naso-pharynx full of adenoid growths. There were an acrid discharge from the nose and crusts on the upper lip. She was much reduced in weight. She had been under treatment for some time, which had been directed to the eyes only. I immediately took her to the hospital, cleaned the throat and nose of its abnormal growths, corrected the kidneys and alimentary tract, ordered baths, iron tonic, and further treatment as described above, forbade sweets or coffee, and in two weeks her eyes were practically well. D. D., age 48. Came to me from Geneva, N. Y., in December, 1901, with infectious keratitis of ten years' duration; had consulted six of our most skilled oculists of central New York, New York City, Chicago and San Francisco without relief. Upon examination, found both eyes badly inflamed with many phlyctenules upon the cornea and conjunctiva of both eyes and both cornea badly damaged with many small leucomas. I immediately asked him if any of my predecessors had examined his nose and throat; as he replied in the negative I immediately examined them only to find that he still had small faucial tonsils, but the post nasal space was completely occluded with lymphoid growths, the central of which (pharyngeal tonsil) was as large as a walnut cut in half. Although a saloon keeper he was not a |